Professor Fox. M.B. 1 Mr,, Cooper's Lectures on Surgery On the effects of accidents, and diseases on the constitution, and sympathy of diseases on it. Sympathy of diseases are those where one part feels pain in consequence of an injury inflicted on another; Irritation may be only sensation in a diseases, which may affect the action of parts.- A pain in the Loins follows an inflammation of the Testes, A stone in the urethra occasions pain in the Testes and high on the side- The knee is painfull when the Hip Joint is diseased, occasioned by the communication of the Sciatic nerve; therefore where the knee is very painfull, and there is no inflammation, we should be particular in our examination of the Hip Joint, as so many practioners have so frequently been mistaken in this case. - A disorder in the liver occasions 2 a pain in the shoulder, outside of the collar bone, also an itching of the nose and rectum takes place when the rectum is irritated; Dr. Hunter called them sympathetic dilutions but they can be dilusive only to the uninformd. - bad affections of the Liver and stone in the urethra produces only local pain - we cannot discriminate with such accuracy as on their sympathetic symptoms, the Testes becomes painfull in consequence of an inflamation of the Urethra: the glands of the groin will swell and inflame in consequence of the passing of a Bougie producing a sympathetic Bubo - an unexpected blow on the stomach the very trifling will sometimes occasion [the] Death: - A man was endeavouring to part two women fighting in the street received a blow from one of them on the stomach and instantly fell, and was supposed at first to have fainted, but was dead; on opening the body no particular appearance 3 of disease was found- A young healthy man received is slight blow by the back of the hand and fell immediately, Mr. Cooper and another of the Faculty tried the usual modes of inflating the lungs, warm bath &c in vain; on opening the body a small discolouration was found in the stomach where the blow had been given occasioned by extravasation between the coats of the stomach: in these cases the blow on the stomach occasioned a cessation of the action of the Diaphragma and stopd. inspiration - Almonds when eaten will with some people produce violent irritation of the Skin; - Sympathy of actions is where one part acts in consequence of Injuries done to another; Thus injuries of the Head, strictures of the Intestines produces vomiting When a stone is passing the Gallbladder vomiting is producd, as is likewise the case when the uterus is inflamed, in the effects of irritation all the functions of the Body are changed by partial injuries Thus in a Compound Fracture in 24 or 36 hours all the functions will be changed 4 in scrophulous habits the change may be rather slower;- we shall find pains in the back, loins, and Head in Fever; the action of the Heart is altered the pulse becoming quick hard and intermittent, the alimentary Canal is affected the Tongue is firrd., white when the degree of irritation is small, brown when it is great, sickness of the stomach takes place and constipation of the Bowels, perspiration is stopd. the nerves become affected sleep interrupted, delirium and subsultus tendinum follow; a profuse sweat will break out and then the symptoms abate, but in a short time they return with greater violence;- The Symptoms should be regulated and checkd,, their Violence depend on the importance of the part Injurd, - a very small wound of the Intestines, will occasion a cessation of the pulse, or make it so faint as scarcely to be perceived - in parts not so essential to the vital functions, the symptom depends on the size of the wound, and on the degree of vital power possessd. by the part. Thus wounds of the Tendons produce more irritation 5. for the tendons being less Vascular require a greater afford of nature to restore Injury - A man was kicked by a Horse on the Intestine there was no pulse felt in the wrist, and yet survivd. 12 hours - The smallest ulcer on the Lungs will produce more considerable effects to the constitution than the largest ulcer on the Legs or any other part - In accidents many things are to be considered. 1st the importance of parts injured. 2ly the extent of the Injury. 3ly. wheather the Vital powers are weak or strong the weaker the better; Symptoms depend greatly on the natural irritability of the constitution A man was brought into the Hospital with a Compound Fracture of the elbow. The bones of which were laid bare. his hand at the same time quite crushd, amputation was thought inevitable but the man refusd. to submit and the arm got well without much pain and without any bad symptoms except a small abcess on the upper part: a much less injury in a person of an irritable habit, would have producd. Mortification and Death - the signs of irritability are great pain, extended inflammation, fear of Death, restless and delirium; 6 Fat persons are generally irritable. intemperate persons have a very considerable degree of irritability; the passions of the mind has a great effect in all operations; and in accidents it is always proper to inspire the patient with hope: the passions that influences the Body are grief, anger and fear- Joy and hope produce stimulating and healthy effects= Grief fear and anger lower the actions of the Vital power, and retart recovery. Grief particularly effects the Liver and produces conjection of bile,. Fear has a more particular effect on the Constitution than the rest. Anger produces a quick hard pulse and influences the irritation of the mind on the Body. - Mr. Cooper attended a gentn. for a Chancre. it had a healthy appearance but suddenly became worse without any apparent cause, it afterwards went on well again & again became worse had frequent lapses of this kind; till at Mr. Cooper accidentally calling found the Gentleman in a Violent fit of Passion and on examining the chancre he found it considerable worse sloughing be 7 on removing him to another place where he was not exposd. to anything which could cause passion the Chancre was soon healed by the same means that had been used before tho the air of the place to which he was removed was not so healthy as where he first resided.- Fear will frequently occasion Death; where there would not have been any danger without - A man with a Simple Fracture of the thigh was brought to S. ThS. Hospital he was prepossesd. he should die, his fears were smiled at, but on the eighth he died there was no inflammation nor was there any union of the bone taken place - a lad 17 years of age died in a similar manner of a simple fracture - Mr. Pott was called to Gentleman of a very timid disposition, who had symptoms of stone, the nature of the complaint his Friends had carefully concealed from him. Mr. Pott made an examination (with the sound) and having found a stone and being ignorant of his timidity told him the case, and that he might be effectually relieved by an operation 98 The Os Femoris is liable to dislocation in four different directions - 1st upwards or into the dorsum of the Illium about two inches above the acetabulum the trocanter Major is turned forwards and the head backwards the foot inwards and the leg on that side is about 2 o 2 ½ inches shorter than the other the limb cannot be moved at the hip Joint being so strongly bound by the muscles - Treatment - Place the Patient on the opposite side to the dislocated one. the Pelvis is then to be fixed by carrying a girt between the scrotum and the Thigh of the dislocated side round to the outer part of the Pelvis and there to be fixd. to a pillar or some steady point. The dislocated Thight is to be brought over to about the middle of the oposide side a bandage then being fixd. above the knee which is to be kept bent. the extension to be made obliquely forwards and downwards. after this has been made for sometime and it does not succeed let 99 a bandage be put round the upper part of the Thigh which is to be so long as to admit the Head of an assistant through it he then is to place his hands upon the Pelvis to prevent its raising than gradually and forcibly raise himself- The head of the bone will be elevated over the brim of the acetabulum and will slip in. this elevation is to be made at the same time as the former extension. or it is sometimes reduced by pressing hard upon the Trocanter major while the extension is made 2nd, dislocation is downward or into the foramen ovale the leg in this is much longer the foot turned inwards. The knee separated at some distance from the other and the patient cannot bring it to the other - Treatment. place the Patient on his back carry a girt round the upper part of the thigh and fix it to a point as the former the limb being bent press upon the knee by the weight of the body inwards. by these means the bone will 100 generally be reduced. 3rd Dislocation into the Ischiatic notch. The leg is very little if any shorter the Toes turned in the knee Lying upon the other, and the heel separated at the distance from the other. Treatt. Place the Patient upon his side and fix the Pelvis bend the Thigh at right angle with the body the extension is then to be made in this direction at the same time bend the knee a little downwards. otherwise in making the extension the head of the thigh bone would be drawn below the acetabulum and pulled into the foramen ovale, therefore to prevent this the knee must be a little bent. the same bandage is to be used here as in the first to raise the head of the bone above the brim of the acetabulum 4th dislocation is forwards as upon the Pelvis. the Foot is turned out. the leg is nearly the same length by rotating the limb the head of the bone is seen moving in the usual situation of a Bubo Just at the middle of Pouparts ligament 101 treatment. Place the Patient upon his side, carry a Girt round the upper part of the Pelvis which is to be confined by a roller from the girt round the thigh a bandage is then to be put round the upper part of the thigh into which a pully is to be fastened. The extension to be made rather obliquely upwards - These Dislocations are to be careful distinguished from Fractures of the cervix of the femoris. this however happens generally in Old People. In these cases the Leg is shorter and the Foot turned out - Dislocations of the Patella 1st outwards when it becomes immoveably fixd, to any common force that is applied Treatment. The leg being already extended (for the Patint cannot bend it) put your hand to the outward edge of the Patella and then press it downwards and at the same time inwards 2nd. Dislocation Inwards when it is situated internally the reduction is the same as the former 102 3rd Dislocation upwards from the Ligament connecting it to the tibia being torn throug: the Patella is then drawn up two or three inches by the rectus muscle about the knee - Treatment A cushion is to be put at the upper part of the Patella and confined by a roller pressing above and below the knee. There is over the Patella between the skin and the Tendon a Bursa Mucosa which often becomes enlarged, and frequently in women who are much accustomed to kneel. The bursa inflames swells and often increases to a considerable size Treatment. the knee is to be bent as much as possible the the tumour will became tense and hard. and if struck two or three hard blows will generally disappear If this does not succeed make an incission the whole length of the tumour and dissect out the sac after which bring the edges of the wound together by plaster and treat as a common wound 103 If inflammation comes on poultice and fomentation are to be applied and also Leeches this operation does not produce such violent symptoms as if it had been left to suppurate Dislocation of the knee joint It is liable to be dislocated in four different directions 1st outwards. the head of the Tibia is thrown on the outer side of the Os Femoris Treatment. An extension is to be made in a straight direction at the same time pressing the bone inwards - 2nd dislocation Inwards which very rarely happens it requires the same treatment as the former 3rd Dislocation Backwards little extension is requisite to reduce this notwithstanding the injures which must happen from these dislocations yet the Joint generally recovers its proper function 4th Dislocation is when one of the cartilages becomes separated from the Tibia and 104 Os femoris and is resting upon the ends of the Tibia instead of the cartilages it produces but little deformity in the Joint. the knee cannot be straightened but allows of flexion. Treatment The limb is not to be attempted to be straightened but bend it back as much as possible towards the nates. This allows the Cartilage to return into its place the Leg may then be straightened and it will resume its proper place when this accident has once happened it is very liable to return the Joint therefore is to be straightened by bandages - There are loose cartilages sometimes forming in the cavity of the knee Joint, and on the outer part which produce great inconveniences, a person when walking is liable to fall down suddenly from the cartilage slipping between the extremities of the bone soon afterwards it will move and the person will be able to walk again. These are 105 to be removed by an operation. the Cartilage is to be pushed if possible to the outside of the Joint an incission is then to be made the whole length of the Cartilage - before the incission is made the integuments are to be drawn very much above the Cartilage. so that the external orifice shall not be even with that communicating with the Joint the incission being made the cartilage is to be extracted. If it does not come out readily it will be right to extract by a tenaculum. the edges of the wound are then to be brought together and confind. By sutures which more effectually prevents subsequent inflammations at the hazard of the Patients life or expose him to extreme pain by the formation of Matter and anchylosis - Dislocations of the Ancle The 1st and most frequent is the Joint being thrown forward on the upper part of the foot the lower end of the fibula remaining in its 106 place and of course must be broke the heel is much lengthened and the distance from the Toes to the end of the metatarsal bones much shortened Treatment. make an extension by putting the Tibia downwards. the Foot likewise extended, after this reduction the Limb should always be laid upon the heel till the parts are recovered otherwise a return of the accident is liable to take place. 2nd Inwards when the end of the Tibia is resting on the inner edges of the astragalus the over extremities of both bones being broke off a large tumour appears on the inner [crossed out] side of the ancle . Treatt. Take hold of the Foot with one hand and with the other hand keep the leg steady a very gentle extension is to be made at the same time let pressure be applied on the projecting bone, when reduced lay the limb on the outside. 3rd when the end, of the bones are thrown on the outside of the Tarsus. the maleolus externus 107 being broken off - Treatment to be the same as the former, and when reduced lay it on the outside - When a compound dislocation happens, the Tibia and Fibula broke appear externally and the Joint laid open, it is a question whether it will be bent to amputate or not. attempts ought to be made to save the limb. for amputation performed so early after the accident is generally productive to the Patient - if advanced in years the operation ought not to be performed as the living power is very weak in those - on the contrary if the Patient is under 40 years a chance ought to be given - On Incysted Tumours These don't require to be removed as they occasion but little inconvenience. if they are large and no considerable vessels near, you may treat them in the same manner as Hydrocele either by Seton or Injection- If small remove them by the knife but if any large vessels are situated near open the tumour with the lancet and inject a little 8 The gentleman replied that the operation would not be necessary, for the idea of having a a stone in the Bladder would kill him - Mr. Pott took his leave but observing a great attention in his countenance sent Dr. Harris to inquire after him the same evening & when he came the person was dead: - A Lady with a scirrous Breast of no great extent was much pressed by her Friends to submit to the operation she refusd. for a long time; but at length she consented: she said she did it in compliance with the wishes of her Friends but was sure she should not survive it. Mr. Cline performed it and nothing could be done in a better manner. The Lady was put in bed; her countenance sunk and she died very soon after; her prepossession was so strong that she ticketed her keys and disposd. of every thing in such manner, that the Family affair might not have any interruption - On the Progress of Inflammation The existence of inflammation is known by redness 108 of the white Vitriol solution - Children are particularly subject to the formation of these incysted tumours On Diseases of the Testicle The diseases rendering its removal necessary are four 1st. Hidated disease this begins in the extremities of the Epydidymus extends into the Body of the Testicle back towards the spermatic cord, it is never attended with much pain, it may therefore be mistaken for Hydrocele; It is not of a cancerous substance; is confined entirely to the Testicle and is of a very considerable size. This diseases generally occurs between the age of 20 and 30 and sometimes later in life - In order to distinguish this Disease from Hydrocele it is to be observed that it differs ins shape, but, is of the form of the Testicle is prominent before and flat on each side, secondly its weight 109 is very considerable, but its want of transparency is the best mark. This Disease is very liable to deceive even the more eminent of Surgeons: Mr. Pott and Mr. Cruckshank have both fallen into this error - If you have any doubt in your mind respecting the disease puncture the Tumour with a lancet, and if there is no water. proceed to treat it as a diseased Testicle. This disease is found to be collection of a number of cysts on the surface of the Testicle filled with a mucilaginous substance, these cysts vary in their size from a pea to a marble, after the Operation for this complaint the Patient in general does remarkable well - The 2nd complaint is the true schirrous Testicle which originates in the body of the Testicle and becomes as it were all at once hard and considerably enlarged, it the proceeds to the Epididymis and spermatic cord- it may be distinguished from all other diseases of the Testicle by its stony hardness, it is likewise attended with considerable pain, but not constant 110 triffling causes produces this disease. it is envisioned by a deposit of coagulable lymph becoming at length cartilaginous runs up the spermatic cord into the abdomen and produces the same disease in the Loins as that originally in the Testicle Before you operate examine if the spermatic cord is diseased for it is of no use to operate if it is, therefore you should operate as early as possible - There is another species of cancer in the Testicle which Mr. Cline calls the Pulpy cancer this is a much more dangerous disease it originates in the same manner as the former, but its effects are much more sooner destructive . In a few weeks this disease extends into the abdomen and renders any operation fruitless and generally in the course of 20 weeks proves fatal, its called the Pulpy cancer because when you feel it it seems like the Hydatid Testicle. great pain attends this disease and if a Lancet is pushed into the Tumour Blood flows out 111 a sallow countenance is another decisive mark of this complaint so that with a little attention this disease may be distinguished from any other. The Operation must be performed as soon as the Cancer is attended with pain. The Tumour formed in the Loins from this disease when allowd. to take its course is much larger than the schirrous amounting in some case to 11 or 12 pounds when it is cut in its early stage it appears like curdly coagulable Lymph, but in the latter stage like Brain broken down by Putrefaction - This disease has been known to extend to the thoracic duct so as to destroy its internal surface - The 3rd is that of suppuration in the testicles. This begins sometimes from venereal causes, leeches are to be applied with a strict Antiphlogistic regimen. Calomel also ought to be given to promote absorption it likewise arises frequently from scrophula. The abscess which is formed in the testicle being of a scrophulous nature - It may arise from a violent blow on the testicle slight febrile attack attend this complaint remitting often 112 for many days, but ultimately the operation will be found necessary. When the Testicle is cut into, a curdly abscess is found in its centre - A fungus on the surface of the Testicle has been supposd to require an Operation for its removal but all that is unnecessary, but make circular inception round the Fungus including a small portion of the surrounding skin - cut it off just as it springs from the Tunica albuginea. bring the edges of the wound together and unite them by sutures On Aneurism By the term Aneurism is meant a Tumour containing blood formed by the yielding of the coats of an Artery, and which tumour has generally a pulsatory motion corresponding to that of the artery of which it is placed These tumours when examined may be divided into 3 stages with regard to their symptoms - 1st, when the tumour is very small its pulsation is remarkable 113 strong and the fluid which it contains, can be made to disappear by pressing on the Artery between it and the Heart, but on the pressure being removed it instantly reappears. in this stage of the disease the Patient suffers but little pain except that he feels slight spasms about the part during the night - 2nd stage If the Tumour is very large you cannot press the blood out of it as before, as the Blood is at this time in a coagulated state and deposited in layers, but the skin remains undiscoloured although the pain is very considerable. in this state the tumour may remain for years especially if it be situated under a Fascia - but with regard to this point every thing depends on its situation. 