General surgical pathology and therapeutics, in fifty lectures : a textbook for students and physicians
Billroth, Theodor, 1829-1894 | Hackley, Charles E. (Charles Elihu), 1836-1925, tr
%-b^k-X^- . e^ r. ■/ s-fof. fc. AO cr?P<5cryt^. Digitized by the Internet Archive in 2011 with funding from Open Knowledge Commons and Harvard Medical School http://www.archive.org/details/generalsurgicalp1874bill GENERAL SURGICAL a//n Jfin A TEXT-BOOK FOR STUDENTS AND PHYSICIANS. BY Dk. theodor billeoth, PEOFESSOE OF SUBGEBY IN VIENNA. TRANSLATED FROM THE FOURTH GERMAN EDITION, WITH THE SPECIAL PERMISSION OF THE AUTHOR, AND REVISED FROM THE SIXTH EDITION, BY CHARLES E. HACKLEY, A.M., M.D., SUEGEON TO THE NEW YORK EYE AND EAR INFIRMARY, PHYSICIAN TO THE NEW YORK HOSPITAL, FELLOW OF THE NEW YORK ACADEMY OF MEDICINE, ETC., ETC. NEW YOEK: D APPLETON AND COMPANY, 549 & 551 BROADWAY. 1874. £*)2,V Entebed, according to Act of Congress, in the year 1871, by Chaeles E. Hacexey, in the Office of the Librarian of Congress, at Washington. Entebed, according to Act of Congress, in the year 1S73, by Chaeles E. Hacelet, in the Office of the Librarian of Congress, at Washington. TRANSLATOR'S PREFACE TO THE REVISED EDITION. The success attained by the English translation of this work encourages the translator to believe that it is adapted to the present needs of the medical profession, and to hope that this revised edition may meet with an equally favorable reception. Since publishing the fourth edition of his work, Prof. Billroth has had increased experience during the late Franco-Prussian War ; much of which is detailed in his " Chirurgische Briefe aus den Kriegs-Lazarethen in "Weissenburg und Mannheim 1870," and many deductions from which will be found in the following pages. Notices of skin-grafting and various other topics recently discussed, as well as many new woodcuts, are among the addi- tions to this edition. TRANSLATOR'S PREFACE. Dueestg the past ten years the microscope lias greatly ad- vanced our knowledge of Pathology ; and it will perhaps be acknowledged that most progress in the study of Pathological Anatomy has been made in Germany. Prof. Theodor Billroth, himself one of the most noted au- thorities on Surgical Pathology, has in the present volume given us a complete resume of the existing state of knowledge in this branch of medical science. The book might perhaps have been entitled " Principles of Surgery," but this would hardly have indicated the specific man- ner in which these principles have been inculcated. Most of the views found in these lectures have been floating through the journals for several years past ; but, so far as the translator knows, they are not so fully presented in any book in the English language. The only work in our language on the subject was published many years ago ; even the late editions are but little changed from the first ; moreover, the two works are, in most respects, entirely unlike. The fact of this publication going through four editions in Germany, and having been translated into French, Italian, Rus- sian, and Hungarian, should be some guarantee for its standing. Some few notes that have been inserted by the translator will be found enclosed in brackets [ ]. 47 West Thirty-first Street, New York, December 1, 1870. AUTHOR'S PREFACE TO THE SIXTH EDITION. The steady advance of science, and the progress that we our 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 hesi- tate 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 en- tirely 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. Yienna, November, 1872. PREFACE TO THE FOURTH EDITION. Almost every time that it lias 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 much 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. The liberality of the publisher has enabled me to increase the number of woodcuts by twenty-nine (Figs. 47, 53, 55, 58, 66, 68, 69, TO, 74, 91, 98, 99, 103, 106, 107, 108, 109, 110, 111, 112, 122, 123, 124, 125, 126, 127, 128, 132, 133). De. TH. BILLROTH. Vienna, November, 1869.. CONTENTS. LECTURE I. INTRODUCTION. Relation of Surgery to Internal Medicine. — Necessity of the Practising Physician being acquainted with both. — Historical Remarks. — Nature of the Study of Sur- gery in the German High-school, page 1 CHAPTER I. SIMPLE INCISED WOUNDS OF THE SOFT PARTS. LECTURE II. Mode of Origin and Appearance of the^e 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. — Hemorrhagic Diathesis. — Haemorrhage from the Pharynx and Eectum. — Constitutional Effects of Severe Haemor- rhage, p. 17 LECTURE III. Treatment of Haemorrhage. — 1. Ligature and Mediate Ligature of Arteries. — 2. Com- pression by the Finger ; Choice of the Point for Compression of the Larger Arte- ries.