Introduction.
A young operator should revolve
every part of an operation in his own
mind before he commences it- and
endeavor to prepare himself for any
accidental Circumstance that can
possibly happen to disconcert during it:
he must at the same time determine
never to do anything in haste- as
those are the worst operators who do generally
doing more than necessary-
but on the other hand go coolly and deliberately 
to work- when the pain to
the patient will upon the whole be less.



Thus an operation for the Stone
may be over and concluded by one
person in a minute- and another
may require ten to perform it in & 
do it better than the former-
Altho' an operation may be very dangerous
in itself- yet we must consider
it in this Light- whether by
leaving the patient to nature it would
not be attended with more- and under
such circumstances it behoves the
Surgeon to have a consultation immediately-
which takes off part of the responsibility-
as if unsuccessful no 
blame can attach to him- but if successful
he acquires equally as much credit-
another advantage in consultations



sultations is the possibility of new
light being occasionally thrown upon the
disease - which might never have struck
either of them separately. Where the
operation is unattended with danger such
precautions are unnecessary - tho at the
same time there is such a difference in
the Constitutions and Strength of patients
that what would be perfectly safe in one
case would be highly dangerous in another-
and this may be judge of in some
measure by the State of the patient's mind 
where he submits to it without reluctance
it generally succeeds - but if there is a
timidity and particularly a prepossession 
of the mind that he shall die under
the operation never perform it tho'



of even so trivial a nature in  An
Instance of this kind occured to W.C.
in his own practice where very young
whilst extirpating a cancerous Breast.
Never press an operation upon a patient
after he has once expressd. an aversion
to it - nor ever be too anxious
to operate - as a many diseases if
sufficient time were given - might
be recovered of without - and as operations 
are sometimes considered a disgrace
to the profession - it ought to be
the study of every Surgeon to leave nothing
unemployed which holds out the least probability
of relief without - and also to
give as little pain during its continuance
as he possibly can - whereby he
lessens the Stigma - in some degree -



Here then it becomes necessary to 
describe the operations - beginning
with those which are used for bringing
parts together either by Suture or otherwise -
after first considering the nature
of union when it is first effected
which it would sometimes be improper
to do - In a division of
any organized part if vascular there
will be a considerable effusion of blood
which from its coagulable principle
may itself became the band of union
tho' it sometimes require three or four
days to effect it completely. This is 
called Union by the first Intention
But as the blood now ceases to flow if
the parts are have not been previously brot.



together this bond would be lost -
Inflammation then takes place and
the exhalent vessels throw out pure coagulable
Lymph - which if the edges 
are brought together in twenty four hrs
or sometimes in two or three days will
effectually prove the bond of union.
But if this time be lost a suppurative
process takes place with a discharge
of pus never proving the bond of union
which can now be effected only by the
slow but ultimately certain process of
granulation - but it is at all times
desirable if possible to prevent Suppuration
and lessen deformity.
Thus there are three Modes of Union.
Gunshot and all contused Wounds



it would be improper to unite by the
first Intention - also Wounds made
in the neighbourhood of above by a
blunt Instrument - which having the
organization destroyed must be sloughed.
These if brot. together would form Abscess
underneath and thus protract 
the cure - which shows the impropriety
of attempting to close them - particularly 
if they loose any extraneous body
which cannot be extracted - we must
then wait till the inflammatory stage
is over and then attempt it - but if
it can't be removed now - allow the
suppurative process to go on - which 
will sometimes effect the purpose
and discharge it.



Where any poisonous matter is inserted
as in the bite of a mad dog
it would be highly improper to attempt
union by bringing the Edges of the wound
in contact - causing certain death
from the lodgment of its virus in the
System. The wound would heal readily
and unite as if made by any other
cause and without more pain than
usual: But in a few weeks
a pricking Sensation is felt in the
part - accompanied with increased
redness and heat - violent pain of
the whole limb running along the
course of the absorbents - restlessness
and no sleep - extreme irritability
from noise or light - touching the 



Surface of the Body producing the
greatest Horror:- when in this
State nothing can be of service the
Patient generally expires in forty 
eight Hours. All that could
have been done was in the first Instance
to have cut out completely the
surrounding part - as you cannot by
any means wash out the morbid matter
there deposited. It may however
be destroyed by inserting the Kali purm:
as deep as the Teeth have penetrated
and destroying the surrounding parts
in five minutes after the wound is 
inflicted and this mode is perhaps
preferable to Excision as the patient
is in general less afraid of it - I
will perhaps be full as certain for



you cannot see how far the matter
has penetrated into the spongy Substance
of the cellular membrane but
the caustic from becoming quickly
fluid will most likely run into
the same interstices as the virus itself.
The disease has sometimes
supervened to the use of the knife.
In all cases where circumstances
lead to a suspicion that article
has been inflicted the part should
be removed by excision tho' some
months afterwards. But where
the wound is in such apart as cannot
be cut out with propriety as the
Cheek or Eyelid - you must hurt 
to caustic Solutions and case 
in the eyelid Mr Cline saw



in Guy's hospital. Under any
circumstance never omit one or other
of these plans of prevention for
that disease which it is evident has no
cure. Mr Cline has seen the caustic
attended with the most happy Effect
in the case of boy who was bitten with
a dog - which then went mad and bit
his muster - both the boy and man
had the Lunar Caustic applied and
escaped. In the case of a Son of
Admiral Rowley who was bitten in
the Cheek which occurred to Mr Hunter
the disease occurred after the Application
of Caustic. The poison
will lay dormant in the System a
long time without producing any 
Change. Mr. C. Has known it 12 mos.



Sutures.
Divided parts may frequently be
united by only placing and retaining
them in a favorable position in
if possible ought always to be done wh.
subjecting the patient to the pain
of passing a ligature and its consequent
Irritation - indeed few wounds require
them - as by adhesive plaster
and proper bandage union is more speedily
effected without. But in
divisions of the hip or Eyelid where
the muscles have a constant tendency
to draw the parts as under a ligature
becomes necessary to prevent it.
In passing one in the eyelid the needle
should only act upon the Skin carefully



carefully avoiding both the Tarsus and
Tunica conjunctiva. In wounds
of the sides of the Tongue a Ligature must
be passed - in those of the Apex - without 
it the Tongue would become forked
and the Speech in Consequence affected.
Sutures must never be passed into
tendinous and Ligamentous parts
which have weak living powers or
into circumscribed cavities as the
Thorax Abdomen or Joints but only
into the outer Integuments - otherwise
the Irritation might cause inflammation
at the internal membrane and
put the patient's left in the most imminent
hazard. 
The Interrupted is the most
common sort of Suture and is made 



with a curved needle of a triangular
form - the angle on the concave Side
its size proportioned to the depth of the
Wound. The Ligature should be
made of several threads waxed into a
flat form and about the Like of the
needle. It should be passed
in at a distance from the Edge on 
one Side equal to half the depth
of the wound - quite to the bottom
and out again on the opposite Side
each Ligature should be about an inch 
distant from the other - thus the
number will be in proportion to the 
Length or so as merely to keep the
edges of the wound in contact.
After they are all passed let an Assistant



bring the edges together and
tie the first knot on the Side of the
side of the wound - the second must
be a slip Knot & not very tight that
if the parts should swell they may be
easily loosed.  When thus brot.
into contact it needs only the further
Security of adhesive plaster and proper 
bandage - and in forty eight hours
a sufficient degree of union will have
taken place to enable you in general
with Safety to remove the Ligatures
by cutting on the opposite Side to the
knot with a knife and then placing
your finger upon the eyes to prevent
their being separated whilst drawing 
away the thread - after this the plasters
only need be continued..



The best rule for ascertaining the 
proper time to withdraw the Ligatures
is to observe when they begin
to cause ulceration but not sooner
tho they may be repeatedly slackened
if the Tumefaction should require it.
The Quill'd is better than any
other Suture for Wounds penetrating 
the Cavity of the abdomen in which
immediate union is required or
inflammation of the peritoneum would
destroy life. This leads to the
consideration of the Cesarean operation
tho' seldom during the life of
the patient nor often successfully
after death owing to the great delay



in Consultations - the elapse of
an Hour is too much as the child
would not be extracted alive - were
the Incision made after that time.
But so great is the deformity of the
pelvis in some Instances that no
Child could possibly be brought away
by the Vagina if taken to pieces.
Mr. Cline has seen two pregnant Cases
one of which measured only seven
eighths of an Inch and the other one
and a half inch from Sacrum to pubis.
The incision for this operation shod. 
be begun at the umbilicus and continued
towards the pubis so low as to 
admit of the Introduction of the hand
and extraction of the Fœtus œ laying
hold of the feet - next the [crossed out] placenta
should be separated from the



uterus and withdrawn - which will
allow it to contract and thus prevent
Hamorrhage. The external opening
in the integuments must then be
closed by this Suture in the following
manner carefully avoiding the peritoneum.
A needle and double 
Ligature the ends of which are tied together
must be passed thro' the Skin and
cellular membrane - at the distance
of half an inch from the edge of the Wd.
and brot. out in the same manner on the
opposite Side - and cut off. Thus
passing each in the same Way at rather
less than an inch from the other.
A piece of bougie must then be passed
thro' the loops of the Suture and another
between the ends after seperating
them - over which the Ligatures must



be tied in slip knots - for the convenience
of slackening them occasionally.
In this way the Edges of
the wound are kept more completely in
contact than would possibly be done by
the interrupted Suture and it should
always be practised in wounds penetrating
large Cavities - where the needle
can only be allowed to pass thro' the Skin
and cellular membrane - but where it
is to penetrate deeper the bougie would
be improper as it makes the Edges turn out.
The Glover's or uninterrupted future
is next to be described. It is
made with a straight triangular
needle and a single ligature beginning
at one end of the opening and
extending to the other.



This suture is now only used in
sewing up dead bodies - as it gives
great additional pain from the necessity
of frequently passing the needle
from the inner to the outer edge.
Besides from the ligature lying between
the lips of the wound union is
retarded instead of promoted.
Gastroraphy or that Suture
which is employed for uniting longitudinal
wounds of the Intestines; a
circumstance rarely happening of sufficient
magnitude to be discovered;
is performed by having an Assistant
to take hold of and keep the divided edges
of the Gut exactly together - and then
passing a straight needle and double ligature
thro from one Side to the other
near the edges - the threads are thus



made to pass over or across the
wound each time at about half 
an inch distance - when cut off
no knott should be made but the Intestine
returned just within the Cavity
of the Abdomen - the ends of the ligature
hanging out at the external opening
which should then be closed and union
promoted by the first intention.
This ligature may be with drawn in
a few days from the intestine - by
laying hold of one end of one of the
threads and the other end of the other
and then gently drawing down they
may be brought out of the Abdomen
without any danger of tearing the 
Intestine or doing any other Injury.



Hare-Lip.
This is a deformity existing at birth
and occasioned by a fissures in the
upper lip extending to the nose
sometimes an each Side - and not
unfrequently accompanied by a fissure
of the os maxillare and its palate 
process - or of the ossa palati - in wch.
last case the Velum pendulum palati
is fissured and there is an opening into
the nose - this is even sometimes the
case without any external deformity.
The only remedy consists in an
operation for bringing the edges of the
lip together and into their natural
position. If the bones are well



formed in a division of the ossa
palati - an artificial palate of 
Silver may be used - with Success.
This operation never succeeds so well
when performed on a very young Subject
as if delayed till two or three
years of age - for various reasons.
In irritable Constitutions from the
child's desire to get rid of the cause of
pain - convulsions and even death have
ensued - The small size of the
lip and the necessity that will follow
of bringing the child up without the
heart - which few unless very strong
can bear - are no small disadvantages.
The proper time seems to be
as soon as the child is weaned - or at
the edge of between two and three years
as the parts will be larger. But
if you wish to remove the deformity



entirely it should not be delayed longer.
In operating for this disease the
fissured edges should first be separated
from the Gums - then a Cornea Knife
must be introduced at a proper distance
from the edge to remove all the thin parts
towards the nose on each side - when 
a little pressure between the finger and 
thumb will be necessary to prevent Hamorrhage
from the labial Artery
two pins in the adult and one in the 
infant must now be passed the first just above
the red edge of the lip - the second midway
between it and the upper part of
the wound - after the points are
screwed off - a ligature must be passd.
round each in the form of a figure of 8
to keep them firm and the edges perfectly
secure - where union will soon be complete.