3rd stage, when the Tumour is about to burst but prior to this taking place, the skin becomes of Brownish red color. after a time it cracks discharging a Bloody Icher it then becomes mortified where it had been red, and sloughs, its edges in separating opens 114 into the sac. The Hemorrhage sometimes destroys the Patient suddenly but this is comparatively a rare circumstance as the progress of its bursting is generally very slow. When the Tumour appears ready to slough Mr. Cline advises it to be bound down with adhesive Plaister which prevents its bursting as soon as it otherwise would - Aneurism is found to take place most frequently in the extending portions of the aorta & its arch which it forms towards the dorsal vertebrae, when it is thus situated it shows itself by forming a Tumor under the sternum or Cartilages of the Ribs When it takes place in the Arteri Innominata a Tumour is seen under the carotid artery in the neck. sometimes an aneurism is formed between the curvature of the Aorta and Diaphragm. then the Death of the Patient is occasioned by the Pressure of the Tumour on the Trachea and osaphagus into which last it generally bursts. When it is situated in the abdomen it produces various symptoms, the Foot 115 being regurgitated generally soon after it is taken into the stomach so that the Patient dies exhausted and in a manner starvd., it generally shows itself by a Tumour situated at the umbilicus - An aneurism is now and then forming in the aorta just when the emulgent arteries are passing off. in this case a Tumour is formed in the side of the spine and which Tumour has no pulsation, these Tumours have been mistaken for Lumber abcesses and opened without detriment to the Patient. but when we do this Mr. Cline advices the puncture to be very small, a difficulty of passing the urine and foeces are sometimes occasioned by these Tumours. On Dissection of Aneurisms you find the artery in general given way only on one side; The aorta has be been known to give entirely, but this is very rarely the case - This disease generally takes place between the age of 35 & 50 Tho sometimes at a more advanced age, one case which Mr. Cline had under his care 116 occurred in a patient only 24 years Pophlitic Aneurism differ from all others from its being liable to be produced by local causes, as Violent exertions &c independent of any constitutional affection and may occur at any period of life. The cause of Aneurism in any other part is that the cuticular or internal coat of the Artery inflames, thickens & destroys its Texture, by which it gives way from the impetus of the Blood passing through it. its external coat remaining unaltered To distinguish this disease from any other you may suppose that its pulsation is a certain criterion, but in this you may be mistaken ..... Tumours sometimes forms, for instance in the neck under the carotid artery which is running over its substance. if you feel this Tumour and find a pulsation you at first suppose that it is an aneurism but if you put your finger on each side the tumour you will find that it does not pulsate, and by this mark you can ascertain whether it is an 117 Aneurism or not, if it is one. by taking the Tumour and lifting it form its bed as much as possible you will find it to pulsate strongly. these therefore are circumstances highly necessary to keep in mind - by attention to diet &c these Patients may be kept alive for a considerable time. Calomel should be taken when any pain is felt in the Tumour and Leeches applied on some part little distance from it - The Operation for Aneurism as it was performed 20 years ago. The first step in the Operation was to secure the artery by Tourniquet. then an incision made the whole length of the Tumour the coagulated Blood became exposed, this being removed and the sac washed out with a sponge dipt in warm water. the mouth of the artery being [removed] laid open then the Tourniquet loosened a little, in order more readily to discover them a Probe is to be passed into the superior extremity of the artery and a ligature made on it about an inch above the Tumour the 9 swelling pain and heat, these are the diagnostic sign’s. Tumors arise from the different causes from distention of the Vessels; where there is much tension, serum is pourd. from the extremity of the cellular membrane, and sometimes coagulated lymph: the nerves are strecthed by expansion of the Vessels, this occasions pain which depends on the degree of inflamation, this may be perceivd in operations which produce sometimes a great degree of pain while others that take a great deal more time before they perform are not so painfull that was increased in inflammation Dr. Hunter doubted from experiments he made on animals he injected corros: sublim into the rectum of a dog and waiting 24 hours when the inflammation was at its height he introduced a thermometer and found that the natural heat was not increased, he tried the same experiment on the vagina of an Ass, in 12 hours when the inflammation was beginning he found the natural heat had fallen one degree, and when the inflammation was at its height the heat was at its natural standard. we may conclude that this circumstance takes place only 118 same was done in the inferior portion of the Artery about an inch below; the edges of the wound were then brought into contract (the ends of the ligature being brought out at the wound) and secured by sutures or adhesive plaisters which finished the operation. but in consequence of the Ligature being thrown off, after the operation frequently, it now entirely laid aside - The present method of performing this operation; make an incision the whole length of the tumour (it is a popliteal aneurism meant) in order to expose the sactorious muscle you are then to dissect it away on its outer edge, pull it on one side and the Fascia is laid bare which encloses the femoral artery vein & nerve which last is to be carefully avoided, the Vein is situated between the artery & bone you are then to cut through for the Fascia to such an extent as to admit an instrument passing freely under it & then pass the director under the artery and in so doing give it a slight lateral 119 motion so as early to tear through the the cellular membrane beneath it: you are then to take an eyed Probe arming it with a double Ligature, having a needle at each end, the Probe is then passed through, along the hollow of the director the director is then to be withdrawn the Ligatures being drawn to an equal length on each side the Probe may be cut away: you then separate the Ligatures about an inch from each other: securing the upper portion of the artery first the same must be done with the inferior portion of the artery; first tearing away away the cellular membrane, this being done, the needles are to be passd through the Coats of the artery and again secured, then bring the edges of the wound in contact with the ends of the Lignature hanging out of the wound and endeavor to heal it if possible by the 1st intention, hemorrhage has been known to ensure when the Ligature came away - In applying the adhesive plaster leave small interstice to allow the escape of matter, but donot apply a roller because by its prepare in the anastomosing branches of 120 of the artery it sometimes produces Hemorrhage. The Patient should be placed on his back with the knee slightly bent and a pillow placed under it The limb being wrapped in flannel as the Patient will complain of cold and unless proper care is taken mortification will ensue, In two or there days after the operation the heat in the affected limb in greater than in the other. If no hemorrhage comes on at first there is no danger till the ligatures come away, which they do sometimes as early as the 4 Day. at other times on the 17 or 23. at this time bring the edges of the wound in contact unless there is considerable suppuration and apply a roller. The consequence of this operation is that the Patient in general complains of a weakness in the Limb with a sense of coldness - In Aneurism of either the Posterior or Anterior Tibial Artery. The Femoral Artery should be secured in the middle of the Thigh in preference to the Ham. as here the Vessel is deeper seated. If the Brachial Artery be wounded in 121 Bleeding cut down on it and secure it above and below and divide it between the Ligatures - never apply a Ligature near an Aneurismal sac. as inflammation may extend to it, produce suppuration and destroy the Patient neither contegious to the Anasomosing branch of an Artery In aneurism of the Carotid, Posterior aural or Brachial Arteries Mr. Cline makes an incision on the sac. securing the Artery above and below as before directed & dissect the Tumour out &c - On Fistula in Ano This Disease in produced by and abscess forming itself in the Cellular substance surrounding the extremity of the Rectum or just by the verge of the anus. The sinus occasioned by this does not always confine itself to a straight direction. but sometimes extends nearly round the Anus - when the Fistula is one formed it seldom or ever heals itself It is because the the Rectum is constantly tearing the sides of the sinus on account of its contractile power, therefore to remedy this 122 The sinus must be entirely laid open This disease frequently attacks Patients after long continued Fevers, or disease of the Bowels or Liver, in this last case Calomel must be given before you attempt to operate. The Piles generally preceeds this Complaint - it is also a frequent attendant in Phthisis Pulmonalis, but it is of no use to Operate in these Patients as no cure will be obtained : Fistula is sometimes depending on local causes as costiveness &c sometimes from long continued exercise on Horseback & from Violent irritation of the Parts - The method of operating. Pass a probe up the sinus with a Finger of the other Hand previously dipt in oil into the Rectum by this you will distinguish if the sinus runs into the gutt then pass Potts Bistary along ye probe untill it meets the extremity of your Finger the lay it open through its whole extent, place a dip of dry lint into the wound after & continue this dressing till a cure is obtaind. - Fistula may sometimes be cured without any operation by Injecting the following 3 or 4 times a Day Rx Aq:Calcis ℥iv Hydrarg Muriate giv M and at the same time give Wards paste Rx Pulv: Enul : Campan Hi semen fenual dule Hip Piper negre H1/2 Pulver bene at adde sacchar et Milles a a Hi M sumat L.N.M vis vel ter in die - 123 On Amputation The first step necessary to be taken in this Operation is to apply the Tourniquet. If The Operation is to be performed below the knee it should be applied a little above the middle of the inner part of the Thigh as there the Artery requires less pressure - If the Operation is to be performed so high up on the Thigh that the Tourniquet cannot be applied pressure must be made on the Artery in the groin as it passes over the pubis by an assistant - When on the Arm apply the Tourniquet on the middle of the inner part of the Arm between the shoulder and Elbow (near the insertion of the Biceps Muscle called the Deltoid) - if very high an assistant must secure the Artery by pressing behind the Clavicle - On Amputation of the Fingers. in amputating the 2 or 3 joints make a circular incission a little above the Joint and then make a Longitudinal incision on each side as far as the Joint in order to leave a double Flap to cover the stump, then 124 pass your knife into the Joint and remove it cover the stump with integuments and apply adhesive plaisters. The first joint is amputated rather different. make an incision between the Fingers on each side which incision should meet on the back of the Hand, divide the Tendons on each side rather short. remove the Finger by cutting into the joint. Cover the stump with integuments and apply ample adhesive On amputation of the Metatarsal Bones In Performing this Operation save as much integuments as is required to cover the stump from the bottom of the Foot, then make a circular incision saw through the Tarsal bones bring the Flap over the stump, pass sutures thro' the integuments and cover them with ample adhesive and light dressings. the parts in general heal readily. In this operation half the Foot is only removed - On amputation below the knee with a flap according to Mr. Hay’s method is as follows. first measure the leg from the knee to the ancle 125 and take half the length as the spot where you are to take off the limb, next take off the circumference of the Leg, one third of which is to be the length of the Flap. The parts should then be markd. With Ink. the catlin is then thrust through the Limb at this place and carried down to 3 or 4 inches in the adult and brought out make a circular incision round the Limb draw up the integuments and cut thro' the muscles to the bone, pass the catlin between the bones to divide the interosseous ligament, and saw off the Bones turning the limb round so as to apply the saw on both bones at once. The Fibula should be sawd. through first. bring the Flap over the stump and pass sutures Mr. Hay makes use of eight in this operation The [am] patients who undergo amputation in these Hospitals suture can rarely be made use of by the advance of Mr. Allamon they are at one time used in the Hospitals but were found to occasion with great constitutional irritation and symptoms of Trismus 126 or lockd, jaw so that in two or three days they were obliged to be removed consequently adhesive Plasters was made use of with a compress of Lint, a cross cloth with the Roller, and the stump kept cool - The Present method. The distance below the knee where the incision is to be made is a hands breadth in the adult, in children about 3 Fingers below the joint of the Patella, or Rotula, make the first incision about 2 inches below the part at which the bone is to be sawn off, in order to save integuments to cover the stump: in Children about 1 ½ Inch divide the Fascia which binds down the muscles on each side of the bone, then draw the Integuments upwards next divide the muscles to the bone. turning the the edge of your knife rather obliquely towards the knee: pass the catlin between the bones and apply the saw as before directed bring the integuments over the stump, having secured the Tibialis anterior arteries and Intercostal artery apply ample adhesive Lint Roller cross cloth and give the Patient an anodyne - 126 Amputation above the knee Begin your circular incision as near as you can above the knee joint. but in case of white swelling be careful not to cut near the diseased part as a cure after the operation will be tedious. make a circular incision through the common integuments divide the Fascia on the Anterior and lateral parts of the Thigh to allow enough to be drawn up then divide the muscles to the bone inclining the knife a little upwards then saw the bone as high up as you can, the Tourniquet being slackend you must secure the Femoral Artery and a branch of the arterial profunda. in securing the this Artery be careful not to include the nerve bring the integuments over the stump and treat as before - Amputation at the wrist – In performing this operation save as much integuments as you require to cover the stump from the Palm of the Hand, feel for the extremity of the Radius and make an incision just at the root of the Thumb to some 10 in the internal parts of the Body, the surface is evidently hot to the touch and the heat occasiond. by the inflammation of blisters has in in a great number of experiments been found to exceed the natural heat from 4 to 7 degrees Inflammations are divided into common and specific common is that which arrives from wounds or spontaneously in a good constitution without any particular change of arterial action producing an effusion different from the common inflammation, it will cause four effects 1st. adhesion or resolution this is by coagulated lymph pourd. from the extremities of the blood vessels- it consolidates the parts a preparation of a Heart shews this in a very distinct manner, it is coverd. With a coat of coagulated lymph which gives the external surface a rough appearance- the 2nd. effect is suppuration, the vessels here pour out matter instead of coagulated lymph - 3rd effect is ulceration which is an absorption of the inflamd. part producd. by a violent action of the absorbents - 4th mortification in 128 depth make an Incision round the wrist so as to meet the Flap whether on the back or inside of the hand, dividing the Tendons completely draw back the integuments and insert the knife into Joint and remove. bring the Flap over the stump and endeavour as much as possible to heal by the first intention, there are two Arteries to be secured the Ulnal and Radial, but this last if in a Gun shot accident rarely requires to be secured Amputation of the Fore Arm This operation is more dangerous in diseased Habits, than the upper Arm as suppuration frequently takes place between the Tendons with high constitutional irritation Lock Jaw and Death - First make a circular incision through the common integuments dividing the Fascia on both sides the Arm, draw back the integuments as much as possible. next divide the muscles to the Bone inclining the edge of the knife obliquely upward, next divide the Interossious Ligament by passing the catlin between the Bones turn the Limb round and apply the saw 129 on both bones at once. when the Limb is removed three arteries must be secured Viz the Radial, Ulnai Intercostal. then proceed as before directed - Amputation of the Shoulder Joint with a flap - The first step necessary to be taken is to secure the Axillary Artery, when this is exposed pass a Director under and carry a needle armed with a ligature along the grove of the director and secure the vessel, next take hold of the Deltoid Muscle between your Finger and Thumb and carry your incision obliquely upwards towards the bone this leaves the Flap which is afterwards to cover the stump, then make a circular incision round the Bone, turn the head of the Humerus out of its socket & cut it away bring the Flap over the wound and endeavour to heal by the first intention. - 130 In Diseases of the Female Breast The first disease we sall speak of is the formation of Hydatis in the breast. similar to those occurring in the Testicle in the Male. in this Disease the Patient at first suffers but, trifling pain. In the early stage, the Breast feels as if small knots were placed under the skin of various sizes, when the disease has continued a long time, one of the Tumours increases in size, ulcerates, and discharges a Glary Fluid, and if more Tumours Ulcerate very troublesome sinusses ensue In the removal of these Tumours there is no danger, and when removd. do not return [or] this disease does not extend by absorption as in cancerous Tumours The next disease to be treated of is that of schirrous The symptoms of which are a discharge of Blood from the nipple. or an uneasy sensation in the Breast when the Arm is thrown back. Pain in the Breast shooting into the axilla, a Tumour formed of a remarkable hardness feeling like a marble under the skin. in an early stage the 131 Tumour is moveable. and the Patient suffers very severe pain at time but not constantly- If the woman is menstruating a Day or two Prior to this the Tumour enlarges and becomes more painful - it goes on gradually until it becomes of a considerable size, the Glands in the Axilla becomes affected, with a slight pricking in the skin forming a kind hollow over some part of the Tumour. when this is the case Dr. Cheston of Gloucester observes that no success will attend the Operation if performed; the skin also appears rather inflamed. one or two Glands under the edge of the Pectoral Muscle first becomes affected and the Glands above the axillary artery and Vein, the disease also extend, into the Chest. Tumours are formed opposite the middle of the Clavicle in this case all you can do is but palliatives - in case of adhesion to the Pectoral muscle only you may operate with advantage as a considerable portion of this muscle may be removed without detriment to the Patient If the Tumour is left to itself it ulcerates and discharges a bloody Ichor. these schirrous Tumours become sometimes entirely cartilaginous 132 Prior to the patient dying of this disease the arm of the affected side swells, becomes oedematous, acute pains are felt shooting from the axilla to the finger ends Patients sometimes die of a Cancer in a very curious manner, they complain of violent and unremitting pain in different parts of the Body. Opium tho given in large doses give but little relief and the Patient lives but a short time Mr. Cline related a case of a woman in Guy's Hospital, who had a cancer in both Breasts extending as low as the navel and not less than 50 small cancerous Tumours in different parts of the Body. the scalp in Particular she was attackd with difficulty of Breathing with violent pains in divers parts, high constitutional Irritation the Womand died. - The true schirrous generally takes place about the time when women cease to menstruate that is between 40 & 50. Old age is rarely subject to this disease - The Fungus Haematodes sometimes though rarely exists in the Breast, it is a disease similar to the pulpy cancer, which sometimes affects the Testicles in the Male and if you take a Lancet and make a puncture into the Tumour a fungus excrescence appears 133 like the Head of a cauliflower. when the Tumour bursts the patient survives but a short time. no advantage is to be [crossed out] gained by an operation as these Tumours will form again shortly – Women from the age of 16 to 24 or 25 are frequently the subject of Tumours in the Breasts which at first sight may be readily mistaken for a schirrus but this Tumour has no sensible limits when felt, appearing gradually to loose itself in the surrounding substance. but in the true schirrous you can readily discover its extent. it is accompanied with pain in the axilla shooting down the arm - It generally attack young women of strong Passions and delicate constitutions also young married women. The treatment in this disease is first to apply leeches to the part when the pain is Violent. apply a soap Plaister and over this apply the skin of some animal as is Hare, to keep up a degree of perspiration. which relieves the Pain and diminish the size of the Tumour give internally Ferri: Ammonia gr.v bis vix ter quotidie Gentle exercise on Horseback should also be recommended - In Performing