— Tourniquet. — Acupressure. — Bandaging. — Tampon. — 3. Styptics. — General Treatment of Sudden Anaemia. — Transfusion, . .... p. 26 LECTURE IV. Gaping of the Wound. — Union by Plaster. — Suture ; Interrupted Suture ; Twisted Su- ture.— External Changes perceptible in the United Wound. — Healing by First In- tention, .............. p. 41 LECTURE 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 LECTURE VI. Changes in the Tissue during Healing by the First Intention. — Plastic Infiltration. — Inflammatory New Formation. — Retrogression to the Cicatrix. — Anatomical Evi- viii CONTEXTS. dences of Inflammation. — Conditions under which Healing by First Intention does not occur. — Union of Parts that have been completely separated, . . page 58 LECTURE VII. Changes perceptible to the Naked Eye in Wounds with Loss of Substance.— Finer Pro- cesses in Healing with Granulation and Suppuration. — Pus. — Cicatrization. — Obser- vations on "Inflammation." — Demonstration of Preparations illustrative of the Healing of Wounds, p. 67 LECTUEE VHI. General Reaction after Injury. — Surgical Fever. — Theories of the Fever. — Prognosis. — Treatment of Simple Wounds and of Wounded Persons. — Open Treatment of Wounds, p. 85 LECTURE 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. 96 CHAPTER II. SOME PECULIARITIES OF PUNCTURED WOUNDS. LECTURE X. As a Rule, 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. 119 CHAPTER III. CONTUSIONS OF THE SOFT PARTS WITHOUT WOUNDS. LECTURE XI. Causes of Contusions. — Nervous Concussion. — Subcutaneous Rupture of Vessels. — Rup- ture of Arteries. — Suggillations. — Ecchymoses. — Reabsorption. — Termination in Fibrous Tumors, in Cysts, in Suppuration, and Putrefaction. — Treatment, p. 130 CHAPTER IV. CONTUSED AND LACERATED WOUNDS OF THE SOFT PARTS. LECTURE XII. Mode of Occurrence of these Wounds ; their Appearance.— Slight Haemorrhage in Con- tused Wounds. — Early Secondary Hemorrhages. — Gangrene of the Edges of the Wound. — Influences that effect the Slower or more Rapid Detachment of the Dead Tissue. — Indications for Primary Amputation.— Local Complications in Contused Wounds ; Decomposition, Putrefaction, Septic Inflammations. — Contusion of Ar- teries ; Late Secondary Haemorrhages, p. 141 CONTENTS. LECTURE XIII. II Progressive Suppuration starting from Contused Wounds.— Secondary Inflammations of the Wound : their Causes ; Local Infection. — Febrile Reaction in Contused Wounds : Secondary Fever ; Suppurative Fever ; dull ; their Causes. — Treatment of Contused Wounds : Immersion, Ice-bladders, Irrigation ; Criticism of these Methods. — Incisions. — Counter-openings. — Drainage. — Cataplasms. — Open Treat- ment of Wounds. — Prophylaxis against Secondary Inflammations.— Internal Treat- ment of those severely Wounded. — Quinine. — Opium. — Lacerated Wounds : Sub- cutaneous Rupture of Muscles and Tendons ; Tearing out of Muscles and Tendons ; Tearing out of Pieces of a Limb, page 155 CHAPTER V. SIMPLE FR AC TUBES OF BONES. LECTURE XIV. Causes, Different Varieties of Fractures. — Symptoms, Diagnosis. — Course and External Symptoms. — Anatomy of Healing, Formation of Callus. — Source of the Inflamma- tory Osseous New Formation. — Histology, p. 175 LECTURE XV. Treatment of Simple Fractures. — Reduction. — Time for applying the Dressing, its Choice. — Plaster of Paris and Starch Dressings, Splints, Permanent Extension. — Retaining the Limb in Position. ^-Indications for removing the Dressings, p. 191 CHAPTER VI. OPEN FB AC TUBES AND SUPPUBATION OF BONE. Difference between Subcutaneous and Open Fractures in regard to Prognosis. — Vari- eties of Cases. — Indications for Primary Amputation. — Secondary Amputation. — Course of the Cure. — Suppuration of Bone. — Necrosis of the Ends of Frag- ments, .......... i ... p. 200 LECTURE XVI. Development of Osseous Granulations. — Histology. — Detacnment of the Sequestrum. — Histology. — Osseous New Formation around the Detached Sequestrum. — Callus in Suppurating Fractures. — Suppurative Periostitis and Osteomyelitis. — General Con- dition.