Sometimes after a tolerably firm
union has been effected and the 
pins withdrawn - the Action of the
muscles has been so strong in a fit
of crying as to break thro' and separate
it. In this operation M. C.
would always prefer the interrupted
suture which may be passed completely
thro' the lip without any part
lying between the divided edges.
Pins are inconvenient on many accounts
besides their hardness is apt
to cause most violent irritation - they
may however generally be removed in
five or six days - taking care to support
the parts well. No dressing
or covering should be employed as the
Saliva and mucus are apt to lodge



underneath. Where there is
a double fissure never perform the operation
on one side till the other is
perfectly healed. And if the bone
project so as to occassion deformity it
should be removed or made smooth before
you commence.
Bronchotomy.
This is an operation for making
an opening into the trachea; and may
be necessary to prevent the consequences,
arising from either external or internal
obstructions. Internal obstructions,
may be caused by anything
slipping into the larynx - causing 



violent irritation, and sometimes
coughing, by which salutary effort,
if the extraneous body be small, the part
is relieved by its expulsion. If very
large, inflammation of the mucus
membrane, or immediate suffocation,
must be the consequence; from its
filling the air tube. Sometimes
an extraneous body may be extended
across the Sacculus Laryngis so as to
cover at others if small it may become
imbedded in the lymph thrown
out in consequence of inflammation 
in either case death will follow from
the violent irritation kept up throught.
the whole of the membrane. The
probability is that when death has followed
immediately to the accident - the



lungs at the time were completely empty
and that on endeavoring to inspire
the Substance has been drawn forward
so as to completely fill the Tube and prevent
the reception of air. Severe
inflammation will sometimes cause
a gradual thickening of the membrane
so as completely to obliterate this canal.
Croup is an illustration of this where
also an effusion of coagulable lymph
will occupy all the upper part of the
trachea. In a diseased state
of the Cartilage ulceration has proceeded
so far as to make an opening 
into the Sacculus Laryngis - the Consequence
of which is a thickening of
the membrane both above and below



the Glottis. This disease occurs
in Venerea, - producing cough,
loss of appetite and flesh, night sweats,
&c. & symptoms not unfrequently
mistaken for those of Phthisis - and
treated as such - but are only to be
removed by the exhibition of Mercury.
Well distinguished from Phthisis 
by a peculiar hoarse hollow
sound of Voice - accompanied by
a kind of wheezing noise.
Obstructions may sometimes be
formed by tumors are the outside pressing
on the membranous part of the
trachea - and at last increasing so
as to cause suffocation.
In each of these cases it may become
necessary to make an Aperture in 



the trachea just below the obstructed 
parts - and keep it open some
length of time - in order to save
the patient's life. In croup or
Abscess between the oesophagus and
trachea - we at least gain nature
a sufficient time to make an effort
for getting rid of the morbid cause.
When from any of these causes the 
patient seems in danger of being
suffocated - we must give him the
only chance by immediately proceeding
to the operation - which is performed
in the following manner.
With a scalpel lay bare the trachea
by a longitudinal incision thro' the
common integuments - when a
transverse one must be made thro'



it between two of the Cartilages the 
best place is between the thyroid &
cricoid - cutting off a piece from
the lower edge of the former to preserve
the opening clear - when if sufficiently
large the patient will immediately
inspire thro' it. In
making the first incision a number 
of small vessels will of course be
divided and the blood must be prevented
escaping internally by keeping
the patient in a sitting posture
and a little inclined forward.
Great care must be taken to avoid
wounding the Thyroid gland - as
violent Hamorrhage from it might
be dangerous. If any small
divided Vessel should bleed freely lay



hold of its mouth by a pair of forceps
and pass a ligature round it - but never 
use a needle unless you are perfectly 
satisfied where it will go.
Where the opening is to be made lower
lay your finger upon the cricoid
cartilage and then proceed as above.
In fat subjects it will sometimes be
necessary to introduce a Silver Tube
but this if possible should always be
dispensed with - as most violent
irritation will be the consequence
of any extraneous body touching the
perichondrium - instead whereof
cutting a piece from the lower edge
of the cartilage and keeping it well
sponged will in general answer 
the purpose.



Wryneck.
This disease consists in a rigid
state of the Sterno Cleido Mastoideus
muscles - whose fibres will
not elongate - but the parts to which
it adheres becoming also contracted
the Mastoid process is drawn towards
the Sternum - and as the muscle
is at all times rigid like a tendinous
cord - there is a total incapability
of raising the head or turning
it to one side. When it has
existed long and originated whilst
the patient was young and growing
the bones will have attained that 



form - consequently the operation
as insufficient to afford relief should
not be attempted. The patient
should be placed either in a sitting
or lying posture - and a longitudinal 
incision made thro' the
common integuments and platysma
Myoides - directly over and in
the direction of the fibres of the Sterno
Cleido Mastoideus muscle - so as to lay
it bare - when a probe should be
passed underneath - carefully to separate
it from the surrounding
parts - afterwards a director - upon
which you may make a transverse
incision of its substance with safety
either with a Scalpel - or the 



Syringotomy - a probe pointed
razor - constructed entirely for this
purpose. - The proper place at wh.
to make the division is as near the
Sternum as possible - or within a
half or three quarters of an inch from
the Clavicle - the greatest distance
from any considerable Blood Vessels.
As soon as it is properly divided the 
ends will retract - and the head should
be confined on the opposite Side -
In contractions of the Arm depending
upon the Biceps flexor cubiti -
this operation may be performed
with Success. - Never perform
the operation unless simply
dependant upon a constructed state
of one of these muscles. -



Fistula Lacrymatis.
This disease is so named from a
fistulous opening being made in
the integuments covering the Lacrymal 
Sac - thro' which the tears escape
and run down the Cheek instead
of the ductus ad nasem - The
first indication of this disease is a
watery eye caused by obstruction of
the nasal passage - next a fullness of
the Sac is felt and an uneasy itching
Sensation in the corner of the eye - to
ease which you press upon the Sac & 
force the tears to flow - which are turbid
and mixed with mucus or



sometimes a little pus - inflammation
with redness increases which causes
ulceration - and the tears mucus and pus
being discharged thro' the opening the
patient feels himself in some measure
relieved - But this causes great deformity
- which will still continue as
the inflammation has produced such
a thickening of the membranous coats
of the duct - as completely to obliterate
its canal. Scrophulous Habits
as being more subject to chronic inflammation
of membranous parts are very
liable to this disease - It sometimes
follows Smallpox or Venerea - and
may be occasioned by a polypus pressing
upon the termination of the duct.
We must of course keep the cause in 



view as our guide in the cure of this
disease. - When only from casual
inflammation our endeavor must be
directed solely to its removal - the
camphorated mercurial ointment
has reduced the thickened membrane
before ulceration had taken place
But if this do not succeed an opening
must be made into the Sac in
the following manner - allowing it
previously to distend itself several
hours - when stretching the Eyelid
a little upwards with the finger make 
a small incision into it with the point
of a lancet in the direction of the fibres
of the orbicularis palpebrarum muscle
- then endeavor to pass a probe
piece of catgut or small bougie thro' 



the duct into the nose - but not to
force it - when there it may be
known by blood issuing from the
nostril - Mr. Ware's Stilette
with a button end is then the most 
convenient thing to be worn till the
opening is perfectly free and well established
- as it may from Time to time
be withdrawn cleaned and returned. -
Sometimes the degree of Inflammation
has been so violent as to cause
union to take place between the Sides
of the Sac when the obstruction has
been so great as to render the introduction
of any thing altogether impracticable. 
- Here a perforation
of the os unguis becomes necessary
- which must be made just 



behind the lacrymal Sac. - with
an instrument like a Trochar the
canula of which may be left in - but
is not so proper to establish an internal
fistulous opening as a piece
of Bougie - which with frequent
changing must be worn several Wks
the outer end should be bent a little
to prevent its slipping into the duct.
The instrument should be inclined
a little inwards and downwards
between the two ossa Turbinati
carefully avoiding injuring them -
When the opening is sufficiently
established - withdraw the bougie
and apply a piece of adhesive plaster
to heal the external wound
Never introduce a Tube - here -



Mennel proposed to cure this
disease by injecting the Puncta
Lacrymalia: - others following
his example have attempted by means
of a glass tube to fill the Sac with
Quicksilver - as thus mechanically
force a passage thro' the Ductus
ad nasem - but if it do not pass
readily it is attended with inconveniences
- either exciting violent
inflammation & ulceration or becoming
extravasated into the cellular
membrane of the cheek and
causing the same disposition there. 



Nasal Polypi.
Polypi of the nose are fungus like
excrescences arising from its mucus
membrane - unattended with pain -
increasing gradually - hanging by
a peduncle - high low posteriorly or
anteriorly. Those anteriorly very
soon appear externally - those posteriorly
hang down till they are seen
behind the Velum pendulum palati
increasing till air cannot be drawn
in thro' the nose - rendering the fauces
dry and unpleasant and forming
an obstacle to perfect articulation



When situated high up they press
upon the turbinated bones - give great
pain - and an increasing expand the
ossa nasi - Their structure is
tender - semi pellucid - rather gelatinous 
- and but little vascular - having
very few vessels ramifying upon their
surface. - They have generally a many
small processes projecting from the
main substance. - Sometimes
they adhere with very great firmness to 
the periosteum - and when an extraction
you bring away a small lamina
of bone consider it a favorable circumstance 
and rest assured the disease is completely
eradicated - but more frequently a 
piece of the Polypi will be left - which
in twelve months will be as large as ever.



In warm damp weather Polypi
increase in size rapidly - but decrease
as much from their usual state
in dry or frosty weather - Consequent
by the operation is best performed in
damp weather as there is more to lay
hold of - In proportion to the 
number of Polypi in the same Subject
is the probability of removing the
complaint entirely - The operation
is performed by first placing the
patient before a good light and then examining
with a probe to find its place
of attachment - where this is the
probe will stop - being provided
with a pair of straight forceps lay hold
of the projecting part - and upon these
slide a pair of crooked ones - so as to 



lay hold as near as possible to the
root - which being effected you must
gradually draw down till it comes away.
When carefully performed it
is seldom attended with much Hamorrhage
- which is always stopped by an
Injection of Alum or Sulphate of Zinc-
which in some degree prevent the return of 
the Polypus. - There is a dark colored
species very vascular - firmly attached 
to the part - attended with pain -
and forming a cancerous thickened State
of the membrane - which never on any
account attempt to extract - as it only
tends to increase the disease and the Hamorrhage
might be very considerable.



Extirpation of the Breast:
During the Secretion of milk women
are very subject to disorders of the
Breasts - inflammation swelling
and abscess - in healthy constitutions
entirely unattended with danger and
leaving only a little deformity.
But women who are not breeding are
more liable to diseases of the Breasts than
those who are - generally coming on
with little or no pain or apparent cause
usually about the cessation of the menses
or between forty and fifty Years of 
age - tho' sometimes soon after puberty
or [crossed out] even in old Age. 