the Operation for schirrus 134 Cancer makes your fist Incission in a semicircular direction over the upper part of the Tumour you then divide the Arteries which supply the Tumour with Blood, compression being made on these by an assistant, dissect out the Tumour so as to lay the Fibres of the Pectoral muscles. no ligatures are required bring the skin over the wound apply [Empt] adhesive & a Roller - The Method of Introducing ye Female Catheter The Patient lying on her back. feel with the forefinger of the left hand for the extremity of the Clitoris which having found carry your finger in a straight line one inch below, when you meet with the orifice of the meatus urinarius, then with your right hand you are gently to introduce the catheter. in introducing it elevate the point of the Catheter by depressing the Handle. The Cather should be somewhat more curved than usual as it then more readily takes the course of the meatus urinarius - 135 The Method of Introducing the Male Catheter - The Patient being placed on a Table. stand by his left side near the shoulder, introduce the catheter untill it reaches the neck of the bladder, the by depressing the Handle backwards so as to let it sink between the Patients Thigh. it elevates the point & the catheter readily passes into the Bladder - On Opening the Temporal Artery The best place for making an incision into this Artery is just as it emerges from the root of the Hair, make an oblique incision through the integuments in order to lay the artery bare. then make a small puncture in the side of the Artery - when you have taken away a sufficient quantity of Blood introduce the Lancet and divide the artery completely if it is not divided Haemorrhage will be continually recurring - 136 On Lithotomy First of the formation of Calculi in the kidneys their presence may be known by the Patient complaining of Pain in the Loins of a dull kind attended with sickness, and on rubbing the Back an uneasy sensation is produced in the side where the stone is lodged. after much exercise Blood is discharged with the urine. where these Calculi are passing along the Ureters the Patient complains of pain in the Thigh of the affected side, extending a little below the Groins in the course of the anterior Crural nerve and the Testicle is drawn up by the action of the Cremaster Muscle to the abdominal ring: Bloody urine is occasionally discharged Death sometimes takes place from a swelling of the abdomen coming on which fluxtuates, and on dissection is found to be an of the kindneys - The symptoms of stone in the Bladder are a cutting sensation at the extremity of the Penis, and when the Patient is discharging his urine it suddenly 137 stops. when the Bladder is nearly emptied itself there is frequent inclination to make water. with a disposition to go to stool at the same time, and when the symptoms run high the Foeces are often discharged involuntarily in any change of position. the Patient always feels pain, when much exercise has been used, mucus passes off with the urine. - If a stone has existed a long time purulent matter is discharged with urine from a disease in the Bladder - If this is unaccompanied with pain in the Loins you may safely operate: The Patient becomes frequently seizd. with violent shiverings like an intermittent succeeded by heat with profuse sweating, spasms of the abdominal muscles and the contagious parts, but the degree of irritability is not proportioned to the size of the stone, as a large stone frequently produces less irritation than a small one Dr. Franklin the Philosopher in America was the subject of the Disease. The size of calculi are various. there is a stone in Mr. Foriter's Possession surgeon to Guy’s Hospital which weighs ℥xxv and of a remarkable compact Texture there is another in the Library of Trinity College Cambridge which weighs ℥xiv & 11 which the circulation cease and the parts require to be separated from each other or Death must ensue.- symptoms of the [state] first state an uniform swelling the skin uninflamd, with a dull equal and constant pain, parts easily pit, in hernia humoralis these symptoms are very perceptible, in the sound state the skin is red however deep the inflammation the most certain criterion is a softness in the middle surrounded by hardness – A man in the Hospital with symptoms of a diseasd. Liver had a Tumor on the side with the appearance of softness surrounded with hardness, it was opend, and a great quantity of matter was dischargd. the abcess was so deep that probe would but part reach the bottom. The pain in this state is variable and darting- the 3rd state has “gnawing pain which marks the action of the absorbents, the skin becomes thin the cuticle loses its color and becomes white it separates, when the matter is dischargd, Ulceration ceases - in the 4th state there is excessive 138 is nearly as large as that weighting ℥xxv The largest stone Mr. Cooper ever saw extract weighd. ℥iv1/2 ounces - In extracting a small stone from the Bladder the flat forceps are preferable - The circumstance necessary to be attended to previous to performing the operation are to observe if the Patient is in good health, for if a pain is felt in the Loins a disease of the Kidneys in all probability exists, give two or three purgatives in the week previous to the operation. and morning before give a purgative Enema. if the Patient is plethoric VS - To Perform this Operation. Place your Patient on a Table of convenient height & having properly secured the Hands and Feet the perineum being shaved, make your incision beginning immediately under the Arch of the Pubis carrying it opposite to the middle of the Anus, this incision lay bare the accelerator urine and bulb of the urethra. this last is divided in making your second incision and sometimes the internal Pudendal Artery (but this is not so likely to happen when the cutting Gorget is used as when you use ye blunt 139 Gorget) In making your second incision you carry it into the Grove of the staff. and keeping your scalpel there to serve as a disector for the Gorgett, and before you withdraw the staff ascertain clearly that it is open throughout its extent having done this remove it, and feel for the stone with your Finger or Forceps having ascertain its situation, pass your Forceps along the Gorget, and having taken firm hold of the stone. remove the Gorget, and in extracting the stone give your Forceps a slight lateral motion which tends greatly to facilitate the extraction of the stone - the staff when you cut into it should be held nearly perpendicular, so that in making your first incision you can’t feel the staff - If the stone is containd. within a sacculus, you are directed to use Potts Bistoury and dilate it. Ricketty children have frequently the Tuberositus of the Ischia so close together, as not to allow the passage of the stone, in this case you must endeavour to break the stone. the case however generally proves fatal. If you succeed in breaking the stone, introduce 140 the flat forceps in preference to the scoop Mr. C observes it is a wron practice to inject any fluid to wash assay the particle of stone- In Norfolk this disease is more frequent than elsewhere. in Norfolk and Norwich Hospitals above 300 stones are collected, and of those Patients operated on, about two fifteen die on an average in these Hospitals according to Mr. C estimate about one in 13 die of this operation Mr. Cline in the first 24 cases he Operated on lost none after that he lost three successively. Mr. Cooper in in the first 24 cases he operated on lost one. which Patient was a very young Child and died of Convulsions. therefore it is more dangerous to Operate in young Children than old people In those Children who labour under Tabes Mesenterica this operation should never be performed, as they stand no chance of recovering, Age makes but little difference in this respect Mr. C Operated on a Gentn. 82 years old who recovered in a short time 141 In order to stop Haemorrhage from the Pudendal Artery. press on for about 10 minutes with your Finger but dont introduce Lint. for in this case the pressure applied is often incomplete and the Blood escapes into the Bladder producing shiverings &c. after the Operation apply superficial dressings - Mr. Cooper thinks there is no occasion for any- If there is a considerable discharge it is a favourable Symptom. If otherwise the abdomen becomes painfull, then you are to apply the Leeches with fomentations of Chamomile Flower & Spts. and when it can be had the warm Bath - In 14 or 20 hours after the Operation a little urine is discharged by the Penis, when you are to bring the Thighs together, and secure them by Ligatures, if the external wounds does not heal in 17 or 20 days pass Bougies up the Urethra - In the Patients who wont submit to this Operation as Palliatives you may employ Alkalies give aq: mephitic for common drink & the following may be taken with advantage twice a Day - Rx carbonate of Potash ʒ1/2 aq 1/2 ♏︎ the PA sapon may be given with advantage - Women are less liable to this disease than men as the meatus urinarius in them 142 is short and a stone of a considerable size will frequently pass of itself, a women who has once been operated on never after requires the Gorget - In Performing this Operation in the Female. Having the necessary preparations Sound the Patient with a small male Catheter in order to discover the calculus, this done introduce another sound with the grove turned downwards the pass the back of the Gorget into the Grove of the staff, and carry it into the Bladder, then withdraw the staff and carry your Finger into the Bladder to fee for the stone, having discovered its situation introduce the Forceps along the Gorget, withdraw the Gorget as before directed, and laying hold of the stone (which is generally found in a hollow immediately over the vagina) extract it using a slight lateral motion in the extraction &c NB Mr. C. observes young women wish to have this operation performed on then for what reason he cannot tell, but believes it to be a species of insanity, these women have generally diseased ovaries - 143 On suspended Animation The causes giving rise to suspended Animation are Submersion, Suspension, Noxious Airs Extraneous Bodies, and Tumours pressing on the Trachea - Submersion Under Water In this case the animal does not die from water getting into the air cells of the Lungs, but from the exclusion of the Air from the Lungs, the blood is rendered incapable of undergoing that change which fits for the purpose of Respiration and Life- It is found from experiment that very little water is found or containd in the Lungs and not more than three or four Ounces generally in the stomach - Mr. Coleman observes that the Blood accumulating in the right side of the Heart is impeded in its passage to the left, but Mr. Cooper differs in Opinion and says that the Blood is not impeded in its Passage but diminished in quantity Suspension It was generally supposed that apoplexy was the effect of suspension, but that is an idea erroneous for if there happens 144 any congestion in the Head it is only within the Vessels themselves which cannot produce this effect. Persons that are hanged die precisely under the same circumstance as in drowning, for if you take an animal and make an aperture into the Trachea below the cord, and a pipe being introduced into it the Animal will live for many hours. It was supposed by some that the Vertebrae suffered and the medulla spinallis became compressed but this like the former opinion is erroneous Vide Coleman on Suspended Animation Introduction of Noxious Air As Hydrogen Gas, Carbonic Acid Gas. these act as Poisons by their effect on the Nervous System & thereby destroy life, a Frog may be kept alive for three hours under water but if Carbonic Acid Gas be employed it will die in 8 or 10 minutes. If Animals are immersed in Hydrogen Gas and taken out just before the functions of Life is [destroyed] cease they will recover for a time but in general die in a few hours with convulsive symptoms. In those who 145 are destroyed by the Mephitic Gas emitted from charcoal or Carbonic Acid Gas - In the Brewers Vatts it is found that the temperature of their of their Bodies is far above the standard and continues so for many hours after Death has taken place - From this fatal exposure scarce any person is ever recovered as it acts as a direct poison when applied to the Lungs, and not as some gasses merely by the exclusion of the respirable part of Atmosphere Air - Extraneous Bodies introduced into the Larynx produces suffocation in this case the Patient dies suddenly generally: sometimes not for many hours, and it has happened where they have lived for 3 weeks, an obstruction is produced in the Larynx by substances in eating dipping under the epiglottis, where it may kill instantly or by the irritation it may cause which when it happens after swallowing a substance great difficulty of Breathing is caused with a Violent Cough – Emetics have been known to eject the substance by their action, which should be used strong The throwing up of a piece of coagulable lymph in Cynanche trachealis is a frequent cause 146 for this complaint, sometimes also from swelling of the Glotis and Epiglotis in Angina Scarlatina, also from an abcess arising on the Cartilages of the Larynx from pressure and irritation Means of Recovery In infants just born, and no symptoms of respiration, bring them to the fire or put them into warm water inflate the Lungs employ friction with hot flannels – If an adult under submersion or suspension warm Bath. Opening the Jugular Veins taking away not more than one or two ounces of Blood, inflate the Lungs by means of a pair of bellows pressing at the same time upon the Chest for the purpose of producing artificial respiration. pour spirits down the Throat probably some of it may pass into the Trachea, and if it excits any emotion it will be the means of recovering him - Electricity is but seldom employd. with advantage as circumstances occur to render it inadmissible. when you have inflate the Lungs, and left side of the Heart begins to Act emply friction with warm flannels, some use salt. in case 147 of suspended animation from the inhalation of Noxious Airs do not take away Blood but heat it as under submersion and suspension When any Extraneous Body is Lodged in the Larynx never use a probeing for its removal but pass your finger under the epiglottis and endeavor to extract it before you attempt any operation If you cannot succeed in that way give a smart Emetic: there has been instances where it has proved effectual. if neither of these succeed set about performing the Operation as follows - Bronchotomy This is the most unsuccessful Operation in Surgery It was once performed by Mr. Andrie with successes and which is the only instance on record Mr. Sharp recommends to make an incision of an Inch in length at the ring of the Trachea half way between the Cricoid Cartilage, and the Sternum, this Incision lays bare the Trachea, you are then to pass the front of your scalpel through the substance of the Trachea between the ring, but this plan of Operating is by no means advisable, as the Thyroidal vein becomes divided and the Blood 12 acute pain, vesications arises containing sanous serum the parts under the vesication is of a brownish red this procedes gradually, delirium takes place when mortification takes place in consequence of accident, singultus comes on, the stomach and Bowels are affected, much air is expeld, constipation takes place, the pulse are in general quick and pain varies according to the importance of the parts affected; when the limbs are the seat of the disorder [it is] they are quick and hard when in the abdomen they are exceeding small sometimes full in the first stage they are slow in inflammations of the Lungs & rises on venesection and becomes more like a natural pulse in inflammation of the Heart the pulse is tense beating work a jerk like a broad wire: in inflammation of the brain the pulse is full and slow: if there is much effusion on the brain, the blood when inflamd, is much thinner and separates into three parts, and takes a longer time to regulate and the red particles are not sustained by the lymph, the Blood becomes cuppd on both 148 gushes into the Treache and suffocates the Patient - Mr. Cooper recommends the incision to be made between the Thyroid & Cricoid cartilages, and a probe to be introduced to push the extraneous body into the Throat in this manner you avoid the Thyroidal Vein and it is an Operation that ought to be performed without fear - Mr. Coleman recommends to make an incision on the Thyroid Cartilage but this Mr. Cooper objects to there not being room left sufficient for the Passage of the Air from the Trachea from the elasticity of this Cartilage and sometimes it being met with in an ossified state On the Operation for Suppression of Urine The best method of performing this is about the Pubis. First make an incision one Inch in length as near the Pubis as possible, feeling for the Symphisis Pubis then pass a Trocar & Canula directly downward towards the Bladder the length of the Trocar & Canula should be 4 inches the Canula should be rather longer than it is generally used as the urine is apt to be extravasated, the coats of the Bladder receding from it as the 149 urine passes off then fix the Cannula by strings to the abdomen- it should not be allowed to remain in more than 2 Days when it should be withdrawn and a shorter one introduced if necessary: even this method of operating is liable to objections as it generally brings on disease of the Bladder from irritation Mr. Cooper recommends an incision to be made into the membranous part of the urethra as it depends chiefly on a stricture in that part : there generally occur about 2 or 3 inches from the Bladder or 7 Inches from the lips of the Urethra - The incision is to be made with a Lancet made straight and this is to be thrust through the Tumour in the perineum into the Bladder - Of Calculi in the Urethra The presence of calculi in the Urethra may be known by the Patients complaining of cutting sensation at the lips of the Urethra a sudden suppression of Urine and if a Catheter is used to surgeon hears it strike against the stone If the stone is lodged two or three inches within the passage make an incision through the Urethra upon the stone keeping 150 it at the same time steady between your Finger and Thumb, and taking care that your external incision is larger than the internal: this done extract the stone with a dissecting hook: the wound will heal by granulation: you must not attempt to heal by the first intention for obvious reasons - When the Calculus is situated directly opposite the Scrotum it is not to be distinctly felt : it is more difficult to extract, and likewise endangers a sloughing of the Penis by the urine extravasating itself within the surrounding cellular [membrane] substance therefore it is recommended to push back the stone in perineo, where it is less difficult to extract. If you intend to operate in its first situation (viz directly opposite the scrotum) make your incision from 1 ½ Inch to 2 Inches through the integuments covering the stone to allow the Urine to escape freely after the Operation and extract the Calculus with the forceps or dissecting hook- In Children this Operation is not so dangerous - 151 apply poultices to the wound, and heal by granulation as before observed - the next situation of Calculus we shall speak of is at the Prostate gland which of itself will sometimes produce Calculi different from those found in the Bladder or Kidneys. before you attempt any operation in this case give the Patient a few hours to wait, for there has been instances of the urine accumulating behind it and forming by his efforts to void his urine from its situation, and it being in consequence expelled with the Urine. but Mr. Cooper advises at the same time Bougie to be introduced as far as the stone, and suffer to remain there as long as the patient can bear it, when it being withdrawn and the Patient desired to void the contents of the Bladder, the stone will in all probability pass off along with it, but if a Fistula in perineo attends this complaint this will not happen but the stone will make its way through the Perineum If after you have tried this plan of treatment and gain no advantage you must proceed to operate as follows 152 First pass a staff along the Urethra untill you distinctly feel it resting on the stone pressing it into the Perineum so as to feel, then cut, make an incision with a scalpel into the point of the staff within its grove pass a probe into it and push it along the Urethra (over the stone) towards the Bladder beyond the stone this done extend the incision with a Phymoses knife untill the extremity of the stone where you may readily extract it with your Finger or a fine pair of forceps. after Treatment as before directed - If a stone is situated at the membranous part of the Urethra with a stricture, it must be removed make an incision through the perineum and extract it with forceps A stone lodged in the Meatus Urinarius of the Female seldom requires any operation for its removal , but it sometimes produces Ulceration, and part of the stone being lodged in the meatus and the other in the Vagina - you must introduce a pair of forceps break off that part in the vagina and afterwards remove the other portion within the meatus urinarius Mr. C. saw this operation performd. on a woman who had previously a 153 very difficult Labour and it was found that one portion of the stone communicated with the other by a narrow neck - On Amputation of the Penis The Penis is subject to two species of cancer First the Watery Cancer so called from its first appearance being similar to that of a Venereal Wart this increases to a considerable size resembling a Cauliflower this Ulcerates and destroys the Penis the Urine is discharged by many orifaces and the Patient suffers excruciating Pain 154 saving of integuments as the corpora Cavernosa recede considerably, and besides that the integuments are more diseased than the Body of the Penis. when the wound begins to granulate you must introduce a bougie, and suffered to remain there, if it induces a discharge from the Urethra it must be only occasionally introduced (viz) two or three times a day if this is not strictly attended to much mischief