— Fever. — Treatment ; Fenestrated, Closed, Split Dressings. — Antiphlogistic Remedies. — Immersion. — Rules about Bone-splinters. — After -Treatment, . p. 206 LECTURE XVII. 5 . Retarded 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 ; Rebreaking, Bloody Operations. — Abnormal Development of Cal- lus, ... p. 216 x CONTEXTS. CHAPTER VTI. INJURIES OF THE JOINTS. Contusion. — Distortion. — Opening of the Joint, and Acute Traumatic Articular Inflammation. — Variety of Course, and Eesults. — Treatment. — Anatomical Changes, pa;je 224 LECTUEE XVIII. Simple Dislocations ; Traumatic, Congenital, Pathological Luxations, Subluxations. — Etiology. — Difficulties in Eeduction, Treatment; Eeduction, After-Treatment. — Habitual Luxations. — Old Luxations, Treatment. — Complicated Luxations. — Con- genital Luxations, p. 2o2 CHAPTER VIII. G UN S H 0 T-W O TIN D S. LECTURE XIX. Historical Bemarks. — Injuries from Large Missiles. — Various Forms of Bullet- Wounds. — Transportation and Care of the Wounded in the Field. — Treatment. — Compli- cated Gunshot-Fractures, p. 243 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. 255 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 ; b, Furuncle ; c, Carbuncle (anthrax), Pustula Ma- ligna. 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 Bursse, p. 266 CHAPTER XI. ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, AND JOINTS. LECTUEE XXII. Anatomy. — Acute Periostitis and Osteomyelitis of the Long Bones : Symptoms, Ter- minations in Eesolution, Suppuration, Necrosis, Prognosis, Treatment. — Acute Ostitis in Spongy Bones. — Acute Inflammations of the Joints. — Hydrops Acutus ; Symptoms, Treatment. — Acute Suppurative Inflammations of Joints : Symptoms, Course, Treatment, Anatomy. — Acute Articular Rheumatism. — Arthritis. — Metas- tatic Inflammations of Joints (Gonorrhceal, Pyemic, Puerperal), . . p. 289 CONTENTS. xi CHAPTER XII. GANGRENE. LECTUEE XXIII. Dry, Moist Gangrene. — Immediate Causes. — Process of Detachment. — Varieties of Gan- grene 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 Spon- tanea.— Gangrena Senilis. — Ergotism. — L Noma. — Gangrene in Various Blood- Diseases. — Treatment, page 307 CHAPTER XIII. ACCIDENTAL TRAUMATIC AND INFLAMMATORY DISEASES, AND POISONED WOUNDS. LECTUEE 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. — L Lymphangitis, p. 319 LECTUEE XXV. 5. Phlebitis; Thrombosis; Embolism. — Causes of Venous Thrombosis ; Various Meta- morphoses of the Thrombus. — Embolism. — Eed Infarction, Embolic Metastatic Abscesses. — Treatment, p. 331 LECTUEE XXVI. II. — General Accidental Diseases which may accompany "Wounds and Local Inflamma- tions. 1. Traumatic and Inflammatory Fever ; 2. Septic Fever and Septicemia; 3. Suppurative Fever and Pyssmia, ........ p. 340 LECTUEE XXVII. 4. Tetanus; 5. Delirium Potatorum Traumaticum; 6. Delirium Nervosum and Mania. — Appendix to Chapter XIII. — Poisoned Wounds ; Insect-bites, Snake-bites ; Infec- tion from dissecting Wounds. — Glanders. — Carbuncle. — Hydrophobia, . p. 363 CHAPTER XIY. CHRONIC INFLAMMATION, ESPECIALLY OF TEE SOFT PARTS. LECTUEE XXVIII. Anatomy: 1. Thickening, Hypertrophy; 2. Hypersecretion; 3. Suppuration, Cold Abscesses, Congestive Abscesses, Fistulas, Ulceration. — Eesults of Chronic Inflam- mation.— General Symptomatology. — Course, p. 378 LECTUEE XXIX. General Etiology of Chronic Inflammation. — External Continued Irritation. — Causes in the Body. — Empirical Idea of Diathesis and Dyscrasia. — General Symptomatology and Treatment of Morbid Diatheses and Dyscrasise. 