Yet during the above mentioned period
they seem to be more susceptible of disease
- Sometimes the Affection
has originated in an Accident and
may be traced as supervening to a blow
received some weeks or perhaps months
before - In this case early attention
should have been paid to the Hurt
Leeches applied and repeated according
to circumstances - equal parts of
Spirits of Wine and Acetated Waters
of Ammonia kept constantly on the
part - purgatives given - and a
regular diet prescribed. -
But when entirely without any known
cause the disease continues to extend
itself in every direction - adhering 
to the fascia over the pectoral muscle
the Veins become enlarged and tortuous



and have their valves also enlarged -
the Integuments discolored - ulceration
at last takes place - attended with
great pain which increases as the former
extends - large quantities of blood
are frequently lost from some Vessel -
there will be a quick pulse - dry Tongue
- loss of appetite - and general
emaciation - The neighbouring
glands now become enlarged if not before
ulceration appeared externally -
When cut into the diseased part - will
be found more solid and of a firmer
consistence and yellower than natural
with cavities - containing a transparent 
fluid formed in the center. -
In general however their origin is in
sensible - progress slow - Extension 



very various - in some Subjects as far
in six weeks - as in others in six Years -
whatever quickens the circulation hastens
the progress of the disease. - When
therefore an indurated Tumor is perceived
soon after a blow - with increased 
action heat and pain - apply leeches &
repeat them but not to reduce the patient's
health - keep it constantly wet with
the following Lotion - Rx Aqua Lytharg:
Acet ℥ss Spirit. Camphor: ℥iiiss
Spirit: Rectipical: ℥iv III & purge occasionally.
- When there is great
debility and loss of Appetite - give the
Ferrum Ammoniacale in the form of
Pills for three six or twelve months -
which has been of Service - If the
tumor be any indolent - apply the
Ceratum acl Emp:m Saponis vel Emp.



Hydrargyrus - to promote Absorption
which when taken early may frequently
be done. - But when in spite
of all your endeavors it still continues
to increase - and you find upon careful 
examination the whole diseased pt.
may be included - an operation is advisable
- if the Tumor do not adhere
to the pectoral muscle - which may be
known by trying to move it when that
muscle is put upon the Stretch - or
when the disease has not affected the Axillary
Glands - those above the Clavicle 
or between the nipple and sternum -
which are each the cause of a chain of 
absorbents. - When there is occasion
to remove the axillary glands the operation
is rendered not only tedious 
but very dangerous from their immediate 



Vicinity - to the plexus of
nerves and vessels. 
The breasts are subject to encysted 
Steatoma - but then their Substance
feels smooth and even - Sometimes
there is a difficulty to distinguish between
Schirrous and Hydatids - in this
case the breast should be opened by cutting
simply thro' the Adipose substance -
Particularly in women who are pregnant
- we should be careful not to
injure the Lactiferous Tubes - by cutting
across them - but always in their
direction or the excretory duct of this
part of the gland would be destroyed -
and prove the Source of Inflammation
and abscess on every fresh Secretion of
milk. 
The operation itself is a mere
piece of dissection - as you must 



not only remove the whole of the disease
but a portion of the healthy Substance
- as some of it may be contaminated
- Begin by making a
transverse incision both above and below
the Areola - then dissecting the flap upwards
and downwards - lay the Pectoral
muscle bare - and take out the whole of
the breast completely nipple and all -
by which plan you save the patient the
pain of dividing the small nerves going
to this part. Afterwards take up the
arteries very carefully with a pair of forceps
and tie them with a single thread
bring the edges of the Integruments into
contact and secure them by adhesive
plasters - promoting union by the 
first Intention prevents Symptomatic
fever - The deformity is very inconsiderable



when the operation is well
performed. - It generally happens
that other parts which could not be discovered
before the operation are now found
to be diseased - these when the wound is 
well begin to increase - extend to the neck
the use to the Lungs the Glands of which taking
out the affection cause Symptoms
of Phthisis which terminate in Death.
Castration.
Diseases of the Testes are very various.
Hernia humouhatis is caused by Inflammation
of the urethra extending 
down to the Veru Montanum where 
the excretory ducts terminate and



generally arises from Gonorrhoeal irritation 
- that of a Bougie or some
accidental cause. The treatment is
however always the same. -Mercurials 
as increasing the inflammation
are improper - bleed immediately according
to the patient's strength from the
arm - as the pain is frequently so excruciating 
as to produce violent Symptomatic
fever - in irritable habits -
with spasm of the chest - endangering
life from the great difficulty of respiration 
- Apply Leeches and Fomentations
or poultices to the Scrotum - &
lotions - as - Sp: rectificat: O. & y: Ammon.
Acet: p : e: or Ammon: Muriat: ℥i
Acet: destitrat: Hi - if this last produce
irritation and Eruption on the surface
apply the Cerat: Saponis - enjoin strict



rest and the patient's being kept in an 
horizontal Position - or the Structure
of the organ may be endangered by suppuration
taking place - the matter becomes
discharged at a fistulous opening and the
Testicle wastes away - This happens
sometimes on both sides when mismanaged.
But without Suppuration they will sometimes
waste away till nothing remain but
a little Epidydimis - occasioned by an
accident - the Testicle becoming gradually
smaller and smaller from the
alteration in its structure by Inflammation.
- The Epidydimis sometimes 
becomes very hard and enlarged - having
its Vessels also enlarged and previous
from the effusion of Lymph uniting the
reliculated parts - this may be removed
by absorption on the application of the



Ungt Hydrargyrus when the Inflammation
has subsided. - The Testicles
sometimes enlarge very considerably 
- without any known cause - or
pain excepting a very slight degree from
its weight occasioning a sensation of
drawing down at the Spermatic Cord.
In these which are generally 
scrophulous - send the patient to the Seaside
and use a Bath of the Temperature
of 90 degrees for fifteen minutes each time
going to Bed immediately after till
its effects are gone off when exercise should
be taken. - Apply Seawater or Sea 
Weed to the Scrotum - which will sometimes
produce a drop of Pustules and a 
gradual diminution of the Testicle -
If this do not succeed smear a dram of



the following ointment over the Scrotum
every day and wear a flannel bag truss
Rx Camphora 1 dram in Sp: rectit: soluto
Ung. Hydrarg: fort: lll which will sometimes
make the mouth sore and affect the Constitution
- and at the same time reduce the
Testicle - A schirrous Testicle
- ultimately becoming truly cancerous
- can with difficulty be distinguished
from the last - may arise spontaneously 
or from accident - but becoming 
large hard and irregular - and attended 
with more pain. - Death is caused 
by disease in the Cavity of the Abdomen
- where the Glands will contain
the same matter as the Testes - It sometimes
at first assumes a scrophulous Appearance
but afterwards a more malignant 
-and may be called Scrophulous



cancer. - These patients seldom
live more than one or two Years.
M Cline has seen a Case in a Child
of five Years of Age. -
Another not very uncommon
disease - and something similar to
the last in external appearance but very
different in nature - is - the Hydatid
Testicle - which is frequently large before
it is discovered - and then only by a
dragging Sensation at the Cord - it has
a pulpy feel when handled - but there 
is no discoloration of the Integuments only
a mere gradual increase of Hydatids -
which escape where cut into leaving the Cells
distended - In some instances continuing 
a great number - of years - only to 



be removed by Castration - after which
there is never the least danger of a relapse
as the surrounding parts are never contaminated.
There is a Species
of enlargement which sometimes occurs
in consequence of a Blow causing
an extravasation of blood within the Body 
of the Testicle - which becomes tense & is
attended with great pain - this is called
Haematocele - But an extravasation
occasionally happens from rupture
from Vessel within the Tunica Vaginalis
we must be careful in our discrimination
and can only be known from the other by
being accompanied with very little pain
and here it would not be necessary to operate
for the removal of the Testicle. -



In the schirrous Testicle the spermatic 
cord becomes enlarged into the Pelvis
the Glands there as well as those of the 
Groin become diseased - The Integuments 
over the Testicle are discolored
and ulcerate - with an extremely foetid
discharge - a fungus sprouts out - the
disease spreads & ultimately destroys the
Life of the Patient - We have no 
power over this disease but is increases
faster or slower according to irritability
of the Constitution - other than an operation
for its removal before the Cord
is diseased. -
A pulpy Testicle is the next disease
- where it grows large without pain
has as oft feel with a sense of undulation




- making it difficult to say
whether it is not a collection of water
within the Tunica Vaginalis - particularly
when from prepare on one
end it enlarges at the other - but on 
putting in a lancet no water will
escape. - Here the cord never becomes
contaminated - differing in this
respect also from cancer - but the Glands
sometimes become diseased and contain
a white curd like matter - resembling
brain broken down by putrefaction -
It may be known from Hydrocele
by the discoloration of the Integuments
and enlargement of the superficial Veins
but as there is no possibility of saving
the Testicle it requires as speedy removal 



as the cancerous - for when you
feel irregular Tumors within the Cavity
of the Abdomen - the operation
will be of no use - but the patient dies
in a few months. - In cases of
extravasation of blood - be careful on
making the first incision not to lay
open the Tunica Vaginalis only by
a mere puncture - as if the collection
is from some some ruptured vessel with
in it - a mere evacuation will be
sufficient for the cure - but if none
escape and you find it within the body
you must proceed as in any other 
case with the operation till finishd. _
The operation is begun by making
an incision from the spinous process
of the pubis above the Abdominal



ring to the bottom of the scrotum that
you may have sufficient room to lay
hold of and secure the vessels - This 
cut thro' the Integuments and cremaster 
muscle lays bare the Spermatic 
cord and Tunica Vaginalis Testis - wh. -
after first opening - as the disease may
be a collection of water and mere thickening
of the Tunic - must be separated
from the Scrotum by dissection - first
on one side then on the other - keeping
the knife upon the Tunic to avoid wounding
the Septum or opposite Tunic -
and removing the whole of it with the Testicle
- but first attend to securing the
Spermatic cord - which may be done in 
various ways - The artery  may be cut
thro' laid hold of with a pair of forceps
and tied - but this mode is subject



an inconvenience The Cremaster muscle
may draw up the cord within the external 
ring - this however will cease
to act - and when it does and the cord
descends pass another Ligature round it.
You need not be alarmed at Hamorrhage 
from this cause. - It is better always
to pass a Double Ligature - with a 
crooked needle in case one should slip.
Tying the whole cord tight gives greater
pain than any other part of the operation
the pressure should only be moderate &
regulated by the flow of blood thro' the
artery - which should be divided - giving 
an assistant hold of the end of the
Cord till the rest is dissected out -
One inconvenience of tying the whole
cord very tight - is- the Ligature causes 



violent inflammation and becomes buried
in the Integuments and Lymph
thrown out in consequence. - M.C.
applies a bolster of Lint round the cord
and upon this makes the Ligature - which
can be cut upon and removed at any time
mostly at the first dressing - if you are
provided with a spare Ligature to leave on
the cord for three or four days - which is attended
with no inconvenience - and may
be removed at first dressing with the other
if there is no danger of Haemorrhage.
One or two Ligatures may be passed in the 
Integuments and the rest secured with adhesive
plasters - where union will generally
be effected by the first Intention.
Patients seldom die simply of this 
operation - but more generally from too
long delay - the Absorbents being diseased.