will ensue- On the Hare Lip Children are frequently born with a deficiency in the formation of the Lips and which forms is its resemblance to a Hares Lip. it has been denominated by surgical writers Labia Leborino this deficiency extend sometimes through the palate to the Uvula. in this case the Operation is more difficult If there is a fissure in the Velum pendulum Palati only it produces a nasal pronunciation of sound. The hare lip exists sometimes on both sides in this case you must succeed with one operation before you attempt the other 155 If this Operation is to be performed in a Child its age is to be first considered Mr. C advises the Operation never to be performed until the Child is two or three years old, there are two reasons for this, in the first place if very early performed it generally prove unsuccessfull, and secondly if delicate Children it proves dangerous. the Lip from the violent irritation it occasions brings on Diarrhea Convulsions &c - Operation Pass the point of a Lancet through the skin of the Lip, extending your incision first upwards towards the fissure and then downwards towards the edge of the Lip so as to make it a recent wound this done on both sides, pass the first suture through the middle of the red part of the Lip and the second half way between the first and the nose exactly; the sutures are then to be tied, you are to bring the cheeks together and apply in a day or two a slip of Empl adhesive across the Lip from the Angle of the Jaw on one side to the opposite angle, this is to remain for 10 days. and if any excoriation is produced by 156 it. first apply a slip of Lint & the empl adhesive over it - If it is a double Hare Lip there is always a projecting portion of bone if in the Adult, this is to be removed by the bone forceps, in young Children it is of no material consequence - In this Operation, the Labial Artery is divided and in order to stop the haemorrhage you are to pass the Lower suture so as to include the Artery if possible and which is not very difficult to accomplish: The Middle Suture must be taken away on the 4th day - and the lower one on the 5th . In Children leave the Ligatures to Ulcerate of themselves, for the inflammation which they produce is trifling, but still keep adhesive plaster over the lip - On Nasal Polypi These Polipi which arise from the Pituitary membrane of the nose, are sometimes found transparent, at other times of an Amber colour, they are found depending by a narrow neck, are easily movable and are contained within a thin Bladder they are not very sensible and but slightly vascular, Patients under 157 this disease complain that when the weather is moist the nose feels stopd up, so that they cannot readily breath, and if they have a a cold the nostrill on the affected side seems stopt up, while the other remains free, they are sometimes found branching and at other times to contain a Hydatid Operation If the Polypus appear at the nose. place the Patient in a clear light and examine with a probe where the neck of the Polypus is attached. it generally to the septum nasi. then introduce a pair of pointed Forceps, take hold of the neck of the Polypus and by a sudden jerk extract it a small portion of bone sometimes is brought with and which is a describable circumstance if not they are very liable to return in a few months Polypi sometimes occur of an Hydatid kind filling up the cavity of the nostril completely and when you attempt to extract them they break under the forceps so that you can’t remove them in this way they contain a small quantity of fluid, they occasion swelling of the 13 sides which is a stronger sign of inflammation than buff, - on Specific Inflamation Specific inflammation is where the arterial action is changed, and the effusion is different from those already described, those in the Gout. the skin is inflamd, but chalky matter is deposited on the Joints instead of lymph - in cancer and schirrous where the disposition is on a peculiar nature. the discharge is very different from pus. small pox erisipelatous fever. Angina scarlatina are specific inflammations. Inflammation is salutary if it does not precede to too great a length; granulation could not be affected without an inflammation of the surface of a wounded part - if matter forms in the interior part it could not get out without a process of ulceration - Bone exposed to accident must always remain so did inflamation produce exfoliation. Inflammation therefore should be suppressd, its symptoms are to be attended to and regulated, weakness is the predisposing cause of spontaneous inflammation 158 cheeks, Ulcerate and destroy the nose producing violent constitutional irritation which puts a period to the Patients sufferings. This Disease is not of a cancerous nature, An Injection of Hydrar: Muriat & aq:Calci is recommended A Cancerous Polypus sometimes occurs between the age of 40 & 80 it’s colour livid & when touched bleed profusely it is attended with a shootin pain thru the Head, sometimes extends through the ductus a nasum and forms a Tumour just opposite to the Lachrymal sac - Treatment - use Injections with Tinct:Opii & give opium muriatae On Dropsy & Method of Operating Dropsy of the abdomen is of two kind. First Ascites which is an accumulation of water within the Cavity of the [abdomen] Peritoneum or Encysted when the water is collected in the Ovaria, or in an Hydatid on its surface - I ascites the water gradually accumulates upwards untill it reaches the navel, when there is but a 159 small quantity of water an undulating motion is felt by the Patient in charge of posture, this Disease produces an accumulation of water in the extremities which there takes the name of Anasarca if it is accompanied with difficulty of Breathing much danger is to be apprehend Ascites is generally the effect of a Diseased Liver, sometimes from the omentum or spleen becoming hard and enlarged, the Tabes Mesenteria is sometimes a cause of this disease, and especially the abuse of spirit Liquors, from it producing a great determination of Blood to the Viscera: whatever hurries the circulation is a frequent cause on Dissecting those who die of this disease the Peritoneum is in general found studded with Patches of coagulable Lymph - Encysted Dropsy caused from an accumulation of serous fluid in the Cavity of the Ovaria. it becomes considerably enlarged before the Patient is aware of the Disease existing forming a large Tumour on one side of the abdomen there is at this time on the Museum 160 of St. Thomas, Hospital, an ovarium which contained 12 Gallons and one Pint of water purchasd. from Dr. Poles collection by Mr. Cooper in General they contain from 20 to 30 Pints The Water is sometimes accumulated in many cysts, therefore it is not advisable to operate early - The fluid which these enlarged ovaries contain, differs much at various times, at first it appears like the serum of the Blood the next time it appears glary & Tenuious as the White of an Egg after which it seems like pus & Hydatis is found in it; the fluctuation in this Disease is not to be distinct as in ascites - water is more & there discharged by the the urethra & vagina Operation Have the Patient in a Chair with a sheet thrown round the abdomen, and confind. there having made an incision with a Lancet one Inch below the navel in the course of the Linia Alba introduce a large Trocar and Canula after the water is evacuated close the wound with Empl adhesive Very Carefully. This operation maybe performed at the navel or an Inch above it if the Tumour is high - If the operation is performed Low down the Bladder should be previously emptied - It requires to be often repeated 161 Scrophula Scrophula is an inflammatory disease accompanied with great debility, all the processes are attempted as in common inflammation but they are slow & imperfect. The adhesive process instead of taking place in a few hours as in common inflammation is sometimes weeks, and there is not that kind of adhesion as in inflammation: the coagulable Lymph is soft and imperfect the Suppuration stage is slow and imperfect. the pus is like a serous fluid mixd with curd like matter Ulceration is also very slow. there is evidence of fluctuation long before the abscess breaks when opened the edges of the skin are curled at the ends and turn inwards, not opposite to one another and considerable scars are produced Scrophulous complaints occur at different periods of life first there is a scrophulous enlargement of mesenteric gland in very young Children called Tabes Mesenterica, at two years of Age the glands of the neck becomes enlarged next from 6 to 12 years there are generally the different white swellings in the Joints about Puberty Phithisis Pulmonatis occurs & generally continues to 35 years of age about the same time lumber abscesses take place upon the spine and also in the Loins and groin. From 20 to 23 the Testicle becomes scrophulous 162 there is no pain, great enlargement & hardness, this extends to the vesicule seminal and Prostrate Gland - Scrophulous Opthalmia occurs at any Period under 35 years, An enlargement of the Prostrate Gland in old age is said to be scrophulous but doubtful, Truly scruphulous complaint are rare after 35 years - Exceptions - Character of Scruphulous Persons Distinguishing mark, Then skin, delicate constitution, light florid complexion light in general, fixed colour in the cheeks you may see the Veins distinctly under the skin usually about the neck and Temples. the hair hangs straight, pliable fine light and sometimes very dark. upper lips much the thickest and projecting over the lower, Scruphulous Children are liable to diseased secretions behind the Ears producing and enlargement of the Glands of the neck - No disease is hereditary Every constitution is liable to scrophula when exposed to particular causes. no Child is born with scrophula but only with that disposition to it like its parents and their disposition must be acted upon by the same existing causes before the disease is produced the Disposition is hereditary but not the disease. Predisposing Causes Weakness generally the effects of some Fever - scrophula frequently occurs after the inoculation of 163 the Variolae prior to the introduction of the inoculation for the small pox into this country scrophula was not so frequent[ly] as it was afterwards, but since the introduction of vaccination scrophula is not frequent as it was. also caused after the Fever produced by Mercury- the most common cause is Angina Scarlatina, the more Violent the Scarlatina the less Violent the scrophula &c close confined situations and scanty nourishment - The treatment consists in restoring the tone of the Arteries and in the formation of better Blood. Begin with enriching the Blood Good Nourishment must be kept up - 3 Glasses of Wine for a Child out of arms per day. Scarcely any Vegetable Food should be given. Meat at breakfast again before dinner & at dinner the Child should never fast long: nutritive food in as small a compass as possible; Exercise with other Children frequently but not to fatigue Good Air. On this plan you must place more dependence than Medical treatment Medicine steel and Gentian combind with Bark. If inflammation is going on give the following Rx Hydrarg Muriat gr 1/8 Tinct. Cinchone 164 Comp 1 dram bis terve die sumendus ex vino rubro. This is particularly beneficial in scrophulous ophthalmia. The above is a dose for a Child, it produces absorption of scrophulous enlargement prior to the formation of abscess - scrophulous Diseases of the Absorbent Glands - In the Glands of the neck an amount of the exposed state of the face and ears inflammation is produced the almonds of the Ears are said to come down inflammation takes place on the mucus membrane of the nose; with these scrophulous enlargement of the Glands of the neck: there is but a slight degree of pain: remain for a long time in a very indolent state, then with no obvious cause on a sudden go to suppuration which is shewn by the redness of the skin afterwards of a purple colour and when the Glands Ulcerates the edges turn in the Granulations or flacid & glassy and take great length of time to heal. sometimes the Tumours produce fatal consequences by pressing on the Larynx obstructing Breathing and from taking sufficient nourishment. likewise pressing on the Jugular vein and occasioning apoplexy - 165 The plan of treatment proper in these cases If you are called in at an early period of the enlargement it is best to apply aq Lith Acet: comp and to give purges of calomel If there is any considerable pain apply Leeches repeatedly and prevent suppuratoin if possible endeavour to keep the inflammation under Medicines Rx Hydrarg Muriat & 1/8 Tint: Cinchone ʒi bis terve die. If the pain & inflammation is great the Tint: Cinchone should be left but, where it does not ammount to suppuration it will promote the action of the Absorbent Vessels- When the Tumour is of a very indolent kind use the soap plaister. If in the early stage the Emph sapon and flannel put over with rest and Calomel purges will cause a cure in a few days. If suppuration takes place after all the means you have tried, as soon as there is any fluctuation open the abscess - If in the Female be a little particular for fear of making a mark - make your incision with a Lancet transversly into the abscess - after it is opened 166 apply the following Lotion Rx Zinci Vitriole gr xÿ Aq: Rose ℥viÿ ᵯ If it checks the discharge too much, mix it up with Bread as a poultice which is the only alteration found necessary- It requires daily attention to prevent it from closing by passing the probe in - The reason scars are so frequent after these abscesses is the skin is suffered to get diseased before the opening is made and the edges of the skin is drawn into puckers Earthy matter is discharged from some of these abscesses sometimes and are more difficult to cure. use the following Rx Ferri Ammon. ʒi Cerat alt ʒi M Ung Rx Ferri Rubigo ʒi Ung & Albi 1 ounce M. or the Martiat Cerate - When granulation is risen near or quite to the skin use white Vitriol or the Vitriolic Acid wash Lime Water or the following Ointment Rx gum: Elemi 2 ounces Milt Commun ℥i or Tercl ℥1/2 Adipis scilla ℥i ᵯ f Ungm to every half ounces of this ointment udde pulv Ammon prop ʒii ᵯ f Ung. The Glands about of the bronchiae are often affected and the Patient cough up a considerable quantity of Earthy matter - they become enlarged & adhere to the bronchiae - 167 Tabes Mesenterica This is a common disease in Children at a very early Period of life attributed by their Parents to worms, but the real cause is an enlargement of the Mesenteric gland these Glands are placed between the Thoracic duct and intestines, by the enlargement of these Glands nutrition is prevented from going into the intestines in a proper manner. the Child makes a chyle as usual but passes it off by stool which is supposed by their ignorant Parents to be worms. The Chyle not getting into the Blood the Wasting of the Body is extreme appetite very irregular. enlargement of the belly: picking of the nose &c Treatment Rx Calomel gr iÿ Pulv e scummon gr v M f Pulv this is to be repeated every five days - In all diseases of Children Mr. C. always recommends the above powder except in those which are considered specific in themselves: such as Hooping Cough: small pox measles &c. as he wishes to produce vomiting and purging – do not depend on Calomel 14 on which account the Legs especially of old persons are most apt to ulcerate, their circulation being slower than that of rest of the Body Intemperance weakens and produces a great disposition to inflammation, for the same reason persons who take too much exercise immediately after they have recoverd. from Fevers are liable to suppurations near the knee Blisters are liable to produce sloughs after Typhus Fever or Measles - The occasional causes of inflammation are those that change the action of the Blood Vessels of a part. thus in Fevers the Blood is pumpd. too fast through the arterial system if it meets with a weak part congestion takes place and an increasd. action of the part is set up to take up the congestion, - the sudden application of cold to parts in a healed state stop these suppurations and a large quantity of blood is impelld to the part to keep up the resistance of these vessels that had been constringed by the cold - violent exercise produces an increasd. circulation 168 alone. if in a very delicate habit use Rhubarb with it at the same time the Vinum Ferri a Teaspoonful in a Tablespoonful of Red Wine three or four times a Day. Nutritive food in small compass and entirely on meat, not vegetable Air and exercise without fatigue. Empl Litharg Comp on Empl fix Burgand on the surface of the abdomen is very usefull - This disease if suffered to go on too long or treated improperly will terminate in Dropsy. and even after the disease itself has been cured it has been necessary to draw off the water. abscesses have been produced and large tumours of earthy matter also - Scrophulous affection of the Joints white swelling called so because the skin remains of its natural colour. symptoms at first, a stiffness is felt with slight pain: then in a few days an enlargement of the Joint begins: this continues for a length of time, & as there 169 is not much pain it does not execute alarm after being sometime in this indolent state a sudden change takes place a general Chilliness, pain and suppuration in the part, the slightest Jar of the Joint causes exquisite pain. when matter has begun to form it goes on increasing in quantity suppuration takes place below the Joint If it is at the Knee it will be 6 inches below and sometimes a little above when the abscess is opened the process of ulceration is very slow - the dishcharg will continue for a length of time for 2 years unless some active means are used to prevent it - Appearance on dissection. under the skin a quantity of Fat is found under which the common capsular Ligament is considerably thickened, the Vascular Ligaments from whence the synovia is secreted are particularly affected: the Cartilages are in part absorbed sometimes wholly so Bones throwing out spicule in several different parts with holes in them- If when it has made any 170 progress and ultimately cured it is anchylosed. Treatment supposing it only stiffness with slight degree of pain Rest. Rx Linim Ammon. Spt Vini camph [an] ℥1/2 Antim Tart 1 dram rub in 1 dram every night and morning on the part affected. in three days there will appear an eruption like the small pox: and if the Linim Camph is omitted the eruption will appear as in Henerial - It is preferable to the use of Blisters & Ungn. Sabina tho the Blister may effect a cure there is always left a greater contraction of the Joint with weakness and Lameness After using the liniment for 3 days apply a common poultice which is to be kept on for 3 days renewing it occasionally at which time the Liniment is to be used again - Another form which is used – Rx Antim Tart ʒiÿ Ungn. Sperm Coli ℥i 1 H f Ungn -this produces a more irritable eruption but the former is far preferable give Hydrary & Tinct Cinchona. If much pain it is usual to apply Leeches but these produce 171 weakness in the part which ought therefore to be avoided if possible - Rx hydrard Muriat combind. with opium to produce nausea answers well - A considerable quantity of opium is sometimes required to be given to prevent pain- the following is the form to give at night Rx Calomel prop gr i Pati: Opii gr 1/2 Ferri Vitriol gr 1/2 M Omni nosta sumendus - The Vinegar poultice is also used. it produces an eruption in about 3 days. it has not so good an effect as the Liniment the Emp Lith the Empl pix Burgand are good applications Emplast Epispast & savn Ointment is in common use - The best means of Restoring the Joint, if you have subdued the inflammation use friction with frequent motion but not too quick nor begin too soon. If suppuration takes place in the Joint no means can prevent it from taking its course. therefore it is best to encourage it, and to bring it on speedily give Tonic Medicines and use warm applications to the part after it has been opened inject the following into the [sinus] Rx Acid Vitriol ʒi aq Purce ℥vi throw this into the joint 172 Put a Blister over the Joint and dress it with savin Ointment, in time the inflammation will be lessened and the discharge but a stop to- Surgeons have several times performed amputation unnecessarily in this disease, It is never necessary unless there are the most powerful hectic symptoms, never suffer it to be amputated though the Patient may be lame the whole of his life - the weakness which the Amputation occasions in that particular constitution will probably prevent the stump from healing and it is a great chance if some other part is not affected - Disease of the Hip Joint. Pain in the knee is the first symptom. If you fix the Thigh bend and extend the knee it will give no pain in the knee, but if you take the Leg and raise it up towards the Body you will cause pain extending to the knee. in walking the Patient turns his Toes out - the Toes can turn in but triffle. The Joint does not feel round but flat - the disease limb appears longer than the sound one, as the Head 173 of the bone is thrust out a little from the Acetabulum by an effusion of coagulable lymph into the acetabulum, the nates of the diseased side is one inch below the opposite - If you turn the Patient on his face there is a fold in the groin by pouparts Ligament while the opposite groin is straight from the lengthening of the Leg at last the limb becomes shorter, so that the head of the Thigh bone becomes diminished greatly and the Acetabulum becomes lengthened upwards: it is one or two inches shorter. If suppuration has taken place they never recover with less than one inch shortening of the limb. Abscesses sometimes break opposite the Trocanter Major, there has been a Case in the Hospital of these Ulcerating the coats of the Femoral Artery and causing Death from Hamorrhage - Treatment. this should be undertaken as early as possible. give the Hydrary Muriat cum Tinct. Cinchona so as to excite nausea this will often diminish the pain in the knee apply Leeches. if very painfull use the following on the Hip Joint Rx Linim: Amon: Camph ℥i Antim Tart ʒÿ M rub in 1 dram nocta manque, and continue untill Pimples are produced. order Rest let