1. The Lymphatic Diathesis (Scrofula) ; 2. Tuberculous Dyscrasia (Tuberculosis) ; 3. The Arthritic Diathesis ; 4. The Scorbutic Dyscrasia ; 5. Syphilitic Dyscrasia, p. 385 rii CONTENTS. LECTUKE XXX. Local Treatment of Chronic Inflammation : Eest, Compression, Eesorbents, Antiphlo- gistics, Derivatives, Fontanels, Setons, Moxse, the Hot Iron, . . . page 399 CHAPTER XV. ULCERS. LECTUKE 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, Contin- ued Irritation, Venous Congestion, Dyscrasial Causes, . . . . p. 404 CHAPTER XVI. CHRONIC INFLAMMATION OF THE PERIOSTEUM, OF THE BONE, AND NECROSIS. LECTURE XXXTI. Chronic Periostitis and Caries Superficialis. — Symptoms. — Osteophytes. — Osteoplastic, Suppurative Forms. — Anatomy of Caries. — Etiology. — Diagnosis. — Combination of Various Forms, p. 418 LECTURE XXXm. Primary Central, Chronic Ostitis, or Caries. — Symptoms. — Ostitis Interna Osteoplas- tica, Suppurativa, Fungosa. — Abscess of Bone. — Combinations. — Ostitis with Cas- eous Metamorphosis. — Tubercles of Bone. — Diagnosis of Caries. — Dislocation of the Bones after their Partial Destruction. — Congestion Abscesses. — Etiology, p. 428 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 tbe Conti- nuity, p. 436 LECTUEE XXXV. Necrosis. — Etiology. — Anatomical Conditions in Total and Partial Necrosis. — Symp- toms and Diagnosis. — Treatment. — Sequestrotomy, p. 44? LECTUEE XXXVI. Eachitis. — Anatomy. — Symptoms. — Etiology. — Treatment. — Osteomalacia. — Hypertro- phy and Atrophy of Bone, p. 463 CHAPTER XVII. CHRONIC INFLAMMATION OF THE JOINTS. LECTUEE XXXVII. General Eemarks on the Distinguishing Characteristics of the Chief Forms. — A. Fun- gous and Suppurative Articular Inflammations (Tumor Albus), Symptoms, Anato- my, Caries Sicca, Suppuration, Atonic Forms. — Etiology. — Course and Prog- nosis, p. 471 CONTENTS. Xiu LECTURE XXXVIII. Treatment of Tumor Albus. — Operations. — Eesection of the Joints. — Criticisms on the Operations on the Different Joints, page 482 LECTUEE XXXIX. Z?.— Chronic Serous Synovitis. — Hydrops Articulorum Chronicus; Anatomy, Symp- toms, Treatment. — Appendix : Chronio Dropsies of the Sheaths of the Tendons, Synovial Hernias of the Joints and Subcutaneous Mucous Bursa, , . p. 492 LECTUEE XL. C. Chronic Eheumatic Inflammation of the Joints. — Arthritis Deformans. — Malum Coxse Senile. — Anatomy, Different Forms, Symptoms, Diagnosis, Prognosis, Treatment. — Appendix : Foreign Bodies in the Joints : 1. Fibrinous Bodies ; 2. Cartilaginous and Bony Bodies ; Symptomatology, Operations, . . p. 502 LECTUEE XLI. Anchyloses, Varieties, Anatomy, Diagnosis, Treatment ; Gradual Forced Extension ; Operations with the Knife, p. 513 CHAPTER XVIII. CONGENITAL DEFORMITIES OF THE JOINTS DUE TO MUSCULAR AND NER- VOUS AFFECTIONS AND CICATRICIAL CONTRACTIONS.— LOXARTUROSES. LECTUEE XLII. I. Deformities of Intra-uterme 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 Fascia and Ligaments. — V. Cicatricial Contractions. — Treatment. — Extension by Apparatus, Straightening under Anaesthesia. — Com- pression.— Tenotomy and Myotomy. — Division of the Fascia and Articular Liga- ments.— Gymnastics and Electricity. — Artificial Muscles. — Supporting Appara- tus, ............... p. 525 CHAPTER XIX. VARICES AND ANEURISMS. LECTUEE XLIII. Varices: Various Forms, Causes, Various Localities where they occur. — Diagnosis. — Vein-stones. — Treatment. — Aneurisms : Inflammation of Arteries. — Aneurysma Cir- soideum. — Atheroma. — Various Forms of Aneurism. — Their Subsequent Changes. — Symptoms, Eesults, Etiology, Diagnosis. — Treatment: Compression, Ligation, Injection of Liquor Ferri, Extirpation, ........ p. 543 CHAPTER XX. TUMORS. LECTUEE XLIV. Definition of the Term Tumor. — General Anatomical Eemarks; Polymorphism of Tissues. — Points of Origin of Tumors. — Limitation of the Development of Cells to Certain Types of Tissue. — Eelation to the Generative Layers. — Mode of Growth. — Anatomical Metamorphosis of Tumors ; their External Appearances, . . p. 562 xiv 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. — Prin- ciples of the Classification of Tumors, . page 571 LECTUEE XLVI. 1. Fibromata : a, Soft ; b, Hard Fihroma. — Mode of Occurrence ; Operations ; Ligature ; Ecrasement ; Galvano-caustic. — 2. Lipomata : Anatomy; Occurrence; Course. 