Lithotomy.
Calculi and concretions are found 
not only in the Urinary but the Alimentary
Biliary and Salivary ducts. 
Most often in the intestine of Quadrupedes
particularly horses - which acquire a
very large Size - one weighing fourteen
pounds - and formed in Lamina like
the human urinary calculi - sometimes
having an extraneous body as a nucleus
in one instance await. - In the
human Subject they more often occur
in the urinary passages - the Tubuli
of the kidneys - or the pelvis which is sometimes
completely filled and the Stone
resembles the shape of the pelvis and infundibuli -



They frequently descend 
thro' the ureters - exciting in
tense pain as they pass - which marks
the nature of the disease - and extends
from the loins downwards so the Thigh
attended with sickness and vomiting &
a construction of the Testicle. These
are sometimes ultimately expelled by
the urethra - but if once they loose - 
they gradually accumulate and accomodate
themselves to the part - particularly
if in the membranous part of the urethra
- forming a tumor in perineo -
but they may be primarily formed in the
urethra without having come from the
kidney or bladder - an extraneous body
- a pin needle or bit of Lead - has formed
a nucleus around which the earthy 



matter has collected. - M. Cline shows
two instances in which a piece of stick
formed a nucleus for calculi in the urethra
- but the patient was able to pass
his urine tho' with great difficulty. -
Calculi in the Bladder vary in size
color external form and number
sometimes single at others numerous
some smooth others irregular and are
called mulberry - At times they are
enclosed in a cyst - where it becomes necessary
to introduce the finger into the
rectum to elevate and push it forwards
that you may be enabled to embrace it
completely with the forceps. - Sometimes
there has been found in the bladder
a collection of coagulable Lymph and
matter mixed with blood and a deposit



of earthy particles nearly filling
it - when the kidneys are very much
enlarged - having the Infundibuli
nearly filled with the same dark colored
substance and communicating a
sympathetic affection to the stomach
in some cases so great as to produce almost
instant Death. - In size calculi
vary very much the largest and
heaviest M. Cline ever saw extracted &
the patient recover - was from a man in 
St. Thomas' Hospital - a patient of M
Cowell's - and weighed thirteen ounces
and a half it could only be extracted
edgeways - being too large in any
other direction for the rami of the Ischium
- They have all a Luminated 
texture but different Strata color



and compactness - the smallest particle
after passing the kidney may in the bladder
become a nucleus - Some are
formed of chalk round these nuclei
which from breaking and thus occasioning
delay are very unfavorable for the 
operation - M.C. thinks this softness
is owing to the exhibition of Alkalies
having in some measure altered
the nature of the deposit - They generally 
suffer much less pain because
the external surface is smooth - but
they increase equally quick in size
at least he has found this the case
on operating - one who has long taken
Alkaline remedies is less fit
for the operation - principally from
the change of structure in the Stone
and its so readily breaking on extraction. -



M.C. shows one Stone of three clearly
marked distinct Lamina - the inner
of a yellowish red - the next of an ash color
beyond which was all Chalk - each
Stratum was perfectly seperate the
supposes owing to the change of Treat "
Calculi in the bladder cause a frequent
interruption in the passage of urine accompanied
always as soon as the water ceases
to flow with a sharp pain at the end of the urethra
or commencement of the Glans - sometimes
very intense & in Children to ease
which they constantly pulling the
prepuce forward - which becomes elongated
and forms a natural Phymosis
to void their urine these patients place
themselves with their knees bent and
bodies forward - in which posture its
flows without pain till the last drop is



about to be discharged. - They also
feel a very frequent desire to make water
- which disturbs them much in their
sleep - they gradually grow weaker &
thinner - and become incapable of taking
such exercise as riding on horseback
or travelling in carriages if over
rough roads - from the constant jerking
of the Stone at the neck of the bladder
- producing such intense pain. -
This Irritation increases the Secretion
of mucus - which is discharged with small
quantities of blood - if the stone be irregular
and the disease have existed long. 
Where the symptoms have become greatly
aggravated you cannot be certain there
is a Stone - the same so frequently occur
in other diseases - as of the Prostrate
Gland - always however have recourse to



the introduction of the sound and when
on jerking it suddenly round you feel & hear
it strike against something - you may
be sure it is a stone - It is sometimes
when in a particular situation difficult
to find one - as on one side of the prostrate
Gland - or it may be found readily at
one time but not at another - that unless
you can feel it at the time of operating
never perform it. - When the bladder
is distended it is sometimes better to use
a Catheter than a sound - as on the collapse
of the bladder the stone will be brought
to its neck and may of course be more easily
felt. There is no other remedy
than an operation for this disease _
M.C. is fully of opinion there is no such
thing as a solvent - on the contrary during 
their exhibition - so far from producing



Solution - the stone is actually
increasing in Size as quickly as it was
tho' every addition during the continuance
of Alkalies is of as of smooth Texture.
- Purgatives should be taken
the day before the operation - and immediately 
previous to its performance an Enema
should be given to empty the Rectum.
In performing this operation after
previously securing the patient's hands & feet -
upon a Table in the usual manner - you
first introduce the Staff which is a sound
with a groove on its convex Side - and after
placing it in the proper situation you give
it into the firm hand of an assistant - then
with a common Scalpel proceed to make 
the first incision in the perineum - beginning
it opposite the upper part of the arch
of the Pubis - and continuing it obliquely



downwards to the outer part of the anus
on the left side - making it sufficiently
free will lay bare the Accelerator urinae
which must be cut thro' between the
the Bulb of the Urethra and Crus Penis - then 
thro' the membranous part of the urethra -
into the groove in the Staff - when fairly
there use it as a director to the beak of the
gorget - where by depressing the handle 
of the staff yourself and at the same time
pushing forward the gorget you divide the
prostrate gland and enter the bladder on its
posterior part - where you must allow it
to remain till the forceps are introduced
by sliding on it. Here you will divide
the pudendal artery but a little pressure
upon the ramus of Ischium will
effectually suppess all Haemorrhage -
The blades of the Forceps should be proportioned



to the size of the Patient or just
so long as to reach from the Arch of the pubis 
to the posterior part of the bladder in an
adult four or four and a half inches - in
young subjects sometimes only two & a half
for it on grasping the Stone the Joint is not
directly under the symphisis their motion
would be impeded - the blades and handles 
should be exactly of the same size or
length by which know minutely from
the separation of the handles the size of
the stone - they should & be well curved and
tough on the inside or they would slip
a circumstance to be guarded against
when you have secure hold of the Stone
withdraw them - and without applying 
any dressing put your patient to Bed.
As the membranous part of the urethra
is situated directly upon the rectum unless



you sit low with regard to your patient
and keep the point of your knife 
upwards you will be in danger of cutting
into it - but with these cautions
unless the rectum be very much distended
you will avoid it. - The blunt
gorget formerly used tears the prostrate
gland very unnecessarily. - Sr. Casar
Hawkin's cut upwards and only
on one side - a great disadvantage -
as the room is wanted in a transverse
direction between the rami. - This
was remedied by having it made flat
and the beak on one Side. - M Cooper's
is flat cuts on both Sides and has
the beak in the middle. - When the
forceps slip or you want another pair
make use of a blunt Gorget without a 



beak and your finger as a director -
A pair of flat forceps are necessary for
the extraction of very small Stones - &
in cases of diseased prostrate or deform.d
pelvis with the Stone above its brim a 
curved pair may be required. - Where
the Stone is very large and there is a thickened
State of the bladder - use a pair
of forceps like those in Midwifery with
two seperate blades sliding upon and
readily locking in with each other - as
by introducing one on each side of the
Stone it may easily be embraced and without
the Violence which the others would occasion.
- Where the bladder is large and
the stone small particularly in females use
a crotchet and your finger. - A scoop
becomes necessary to clear out all fragments 
when the Stone happens to be broken



Occasional remarks - As the Stone
may be enclosed in a Sacculus always
be careful to feel it distinctly before the
operation is begun. - The table sh.d
be of such a height as that the pelvis of the
patient may be even with the operators
breast; much depends on having the staff
properly placed, that when turned back into 
the hands of the Assistant it may not slip
out of the bladder. - The incision must
be made from opposite the arch of the pubis
between the left crus and the rapha; - the
first cut laying bare the accelerator urinae
which must be cut thro' thus exposing the
membranous part of the urethra - division
of which must then be made directly upon
the staff / the knife being kept there 'till the
gorget is introduced /* when in the bladder it
must be retained there till the forceps are
slidden in upon it - but before you expand
them always feel for the stone; when you have
hold of it introduce your finger between
the blades to ascertain whether it is in a favorable
position for extraction - for if lengthwise
you may easily turn it a little -
* This part requires the greatest care as the gorget is apt to slip out of
the groove and pass between the bladder and rectum -



The operation performed, and Haemorrhage suppressed
by pressing the external pudendal artery
upon the Ischium; the patient must be
put to bed; dry lint applied to the wound &
cloths to keep him dry, unless very restless do
not give Opium, particulary to Children. -
The wound soon heals, sometimes in a fort
night if kept on the antiphlogistic plan; 
but if there has been a fistulous opening it
has occured after the operation where there
was a diseased prostrate. This operation
may be performed at any age Mr Cline has 
performed it successfully at 80 yrs frequently
above 70 years of age. -
Aneurism
Aneurism is a disease to which the Aorta
and its branches are particularly subject:
but where situated in large cavities no
remedy can be employed, it is only on
these external branches a sufficient portion
of which can be laid bare to pass two
ligatures round - it may be safely done if
in the femoral taking care not to include
any portion of the peritoneum: Small



branches are very little subject to this
disease - the smallest Mr. Cline ever
saw was the radial where it runs round
the thumb. - Aneurisms gradually increase
in size till they break when the
patient dies from Haemorrhage. The
sooner the operation is peformed the greater
chance of success. - It used to be the
constant practice to amputate the limb in
this disease; - but as the patients were always
previously very much reduced such
cases generally terminated fatally - After
this it was customary to open the sac - and
till the artery close above and below, but
here a diseased portion was frequently included
& the ligature slipping the patient
lost his life - or a great deal of blood at
others from the anastomosing branches -
Lastly it became common to tie the Artery
at a considerable distance from the Sac
leaving it unopened - which has been done
either by a single or double ligature, in
one case by passing a piece of ribbon below
and cork above Mr Cline succeeded completely
in obliterating the artery without
the process of ulceration - pulsation
continued in the tumor 9 or 10 days under
this pressure, absorption did not as usual
take place, the integuments became purple,



then ulcerated extensively and a discharge
of coagulum took place from the Sac; -
& the patient / a female/ died of Consumption
with tubercles in the Lungs - This
shows that under pressure of an artery the
vasa vasorum will from inflammation
deposit coagulable lymph on the internal
surface of the artery and thus plug up its
cavity. - Where this operation does not
succeed it is from ulceration taking place
before the arterial canal is obliterated; tho'
if you can tie above and below the ulcerated
part as in one case of Mr Cline's you might
succeed in saving the patient. - In making
a ligature upon an artery never do it near
where it is given off; as the pulsation is there
so strong that coagulable lymph cannot be
deposited in sufficient quantity to unite its
sides - always rather tie it above where the
branch is given off. - But without division
the disposition of an artery to contract is
not so great - clearly elucidated by the division
and puncture of an artery. So
that wherever you wish to obliterate the
canal pass two ligatures round the Artery
and cut between them. On a very large
vessel the force of the blood is so strong as 




to push the ligature, if only passed round
the artery, lower and lower - to obviate
all danger from this Cause Mr Hy. Cline
suggested a method of passing the ligature
thro' as well as round the artery consequently
it is necessary to use an eyed probe threaded
with a double ligature at each end of which 
is a crocked needle to pass thro' the ends of the
artery. - The most convenient part 
in which to perform this operation is just above
the middle of the thigh and on the inner edge of
the Sartorius muscle - where by an incision
of three inches in length you have only to turn
the muscle on one side where the artery is exposed
to view - there is a small cutaneous 
nerve must be turn.d aside with the sartorius.
When the fascia of the femoral vessels is exposed
you must open it carefully and seek for the
artery alone which is the first vessel that presents
itself - between it and the bone lies the nerve
and further on is the vein - which must all be
carefully separated. - Then take the probe &
pass the ligature under the artery - cut off the 
probe and separate the ligatures about an
inch asunder - tie the upper one very gradually
so as to make a pressure just sufficient
to prevent the escape of blood into the part
below - for the longer the ligature remains 



upon the artery without ulceration the better
but if tied very tight - the coats of the artery
would be cut and the ligature from its pulsation
soon thrown off - or ulcerated thro.' -
The needle must then be passed thro' the artery
just below its centre so as to include the greater
half which must be tied - and the artery divided 
by a probe pointed bistoury which will
allow it to retract after the lower end has been 
tied moderately tight in the same manner
when both ends will be secured without a possibility
of slipping - make no pressure upon
the limb - only securing the external wound
with adhensive plasters - leaving the anastomising
branches at liberty to perform their utmost. -
Amputation
Amputation is an operation which becomes
necessary from various causes - either external
injury or incurable disease - destroying the
constitution or life. - Among accidents requiring
amputation the chief are compound
fractures extending into the joints - but even
here it is much less frequently performed than
formerly - from the more improved method of
treatment - lessening inflammation &c. -