the Patient use 174 Crutches and no motion of the limb be employed whatsoever. if you do not succeed in this plan early, make an Issue with Kali purum about the size of a shilling on each side of the Trochanter Major: this is preferable to a Blister with the Ungn Sabina, these Issues should be kept open for six Months or more: untill the pain in the knee has ceased - If abcesses are formed from the Joint let them take their own course. if they are opened the inflammation will extend upwards and the whole of the Joint will become inflamed - should the Patient recover fast he should be in haste to use the limb as he may bring on the disease again. and ought to continue the crutches for some time after. the cavity of the acetabulum becoming absorbed the head of the Thigh bone passes into the pelvis, and by its irritation destroys life or produces abscesses bursting into the Rectum and kills him also. if in a woman the abcess burt into the Vagina and may recover - Ulceration of the vertebrae. This complaint begins with a pain in the affected part soon after there is a projection of one 175 of the spinous processes, which becomes detached and the spine suddenly forms an angle, weakness in the lower extremities so that he often falls down suddenly when sitting he draws his heels under his seat. during the night spasms of the muscles of the lower extremities at length producing a paralytic affection, but the muscles are not relaxed, but spasmodically affected - the Vertebrae press on the spinal marrow and produce irritation: the Bladder [find] looses its retention power as does the Rectum. If the cervical vertebrae are affected, the patient has no use of his Arms or Legs, the Head only being free from disease. in some Case as many as four or five of the Vertebrae has been destroyed and yet recovered, sometimes there is a considerable abcess forming in the fore part of the spine adheres to the Lungs burst, and is discharged by coughing - Treatment setons or Issues by the side of the Vertebrae. Issues are most affectual but setons are most convenient these Issues must be kept open for 12 months or more and sometimes two years. but it depends on the Relief afforded if sufficient irritation irritation is not made dip the pea in unguent cantharid - 176 When a Cure is affected it is with an Anchylosis of the Vertebrae so that the spine never after becomes straight yet the spinel marrow does not become compressd. The constitutional treatment should be the same as before directed as Hydrar Muriat & Tinct Cinchona - Psoas and Lumber Abcesses, these are singular to the last symptoms. Pain in the Loins for months before there is any appearance of disease. a small Tumour in the Groin where Bubo appears, which dilates in Coughing as in Hernia. this Tumour extends downwards and is of a considerable size. this sometimes form two las one on each side the Femoral Artery and Vein, the tumour at length bursts and discharges from H1/2 to Hi of Matter three or four days after: much Fever is excited and hectic symptoms come on, night sweats chilliness succeeded by heat. and the case soon terminates fatally - On Dissection the Origin is found to be from the Spine and the Matter Ulcerates through the Psoas muscle to the Thigh under pouparts Ligament. it destroys the Ligaments of the spine where it is situated and the Psoas Muscle become hollowed 177 Treatment. Excite irritation at the part where the Patient complains of pain. make Issues and keep them open for a month or six weeks before you have any thing to do with the abscess, then you are next to consider the propriety of opening the abscess. Mr. Abernethy consider making a puncture into it is advantageous to let the matter out gradually - as this diminishes the constitutional irritation pass a Lancet at the part where the abscess feels rather thick introduce it from the side and make an oblige incision as you have a larger fur pure of the escape of the matter which is generally mixd with clots which must be removed by a probe, then lay a puic of lint over the wound. and over that Empl adhesivim - as the Matter accumulates you must repeat the Operation not suffering much matter to collect - Scrophulous Ophthalmia. This produces very quickly opacity of the cornea even in a few days, give Hydrarg Muriat with the Decoct. Cinchona & Tinct. Cinchona, if the Eye is irritable apply. Rx Hydrang Muriat gÿ Aq: Calcis ℥vi Tinct: Opii ʒÿ Aq Pura ℥i M or Rx Aq: Litharg acet 30 gtt Zinic Vitriol giv Aq: Pura ℥iv this forms the acetate of Lime 15 and congestion takes place in any weak part as before mentiond, - The division of Blood Vessels is the most frequent cause of inflammation. the division of an artery stops its circulation and the neighbouring arteries throw more Blood on the part to keep up a due circulation:- Laceration contusions &c are the existing cause of inflammation: extraneous bodies Gunshot Wounds and ligatures occasion more or less inflammation according to the irritability of the system. Proximate causes the state of the part which produces the symptoms, it has been supposd, that the Blood when in an inflamd, state, was thicker and would not pass through the smaller branches of the arteries, which made the arteries push with great force to get it through, this is now found to be a false idea, the Blood when inflamd. is much thinner, Dr. Cullen thought that inflammations was occasiond, by spasms of the arteries, the contraction of which obstructed the passage of the blood, that the neighbouring arteries pushed with more force to obtain one if the Blood was thus returnd. it would 178 which is to be introduced between the Eye lids: give Calomel. In scrophulous testis give. Calomel to affect the Mouth and Mercurial poultices must be applied It generally occurs in people from 20 to 22 years of Age. It is not attended with much pain and one Testicle is affected which soon extends to the other On Gunshot Wounds Any wound produced by a substance entering the body with great Velocity is of the same consequence as Gunshot wounds The Gunshot Wounds differ from common wounds in their being much more intense extraneous substance most frequently loose and having a sinous tendency during cure. They are divided into two kinds 1st When the Ball is passed through part of the Body: 2nd when they continue to lodge. they require different mode of treatment, the former much the simplest, the surface of the wound is covered by a thick slough as if 179 caustic had been used in consequence of the velocity with which the Ball has passed in the wound where the Ball has passed through there is always less haemorrhage than from incised wound: for the first four days the Patient complains of great pain a Glutinous substance issuing out of the wound. untill the sixth day there is no appearance of suppuration and when it begins it is in consequence of separation of eschar not completed till the tenth day or a fortnight; when the eschar has separated it forms a sinus, unless the Ball has struck a bone no pain is produced but if it has then it communicates a shock to the Body if there is no sinus formed it then goes on as any other common wound Treatment. Bleeding is highly essential in Gunshot Wounds at first to prevent inflammation and afterwards when it is come on the Bowels are to be kept regular, but in these there is the same objections as in Fractures: doses of opium with saline medicines every four hours to keep the patient comatose state to alley the irritability of mind and prevent 180 the locked Jaw, regimen to be the same in moderation. Poultices not only upon the wounded part but upon the whole Limb if there is not much Haemorrhage. but if there is use cold spirituous Lotions with Vinegar. the poultice to be used till suppuration happens, as slough often came away during the cure. the best method of separating them is by the injection of warm waters into the sinuses not using any force. scarify the edges of the wound at the time of inflammation if you have not the opportunity of applying leeches, and do this occasionally as you find inflammation coming on sometimes the inflammation is so great as to produce mortification. there is no discharge from the wound. Apply leeches about the part scarify so as in some degree to dilate the wound with fomentations, & vinegar poultice. The sinus has sometimes been very difficult to heal, make an incision between the two orifices and divide the sinus then it will probably heal. if it does not then pass 181 a Bougie with stimulated ointment on 2nd. Gunshot Wounds, with the Ball lodged. when the Ball and extraneous bodies remain lodged in the parts. Pass a probe or a long bougie into the wound and search for the Ball and if you can feel it attempt its extraction, or if it has passed nearly thro so that you can feel it under the skin you mat cut so as to take it out, but not otherwise, for it is not proper to make extensive incisions to follow them as it is well known that Balls sometimes remain for years in the Body without any disagreeable effect being produced - and from their curious course it is often impossible to find them, and as they pass a long way to make a large incision will be very dangerous for they have been known to enter the middle of the forearm and pass out at the neck, also to enter at the scorbiculus cordis and pass out at the back part by the spinous process of the Vertebrae going round the out sides of the ribs. if the Ball is left and does not form cyst it generally produces inflammation which will ovation the expulsion of it in time 182 therefore it is much better not to cut to far for it- Gunshot Wounds of Arteries Arteries when divided by a Ball Bleed much less than if incised because it leaves a fringe of cellular membrane. and the tone is lost. but still there is considerable danger, even if it has passed near an artery as it will cause the coats to slough & the Patient will die from Haemorrhage when passed near an Artery apply a tourniquet, for if it does not Bleed at first. still it will Bleed, In tying an Artery from a Gunshot Wound it should be done high up from the divided or contused parts as they will soon separate or mortify - the Patient if there is a wound near the Artery should be directed how to manage the tourniquet in case of haemorrhage - Gunshot Wounds of the Abdomen If a Ball passed directly through the abdomen it is fatal in a few hours as it must pass through many folds of the intestines - Bleeding & remedies 183 against inflammations must be used. Opium freely: when shot through the stomach in general die in 30 hours and when through the intestines in 24 hours - an intestine may be wounded and the patient may recover. Gunshot wounds of the Liver spleen or Kidneys Mr. C has not seen Gunshot wounds through the Chest into the Lungs are not so dangerous as incised many instances are occurring, when recovery has been affected when there has been considerable injury, these require only simple mode of treatment. Perfect rest, bleeding very freely, - more danger ensues frequently from bits of cloth & being carried in with the Ball than from the Ball itself causing so much irritation, but it is never necessary to make incisions to take them out for the wound will heal from where the Balls enters and will Ulcerate externally towards the extraneous body. thus closing at the part furthest from the Ball and gradually opening to it silk clothing is safer in this respect as it is not so soon separated and carried in - 184 Gunshot Wound of the Heart are instantly fatal. wounds of the Brain are fatal, yet when only the skull is depressed the Patient may do well after trepanning; the Ball has been known to enter and do through the Othmoidal & Sphenoidal sinus and have not proved fatal nor done any injury to the Brain Compound Fractures occasioned by Gunshot wounds are much worse accidents then when happening from other causes : and consequently more difficult in their treatment as the Bones become much more splintered in these it is necessary to dilate all the wounds, to extract all loose portions of bone for if they remain the Patient will die of the consequent discharge, but if removed tho the limb will be shortened, he will commonly do as well as in other compound Fractures and perhaps render the operation of amputation unnecessary - If the Ball passes near or through a Joint so as to splinter the Joint as in the Ancle, Knee, or Elbow, it is very dangerous much more so than Compound Fractures from other causes, it is necessary to amputate, but it is much better to wait and see whether the wound is of such a nature as to Create symptomatic Fever, and the to consider 185 whether the Patient will be able to bear that Fever if you think the latter it is much better to wait till that has subsided before you begin to Operate. Dr. Babington was Surgeon sometime ago on board a ship, after an engagement 24 were amputated in consequence of [a] Gunshot wounds 21 died soon after and three lived to go to a Hospital where one of the three died after so that two only lived when probably if their limbs had not been amputated till the symptomatic fever had subsided some (if not many) of their lives might have been saved - Burns and Scalds The effects of Burns and scalds are of three different kinds. 1st Vesications of the Cuticle 2nd separation of the Cuticle so as to expose the cutis to a great extent and 3rd Destruction of the cuticle and cutis so as to occasion sloughing these three states require different mode of treatment - in the 1st state when the cuticle is detached in the form of a Blister though extensive it is not dangerous. if the cuticle is over it such burns will always do well under this kind of treatment Rx Aq Litharg: acetat. g xxxÿ Zinc Vitriole gr iv Aq Pura ℥iv M Spt. Vini: Camph is a good 186 application. but the following is the best Lotion to prevent the separation of the Cuticle Rx Spt. Vini Rut. Acet communis part equalis ᵯ - In the second stage. It is most dangerous with the cuticle separated and without the life of the cutis being destroyed. The patient soon dies (though the sore in some cases may be extremely small) let you follow what plan you will: for the extremities of the nerves are exposed and occasions such a Violent degree of constitutional invitation that in a few hours it terminates fatally. sometimes the Diaphragma becomes affected breathing Laborious with spams & in this state a solution of opium will moderate the pain, but as it produces costiveness it out to be guarded against Lime Water and Linseed Oil is a good application to allay the pain and heat at first, but it produces a great discharge from the part, and may also produce pectis symptoms, therefore to not continue its use long - in Consequence of what has been written about spirits of Turpentine in this state of burns M. C had been induced to give it a fair trial. It produces excessive pain and very often extensive sores In a Case now in Guy’s Hospital A Man’s Legs were both equally burnt. to one Leg he applied 187 the Aq Litharg : acetat &c and to the other spirit Terebinth. The Leg which was dressd with the Aq: Lith. &c is completely well and then is on the other a very extensive sore- the danger in this second state is not all over when the immediate symptoms cease for a very profuse discharge will sometimes follow if the surface is large. but this may be restraind. by applying the Lotion of the Aq: Lith: acet &c as before recommended on Lint over the surface it also quickens the formation of cuticle - In the 3rd state when the true skin's life is destroyed it is not so quickly fatal as when the cutis is sensible, the constitution does not become affected for several days, but probably will when it begins to slough: If you do not Judge it proper to amputate you must use fomentation & poultices. When large surfaces have lost their cuticle it is a long time before granulation forms but if you use the Linn Vitriolate & Aq Lith Lotion, granulation will form in a few hours - Sprains. A Laceration of a Ligament, the best mode is to apply the following lotion Rx ammon: muriat ʒi Aq: Ammon Acet. ℥vi M Lotion. if there is 16 Change color; the redness of inflammation proves it does not, it likewise proves that vessels are not lessend, which must be the case if Dr. Cullen's hypothesis was true; The Blood Vessels are distended on the inflamd. part but their actions is not increasd. the arteries near the inflamd. part have a stronger pulsation, but are not distended, the distention is occasiond, beyond particles being pressed into the small vessels, that before only containd. white ones, thus it may be stated that there is always distention without increasd, action of the inflam part increased action without distention on the surrounding parts - to ascertain this Mr. Cooper put a young Frog (as their circulation may be easily seen) with a microscope he applied a stimulus to a part, and in a few minutes saw a red particle forced into the artery on that part it passed into the veins and at every pulsation of the Heart, fresh red particles were forced in till the vessels were filled with them 188 inflammation apply Leeches: put on a bandage as soon as the inflammation will allow: the Patient must be kept quiet four days or the Ligament will be torn through again by walking - a light Bandage should be used if he lay by a month or six weeks it will be difficult to walk a little exercise about the third or fourth day is necessary - Fractures Fractures are divided into simple & Compound called simple when the extremities of the bone are not exposed: there may be wound tho we may call it simple the exposure of the ends make the destruction 189 bone in the Body requires different spaces of time, depending on their size, as the Radius and Ulna will unite in three weeks The tibia never under 5 weeks and in very old people never under 7 or 8 weeks the large Bones in general, as the os femur and Humeri require 5 or 6 weeks before a firm union takes place. Simple Fractures are seldom dangerous to life except under certain circumstance. as a great depression of mind in very old age - Simple Fracture of the Tibia is ascertained by feeling along the skin. or by holding the foot in one hand and rotating it gently, passing the other hand along the bone untill you discover the crepitus when ascertained a slight extension is necessary to replace the bone in contact. but if the muscles oppose much by spasm you must not attempt replacement by force, but foment and poultices a day or two till it is subsided, when it may be readily replaced. You mush then apply the many tailed bandaged over the whole limb: this bandage is better than a long roller, for as the limb will afterwards swell the bandage 190 may be entirely loosed without disturbing the position of the Limb. if there is not excoriation of the skin or much swelling you had better put a rag dipped in aq: Ammon Acet under the Bandage. If excoriation has been produced then the aq. Lith: comp is preferable; over the bandage the whale bone splints are the best, as one set can be adapted to either Limb, and are known in the shops by the name of Martins splints - The posture. The Leg to be laid on the outside, knee a little bent the foot a little raised and supported by or pillow - The Fibula when broken is not commonly about three inches above the ankle and cannot be felt exept by rotating the Limb the other hand gradually feeling up the outside of the Leg untill you discover the crepitus, it is generally connected with a sprain of the ancle and is often mistakes for it rendering the Patient always lame 191 of the Leg with one hand, and rotating it: at the same time feeling along the Os Femoris carefully. when you arrive at the Fracture you will distinguish the crepitus: or by placing one hand on Trochanter Major & rotating the Leg with the other. If there is any Fracture the motion of the Leg will not be obeyed by the Trochanter. Treatment. Apply the many tailed bandage over the Limb, then three splints lined with wool, one before and one on each side. the Position of the Limb should be the Leg resting on the heel rolling a pillow up and laying it under the Ham so as to raise up and bend the knee - Fracture of the Clavicle may be known by tracing the bone with a finger from the sternum towards the scapula, you will find the bone sunk down at the fracture: Treatment. assistant must put the shoulders as much back as possible to bring the fractured ends in a line. then raise the arm so as to keep the clavicle in its place, then apply the stillate bandage (along roller) pass under both 192 axilla &c. not press on the broken extremity of the Clavicle for it would render the Fracture Compound. apply Emplast sapon under it. The shoulder is to be elevated in a sling, during the Cure no use of the Arm is to be allowed. The best mode of elevating the shoulder is to carry it close to the side and bind it down by a lon roller. the just support the arm in a sling - Fracture of the Os Humeri is distinguished easily by feeling the bone. A long roller should be applied round the arm then two splints one before & one behind will answer equally well when made of thick pasteboard, these are to be confined by another roller passed round the Limb in the opposite direction to the first ie. one from without inwards the other from within outwards which prevend. an appearance of twist of the Bone after. The position of the Arm should be hanging by the side supported by a sling on a pillow If in a very plethoric person he should be confined to bed for little while as very great swelling of the arm & forearm is likely to ensue 193 Fracture of the Radius & Ulna requires the same treatment as fracture of the Os Humeri- Fracture of the Radius only generally happens from falls in running - about two inches above the wrist known rotating the hand and applying the other hand along the Radius the fractured end of the bone generally protrudes among the tendons of the fingers so as to impede their motion - Treatment. the same as fracture of the Radius and Ulna to be suspended in a sling on a pillow - Fracture of the Ribs are ascertained by applying the finger to the part where the pain is and when the Patient Coughs a kind of grating sensation is perceived from the ends of the bones rubbing attended with pain Treatment it is necessary to hinder any motion of the ribs, therefore they must be bound very tight with a double headed flannel roller so that respiration is to go on by the