3. Chondromata : Occurrence; Operation.— 4. Osteomata: Forms; Operation, p. 585 LECTUEE XLVII. 5. Myoma. — 6. Neuroma. — 7. Angioma: a, Plexiform; b, Cavernous. — Operations, p. 603 LECTUEE XL VIII. 8. Sarcomata. — Anatomy: a, Granulation Sarcoma; b, Spindle-celled Sarcoma; c, Giant- celled Sarcoma ; d, Stellate Sarcoma ; e, Alveolar Sarcoma ; /, Pigmented Sarcoma. — Clinical Appearance. — Diagnosis. — Course. — Prognosis. — Mode of Infection. — Topography. — Central Osteosarcoma. — Periosteal Sarcoma. — Sarcoma of the Mam- ma, of the Salivary Glands. — 9. LympTiomata. — Anatomy. — Kelations to Leucaemia. — Treatment, p. 611 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. 632 LECTUEE L. 13. Carcinomata. — Historical Bemarks. — General Description of the Anatomical Struct- ure.— Metamorphoses. — Forms. — Topography. — 1. Skin and Mucous Membranes with Pavement Epithelium. — 2. Milk Glands. — 3. Mucous Glands with Cylindrical Epithelium. — 4. Lachrymal Glands, Salivary Glands, and Prostate Glands. — 5. Thyroid Glands and Ovaries. — Treatment. — Brief Bemarks about the Diag- nosis, , p. 646 LIST OF WOODCUTS 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, .... 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, 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, 18. Cicatrix from the upper lip of a dog,. 19. Ends of divided muscular fibres, .'. 20. Eegenerative processes in transversely-striated muscle, 21. Eegeneration of nerves, ..... 22. " ".*... 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-day-old thrombus, .... 28. Completely-organized thrombus, 29. Longitudinal section of the ligated end of an artery, 30. Portion of a transverse seetion 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, 35. Aneurisma traumaticum, ..... 36. Varix aneurismaticus, ..... 37. Aneurisma varicosum, ..... 38. Granular and crystalline hasmatoidin, 39. Detachment of dead connective tissue in contused wounds, 40. Central end of a torn brachial artery,. PAGE 49 50 59 70 72 74 75 79 80 80 81 81 S2 83 83 84 84 103 104 105 106 106 10S 109 110 111 111 112 113 114 116 116 117 124 125 126 127 136 147 173 XVI LIST OF WOODCUTS. FIG. 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 tht 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, 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 septicsemia, . . •. 72. Cutaneous ulcer of the leg, 73. Granulations of a common ulcer, .. 74. Caries superficialis of the tibia, 75. Section of a piece of carious bone, . ? 76. Sclerosed tibia and femur, . .. 77. Point of caseous degeneration in the spinal column 78. Destruction of the vertebral column,. 79. Total necrosis of the diaphysis of a hollow bone, 80. Total necrosis of the diaphysis of a hollow bone with detached sequestrum, 81. Total necrosis of the diaphysis of a hollow bone after removal of sequestrum 82. Total necrosis of the diaphysis of the femur, .... 83. Total necrosis of the diaphysis of the tibia, 84. Necrosis of the lower half of diaphysis of femur, 85. The body extracted from Fig. 84, ... 86. Diagram of partial necrosis of a hollow bone, 87. Diagram of Fig. 78 in the later stages, 88. Fig. 87, after removal of the sequestrum, 89. Scapula of a dog, resected with and without periosteum, 90. Eachitic malformations of the leg, 91. Disappearance of chalky salts in osteomalacia, 92. Woman with extensive osteomalacia, 93. Section of knee-joint with fungous inflammation, LIST OF WOODCUTS. FIG. 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, 113. Varices, 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 angiom 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, 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, 141. Section of Fig. 140, 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 145, ..... 147. From an adeno-sarcoma of the female breast, 2 PAGE 476 . 477 480 . 496 499 . 503 505 . 505 505 . 511 514 . 515 515 . 516 516 . 532 533 . 533 537 544 549 585 586 587 588 588 594 596 598 598. 599 600. 600 601. 605 606 612 612 „ 613 614. 614 C15. 615 615 , 617 617. 621 621. 