Fractures extending into the large joints sometimes
produce greater violence to the Constitution
than it can bear - often times death in
two or three days if the operation be delayed,
but no accurate rules can be laid down to
decide where it is necessary to amputate; -
this must depend upon the Constitution, ex-
of injury &c - and how far the subject is capable
of bearing the inflammation and subsequent
irritation. - If the operation be
not performed directly you must wait several
days - or till all inflammation is gone
off and the supparative stage has taken place.
Gunshot wounds most frequently require amputation
being attended with considerable
contusion and laceration - and the inflammation
of course more extensive - especially
when accompanied by fracture into the large Joints.
But even here we should not form a hasty decision
as some hopeless cases are recovered from
therefore if you judge your patient capable
of bearing the inflammatory stage leave it
till that is over - as a patient when reduced
suffers less from the removal of a limb than when
in perfect health recovering much better and
faster. - This is the cause of such good success
so uniformly attending the removal of a 
large limb for some long continued disease.
In mortifications it was formerly always 



deemed necessary to amputate in order to
prevent its spreading. - Mortification
generally arises from some great external
violence as contusion laceration and inflammation
which the parts not being able
to support death takes place in them; the
most violently inflamed part is always the
first to mortify - In old persons mortification
sometimes ensues spontaneously as
in one toe - first turning purple and then
black the circulation being stopped - This extends
up the leg; - on making an incision into it,
the structure of the part is so much altered, no
blood will follow, - the patient generally dies
before it reaches the knee - From great
restlessness and intense pain delirium ensues
the treatment consists in Tonics bark wine
& opium - externally anodynes fomentations
and poultices of stale beer grounds. On amputating
in this case you only hurry on the 
complaint -as the same degree of constitutional
irritation still continuing causes mortification
in the stump and the death of the patient.
Amputation of the smaller parts of the body
tho' attended with great inconvenience to the
patient does not cause much constitutional
irritation; it should be done at the joints saving
skin enough to cover the bone which is the
best covering and the wounds heals in much shorter 



time - making it a general rule to cover
the exposed surface in all parts of the
body. - Amputation ought only to be
performed in the small joints - but the
wrist tho' extensive may be amputated taking
care to cover the the surface of the bone 
with integument - the shoulder also is not 
to be objected to, as the whole of the cartilaginous
surface exposed is that of the glenoid
cavity. - Petit's Screw Tourniquet 
is the most convenient where you have
not sufficient assistants - but where you 
can always spare one the common stick
Tourniquet is the best - on the arm it
should be placed above the elbow on the
leg above the knee - the middle of each
is most convenient : the femoral artery
may easily be compressed at the pelvis
by the thumb so as completely to prevent
the passage of blood: - the knife should have
a concave edge and be proportioned to the
size of the part as the arm or thigh - in cutting
it must always be done by or owing
the edge from the handle to the point which
lessens the resistance to mere pressure;
to divide the parts between the bone a Cataline 
must be used - which a straight 
two edged knife - moving it first [crossed out]



one bone and then the other - only requisite
below the knee and elbow. - The common
tenant saw is the most convenient being more
steady than the old one. - When the limb is
removed have needles and ligatures ready for
the large arteries - by which they may be more
perfectly secured - but in small branches use
a tenaculum only passing a ligature round
then whilst held out; - but the sliding forceps
are of the greatest use where the operator
has the ligatures to pass & tie himself. -
The great toe ought not to be amputated
without absolute necessity as it aids more
than all the rest in walking - in the first
joint or last phalanx make the incision
near the root of the nail to have integument
enough to cover it - which must be
drawn back and the tendons divided - when
as the capsular ligament is stronger above
and below than on the sides make the incision
there which will easily open the joint
for the introduction of the knife. - When
the disease extends into the metatarsal bones
make an incision completely thro' on each
side and with the metacarpal saw take
out the bone as far as diseased: - if the
tarsus is affected but not the calcis and 
astragalus - they maybe left and the



patient will walk on the heel - but when
it is necessary to remove the whole foot take
it off just below the knee - if more is left 
it proves extremely inconvenient - On
amputating below the knee you must stand
between the legs- as you have the advantage
of cutting both bones at once; the best
distance is about the breadth of a hand below
the patella in the adult - or in general in
all cases the tuberosity of the Tibia; - standg.
as was said before on the inside make the incision
at one cut all round - and after drawing
up the skin make the second near the edge
of the former thro' the fascia and muscles to
the bone - when the cataline must be used
to divide the ligament between the bones and 
still preserving the same state on saw thro'
the bones - when the vessels must next be tied
which consist of the anterior and posterior
tibial and interoseal arteries and sometimes
one or more muscular branches
which if likely to give the least trouble you
should be careful to secure - as there is increased
action - the bed chamber should be cool
and airy - or the heat &c may cause haemorrhage
from same vessel which would not
otherwise happen: the Integuments must
be brought together with adhesive plasters -
sometimes the whole has been united even
at the first dressing - requiring in the former 



mode of treatment several months. - Amputating
where there is only one bone always 
stand on the right side of the patient which
allows free scope for the left hand to draw the
integuments back - when above the knee
make the first incision thro' the integuments
as near the knee as you can - provided it does
not enter the capsular ligament - withdraw
these and cut thro' first the loose muscles there
those immediately attached to the bone - then
the bone must be cut thro' and after the vessels
are properly secured the integuments brought
together - The fingers should be amputated 
as the Toes. - When necessary to take off
the hand it is most conveniently done at the
wrist by a circular incision thro' the Flexor
&c Tendons - and afterwards opening the joint
by a division of the capsular ligament on the
side of the radius. - You amputate the forearm
the same as below the knee and the upper
arm the same as the thigh except where the
humerus is diseased near its head when it
must be taken off at the shoulder joint; - but
in order to effect this you must first lay bare
the axillary artery and pass a ligature round
it as in aneurism letting an assistant
keep it out of the way of the operator; then
make an incision thro' the deltoid muscle
upwards till the head of the bone is exposed &
from the incision where the artery was 



secured extend one round to the other at
the head of the bone; - lastly cut thro' the
ligament and the limb is removed and the
integuments when brought together will
form but are extended line around the part.
Calculi in the Urethra.
A small calculus in the urethra if smooth
generally passes off with the urine - sometimes
at one, at others after frequent efforts;
but when uneven becomes wedged in and
grows larger - sometimes being an inch broad
and one or two long in the membranous part
of the urethra - rendering its removal necessary.
But Mr. Cline has never been able to extract
them in situation with the forceps used for
that purpose - because you can't sufficiently
overcome the contractile power of the urethra
to open them so as to grasp them therefore don't 
attempt it - but according to its situation
whether in the membranous part or that part
of the penis attached to the pubis when it may 
be felt by pinching the part - Embrace the
stone between the finger and thumb and
make a cut thro' the urethra directly upon
it and sufficiently large to turn it out; the
wound will readily unite - But when 




the stone is situated in that part covered
by the Scrotum and you have it and the
septum to divide - the urine insinuating
itself into the cellular membrane will by its
irritation cause inflammation and consquent 
ulceration - that if you can without
injury force down a sound or catheter and
push the stone into the perineum it is better
to do so; but if not after performing the operation
keep a catheter in the urethra three or four
days 'till you are sure the wound is united. -
When the stone is situated in the membranous 
part of the urethra the patient must be 
placed in the same position as in the bladder
an incision must be made upon the left side
on the accelerator urinae between the bulb and
crus penis and upon the stone - dilate the
opening introduce the crotchet behind it &
draw forwards and downwards - but if very
closely wedged here push it back into the
bladder and use the gorget to divide the prostrate 
and afterwards the forceps as in Lithotomy
treatment the same and recovery as speedy. -
Sometimes there are one or more stones loop.d
in a cyst having communication with the
membranous part of the urethra - One case
Mr Cline shows with four stones of the size of
nuts. Mr. Else also met with and described
one. - In these cases there is intense pain after 



voiding the urine from irritability of the
cyst and its having an opening into which
the urine insinuates. - When the cyst is
in the membranous part of the urethra there
will be the same pain and symptoms as
with stone in the bladder. - Often in these
cases the patient has had the disease from
birth perhaps soon after causing danger to
life from retention of urine - or Mr Cline
thinks it may arise from a stone getting out
of the urethra into the surrounding cellular
membrane - producing inflammation &
adhesion - thus forming a cyst. - Mr Cline
has seen one instance of stone in the bladder
of the foetus - The symptoms of 
encysted stone in the membranous part of
the urethra often make the surgeon think 
it is in the bladder - but on striking with
the sound if the stone is encysted a vibration
will be produced - which will not be the
case by striking immediately upon the stone.
Mr Cline has known this mistake made and
the operation performed when the stone was
found encysted behind the bulb - but when
in this situation it may always be felt by
pressure carefully made upon the perineum 
and be known by a dribbling of urine which
is so constant that he can't be kept dry -
Their removal must be effected by carefully 



dissecting down to them in whatever part 
they may be situated - and it is also necessary
to remove the cyst or you will have a fistulous
opening for which purpose introduce
a flexible metallic catheter and dissect it
out and the opening into the urethra; leaving
the catheter in till the wound is healed
the water being let off by a screw stopper. -
This operation requires much nicer after
treatment than any other for the stone an
account of the alteration of structure or a
fistula will be the consequence. -
Females are much less subject to stone in
the bladder than males - owing to the meatus
urinarius being so much wider and shorter
and capable of such extensive dilatation as
to allow of the passage of a stone of the size
of a pigeon's egg - But as there is the same
symptoms excited the operation becomes equally
necessary, but is much more simple.
After examination made with a male sound
the operation must be begun by placing the
patient is the posture before described and
then introducing the female staff make an 
incision between the crus and vagina in a 
slanting direction downwards then introduce
the gorget and pushing it forwards dilate
the urethra into the bladder; when the
forceps may be introduced; but where the stone
is small and bladder capacious the crotchet  



may be introduced and the stone brought away
between it and the forefinger of the right
hand. - Female patients generally suffer less than the
male from this operation and from the
parts being constantly covered require no
dressing - but keeping clean and sprinkling 
a little fuller's earth to prevent exfoliation.
- Retention of urine arises
from some stoppage - within the bladder or
or calculi in the urethra and must be removed
as before described. - Stricture
of the urethra when long neglected becomes
thicker and thicker and the urine at last
completely stopped - there is at first extreme
irritability with a frequent desire to make
water or a constant dribbling; - when the suppression
is complete we make use of something
to remove the spasm; bleeding & afterw.ds
the warm bath or semicupium but never use
these before as the inflammation is frequently
increased by it and the patient becomes worse
but if bled first he frequently finds most essential
relief; give a glyster with IX drops of Laudanum 
in an ounce or two of any fluid; and make hot
fomentations on the perineum and pubis; these
means will generally afford relief tho' not always
as the bladder has been known to burst and the
urine effused into the cavity of the Abdomen; or
death has taken place before this from the violence
of inflammation which has come on without bursting.