Diaphragma - If the Lungs are wounded it is known by the Emphysima the bandage must be applied as before and a number of punctures made above and below it to let the Air escape. this 194 Accident generally gets well in about three weeks or a month unless in very old people - Fracture of the Sternum is a very similar accident to the former and is easily ascertained the lowest end of the bone generally lays under the upper, therefore the union is often irregular - Treatment the same as in Fractured Ribs. in both Bleeding is necessary - Fracture of the Lower Jaw, this happens generally at the symphysis from blows on the angle. The best bandage is leather sling with four heads. The sling being put under the lower Jaw the four ends carried over the head & brought down again and carried under the chin. Liquid food only must be allowed during the Cure - Another method of curing this Fracture is by passing a wire between the Teeth (2 on each side) twisting the ends firmly together this method must only be employed when the Teeth are firm Fractures of the Flat Bones unite exactly in the same way as cylindrical ones ie. by cartilage gradually becoming ossified thus in the skull where if 195 the bones could be brought together would unite gradually and equally as well as others but in these bones where a piece of any size is removed the place is not again filled up except by ligamentous substance - Fractures of the Patella happens generally from falls. the different portions of the bones become divided the upper one being drawn up the Thigh from three to six inches by the muscles inserted into it. the person becomes instantly lame if the pieces are not brought in contact the union is by Ligament but if brought in contact the Union is by bone. Treatment. you must bring down the upper portion in contact with the Lower by extending the Leg and pushing down the piece gradually from day to day as it cannot be done at once but will be done generally in about a week. If the bones is not brought in contact the Ligamentous union will be four or five months and the Patient is always to falls as that Limb is much weaker than the the other from the length of Ligament the patient should begin to move the limb gently after 1 month 196 Fracture of the Olecranon, is generally broke of about an Inch from the upper part and the portion of bone becomes drawn up about 2 inches high, the union as in the patella is either by Ligament or bone, Ligament when the Bones are not brought in contact. but bone when they are; to bring then in contact you must gradually and daily press the upper portion down till they come together. the arm must then be kept extended and a small square cushion laid just above the process which is to bound down by a roller. After the third week the arm must be gently moved every day to prevent anchylosis. - Fracture of the Os Calcis or other bones where large tendons are inserted unite them in the same manner as Fractures of the olecranon Fractures will sometimes not unite at all this happens from some peculiarity of constitution. there are no particular symptoms by which you can foretell it if appears to arise from a languor of constitution so that there is not sufficient inflammation produce to unite the separated parts 197 only Ligamentous substance without ossification. It has been recommended to cut off the two extremities of the bones and keeping the external wound open for some time this but rarely succeeds - If the muscles are affected with at a fracture give large doses of opium Tinct: Opii 30 gtt mane et Meridie et 4x nota hora somni with wine and a free use of spirits. Compound Fractures A Compound Fracture is when a bone is broken and there is at the same time an external wound communicating with the Fracture the wound is generally occasioned by the end of the bone. sometimes there is a haemorrhage. in twelve hours after the fracture there is a discharge of bloody serum much tension and great symptomatic Fever which continues from four to six days when the discharge becomes purulent and granulation arise from the sides and soon after from all the cavity which fills it up and the wound heals The greater degree of danger in compound than simple fracture arises from the greater degree 17 in the same manner great number of vessels were filled that could not be seen before their distention was produced. - the action of the vessels were not increased in this part but in the surrounding parts. The pulsation was much increasd, - Mortification takes place when a part is amputated in an inflamd, state, the living powers are to weak to support it - distention is not confind. to the part at first inflamd. it gradually increases and the whole brachial artery will become enlargd. in consequence of an inflamd. hand: if inflammation extends to a very great degree, the Heart will become enlargd. in which case the pulse will be scarcely perceptible, in case of very extensive inflammation constitutional treatment is necessary, particularly bleeding, this Mr. Cooper thinks is too much laid aside, but there is no occasion to bleed if the constitution is not affected - Blood should be removed quickly, if some degree of faintness is producd, it will be more effectual. 198 of inflammation and suppuration produced. and requires twelve or thirteen weeks to Cure when a simple one require only four or five - Treatment. Extension must be made at both end of the Limbs to bring the parts in opposition not using much force as it is not very material to have it done directly. if there is any haemorrhage apply dry Lint no Ligatures should be used if you can possibly avoid: if there should be tension apply poultice for the first few days. but if not attempt Union by the first intension with a linen rag (thin) in the Blood which comes from the wound. over it apply the many tailed bandage and over which put the splints. (Martins)- If the Fracture happens to the leg it must be laid on the most favorable position for dressing the Wound. if in the Thigh the same bandage is necessary as in the Simple fracture and the same position. the same application in the Upper extremity as in the simple fracture. the only difference is to wrap up the Limb in the rag with with the Blood from the wound. Get 199 the external wound to unite of possible by the first intention, always attempt it as it relieves the patient from great danger. unless there are very great Bruises then you must poultice - Much inflammation often comes on about the fourth day with great pain. loss of sleep stoppage of the discharge the parts about very much swelled. Air coming from the part when pressed the wound appearing dark pulse quick and small, with delirium. Blisters arising on the part with mortification killing in 24 hour - Treatment apply six or eight leeches to the part, general Bleeding im proper. poultice of beer grounds over the wound. Opium freely- Bark 1 dram 2ly poris and let the patient take freely of wine. Porter or Brandy according to the Habit he has been accustomed to live. The less medium the better internally so as to relax the Bowels. these means when employed early will generally prevent the Mortification - Mortification sometimes comes on in old people without any previous pain cheaply in old drunken people: this soon extends a great way and often proves fatal 200 In the reduction or replacement of the bone. when it cannot be done by extension. the most preferable mode is of the bone is not much denuded of its periosteum is to enlarge the wound. but if it is you should saw off the end which is denuded, but this is rarely necessary. if this happens to the Tibia, and the Fibula not broken it must not be sawn off on any amount as the ends of the bone will then be so far distant that no union well ever be effected When a large Artery happens to be divided which occurs oftenest in the Leg the Anterior tibial artery, and the Arteries of the Arms, you should not amputate hastily but cut down on the divided portions and take them up, then treat the fracture as before. A want of union will sometimes arises from a bad constitution and from exfoliating pieces of bone being enclosed. when a Compound Fracture extends unto a Joint it renders it a much more dangerous accident as the suppuration extends into it. Locked jaw coming on &c - Cases that require Amputation 1st when a bone is fractured in numerous pieces and the removal of which will cause such deficiency as will render the Limb 201 useless afterwards - 2ndly The division of a large Artery when it cannot be easily secured, as the posterior tibial Artery and when they are taken up high the Patient generally dies of mortification, but in the Branchial Artery as it is easily got at take it up and try to cure the fracture likewise in the fore arm - 3rdly when a large Joint is opened as the Knee or Ankle, but at the Elbow it should not be done hastily as the use has been sometimes recovered 4ly when the lacerations are very extensive though the fracture be not but should not be amputated hastily as great recoveries are founded to happen - 5ly It has been recommended where locked Jaw has come on - but the removal of the part is useless as it does not appear to relieve the disease at all - Young people often do well under accidents of this kind, when old ones dies - if the patient, Constitution is very irritable Amputation must be performed sooner than in one that is cool and patiently suffering. for in these delirium always follows quickly 202 the upper extremity may be amputated earlier than the lower. Mr. Cooper thinks that amputation in general succeeds better when performed after the patient has recovered from the symptomatic Fever than early if his constitution appears likely to sustain the first symptoms of irritation. - Wounds of Veins - These wounds are but of little importance with regard to the haemorrhage as they can be easily stopped. a wound in the Axillary Vein can be easily stopped with a dossel of Lint. so also the femoral Vein. the greatest danger of them arises from the inflammation of their internal coats the symptoms of which are a stiffness in the limb and part where the wound is and when occasioned from bleeding in the arm a difficulty of extending it. a swelling from the wounded part up the skin the size of a quil of a red colour: an abcess forms nigh the part with Violent shiverings and the matter with great difficulty gets to the skin, before are abscess breaks another forms higher up and often a third above that, when it breaks into the vein 203 then it proves fatal soon. these effects have by different authors been thought to arise from a wound of a Nerve, Tendon or Fascia. Treatment to be pursued is when the inflammation appears to apply leeches to the part & poultice - If these should not abate the inflammation quickly they best mode is to cut through the inflamed part down on the Vein and cut it across it may be done with a Lancet and afterwards compress the Bleeding Vein Wounds of the Nerves - On the division of a nerve the part to which it is distributed becomes senseless, yet the involuntary actions will go on in it as before, a Blister will rise in the usual time on it, and an Ulcer will granulate through not quite so quickly. for a few days after the division, the heat of the part will be greater than where the nerve is entire. as 78 in the entire part and 86 in the senseless part but after a few weeks it becomes much colder. a small branch is sometimes divided in Bleeding. it only causes a sharp pain at the time and a numbness at the fore part of the arm 204 for a month, but it is of no consequence further than that sometimes divided by the ends of fractured bones causing a numbness of the Limb below. When nerves have been divided after sometime they reunite by forming a sort of ganglion or knot at the divided part, and the powers of the part becomes gradually restored, this is also found where the ends of the nerves have been purposely separated. if the divided branch is very small the sense will begin again in three weeks if large from 4 to 8 months or if very large as the sciatic nerve at the Hip two years - Electricity quickens the restoration of sensation and motion: when a nerve is tied and remains undivided it generally kills the patient if large by producing violent pain and irritation & quickness of the pulse. If a nerve that has been cut through has been included in a Ligature as in a stump. the effects produced are according to the patient, constitution in some no ill consequence ensue, in others Violent and Universal spasms Treatment. when exposed lay the extremities in contact only and they will unite. 205 Wounds of Tendons The Tendo Achillis is often accidentally divided or cut across after which the Heel falls down and the upper portion of the divided tendon is drawn up within its thicken an Inch Treatment. Elevate the heel as much as possible by a high heel shoe with a strap extending up the Leg from the back part [of the] which is to be bound in with roller and applied round the calf of the Leg to hinder the spams of the gastrocnemii muscle: no pressure should be made at the divided portion as it will cause an adhesion of the Tendon to the bones and lameness ever after - The dressings are to be lint spread with carat simplex just laid on, if this plan is pursued the Tendon will readily unite and the patient walk with the shoe in ten days, no suture must be used. This tendon is often lacerated by great exertions in walking & ramming. the treatment is exactly the same. The patient may be allowed to walk as soon as the inflammation has a little subsided. it becomes completely united in 3 weeks and height of the shoe heel must be 206 gradually diminished. Partial laceration of the fibres of the tendo Achillis or of the Gastrocnemii: muscle is words accident than either of the former. It happens generally by a false step. the sensation at the time is as if the part was struck by a stone. Where the fibers are ruptured a depression can be felt and an Ecchymosis follows. This injury causes Lameness for years or for ever, if the person walks much on it for sometime after [a] high heeld shoe should be used for sometime with a bandage on the Gastrocnemii muscle for the reason before mentioned and in this manner the part will frequently recover itself in about three weeks or a months time - Wounds of the Abdomen These are of two kinds. Those where the Viscera are wounded. and those where they are not . If no Viscera is wounded, the wound is no otherwise dangerous than from its extent, or the protrution of the intestines which becomes strangulated by pressure 207 When the stomach is wounded the countenance collapses this person becomes insensible, the pulse cannot be felt. blood is vomited up mixd. with the contents of the Stomach, and liquids when swallowed come out at the wound, when this has happened no food should be taken either Liquid or Solid for a week or ten days, the Patient should be nourished by Clysters of Broth in which 120 drops of Tinct: Opii should be put three times a day to retain them after which a small quantity of Jelly may be taken for the space of a week and then solid food Wounds in the small Intestines are accompanied by the same symptoms as Wounds of the Stomach except that the Vomiting is without blood the same Treatment is necessary, but if it protrudes at the external wound, if partially wounded longitudinally and the intestines is seen externally it is right to pass the interrupted suture in it, the stiches only half an inch as under, then return the Intestines just within the Cavity leaving the ends of the Ligatures hanging out 18 There is but one objection to a large orifice it is apt to inflame. Venesection maybe used not only when the pulse is full and hard, but even when there is a weak thready pulse, as that will frequently rise after bleeding, of this we have frequent instances after amputation where the Patient is sinking very fast. if the stump bleeds the pulse rises and he gets better. the same effect take place in the bleeding of a compound fracture: it has been the custom to give bark & wine in these cases of slowness, but it is injudicious as they irritate too much in cases of incipient inflammation; taking [place] away blood in small quantities, will frequently stop its progress and not weaken so much as taking a large quantity at once, which should never be done but, in very extensive inflammation: when there is a very irritable jerking pulse, but if arising from a slight cause we should not bleed as it will only weaken. purgatives relieve by evacuation 208 then unite the Eternal wound by sutures which should not pierce the Peritoneum in eight days gentle efforts are to be made to bring away the ligatures of the Intestines - Wounds of the large Intestines may be known by the escape of the true foeces from the wound which should be treated the same as the former except that the nourishment must be given by milk only by the mouth instead of Clysters, as it will not make so much foeces. When any wound is made into the Cavity of the Abdomen and there is much haemorrhage the wound should not be closed till the haemorrhage ceases, for if Blood is extravasated into the Cavity of the Abdomen it is certainly fatal and not any great degree of inflammation is excited by leaving the wound open as long as twelve hours Wound of the Liver. This is not a fatal accident unless the wound is large a quantity of venous blood is discharged mixd. with bilious matter If the external wound is closed directly a quantity of this matter is extravasated in the abdomen; it should therefore be kept 209 open – lacerations without external wounds are fatal and it is not an uncommon accident. the abdomen swells to an enormous size and the Patient dies in a few hours Wounds of the Gall Bladder. Fatal in about 40 hours known by a discharge of bile Wounds of the Spleen. Although this is a viscus that may be removed from the Body without injury yet the most trifling wound of it is fatal, as great haemorrhage into the Cavity of the Abdomen follows. attended with such an inflammation as destroys the Patient indeed Blood when in any way extravasated in the abdomen proves fatal Wounds of the Chest. These are of two kinds. those which injure , and those which do not injure the contained Viscera: when only a wound is through the parts which contain the Viscera it may be known by the Lungs protruding when the patient expires and in the rushing in of Air at the aperture when he inspires. the wound must be united by sutures & covered with adhesive Plaisters to exclude the air and over them the applications of a roller. the opening closes inside by adhesion of the Lungs 210 Wounds of the Lungs. In these the breathing becomes difficult. coughing and vomiting of blood florid and frothy. with much haemorrhage externally and Emphysema. If the haemorrhage is not stopped you must bleed the patient till it does in general to 20 oz and when it is stopped you must close the external wound as before and the plaister applied, also the roller if the difficulty of Breathing does not prevent it. The Patient should have 20 drops of Tinct: Opii every three hours after. speaking should be avoided. these means will prevent immediate danger, but inflammations comes on sometimes on the fourth or fifth day after the accident which renders it necessary to take away large and repeated quantities of blood. Another danger is haemorrhage happening many days after the accident. when the external wound is healed it is shown by difficulty of breathing coming on without pain: the wound must then be opened again: when the Emphysema is very great small punctures may be made round the Wound not further than 6 inches off. Wound of the Heart & Pericardium are universally fatal as they have no opportunity of healing or uniting because of the Perpetual Motion of the Heart - 211 Of the Tix Doloreux This is the most painful disease the human Body is liable to it produces no disorganization of part. The pain during the fit is compared to a flash of lightning darting through the part with a vibrating or undulating feel in the part. an effect may be brought on from the most trivial causes: the nerves subject to this painful affection are the suborbitary: the ophthalmic branch of the 5th pair. The dental, the pes anserinus of the 7th pair. The nerves distributed to the Tongue & tonsil gland, sometimes the par vagum. the radial and the Anterior tibial nerve ... To Perform the Operation when the suborbitary nerve is affected (which is oftener affected than any other) make an incision with a Phymosis knife 1/2 an inch below the edge of the orbit and divide the nerve near the suborbitary foramen: the incision is to be made about 3/4 of an inch passing the cheek over the knife with the fingers which divides the nerve and the Patient feels a numbness in the upper Lip: the suborbitary artery being also divided. it is necessary to make a pressure on it with the finger for 5 minutes The complaint is very liable to recur in a few months after the operation from the reunion of the nerve. Lord Carlile & Capt Elliot in the navy have undergone this Operation with complete success - 212 As palliative remedies in affections of this nerve. salt held in the mouth and cicuta given internally have proved useful though never wholly effectual - In affection of the Anterior Tibial nerve apply a Caustic upon the part to produce an eschar, this is to be kept open by the introduction of a pea On Gonorrhoea The symptoms of this disease are an Itching sensation near the fraenum generally about the fifth day after impure Coition and on Examining the lips of the Urethra. they appear of a florid colour. on pressare a drop of mucus appears, in a few hours some pain is felt in making water. as the inflammation increases the discharge becomes yellowish, and when it is at its height it is of a greenish yellow colour mixd with blood erections are frequent, proceeding from irritation and is attended with considerable pain. after the pressure appears oedematous producing Phymosis and the dorsum penis when pressed on by ye Fingers feels knotted ie, the absorbents. then the glands of the Groin become enlarged. these symptoms decline if the constitution is very irritable. the will complain of a weighty sensations in - Posines - 213 near the membranous part of the Urethra. frequent inclination to make water, at this time the Testicle frequently enlarges, more especially if he is exposed to