622 622 , 628 624 624 626 LIST OF WOODCUTS. FIG. 148. Prom the cortical layer of a hyperplastic lymphatic 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,. gland, PAGE 629 633 636 638 652 652 653 654 655 659 - 662 662 663 664 664 665 666 667 671 672 674 675 SURGICAL PATHOLOGY AM) 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 Sur- gery 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 inter- nal 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 de- pends on the correct and instantaneous recognition of a surgical disease. 2 INTRODUCTION 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 inex- cusable 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 con- sisted only in operations. I hope to give you a better idea of this branch of medicine than is conveyed by the above remark, which un- fortunately is too popular. From the fact that surgery has to deal chiefly with patent dis- eases, it certainly has an easier position in regard to anatomical diag- nosis ; 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 de- scription 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 diag- nose diseases of organs of which we do not know even the physiolo- gical function, as of the supra-renal capsules ! This is some compensa- tion 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. The irritation of the finer, cultivated portions of the mind in inter- nal medicine is, however, richly balanced by the greater certainty and clearness of diagnosis and treatment in surgery, so that the two branches of medical science are exactly on a par. And it must not INTRODUCTION. 3 be forgotten that the anatomical diagnosis — I mean the recognition of the pathological changes in the diseased organ — is only one means to the end, which is the cure of the disease. TJie true problems for the physician are to find out the causes of the morbid process, to prog- nosticate the course, conduct it to a favorable termination, or control it, and these are equally difficidt in internal and external medicine. Only one thing more is required of the practical surgeon : this is, the art of operating. This, like every art, has its knack ; the facility of operating secondarily depends on accurate knowledge of anatomy, on practice, and on personal aptitude. This aptitude may also be culti- vated by persevering practice. Just remember how Demosthenes suc- ceeded in acquiring fluency in speaking. This knack, which is certainly necessary, has long separated sur- gery from medicine in the strict sense ; we may historically follow this separation as it constantly became more practically felt, till in this century it was finally recognized as impractical and was abol- ished. The word " chirurgery " at once expresses that originally it was regarded as entirely manual, for it comes from %etp and tpyov, which literally mean " hand-work," or, in the pleonasm of the middle ages, " hand-work of chirurgery." Little as it comes within the scope of this work to give a complete sketch of the history of surgery, it still seems to me important and in- teresting to give you a short sketch of the external and internal de- velopment of our science, which will explain to you some of the va- rious regulations affecting the so-called "medical staff" still existing in different states. A fuller history of surgery can only be of use to you hereafter, when you shall have acquired some knowledge of the value or worthlessness of certain systems, methods, and operations. Then, in the historical development of the science, especially as regards op- erative surgery, you will find the key for some surprising and for some isolated experience, also for much that is incomplete. Many things that may be necessary for the comprehension of the siibjects, I shall relate to you when speaking of the different diseases ; now, I shall only present a few prominent points in the development of sur- gery and of its present position. Among the people in former times, the art of healing was inti- mately associated with religious education. The Hindoos, Arabs, and Egyptians, as well as the Greeks, considered the art of healing as a manifestation made by the gods to the priests, and then spread by tradi- tion. Philologists