Those who have once had spasm of the
urethra are liable to future attacks. -
Mr Cline here relates a case of a man in
the Isle of Ely - who was subject to frequent
attacks but never obtained relief in less than
forty eight hours - Mr Cline gave the Tobacco
glyster with all the usual effects of this remedy
and when they subsided the urine began
to flow from the involuntary contraction of
the bladder; - but the man would never submit
to have another from the death like sensations
it produced. - In the next attack 
Mr Cline gave ten drops of the Muriated Tinct
of Iron every ten minutes till sixty had
been taken in an hour and the urine began 
to flow in a full stream: a second time
and repeatedly afterwards it answered the same
purpose when given in the same manner. -
By taking this remedy several times a Day the
man at last got perfectly well it gave such
tone to the system. However this can only
be regarded as a remedy in cases of spasm in
any other case it might be hurtful and even
here should always be given soon after the occurence
of the spasm or otherwise it is
not likely to prove effectual. - Another
cause of retention is that of diseased prostrate
particularly in old men who frequently die 



from this cause & if they happen to retain
their urine longer than usual the bladder
from its compression of the prostrate has not
the power to discharge any part of its contents.
And where there is an attack of only a few hours
continuance inflammation occurs with
swelling of the prostrate causing an almost 
constant necessity for using the catheter which
by frequent introduction keeps up the inflammation.
- A flexible catheter with a
screw stopper should be introduced and retained
without the use of a ligature they adapt
themselves so accurately to the curve of the urethra 
- better than silver or Gum. - A patient
of Mr Cline wore one two years only taking
it out every two or three weeks to examine &
clean it and the person recovered completely.
One of these metallic catheters may generally
be worn three months without danger of 
breaking - which happened in one case to
Mr C. - but he succeeded in extracting it
with the forceps used for the purpose of extracting
stones from the urethra. -
It sometimes happens that you cannot introduce
any instrument to draw off the water when
it becomes necessary to perform an operation - a
puncture of the bladder may be made either
above the pubis or in the perineum or rectum.
- The first consists in making an 
incision in the linea alba between the



recti and pyramidales muscles exposing
the anterior part of the bladder without injury
to the peritoneum for when the fundus
of the bladder is pressed upwards the peritoneum
adhering goes with it - if it were punctured
the water would become effused into the cavity
of the abdomen producing inflammation wh.
would kill the patient - a trochar with a
long canula must be used after the incision
is made and when the water has begun to flow
introduce thro' the canula a flexible metallic
catheter and withdraw the canula over it - as
the former irritates much less the sharp edge
of the canula - and as it's necessary to retain
this in order to keep open the aperture and prevent 
the extravasation of the urine into the
surrounding cellular membrane it may
easily be effected by a bandage round the
waist, till the stricture in the urethra is
overcome when it must be withdrawn and
the natural passage established. - But it
has happened that the canula slipping out 
and the urine becoming extravasated has caused
the patient's death. - The puncture thro'
the rectum must be made a full inch behind
the basis of the prostrate an account
of the inflammation which should be the
consequence of a division of the vas deferens
and destruction of the function of the testicle; 



it must be made with a curved trochar &
has sometimes been performed with success
it is also necessary to keep the canula in
the parts till the natural is free from obstruction
- if withdrawn sooner the urine
would become effused & from its stimulus
cause a great degree of tenesmus - but
keeping in the canula also gives a great
degree of Inconvenience at each time the
fœces are passed with constant tenesmus.
The operation in the perineum which
is the best must be made in same direction
as for the stone - between the bulb and
crus penis - the finger must be introduced to
feel for the prostrate and make the puncture
with a trochar on the anterior part of the
bladder then introduce a metallic catheter
thro' the canula & withdraw it over it leaving
the former in 'till the opening is established.
- This operation is too frequently 
delayed till inflammation has proceeded
so far as to destroy the patient : which happened
in one instance to Mr. Cline where he
thinks the patient would have died from
inflammation could he have introduced
the catheter. - The operation in the perineum
has highly the advantage of the others as were
the canula to slip out there would not be 



any risk of extravasation of urine but it
would be voided as in stone - Where a 
person has had considerable injury done
to the perineum opposite the arch of the
pubis or where the membranous part of
the urethra has been lacerated and as Mr
Cline has seen the corpus spongiosum divided
- effusion of blood into the surrounding
parts and scrotum is the first symptom
and an utter incapacity to void the urine
by the urethra which is emptied into the
cellular membrane - putting the patient
by delaying the operation in imminent
hazard of his life every attempt to introduce
an instrument proving abortive. - Here
after opening must be made in the perineum
a probe and director introduced into the
bladder passing a Catheter down the urethra
into the groove of the director and so into the
bladder where it must be retained and the
wounded parts united as quickly and well
as possible after taking care to remove all
the coagulated blood you can at the time.
In one case Mr Cline has seen a cure completed
with the use of a catheter in the parts.
But it sometimes happens there is not only
laceration of the urethra but also of the integuments



which are torn by falling upon
any thing sharp when the urine instead
of flowing thro' the penis will pass off at
the wound - not endangering life - but if
neglected a complete fistulous opening is
established - which is difficult to manage
in order to unite the divided ends of the urethra
- but Mr Cline succeeded in one case 
of four years standing by passing a probe into
the fistula as far as it would go and a catheter
down the urethra - the accelerator urinæ
was then laid bare by an incision and the
probe pushed forwards thro the aperture into
the bladder followed by the catheter which 
was omitted in 5 Wks; - bougies were however
occasionally passed for 3 mos; after which he
never ailed any thing. - But in another
case of an irritable habit Mr. C. could not
succeed from which is to be inferred the necessity
of having the patient in a previous good 
state of health. -
Phymosis
Phymosis consists in such a small orifice
to the prepuce as prevents the denudation
of the glans penis - is common in children
at birth when it is called natural. But 



from whatever cause is always attended
with inconveniences: first from the sebaceous
matter secreted by the glandulæ odoriferæ 
accumulating behind the corona glandis
and lastly from its causing itching and
sometimes ulceration with a discharge like
that invirulent gonorrhea; - in this state
an operation must be performed or an opening
on the upper part as the wounding of
the vena magna ipsius penis is of no consequence
- first pass a probe round the glans
to discover whether there are any adhesions, then
take a phymosis knife and stick a piece
of wax on its point lay hold of the penis and
draw the prepuce as far back as possible to
put it upon the stretch or you make a large
internal wound without affording the proper
degree of relief; put in the knife at the orifice
and push it back nearly as far as the corona
then thrust the point thro' and drawing it
towards you will complete the Division, a piece
of lint must then be put in between the edges
and renewed from time to time as it grows foul
to prevent adhesion. - But as the greatest 
inconveniences arise from slitting up the
prepuce too far - never go quite behind the Corona
- as the prepuce would fall down on each
side and leaving the glans uncovered the linen
would irritate it extremely. - If there are



adhesions whether from ulceration or granulation
you must not only slit up the prepuce
but dissect away them; - however if
these are considerable it is better to remove the
prepuce by circumcising your patient -
But where in can be drawn a little way &
then slips behind the corona and can't be
drawn back it forms a stricture swells
the penis from the stoppage of blood thro' the
vena magna ipsius penis - and endangers
mortification; - it may sometimes be reduced
by pressing upon the glans and thus diminishing
its size by forcing out all the blood
then pressing back the glans with your thumbs
and drawing forward the prepuce and skin
with your fingers; however when inflammation,
from, waiting some hours, has
come on, it becomes necessary to perform
an operation by pushing in the phymosis
knife on each side in several places; taking
care not to wound the arteries on the
dorsum; - where it can be returned you had
better slit up the prepuce on the back; afterwards 
keeping the penis in an erect position
will lessen the swelling that would otherwise
be induced by allowing it to 
hang down. -



Amputation of Penis
Cancer of the penis - not very uncommon
its origin is in the glans - sometimes in the
prepuce; it arises like a warty excrescence
which if not covered is constantly peeling off
progress very slow, being months or even years
before it attains any size; but gradually
extending in circumference as well as
height becomes irregular and discharges a
foetid matter with heat redness and pain
which extending along the absorbents they
sometimes become contaminated and ulcerate
when at last the internal chain partaking
of the disease the patient dies. -
When it originates in the prepuce it will
extend to the glans and so go on, till there is
an absolute necessity for amputation, with
a great degree of hardness in the whole of the excresences
which as there is no other mode of 
cure must be completely removed; but if
it exist distinctly only in the prepuce it
will be sufficient to amputate this alone.
As soon as the nature of the disease is clearly
ascertained the operation should not be delayed
as the glands soon become diseased 



without our being capable of perceiving
it. - When the glans is diseased
we must remove the whole of it, as it
would be extremely dangerous to cut out
a part from such an extremely vascular 
substance. - The operation consists
in cutting thro' after drawing back the skin
both corpus cavernosum & spongiosum at
one cut when sufficient skin will be
left to cover the end without stretching it.
There would be considerable Hæmorrhage 
from the four arteries were it not completely
compressed by a piece of tape before the
operation; next look for the vessels and when
you see them distinctly draw them out
with a pair of forceps and tie a small ligature
round them; then bring the skin
forward and cover the cavernosa only leaving
the spongiosum uncovered to allow
of the free passage of the urine; but here the
greatest difficulty lies in keeping open the
urethra so as to prevent great difficulty in
passing the urine - from the granulations
causing contraction and closing its orifice
which is sometimes not larger than would
admit a pin - tiring the muscular or contracting
fibres of the bladder before all the urine 



is passed and making it necessary daily
to introduce a bougie till all disposition
to contract is lost or till the part is healed;
otherwise the patient may suffer a great
deal and become very difficult to manage
Tho' in one case Mr. Cline succeeded by
passing a piece of small catgut which by
swelling gradually overcame the contraction.
Trephine.
Injuries of the head - require great discrimination
and judgment in their discovery
and treatment. They are concussion, 
fracture, extravasation, and inflammation
of the brain and its membranes; which 
may all occur in the same case or separately
- Concussion is the effect of a 
blow where all the functions of the brain cease
there is insensibility and loss of motion; but
the involuntary motions as not dependant
on the brain continue; the pupil does not
contract from the stimulus of light on raising
the eyelid; noise produces no excitement;
these symptoms are however not always in
the same degree: where loss of sensation or
motion continues only a few minutes or 



hours or days or sometimes weeks and
sometimes in a still less degree or where
it is only partial; as ringing in the ears,
flashing of light in the eyes, inability to
stand upright, can only walk feebly and
that with assistance; here the motions
are only impaired not completely lost:
sometimes recovering soon so as to go about
their business without further injury at others
attended with great danger. In 
these cases we should bleed altho' the pulse
is slower than natural as Mr Cline says
it has a good effect if freely taken and should
be repeated if the symptoms continue - There
was a case of Mr. Baker's in St. Thomas' Hospital
who continued in this state 3 Wks:
and was bled twenty different times; and
Mr Cline attributes his recovery solely to the
evacuation lessening the force of the pulse;
procure free evacuations panum; and if
the symptoms still continue repeat both
bleeding and purging; it will be necessary
also to keep up a free determination to the
skin by Dover's Powder or Antimony and
shave off the hair immediately, blister the
head but only after the symptoms have continued
several days without any signs of 
amendment. - At first allow nothing but