cold: the Urine passes in two or more streams as in stricture of the Urethra. If the discharge is of a white colour the inflammation is inconsiderable if it is yellow it is more extensive and if mixd with blood and the lip of the Urethra are excoriated inflammation run very high the appearance of this disease is uncertain sometimes in 24 hours and in others as long as 3 weeks - when the disease is protracted as it generally is in scrophulous habits the cure is more difficult. sometime there will be every Symptom of Gonorrhea present without any discharge The seat. of this disease in a lacuna Just an inch from the lips of the Urethra opposite the fraenum this lacuna is inflamed and in a virulent Gonorrhea the inflammation will extend to the neck of the Bladder and streaks of coagulable Lymph are discharged with urine It has been supposed that an Ulcer exists in the Urethra. but this very scarcely the case, and then only when the lacuna suppurates and bursts. The Progress of Gonorrhea is arrested by an attack of Fever when to all appearance it entirely ceases but as soon as the fever is subdued it returns with unbated violence 214 Treatment. Mercury given to effect the mouth does much mischief by its irritating effect, but mercurial purges may prove serviceable. If a patient has had several Gonorrhoea he is much easier cured than if it is was the first time. In a first Gonorrhoea the inflammation gradually extends for the first ten days, and if at this time you use astringent injections. you will in all probability produce hernia humoralis, or a stricture. If the Urethra will be the consequence. In order to lessen the inflammation give the following - Rx magnes Vitriol ʒÿ Nitri Puri ℈i P.G Arab: ʒ1/2 ᵯ pulv bis vel ter die ex Aq sumed As a purgative in some habits Calomel with Ext. Cath: proves useful. When the ardor Urina is very considerable give the following Rx Aq: Kali: purae gr xv ad xx Ext. Cicuta g iv Mist e: Camph ʒÿ M Haustus. the warm bath is a good remedy soda water is useful after taking the the powder or the following. Rx Kali: Carbonat ʒ1/2 Aqua H1/2 this should be drank mixd with milk it is of a diuretic nature. Local remedies: Rx ol: olii: opt ℥i Pul. Opii ʒ1/2 m. Tinct: Opii ʒÿ Aq: Purae ʒiv ᵯ the Penis should be shaked in warm water frequently for ten minutes. when the inflammation from very high apply a leech or two to the lips of the urethra 215 and the Patient should drink freely of then Gruel or Barley water. When the inflammation has a little subsided use the following injection Rx Aud: Vitriol gr i Aq: Rose ℥i or gr iÿ to ℥ÿ or Aq Vitrol: Albi gr i Aq: Rose ℥i sometimes gr iv to ℥ÿ may be used when the inflammation is nearly abated direct the use of Rx Zinci: Vitr gr iv Aq: Lith Acet 30 gutte Aq: Rose ℥iv M [if] injectio. in this injection a decomposition take place forming an acetate of Zinc, or the following is equally useful. Rx Zinci Acetat gr vi Aq. ℥iv aceti ʒi M - This preparation Mr. C objects to as by its astringent power it is liable to produce strictures - The following is a slow but a sure remedy- Rx Calomel ppr. ʒi Aq Calcis ʒiv M Inject. - The strength of the injection may be determind. by the constitution of the Patient and it ought to be changed every two or three days, they should four or five times in the day and in the night of awake in injecting he is to press under the symphisis pubis so that the injection may not pass further than two or three inches within the passage It should be thrown up with a little force the Elastic bottle syringe is the most convenient for this purpose - In some habits a Gleet will take place after the Inflammatory Symptoms have subsided for which give the following Rx Bals: Cobail ʒi (VO) q's aud Vitriol 4 gtt aqua cinnam ℥ÿ M g Haustus or Rx Bals: Cobail ℥i (VO) [illegible] 216 Aud: Vitriol 20 gtt Aq: Cininam ℥iv M Caps cochl amp tres vel quater in die, when there remains a discharge like the white of Eggs. use the Injection with the acet of Zinc. The Bals Cobail is apt to throw out an eruption on the skin like nettle and which take place in some people after eating Mussels but this disappears by the use of purgatives - the face swells with a troublesome Itching - Consequences of Gonorrhea. Strictures of the Urethra divided into two kinds. permanent and Spasmodic, there is likewise a stricture of mix'd kind, the symptoms of the most common kind are increase of inflammation on discharge of Urine when in Bed frequent inclination to make water a question necessary to ask- this precedes an alteration of size and appearance of the stream which is diminished, and instead of coming out in a round, stream it is broad and sometimes spiral- The most common effect is two or more streams, and when the complaint has been for sometime it will almost stop, and at length either from cold or something very triffling a retention of Urine is occasioned. There is a glary fluid discharge from the Urethra which stains like white of Egg: if guilty of Excess of yellow colour in consequence of inflammation but no Ulcer - The Bladder is affected and thickened with a weight above the Pubis, it’s contracting causes a 217 painful sensation at the upper part of the Pubis. pain of the Loins extending down the Thighs from perineum. Venumd sensation in direction of the crural nerves are the symptoms of the common state. it will produce Fistula in Perineo- The manner it is produced there is an enlargement of the Urethra between the stricture and the Bladder. The occasions a corresponding enlargement of the lacunae. The lacunae in consequence of the collection of Urine and being distended at length bursts. and the urine becomes extravasated between the cellular membrane: every time he makes water there is a great collection and after matter is produced - it depends much on the part where the strictures is formed. Bladder becomes thickened in consequence of stricture where it is existed for considerable time. the Urine becomes like whey being mixd. with Coagulable lymph, the irritations which it occasions the Constitution is mistaken for an intermittent sometimes with rigors & hot pungent skin relieved by sweating and so indeed do the symptoms give away to the use of Bark Kidneys become affected. An enlargement of the Pelvis and infundibule, and wasting of its substance when it continues long a suppuration of the Pelvis of the kidneys takes place so that the whole of the Urinary organ becomes diseased in Consequence - Seat of Stricture it is 7 inches within 19 and lesson the irritation of the Bowels by carrying off any foreign matter that may remain therein Calomel & Extl Cathl. produces this effect the most efficacious- saline purges tho' they occasion plentifull evacutions have not so good an effect - The 3rd mode of stopping inflammation is to excite perspiration - the warm bath relieves inflammation especially of the chronic kind, warm water applied to the feet in bottles or Bladders, are to be used to excite perspiration and hot diluent drink open the pores as soon as they are received into the stomach: in weak irritable inflammations, the Hydrarg. Muriat. in the dose of 16th part of a Grain given three times a day with Decoct sarsaparilla comp: in Decoct Cinchona is of great service. A Girl at Guy's Hospital had lost the use of one Eye by inflamation and the Cornea of the other opacity, many remedies had been tried without effect. it was supposd. a lost case by the use of Hydrarg. Muriat. The inflammation was stoppd. and the opacity of the corner 218 the Urethra. the length of the Urethra is 9 Inches, 2 Inches from the Bladder where Cowper Glands terminates. Which part is always a little naturally contracted. sometimes there are two strictures one an Inch behind the other they differ in length being from 1/8 to half an Inch. There are likewise many in the same Person. and some very near the orifice of the Urethra: description of stricture there are three kinds met with on dissection the first and most common is as if a cord was tied round the part: the 2nd kind is of a considerable length as if there was a broad round ribbon. difficult to cure. requires the use of bougies several times. The 3rd is a membranous band forming a cross the Urethra and sometimes several at the membranous part of the Urethra. There is also a species of are elastic kind in which if you pass a very small Bougie it will resist. but will not a large one. it will not sometimes yield to the passage of Urine. it is dangerous in this kind to make use of Caustic bougie. The cause is from an inflammation of the Urethra from whatever cause that may arise. Mr. Hunter says it does not arise from Gonorrhoea because he has found it in Boys, but the frequency 219 that it follows Gonorrhoea shows this disease is brought on in Consequence of it, but it is more the more of treating it than the Complaint itself that produces. the use of Astringent injection in the highly inflammatory state of Gonorrhoea extending it down the Urethra to where the stricture is situated. riding on Horseback & hard drinking - Method of Treating - The first thing a surgeon is to take a Bougie of the size of the passage. tho Patient Sensation may lead him to suppose it is opposite the frenum. when you have got a Bougie to the size keep increasing the size as the Patient can bear it - If not able to introduce a small bougie, bend it and give it the form of the Urethra. it may be softend by the fire. When there is discharge like common mucus stricture is to be suspected. The Elastic Bougies do not answer so well as the common ones. but Mr. Smith Covent Garden flexible bougies are usefull. Catgut Bougies are seldom used. the have one advantage that of swelling after they have been in a short time and thus dilating the stricture. if there is suppuration of Urine instead of the Catgut use the flexible bougie but this is not so certain a the common Catheter 220 A Catheter of the Natural size will generally where a bougie of a smaller size will not. It is not to be depended on for a Cure but only as a relief to draw off the water - On Caustic Bougie. when a common bougie cannot be passed through the stricture and when a small one does not enlarge the diameter of the stricture and give relief. then it is necessary to have recourse to the Caustic Bougie. Dr. Hunter revised this Practice and instead of a Bougie he conveyed a Caustic up the Urethra in a silver Cannula pushing it forwards untill it arrived at the stricture, but the Bougie is more convenient when the Caustic is inserted at the end of it. a soft Bougie larger than that containing the caustic should be passed first in order to dilate the Urethra as far as the stricture If the Urethra is not distended by this means the caustic will touch it and cause a contraction and will also bring on an haemorrhage. the caustic should not be suffered to project beyond the end of the Bougie. at first application it should only touch the stricture and be immediately withdrawn, after it may be suffered to remain in the Urethra against the stricture for ½ a minute but never longer. the surgeon should proceed cautiously that he may know what degree of irritability the Patient can bear. If 221 the Caustic Bougie remains in the part too long it will inflame and cause a suppuration of Urine Use it twice or three times a week. the slough occasioned by it seldom separates in less than 3 days. if applied oftener the Caustic acts upon the Slough produced. the day before. the Bougie should be of the size of the staff used in the operation of Lithotomy. The Caustic Bougie in strictures have been used with very good effect. and no doubt many lives saved. In a case of stricture under Mr. Coopers care that had continued two years and caused a fistula in perineo. the application of the caustic only 8 times destroyed the stricture and cured the fistula - In general the application must be repeated in proportion to the length of time the compliant has been standing In another case Mr. C. applied the Caustic 104 times. but this stricture had continued 14 years and at length cured by the application. The time it will take to cure is so uncertain that it is wrong to promise any time. The Patient always experiences instant relief but not a certain permanent cure. and if a common bougie or Catheter is not passed from time to time it will return in two or three months Though it has a general good effect. it is liable to inconvenience but in those most 222 Likely to happen when injudiciously used, one is Haemorrhage form the Urethra. Mr. Cooper was called to a Case where after the application of Caustic bougie Blood was discharged and a small pulsatory tumor was found in the Urethra. pressure did not stop the Bleeding and it appeared that the Artery of bulb was divided the tumor was opened, the blood collected in it was discharged. and a compress of Lint introduced into the incision stopd the bleeding for several days. The Gentn was at this time very weak - as soon as he recoverd his strength a little the haemorrhage returned and distended the Scrotum: the blood was again discharged and the hamorrhaege stoped by a compress of Lint: as it returned again Mr. C only supposed the artery of the bulb only half divided and found it in this state divided at quite with a Lancet, this stopt the haemorrhage but the Patient was so weak that he died in a short time after - Another inconvenience is the formation of a false passage. when a Caustic bougie has been used without relieving the Patient. it may be supposed that the Caustic has acted upon a neighboring part instead of the stricture. in this case a large bougie must be used whose end will not enter the false 223 passage but it is a far better way to pass a a piece of caustic in a catheter with the end cut off: this at first will go into the false passage, but if it is then drawn back and passed straight forward it will go to the stricture (it may be easily felt when in the false passage). When drawn back the point of the Catheter should be elevatd before it is passed forward - The Edges of the Catheter round the caustic should be defended by a thin coat of wax to prevent injury to the Urethra - Another inconvenience is the bursting of the Urethra, this will sometimes happen after caustic has been used and the symptoms of stricture very much relieved by: When the Urethra bursts the urine will insinuate itself into the perineum & scrotum and must be discharged by incision If the patient has not a very good constitution it generally proves Fatal - If a Caustic Bougie is kept in for more than a minute it will bring on suppression of Urine on the Treatment of Fistula in Perineo brought on in consequence of stricture. This abcess will take place even as far as opposite the Fraenum it then requires the same Treatment as in perineo, and when it has 224 extended into the scrotum it is particularly necessary as soon as you have found out the complaint to make an opening into it the earlier the better. The urine accumulates in the Cellular Membrane the skin becomes diseased. and so much so in perineo that unless it is opened it gives much pain. The Caustic Bougie must be used for that purpose. there are some whose Urethra is so irritable that the Caustic Bougie will bring on such irritation that it is dangerous to use it. In these Cases use the Catheter. it is to be kept in constantly. only to take it out for 10 minutes twice a week to clean. The Patient should always make water through the Catheter and not suffered to come the natural way if it does it will keep increasing the extravasation. by attending to these rules the aperture soon closes and in about 3 weeks a complete cure is affected. Mr. C has invented a screw to screw on the other. that is should not run down the Thigh. and to prevent the Catheter from [running down] slipping into the Bladder. there is a stop to the top If there is extravasation in the scrotum it is particularly necessary to attend to these rules. Sudden bursting of the Urethra behind the stricture the Urine becomes 225 extravasated in the scrotum and perineum at the time of being at stool or from other causes make an incision into the part by pushing a Lancet to where the Urethra has busted and let the Urine run out at the orifice. as soon as you have cut down upon the rupturd. part, pass in your fingers. let the inflammation be ever so great provided there is not a very great extravasation in the scrotum it will generally give way to this operation. This Rupture of the Urethra arises sometimes from accident it is to be treated in the same manner - Spasmodic Stricture. A sudden suppression of Urine so as not to be able to discharge a single drop of Urine. This sometimes accompanies the permanent stricture after it has existed some years it is an inflammation of the muscular fibres which surround the membranous part of the Urethra. Cause extended inflammation in walking there appears to be a collection of water there with Spasms upon the muscular fibres, extreme pain which is generally relieved by passing a Bougie but it is very difficulty to do it. for when it is passed. the part by the stricture resists it and force is of no use. let the Bougie rest gently against the stricture for several minutes accustom the Urethra to its use and in a little time, it will slip suddenly into the Bladder. 226 Sometimes the bougie will not succeed then you should have recourse to the Catheter which will always succeed: the common are of a large size. In the introduction of it it may be necessary to change the posture of the Patient. slight causes has been relieved by the warm bath. sitting in a common tub of warm water is the best way - Medicines does not give relief. Opium does not relieve the stricture. prefer a small dose of Antim Tart. to create a nausea, If Opium is given join it with Calomel. If an uneasy irritation of the neck of the Bladder and the patient has a constant desire to void his Urine, give the Hydrarg Muriat cum Decoct: Cinchona. If accompanied with a high degree of inflammation extending into the adjoining muscles. take 14 ounces of Blood from the Arm and apply Leeches to the part. apply a poultice composd of 1/3 mustard 2/3 Flower this will bring on a redness and give relief, this is to be preferred to Blisters as they will prevent the Patient from walking for sometime after. give a Pill composed of Ext Cicuta and Camphor, after Bleeding inject an Anodyne Enema. which will answer a good purpose as it will act on the muscles - Irritability extending to the Bladder occasions constant desire to make water. Open the Bowels, when evacuants have failed, and indeed has every other Medicine. The following remedy which was discoverd lately has never been known to fail 227 and always gives instant relief: make a small Pill from 1/4 to 2 grains of Ext. of Opium. this to be introduced by the Urethra (with the help of bougie or Catheter) into the Bladder where it becomes readily dissolved - It is wrong to use Bals Cobail if there is much inflammation — If a Discharge of [Urine] Blood with the urine. use the following Rx Opii 1 1/2 gr Cicuta gr iÿ Camphor gr ÿ M f Pilul. Calom may be added to prevent caustiveness Inflammation & Enlargement of the Prostrate Glands- The Prostrate Glands is of diseased by a simple inflammation in Gonorrhoea. more frequently so in old People who have indulged very free in Venereal Actions. it begins with a sensation of weight in the perineum occasioned by its enlargement. This also accasions it to press on the rectum and obstruct the Passage of the foeces- a frequent inclination to make water. and is not able to pass it without they kneel and their Legs wide assunder They generally void their foeces at the time of making water- a pain is felt at the end of the Urethra like that occasioned by a stone. The Urine is sometimes of a Whey colour and when suppressd is of a chocolate colour very offensive looking as if it came from a mortified surface- When thus enlarged the prostrate may be distinctly felt by the Rectum 20 diminished: irritability should be lessoned by medicines which act on the nerves as Opium Cicutæ &c, of the local treatment where inflammation is superficial we may apply cold lotions which diminishes it by restraining the vessels that are distended Lead is one of the best as it has a particular effect on the nerves. the application of Spirits by the cold they produce in evaporation constringes the vessels; other may be applied till the parts are frozen - if these application should not relieve the inflammation Leeches may be applied and the bleeding kept up as long as possible, and the cold applications returnd. to after the bleeding. Fomentations and poultices if not applied very hot will not promote suppuration but when the matter is formd. will bring it forward more speedily when inflamation is very deeply seated, it is servicable external inflammation by means of stimulating Plasters 228 On Dissection it is found to be divided into three tumours. one on each side and one behind between it and the Bladder. The valvular projection of the Prostrate pressing one of the tumours upon the Urethra and occasions the stoppage of the water - If the Prostrate is inflamed on passing your finger up the rectum it will cause much pain which goes on sometimes to be production of matter. the Urethra is three times its natural size that in passing the Catheter a surgeon is often deceiv'd thinking he has got into the Bladder as it may be turned to either side without resistance its length from 1 1/2 to inches more than common - this state of the Prostrate is the effects of growth in old men, or of simple inflammation from Gonorrhoea. in this last case it often suppurates or bursts of itself or is burst in passing a Catheter. This at once relieves the suppression - Treatment Take a large Catheter ½ or 2 Inches longer than the common size which is bent towards the end suddenly. When passed as far as the Gland it must be lifted over the tumour by depressing the handle between the Thighs elevate the point over the Prostrate and pass it into the Bladder. if pushed strait on. it would Rupture the Patient. the Catheter is 229 to be left in the Bladder. The French elastic Catheter is best as it does not soften and become rough like the English Elastic Catheter in three or four days it should be withdrawn to try of the passage is restored if not it must be introduced again - the Bladder is sometime so irritable as it will not bear the Catheter to be left in under this state the Patient generally dies - During the Use of the Catheter the Hydrarg Muriat may be given in Decoct. Cynchonae Soda Water has also a good effect in taking off the irritability of the Bladder or Rx [Sali] Carbonat: ʒ1/2 Pulv. Uva Ursi ℈i Ag Pura ℥iÿ Capt Cochl / major sepi et lactes - most dependence on Hydrarg: Murriat for Permanent relief . Bleeding from the Urethra in Consequence of Gonorrhea - this take place when the inflammation runs high and generally offords some degree of relief but is rather alarming to the Patient. tho it serves to lessen the inflammation. but sometimes a large Vessel is ruptured. and much Blood is discharged and in a very short time ye Blood will run back into the Bladder and be discharged from it in the same manner as the Urine The hemorrhaege generally takes place in the Membranous part of the Urethra. it is wrong to use Bougies - Treatment to find its situation pressure should be made along the Course of the Urethra it is best to begin at the Anus and pass along the 230 perineum to the Scrotum. when its situation is found pressure with the finger for 10 or 15 minutes will stop the hemorrhage. In irritable Habits it is sometimes very troublesome and will not stop by pressure with the finger contined pressure is required and it is best made by binding a Roller up with a [illustration] bandage on the perineum Chordee is a very troublsome symptom caused by imperfect erection making the Penis to be crooked to one side. pain very Violent it feels sometimes as if cord was passed along the under part of the Penis. it usually comes on when warm in Bed. it is caused by inflammation attendant on Gonorrhoea which throws out an effusion of coagulable lymph into the corpus spongiosum and cavernosum. and adhesion is produced in some of the cells which are in consequence glued together and prevents complete erection. a knot is generally felt where the obstruction is. there is sometimes another sort where the erection will be complete. we may call a cordee of two kinds. Viz Simple inflammatory or inflammatory with effusion. The pain is so very Violent that he is obliged to get out of bed and lie down with the part on some cold place. As the best Palliative remedy the Patient may apply a bottle of cold water between the Thighs. Treatment in the first place. 