were not agreed as to the age of the Sansciit writ- ings discovered not long since ; formerly their origin was placed at 1000-1400 B. c, now it is considered certain that they were written in the first century of the Christian era. The Agur-Veda (" Book of i INTRODUCTION. the Art of Life ") is the most important Sanscrit work for medicine ; it is the production of Susrutas. It very probably originated in the time of the Roman Emperor Augustus. The art of healing was regarded as a whole, as is indicated by the following : " It is only the combina- tion of medicine and surgery that makes the complete physician. The physician lacking knowledge of one of these branches is like a bird with only one wing." At that time surgery was without doubt by far the more advanced part of the medical art. A large number of op- erations and instruments are spoken of; still, it is truly said " the best of all instruments is the hand ; " the treatment of wounds given is simple and proper. Most surgical injuries were already known. Among the Greeks all medical knowledge at first centred in iEs- culapius, a son of Apollo, and a scholar of the Centaur Chiron. Many temples were built to JEsculapius, and the art of healing was handed down by tradition through the priests of these temples ; the number of these temples induced various schools of JEsculapides, and, although every one entering the temple as a priest had to take an oath, which has been handed down to our own times (although of late its genuineness appears rather doubtful), that he would only teach the art of healing to his successors, still, as appears from various cir- cumstances, even at that time there were other physicians besides the priests. From one part of the oath, even, it is evident that then as now there were physicians who, as specialists, confined themselves to cer- tain operations ; for it says : " Furthermore, I will never cut for stone, but will leave this operation to men of that occupation." Of the different varieties of physicians we know nothing more accurate till the time of Hippocrates / he was one of the last of the Asklepiades. He was born 460 b. c, on the island of Cos ; lived partly in Athens, partly in Thessalian towns, and died 377 b. c. at Larissa. We might expect that medicine would be considered scientifically at this time, when the names of Pythagoras, Plato, and Aristotle, were shining in Grecian science ; and in fact the works of Hippocrates, many of which are still preserved, arouse our astonishment. The clear classical de- scription, the arrangement of the whole material, the high regard for the healing art, the sharp critical observations, that appear in the works of Hippocrates, and compel our admiration and respect for an- cient Greece on this branch also, clearly show that it is not a case of blind belief in traditional medical dogmas, but that there was already a scientific and elaborately perfected medicine. In the Hippocratic schools the art of healing formed one whole ; medicine and surgery were united, but there were various classes of medical practitioners ; besides the Asklepiades there were other educated physicians, as well as more mechanically instructed medical assistants, gymnasts, quacks, INTRODUCTION. 5 and workers of miracles. Tlie physicians took scholars to train in the art of healing ; and, according to some remarks of Xenophon, there were also special army physicians ; especially in the Persian wars, they, together with the soothsayers and flute-players, had their places near the royal tent. It may be readily understood that, at a time when so much was thought of corporeal beauty, as was the case among the Greeks, external injuries would claim special attention. Hence, among physicians of the Hippocratic era, fractures and sprains were particularly studied ; still, some severe operations are treated of, as also numbers of instruments and other apparatuses. They seem to have been very backward regarding amputations ; probably the Greeks preferred dying to prolonging life after they were mutilated. The limb was only removed when it was actually dead, gangrenous. The teachings of Hippocrates could