barley water - in a few days panada -
no broth or fermented liquors or any stimuli.
- On recovery he first begins to open
his eyes directing them in a languid manner
to some particular object, the same
by speaking which is at first very indistinct.
- Strabismus is a very common
result of concussion one eye being turned
out of the line - or seeing objects out of
their natural situation, to one side or
the other when opposite and directly before
when on one side; hearing is also
altered and sense of taste lost; but generally
recovering gradually tho' it may be
months or even years; - Loss of memory a
very common effect of concussion, shall
see a person know him & not be able to 
tell his name - this extends sometimes to
an extraordinary degree; loss of language
has been the effect; a patient in St. Thomas' 
Hospital who was a Welshman after an accident
of this kind lost his english and spoke
welsh; there is often an imbecility in the
reasoning faculty even to such an extent
as to amount to idiotism; Mr C. has seen it
continue for months and the patient recover.
Mania has not unfrequently occured after 



then injuries and the patient never afterwards 
recover; a particular instance of
which Mr. C. notices who had concussion
from a fall. - The complete or incomplete
recovery Mr. C. thinks depends upon the
treatment during the complaint, diet &
evacuations. - Fractures are of two
sorts only fissured, or accompanied with separation,
or broken and driven inwards to
the membranes compressing the brain itself &
in proportion to which pressure is the degree
of danger and on this account requiring the
particular attention of the Surgeon. Where 
simply a fissure unaccompanied by any 
wound of the membranes the parts will unite
by callus as in every other part when kept on
a cooling diet. - Compression which accompanies
fracture with depression occasions if
considerable immediate vomiting & nausea
a loss of the voluntary motion of some part
of the body as one side & that the opposite to
the injured and convulsive tremors; if still
greater all voluntary parts are motionless
stertor & apopleptic breathing, bleeding at the
ears or nose & a slow and oppressed pulse wh. 
is irregular or intermits. - These symptoms 
being present carefully examine the
head after first removing the hair & if there



is a wound in the scalp you know
where the injury is - but if there is no
external wound but injury underneath
the scalp, there will be a puffy feel &
on pressure it will frequently give great
uneasiness: - here you should lay the bone
bare by a free longitudinal incision &
if a fracture is discovered it should be
traced throughout its whole extent above
the basis of the Cranium further attempts 
would be improper. If there is any portion
driven inwards it must be removed or elevated
for which purpose the instruments necessary
are a knife to divide the scalp at the end
of which is an instrument to seperate the
prericranium from the bone without injury
to the knife and is particularly useful in tracing
a fracture; where it is necessary to take 
out a portion of bone the Trephine is used wh.
is a circular saw fixed into a handle which
takes off - within the crown of the trephine
is a sliding pin that may be set just beyond
the teeth of the saw - to the crown Mr. 
Henry Cline has had a cutting edge added wh. 
slips on it and takes off a piece of pericranium
only of just such a size as to admit
of the saw for wherever the bone is bared of this



membrane it will exfoliate; - then take
off the cutting part and when a sufficient
groove is made in which the saw will work
the pin must be drawn out; - but care must
be taken to examine from time to time with
an eyed probe that you do not wound the dura
mater, which would endanger the patient's
life as you may be thro' on one side
and on the opposite only thro' one table of
the skull: - when this portion is removed
if there is depression the elevator must be
introduced to raise it and thus take the
pressure off the brain. - The trephine is
always applied on a sound part of the bone
or the injury would be increased. - Fractures 
are often situated in such part as
to render an operation impracticable; as
the Basis of the skull frequently occasioned by
falls on the summit. - The frontal and
longitudinal sinuses should be carefully
avoided as very inconvenient tho' the
operation may be performed with caution
where circumstances require. An operation 
on the anterior and inferior portion of
the parietal bone where the dura matral 
artery enters if not dangerous might be attended 
with troublesome Hæmorrhage but 



even here it may be done observing due
caution to avoid injuring the artery. In
one Case Mr Cline look out a piece over
the sinus and over the anterior and inferior
portion of the parietal bone. - Even the
temporal muscle may be raised to apply
the trephine. - No part of the Scalp should
ever be removed as formerly for it is never
necessary however extensive the fracture,
but the pieces must be brought nearly together,
but no attempt made to unite them
by the first intention as matter may collect
underneath and consequently it's better to
have an aperture for its discharge. - In
the cure of these injuries a luxuriant vascular
fungus is apt to rise to which a piece
of dry lint and very gently pressure should be
applied and are generally sufficient to remove
it - The patient should be kept cool and quiet
and never be alarmed as complete serenity of
mind is absolutely necessary to recovery -
Mr. Pott recommended that in every case
and however trifling the fracture the trephine
should be applied as he said there was always
rupture of vessels and consequent extravasation;
but if the dura mater is not seperated
Mr. C. thinks the matter would ooze
out without inducing any symptoms. -



There have been symptoms of Depression
where the patient has recovered without an
operation; but where one does fifty would
die for tho' they may appear recovered for
a while symptoms may and frequently do
occur at a future time - Therefore in
all cases of fracture of the Skull with depression
- whether with or without symptoms
Mr. Cline would lay it down as a rule &
thinks it right to operate - as it gives the patient
so much better chance of permanent 
recovery and life; - he considers the operation
itself as attended with no danger nor
even risk if carefully performed. - Very
little injury will sometimes occasion great
and dangerous symptoms - as a small spicula
of bone which tho' not perceived it
the time occasions a predisposition for epilepsy
and an incapacity to transact
business - In one case of this kind the
spicula attached to the portion depressed
on being moved during the operation bro.t
on a violent epileptic fit. - These injuries
are attended with far greater danger
in the adult than young subject because
the bones are more yielding and the brain



will support greater pressure without inconvenience.
- Sometimes the injury is so
extensive as to produce great deformity of
the skull and yet recover and live a number
of years; - but the functions of the brain in
all probability are impired. - A man was 
admitted into St. Thomas' Hospital, in a state
of complete insensibility of 12 mos. standing
voluntary motion lost, involuntary perfect,
he showed motions of want as to drink and eat
which he chewed and swallowed, on holding up
the eyelid the pupil did not contract but was
turned up so far as to be nearly out of sight 
nor would any thing stimulate it, on wanting
to evacuate his fœces he writhed in bed, &
on putting a bed pan underneath or rasing
him to the night stool he had an evacuation.
- A depression of some considerable extent being
found on the parietal bone to which part
the trephine was applied immediately upon
the drepression which was united by callus.
and the portion removed; - when this was done -
his hands moved - the pupils turned into their
natural situation but there was a dulness
over them which made him appear not to see,
the same evening he opened his eyelids and 



looked at different objects, next day he
appeared rational, and tho' slowly he gave
direct answers, when it appeared that he 
was cruising off the Isle of Minorca and
having just taken a prize he had the misfortune
to fall from the mast head from
which time he lost all recollection; he
was in the hospital there 2 mos. then removed 
to Gibraltar from thence to Deptford
and so to St. Thomas' where Mr. C. operated.
A blow will frequently hurt some vessel of
the brain without injuring the skull; when
there will be felt a dull aching pain; drowsiness,
increasing to complete coma - from
which there is no being aroused without the
application of some violent stimulus; Apopleptic
stertor; and involuntary discharge
of both urine and fœces; when these symptoms
come on in a few hours after the accident
it is a plain indication of extravasation
of blood. Such symptoms often supervene
immediately on concussion, if there is no
visible contusion on the scalp you know
not where the injury lies - but when there
is a wound, enlarge it, apply the trephine
and take out a portion of the skull, when 



if there is extravasation the blood may
be removed from the membranes and even if
these symptoms have continued a long time
the patient will soon recover. - But where
the injury is deeper seated you have no other
chance than to promote absorption by bleeding
purging and gentle diaphoretics with a
strict regimen. - Inflammation of the
brain and its membranes, the consequence
of injury to the head is more dangerous than
any other species; a hurt is sometimes tho.t
of little or no consequence from the pain
soon going off and there being no wound of the scalp
but the usual mode of living and exercise
being followed, these symptoms may occur
at the end of a few days or weeks; - [crossed out] chill rigors
- increased pain in the head - heat &
restlessness - pulse quick small & hard -
light and noise offensive - tunica conjunctiva
bloodshot or more red than usual - the
restless and anxious pain in the head increased 
to throbbing on the application of cold
to the surface of the body: all which being indicatory
of inflammation of the brain or
its membranes you should immediately
open the temporal artery and bleed to the amount



of 30 or 40 oz: till he faints or the
pulse becomes very feeble, then give Magnesiae
vitriol: 1 dram in Infus. Rosoequâque horis:
keep him constantly in bed & without
exciting heat produce some determination
to the skin - the Haust: Salin: et Aut.
tartar: but if these symptoms continue
repeat the bleeding in the opposite temporal
artery afterwards from the external jugular
or the arm as often as the pulse becomes hard
two or three times in twenty four hours; the head
must be shaved and if there is a puffiness an
incision made even on the opposite side to
the blow; repeat the evacuations so long as the
symptoms continue; but when the pulse
becomes soft and calm - neither bleed nor
purge but keep up the diaphoresis which now
will afford the greatest relief; - but if the
patient grow delirious and light and noise 
become intolerable; rest is absolutely of the
utmost importance, nothing that may interest
or that is likely to agitate him should
be said as a tranquil state of mind is requisite;
apply a blister behind the neck; but not till
after other evacuants have been pushed as far
as you can; if the inflammation still continue




the deposit of matter causes paralysis
of some extremity and death takes
place as in fever. - Even where a patient
recovers no strong exercise, wine or
any thing which increases or accelerates
the circulation should on any account be
permitted, as the sensations are sometimes
felt for years rendering the person incapable
of eating animal food or drinking a single
glass of wine. - Symptoms of inflammation
more often come on where symptoms
of depression do not occur immediately after
the accident - that it is necessary tho' the
injury be ever so slight to put the patient
upon a very spare diet and bleed and purge
which must be strictly followed up - as for
want of it many loose their lives who might
otherwise be saved. -
Empyema.
Empyema is a collection of pus in the Cavity
of the thorax arising from inflammation
of the pleura - & following pleurisis or peripneumony
- a more common effect of inflammation
of the pleura is adhesions between
it and the lungs - tho' where these adhesions are 



extensive suppuration still may take
place - which being confined is called
spurious - when effused true empyema
the former being a small the latter a
large collection of pus. - Ulceration
of the substance of the Lungs sometimes takes
place when the matter is suddenly cough.d
up - at others this occurs between the ribs;
but so soon as it makes a protrusion of the 
integuments it should be opened - as it is
very desirable to have an immediate external
outlet; but where this opening in
true empyema should be made is not indicated
as the pressure is equal on every side.
but at last the lobe of the Lungs in which
the disease is situated becoming consolidated 
respiration is performed only by the other
still the matter continuing to accumulate
the chest becomes enlarged or distended on that
side - cough comes on - the patient can't sleep
in a recumbent posture, but only half sitting
or leaning forward - pulse small & quick
from 110 to 120; - here the only chance of relief
depends upon making an opening into
the chest which must be done between the
sixth and seventh ribs midway between the