not at first be carried any fur- ther, for lack of knowledge of anatomy and physiology. It is true there was a faint effort made in this direction in the scientific schools of Alexandria, which flourished for some centuries under the Ptole- mies, and by means of which, after the wars of Alexander the Great, the Grecian spirit was spread, at least temporarily, over part of the Orient ; but the Alexandrian physicians soon lost themselves in phil- osophical systems, and only advanced the science of healing a little by a few anatomical discoveries. In this school the art of healing was at first divided into three separate parts — dietetics, internal medi- cine, and surgery. Along with Grecian culture, their knowledge of medicine was also brought to Rome. The first Roman physicians were Grecian slaves ; the freedmen among them were allowed to erect baths ; here, first, barbers and bathers became our rivals and col- leagues, and for a long time they injured the respectability of the pro- fession in Rome. Gradually the philosophically-minded took posses- sion of the writings of Hippocrates and the Alexandrians, and them- selves practised medicine, without, however, adding to it much that was new. The great lack of original scientific production is shown in the ency eloped ial revision of the most varied scientific works. The most celebrated work of this nature is the " De Artibus " of Aulus Corne- lius Celsus (from 25-30 b. c. to 45-50 a. d., in the time of the Em- perors Tiberius and Claudius). Eight books of this, " De Medicina" have come down to our time ; from these we know the state of medi- cine and surgery at that time. Valuable as are these relics from the Roman ages, they are only, as we have said, a compendium, such as is often published at the present day. It has even been denied that Celsus was a practising physician, but this is improbable ; from his writings we must, at all events, credit Celsus with using his own judg- ment. The seventh and eighth books, which treat on surgery, could not 6 INTRODUCTION. have been written so clearly by any one who had no practical knowl- edge of his subject. Hence we see that, since the time of Hippo- crates and the Alexandria school, surgery, especially the operative part, had made no great progress. Celsus speaks of plastic opera- tions of hernia, and gives a method of amputation which is still occa- sionally employed. One part, from the seventh book, where he speaks of the qualifications of the perfect surgeon, is quite celebrated, as it is characteristic of the spirit which reigns in the book ; I give it to you : " The surgeon should be young, or at least little advanced in age, with a hand nimble, firm, and never trembling ; equally dexter- ous with both hands; vision, sharp and distinct; bold, unmerciful, so that, as he wishes to cure his patient, he may not be moved by his cries to hasten too much, or to cut less than is necessary. In the same way let him do every thing as if he were not affected by the cries of the patient." Claudius Galenus (131-201 a. d.) must be regarded as a phe- nomenon among the Roman physicians; eighty-three undoubtedly genuine medical writings of his have come down to us. Galen re- turned again to the Hippocratic belief, that observation must form the foundation of the art of healing, and he advanced anatomy great- ly; he made dissections chiefly of asses, rarely of human beings. Galenas anatomy, as well as the entire philosophical system into which he brought medicine, and which seemed to him even more im- portant than observation itself, has stood firm over a thousand years. He occupies a very prominent position in the history of medicine. He did little for surgery in particular ; indeed, he practised it little, for in his time there were special surgeons, either gymnasts, bathers, or barbers, and so unfortunately surgery was handed down by tradition as a mechanical art, while internal medicine was, and long remained, in the hands of philosophic physicians ; the latter knew and com- mented freely on the surgical writings of Hippocrates, the Alexandra- ans, and Celsus, still they paid little attention to surgical practice. 