sternum and spine drawing up the integuments
first, cutting thro' them the
intercostal muscles and pleura on the
upper surface of the seventh rib by which
you avoid wounding the intercostal artery
then introduce a trochar and after
all the matter is discharged thro' the
canula close the opening by drawing down
the Integument which forms a valve for
the exclusion of the air - and allows the patient
to breathe freely by a ready expansion
of the lungs. - In several cases of severe
peripneumony in children under 12 years
of age Mr Cline has discharged a washhand
basin of matter. - A little comes away daily
till the child's health is restored and the chest
assumes its natural figure. -
Enlarged Tonsils
The Tonsils are very vascular glands - &
every catarrh in some subjects induces inflammation
sometimes so great that
they even came in contact with each other
producing great difficulty in breathing and
swallowing - rendering it necessary to bleed
them by punctures with a lancet, but if 



not very large apply crude Sal ammoniac
which will produce a slight evacuation
of blood - and blisters to the sides of the
neck. - Sometimes tho' rarely deep seated 
suppuration takes place when relief will
only be obtained by a deep puncture letting
out the matter whenever it does not yield to
an antiphlogistic plan, - but frequently
inflammation produces induration and what
is called thickness of speech with interruption 
in swallowing. - But sometimes these 
enlargements arise without any other cause
than a scrophulous habit - here sea-air &
bathing with improvement of the general
health are to be advised - There are indolent
enlargements which not yielding to any
of the usual means of reduction became indurated
and are improperly in general called
schirrous - but Mr. C. never saw but
one cancerous - neither are they, like other
glands, subject to cancer; which would recur
if operated upon as they cannot be
brought away altogether but some part
must be left. - To tear them away as formerly
might excite great injury on account
of their situation & broad attachments. excision



is not very proper for the removal
being so vascular troublesome Hæmorrhages
arise and to which are account of the irritability
of the parts nothing can be applied
to suppress it without giving great uneasiness.
Mr Cheselden was the first to remove
them by ligature - which he introduced
by passing in a Tonsil probe with
a double ligature - keeping one in the 
hand and passing the other round the
base of the Tonsil where it must be
tied by introducing a Tonsil - Iron 
upon one ligature and drawing at
the other; - but when you can reach
the fingers is the best instrument that
can be used to pass the ligature round
the basis of the Tonsil - where two knots 
must be tied tight & cut off close - wh.
by intercepting the circulation - will
destroy or remove the Tonsil. - Sometimes
the base is so large - that as soon
as ever you attempt to pass a ligature
round it slips off - here a Tonsil- 
needle having an eye the point
must be used which with a double 



ligature must be passed thro' the Tonsil
one ligature must be tied above and
the other below - thus including the whole
base of the Tonsil - But when it has
been passed thro' and from the involuntary
motions of the tongue you cannot
lay hold of the ligature with the hook it
is extremely inconvenient - Here you
must use a needle and ligatures of the
common kind but one thread black & 
the other white - where by a slide instrument 
to hold the needle push it
thro' the base then loose the needle
and draw it thro' with a pair of forceps
- divide the ligature - tie the
black ends with the Tonsil - iron to include 
the upper - and the white the
lower portion of the Tonsil. - After
the removal of the Tonsil the part
soon heals with the application of
an astringent gargle _



Hæmorroids.
These are a varicose state of the veins
- painful & inflamed - accompanied
with swelling and sometimes extravasation
- they are either external
or internal - tho' more frequently
external - those within the sphincter
are often filled with a coagulum of
extravasated blood; - they are very 
common in sedentary but constipated 
habits - and this more particularly
with Seamen when at Sea - Medicines
which only keep the bowels regular 
are the best - as Sulphur; from the 
severe pain more active means are
sometimes necessary - as the application 
of Leeches the nearer to the part
the better - if these cannot be got 
make punctures with a lancet, but
when there are numbers you generally
find one more particularly prominent 
within a circle which may keep
up the swelling of the others this should
if influenced be cut away by taking
hold of it with a pair of forceps & with 



a probe pointed bistoury cut it off at
one Incision & let him loose 8 ounces or 10 ounces
of blood before you suppress the hæmorrhage:
but where they have contin.d
long attended with a difficulty of expelling
the fœces prolapsus ani is a
common consequence - the pain and
difficulty every time is increased &
from the protrusion of the rectum the
vessels are enlarged and there is great
difficulty of returning it - which
might more easily be done by setting 
the patient on his knee and elbows
and using a gradual pressure - or 
if inconsideable sitting on a hard
seat may effect its reduction.
Sometimes three or four hours elapse
before they become tolerably easy -
even an erect position of the body in
some of these will without any violence
push down the rectum - here
a pad must be constantly worn to
relieve the patient. But where there 
is great weakness you had better remove
them by ligature in the manner



mentioned when treating upon
Tonsils when situated without the
verge of the anus or if within -
pass the ligature when they come down
and then return the rectum - Ligatures
generally give great pain for 48 hours
but as soon as mortification ensues
they grow easy & the rectum is improved.
When tumors protrude from the rectum
if not of a schirrous nature
they may be removed by ligature - but
if schirrous the removal sometimes
hurries on and increases the complaint.
Polypi of the Uterus & Vagina.
These gradually enlarging, entered
thro' the os internum into the vagina
become very troublesome - sometimes
pressing upon the meatus urinarius 
the cause retention of urine - thus
an operation becomes necessary for 
their removal by ligature - when a
needle of Dr. Hunter's after careful



examination and distinction between
the os tincæ and polypus -
must be passed round with a double
ligature - the ligature being first
put thro' a ring and each end tied to
the projecting ends of the handle of
the ring - which must be inspected
from day to day and drawn tighter.
Sometimes these Polypi grow from the
cervix uteri and there cause a complete
retention of urine. -
Enlarged Uvulæ.
Proceed from inflammation & subsequent
swelling - and sometimes
require an operation; - but if recent
astringent gargles will sometimes
cause them to contract - when indolent
and long continued push a
pair of forceps round it and with a
pair of scissors snip it thro' only leaving
it of its natural length - the
Hæmorrhage is always very inconsiderable.



Paracentesis.
There are two species of dropsy: -
Ascites within the peritoneal cavity
which is the least favorable for an
operation on account of the inflammtion
of the peritoneum; - & encysted
Dropsy or dropsy of the Ovaria
which may be tapped with impunity
a great number of times.
Sometimes there is a number of granulated
parts on the surface of the
abdomen - sometimes general anasarca
when it may be necessary
to amend the state of the health first.
Dropsical ovaria dont injure the general
health - they are felt first only on
one side - but at last extended across
the abdomen with undulation on
striking - and impeded respiration
from pressure on the diaphragm -
here an operation tho' attended with
some risk is necessary and must



be performed by a trocar and canula.
It used to be performed between the
navel and superior spinous process
of the left Ilium - to avoid an enlarged
Ilium but the spleen has here
been wounded and the patient bled
to death - Mr Cline's method now
is from having once divided the epigastric
artery in this direction
to make the puncture in the Linea
alba under the navel - In the above
case the man died from internal 
Hæmorrhage an hour after the 
operation. - When the abdomen is
distended the artery which runs on
the middle of the rectus when it is
expanded is carried along with it
to exactly midway between the navel
and spine of the Ilium - that
Mr. C. has since always made the
puncture in the above situation;
first with a lancet which takes off
the danger of wounding the viscera
if enlarged by the force which is 



required for the puncture. - In
order to prevent extravasation during
the operation - it is necessary
to pass a sheet round the abdomen
& keep up a constant pressure on 
the parts equal to that of the water
evacuated - Great inconvenience
arises from making the puncture
whilst the patient is in a lying posture
- for tho' it prevents faintness
the viscera fall upon and obstruct
the flow of water thro' the canula - &
it once happened to Mr. C. to wound
the viscera by introducing the trocar
in this situation - & the man bled
to death from an artery of an enlarged
omentum which was diseased 
& of which he would have died.
In encysted dropsy if the canula is 
not very long you can't evacuate
the fluid - nor unless it is very large
the fluid is so thick and gelatinous
or contains hydatids which get into
the canula. - Mr C. once met 



with a case of the gelatinous sort - in
which tho' the patient had been tapped
three times nothing would follow - but 
at last by the constant pressure of
the abdominal muscles she became
emptied - but inflammation of 
the cyst coming on destroyed her. -
Cataract.
Is an opacity of the crystalline lens,
from which vision is lost - this
change begins in a small spot or
speck of a white color - which increases 
till the whole humor becomes
opake and intercepts the transmission
of light - but some rays may pass
thro' the edges of the lens to the retina
from which he may be conscious of
light but cant distingush any object
still when the pupil contracts and
dilates it is a favorable circumstance
but when not the nerve may be diseased 
or there may be adhesions of
the Iris to the capsule of the Crystalline



and this all round - this disease
comes on insensibly - in general
without pain - tho' sometimes there
is a pain felt before in the upper
part of the orbit. - Medicine has
no effect therefore an operation is
absolutely necessary - but sometimes
a cure has been effected by
a violent inflammation and irritation
in consequence of an unsuccessful
operation or a blow causing
inflammation in the transparent
cornea - and producing
absorption of the crystalline humor.
They are at first fluid or what is called
milky cataract - which exists more
frequently in young than old - infants
are sometimes born with it.
Sometimes there has been found an
earthy substance - but here the
cataract is generally of a brown color.
Cataracts occur in all ages - and
in some cases there is an hereditary
predisposition to this disease



A man at 25 and his two sons one 
at seven and the other at fifteen
years of age. - There are circumstances
to be objected to an operation
- as a cataract in one and
not the other eye - as if the operation
is here performed sympathetic
inflammation may prove the loss
of the other - if not and he is operated
upon it is without benefit as
the focal distances of the two eyes
will not correspond and he would
be better with one than both eyes
if he were to wear a convex glass
over the operated eye he would have
to contend with the difference of
size in the objects - but in short
no operation ought to be performed;
wait till both are affected and then 
operate upon both at the same time,
as there will be no greater disturbance
of the system and a double 
chance afforded for the cure. -



The adhesion of the Iris is in some
measure an objection - but still
not sufficient to prevent an operation.
- There are two ways of 
operating for cataract - One is
called extraction and consist in
removing the lens completely; -
the other Depression - which consists
in moving the lens out of
the line of vision or displacing it.
Depression or Couching - is performed
with with a needle - flat small in
size & cutting on both edges - the
patient should sit on a seat below
the operator - if he sit low the patient
should be on the floor, that
the operator may have sufficient
command of the ye without raising
his hand - the best light
comes from only one window &
the patient placed so that the light
may fall obliquely between him 
and the operator - the head must 
be



held by an assistant placed behind
him who with his fore and middle
finger must take hold of the upper
eyelid and press it against the
orbit avoiding the globe - using the
right hand for the left eye & vice
versa - the operator with his
spare hand may draw down the
under eye lid and press it against
the globe to steady the eye - then taking
the needle between two fingers
and the thumb & resting his hand
upon the temple with the other two
fingers - using the right hand for the
left eye & vice versa - the needle
should be passed thro' the opake cornea
- about 1/10 th of an inch behind
the cornea transparens towards
the outer canthus to avoid
the ciliary processes and continued
to the upper part of the crystalline
then turn the flat side down and 
press the cataract into the vitreous



humor till you can see thro' the
pupil that the whole has disappeared;
when this is done withdraw the instrument
in the same manner you
introduced it - The depression
ought to be made with a slow motion
taking care to use no violence.
When both have thus been depress.d
close the eyes and keep a folded linen
wet with some cooling lotion constantly
upon them - The day
before the operation - purge - and
order a spare diet - which should
be strictly persevered in for a 
forthnight - or more - or till all
tendency to inflammation is gone
over. - But the lens is apt to resume 
its proper situation - thus
requiring a repetition of the operation
- which from repeated inflammations
may destroy the organ
the proportion of success diminishing



with every repetition - there is 
also a disturbance of all the coats
and one of the straight muscles
of the eye is wounded in this
operation - After the operation
the patient should wear convex
glasses without which he can
neither read nor see distinctly.