231 purgatives to reduce the inflammation give the following Rx Calomel 2 gr Opii gr i1/2 Cicuta gr iÿ Camphor gr ii M Piled hora somni sumendus this will take off the irritation and prevent the imperfect erection in the day time to take the aq. Kali: pine & Soda Water deaden the irritation of the parts. Local Applins. soak the Penis in warm water and apply a poultice during the night if the inflammation is considerable apply Leeches on each side of the Glans Penis - When the Cordee is gone off the knot may still remain. but may be dispersed by the Camphoratic Merc. Ointment - Hernia Humoralis is an inflammation of the Epididymus more than the body of the Testicles this begins with an uneasy sensation in perineo with inflammation appearing to extend to the neck of the Bladder, pain is then felt in the Spermatic cord. and the Heat extends to the Epididymus which at first appears swelled and afterwards to a considerable degree. when the Testicle becomes affected, the scotum is always much so by a remarkable florid redness, its Vessel, distended on pressure great pain. The spinous process of the ilium & the loins are also affected with pain - causes. This is not as has been thought a sympathetic affection. It is an inflammation beginning at the 232 opening of the seminal ducts in the Urethra and extending along the spermatic cord to the Epididymus. The most common cases is the use of injections in the inflammatory state of Gonorrhoea at that time even when the inflammatory state is subsidded. yet if there is pain in perines. Injections should not be used for they will cause inflammation to spread up the Urethra and produce this effect This inflammation is often brought on by the passing of a Bougie. to prevent such effects the parts should be suspended, during its use and so they ought during the Cure of Gonorrhoea cold water injected for a Gleet has occasioned a hernia hummoralis - Treatment the testis are to be well suspended by a Trap (the common bag Trap is very improper) Calomel purges if it is a slight affection this will be sometimes sufficient. If you find the inflammation continue use fomentations but first apply Leeches. Aq. Ammon: Acet as a Lotion. to be kept in a recumbent posture for this blood is sitting in those parts on account of its Vascularity V.S. in Brachio is sometimes necessary more than once. Sal. Amn and Acetum will sometimes relieve the inflammation but if it will not speedily do it it will excoriate the scrotum. poultices and fomentation are to be preferd 233 after the Leeches - If connected with pain in perineo Bleeding is necessary. Emollients in preference to astringents The Testicle will sometimes enlarge & suppurate in consequence of Hernia Hummoralis fomentations are necessary - make a free opening into the part. give the Bark and in general the patient will recover rather speedily but often when suppuration takes place it arises from a scrophulous Constitution. there is but little pain a long time before it points. and a Curdy substance is discharged a quantity of semen is [discharge] emitted from its Orifice. Inject into the sinus the following with an intention of causing a slight inflammation and promote union of the parts rx Zinic: Vitriol gr iv. Aq: Rosae ℥iv M vel Rx Acid: Vitriol gr ÿ Aq: Rosae ℥ÿ ℥ÿ M f Inject there is a fungus projecting from its orifice like Cauliflower of the size of half a Crown it is unnecessary to remove the Testicle sprinkle powderd. blue Vitriol over the Fungus or take it off with a knife and Join the edges of the skin with sutures, draw it over the sinus and it will heal. After the inflammation has subsided there will probably remain an uneasy hardness of the Epididymus. the best 234 external application is a piece of old silk over the scrotum it causes a copious perspiration and in consequence lessons the hardness and enlargement. this has a greater effect than the Ungn. Hydrarg fort Calomel ppr. externally - Emetics are not improper this enlargd, and hardend. state of the Epydidimus is often the source of much uneasiness to the Patient as he is apt to suppose it will lessen the virile power. but it has not such effect Sympathetic Bubo occurs during the inflammatory state of Gonorrhoea: when you find more than one Gland in the Groin enlarged never use Mercury as you are to believe it sympathetic. many of the Glands in the groin are affected. Simply by the application of Aq: Ammon acet and purges they will give way- they never suppurate unless by the use of mercurials which will occasion an increase of inflammation. Apply emplast: sulfur to the part affected - Impotency is in consequence of Gonorrhoea in some cases - Loss of Testicle. This was formerly considered a loss of Virile power. but it is not the case sometimes in consequence of disease. The testicle will become completely absorbed. if you see the other Testes begin in the same way. though the advice is by no means moral, his only resource is to have frequent connection with women 235 Mr. Cooper mentions a remarkable case of a man Castrated 22nd March 99 in June 22. 1802 having frequent emisions afterwards but at length they subsided, but he had erections. at command - [If the Tes] If both Testes are taken away the beard does no grow - Impotence is produced by loss of the retentive power of the semen. tho Vesicular seminatis loose their power of retention: the semen is dischargd. while he is at stool without erection. this brings on great degree of debility and the parts are incapable afterwards of doing their office. this particularly happens if the Body is in a Costive state. The following form has been found very useful. Rx Gum Oliban ℈i Myrrh ℈ii Ferri [pro?ef]: ℈1/2 Bals:Canud qt M Pilul 20 Capti 3 ter quotidie. at the same time the Bark should be given and the cold bath used. - The next cause of impotence is an irritability of the Vesicula seminalis. causing a discharge of semen by whatever excited Venereal ideas as the sight of a fine Woman. or touching the Penis. as soon as the Patient is warm in bed he has imperfect erections and emissions. which bring on great debility and even impair the mental faculties. Tonics only increase the irritability sedatives are the only remedies to be depended on the Path composed of Opium: Cicuta and camphor succeed the best - 236 Emissions during the night alarm some men but provided they do not occur oftener than once in a week or 10 days he not be under any apprehension as it can only then be called natural. If it occurs frequently a Yoke should be put on the Penis (Composd. Of elastic Gum) is the best. this gives a painful sensation when an imperfect erection comes on, Wakes the patient and thus ye discharge is prevented - Treatment- Cold Both and Pilulce Cicuta- Impressions on the Mind- when a person think himself incapable of coition, supposing a wasting of one Testicle from hernia humoralis &c will impede his power: his fears in this case will render him incapable. but if he can overcome his fears he will find that he has sufficient however - Dr. Hunter advised a person in this state to lie by the side of a very fine woman seven nights and to attempt to have any connection with her untill the end of that period. When he promisd, him that he would have power. this he bound himself to observe that after the 4th or 5th night his were passions were so much excited that he acted with effect and got cured - Stricture in the Urethra will occasion impotence in a case under Mr. Cooper, are the powers had gradually abated during two years, at first pain and difficulty was felt in the emission of the semen, at last it 237 it was totally obstructed passing backwards into the Bladder, and no erection from these circumstance and by a slight Gleet. Mr. Cooper was led to suspect a stricture, this he destroyd. by a Caustic bougie and the Virile powers soon returned. Gleet is a discharge continuing after the affection of Gonorrhoea has ceased Glary in general like white of egg; by irritation produced either by walking dancing riding it becomes yellow and sanous will influence the Urethra so much that a cordee will be produced and very difficult to distinguish from Gonorrhoea. the seat of a Gleet is in the same place as Gonorrhoea, but the lacuna magna is more particularly affected. generally accompanied with a stricture it is difficult to determine when Gonorrhoea ceases and gleets begins. The longest period Mr. C ever knew it infectious was after 5 month and 3 days - Treatment by the use of injections and bougies- Rx Hydrarg Muriat gr i Spt Vini Ten: ℥i Aq: Rosae ℥xÿ M Inject: their strength should seldom be exceeded. If stronger it will inflame the Urethra and cause hernia humoralis. Rx Liqur Cupri: Ammon: grx Aq: Rosae ℥i M [illegible] is particularly recommended. Combine the use of injections with bougie, which you are to introduce three times a week. injections 21 as good an application as any for this purpose is an ointment composd. of ʒÿ antimon Tartar and ℈i of Hogs Lard, which rubd. on the skin produces considerable vesication. Ungm. Hellebore Ungm. Sabrina are used with same intent a Vinegar poultice is frequently of use in inflammation of the Joints when irritation fails poultices will sometimes relieve, soap plaisters by keeping up perspiration are usefull in deep seated inflamations of the Joints, if the parts are in an indolent state, stimulation is necessary, and where inflammation is removed a Tonic plan externally and internally should be used On Wounds Wounds are Violent separations of the skin, and sometimes connected with the Parts beneath, if the parts beneath are divided, and the skin is not. it is not to be considerd. as a wound, - wounds are divided into four kinds 1st. the simple incised 2nd the lacerated 3rd, the puncturd. which is the most dangerous. 4th the contusd., - when the parts are disorganisd. 238 produce stricture. Bougie create a discharge the Injections diminish the discharge and Bougies the stricture. Rx Bals: Cobail ℥i spt. Aether: Nitrosi ℥i M Caht M 40 Cochl; parva ter quotidie - when there is Gleet with stricture use the Bougie oftener & Rx Pulv: Cynchone ℥i Bals: Cobail: gr1/2 Elactn. Caht Cochl 1 parva bis quotidie Mercury does no good in Gonorrhoea but Mr. C knew of one exception in a Gleet & stricture A gentlemen had a Gonorrohea after several months of Gleet and stricture and trying all other remedies, it gave way to the following Rx Hydrarg: nitrat gr i spt. Aether Nitrosi ℥i M Capt Cochl 1 Min vis die - An obstinate Gleet is often brought on by an abscess in one of the Lacunae alternately collecting and bursting: it may be felt on the outside of the Urethra. the Caustic bougie should be used to destroy it. An abscess in the lacunae has been known to bring an hectic symptoms and destroy life - External Gonorrhoea takes place at the External part, only at the Glands, from the Glandula ordoriferia near the fraenum frequently attended with Phymosis. An injection with Rx Calomel prop ʒi Aq: Calies ℥iv M Injection [gr] Rx Aq: Litharg : Acet: 30 gutte Tinc: Opii ʒi Aq Rosae ℥iv M Inject. as Phymosis almost always attends : apply spt. Vini : Camph & Aq Pinae to the Penis 239 Gonorrhea in Women. is a disease which affects the nymphae. and extends to the Glands of the Os externum of the Vagina. when it effects the Meatus Urinarius and occasions a great discharge from the lacunae like that from the Urethra in Men. on account of the shortness of the Meatus Urinarius the external coat of the Bladder is affected. this causes an incontinence of Urine. the Bladder contracts as soon as a very small quantity of water is collected - Pain is more excruciating in the Females than in men. the Glands of the Groin very generally become inflamed forming the sympathetic Bubo. Treatment – at first fomentations should be used: at the same time it will be proper to give purgatives. When the inflammn is subsided use the following Injection Rx Alum: 1 dram Decoct: Cynchona 2 H M It is a good way to keep a sponge with this Injection in the Orifice. All the other Injections mentiond. for the Male are proper - Gleet in Females in very common: it is difficult to say when it has commenced. the discharge may be like the White of Egg. yet it may infect - It will appear that a woman may give the Infection & not know of it herself 240 Treatment, the same as in Gonorrhoea sympathetic Bubo is not Venereal tho it sometimes suppurates: Mercury is very improper these Buboes seldom suppurates when Mercury is not given. If usd. they always do - when irritation is the cause several Glands enlarge. but when a Bubo is occasioned by Gl absorption of Venereal poison. Seldom more then one is enlarged - Treatment- The application of Leeches to the part using the Aq: Ammon: acet as a lotion. and purgatives. when inconvenient to the patient to use Lotions a soap Plaister will prevent suppuration - Chancre. milder form. This is an Ulcer occasioned by the application of Veneral poison to the Cuticle. on its first appearance there is an Itching in the part arising from a small pimple which breaks & discharges, leaves a deep Cavity. edges ragged and very [deep] thick with efflorescence & redness round with tumour. it is a point of importance to distinguish Chancre from simple excoriation. attend to the following circumstance. on taking it up between the Finger & Thumb a hardness is perceived like half a Pea. and excoriation is more superficial & no hardness to be felt 241 Chancre in its progress has much the appearance of a pustule in the small poxs - the time of its appearance after coition is uncertain. being as early as 24 hours and as late as 6 weeks. It attacks different parts, most commonly the Glans & prepuce. it caus Phymosis by thickening the skin. it also attacks the fraenum and commonly destroys it. this is the worst species as it very soon makes a hole through. even if the Patient washes immediately after connection the Poison lodges in the hollow of the fraenum and remain there. on the margin of the prepuce chancre is certain to form Phymosis. they sometimes form in the orifice of the Urethra and produce stricture when on the skin of the penis they have the appearance of wart. and also on the Scrotum occasioned by hanging down of the Penis after impure coitions - no Gonorrhoea accompanies chancre and when both are receivd. together chancre appears after Gonorrhoea has gone off - Treatment. It is to be supposed that Caustic will destroy the whole. if small it may do, this is desirable if the chancre attacks the fraenum. but although the sore will heal it does not necessary follow that it will prevent the symptoms. Give Mercury so as to affect the mouth: [O use] the following Rx 242 Rx Calomel prop ʒi Aq: Calcis ℥iv M : the time necessary to cure is about 3 weeks. give Morning for ten days after disappearance of the Cancre. Unctuos applications are very improper and have a tendency to inflame Calomel sprinkled on the sore is sometimes of service but will in general inflame and cause a deep slough. Red precipitate is a good application when the part is very focal and looks black it may be sprinkled or mix’d with Conser Rosae vel Cynosbat - sometimes after mercury has been use for sometime the Chancre appears stationary apply the following Rx argent Nitrat 1 dram Aq Rosae 1 ounce M once a day use this & constantly wash it with the Aq: Calcis & Calomel solution or if you find it indolent you may apply the Argent Nitrat every 24 hours it will cause a dry scab to form over it, under this a skin will be produced and heal it over. in the most lenient kind of [Mercury] canires it is absolutely necessary to give mercury to prevent the Venereal Virus from again breaking out and probably attack the Throat - Phymosis occasioned most frequently by Chancre on the external margin and sometimes in the Corona Glands. if taking mercury immediately desist from its use. it shews a weakly constitution with irritability. the best plan 243 is to order the lotion with Aq: Calcis & Calomel ℥iv if the pain is severe add Tinit: Opii ʒiÿ this will bring on a healthy state of the sore when the inflammation is subsided. then return to the mercury. suspend the penis towards the abdomen with rags round it will with the Lotion. this plan will sooner reduce the inflammation than any other. sometimes Phymosis will not go off when inflammation has subsided. then use fomentations. for they will absorb it and reduce it. the Mercurial Oint will produce the same effect. if these will not succeed then perform the operation which is very simple - make an incision upon the upper part of the penis. pass a director between the Glans & prepuce make a division with the Phymosis Knife midway between the extremity and the Corona Glands. the prepuce drawn back as much as possible before the operation is performed. make a small incision of the inner parts afterwards. this produces no deformity the Bleeding is very slight apply dry Lint. in healing it keep the skin back behind the Corona Glandis & apply poultices - when the skin is drawn behind the Corona Glandis it is called Paraphymosis. both the prepuce & Glans become swelled and inflamed - an 244 effusion of coagulable lymph into them is taking place, in order to reduce the swelling as much as you can. apply at first a cold Lotion with Aq: Litharg: Acet Comp with Spt Vini the evaporation of the spirits producing a greater degree of cold. but it is much better to proceed at once to the reduction it is wrong to perform even any operation. Take the Glans penis with in the palm of the Hand squeeze it so that it will become quite flacid. by the pressure it forces the blood back. but your fingers over and under the penis bring the integuments forward. and pressing the Glans backwards. so as to push it within the prepuce. A poultice is to be put on the part. It is alarming if attended with Chancre and is not quickly reduced. for it will cause Mortification & sloughing Chancre in an irritable constitution instead of mercury having a good effect. it will make it worse, and the Lotion recommended will be hurtful and Penis lost in consequence. A Chancre itself does not destroy the penis but by inflammation with succeeding sloughing together with high constitutional irritation pulse from 120 to 130 Symptoms are the Patient cannot sleep the part swelled the edges look discolord a sign of approaching Mortification 245 this sloughing extends more along the skin than the body of the penis. it will in general soon cause the whole sloughing of the penis untill it reaches the pubis; If you donot arrest the progress at the beginning it will be of no use - abstain from the use of Mercury if you see any considerable degree of inflammation, and attend to the constitution - do not fear the Penis being destroyed - In this sloughing state of the Penis it has been a custom to use fomentations and Poultices, but it will go on worse if any poultice is used. the following is the best A Tablespoonful of Yeast mixd up with Linseed meal - use also the following Rx Calomel: prop: ʒi1/2 Aq: Calcis ℥iv M there is in this a precipitation taking and which is the oxid of mercury. shake the bottle and tun the mouth upon the tip of your finger, the powder will be deposited on it. apply it on the surface of the sloughing sore- Rx acid: Nitros 30 gtt Aq: Fontan 2 H: M p Lotio. this may be injected under the prepuce even with Phymosis. this is as strong as the Penis is able to bear. check the irritability of the constitution with opium. Bark & sarsaparilla 246 give porter & wine. but in this you must be carefull, and regulate it by the heat of the skin - to put a stop to the bleeding sores dip Lint in ol: Tereb. press it for 4 or 5 minutes but where the Vessel is very large use a needle and Ligature. it is surprising with what good effect this may be used. no degree of irritation will be occasioned by it and the sore will heal in the same manner as if not there - The Urethra bursts from sloughing sometimes with a hole opposite the fraenum if a very small part treat is as a hare lip pare the edges and introduce a hollow bougie to prevent the urine from coming through then pass a suture through the hole. If 1/3 of the Urethra is burst it will be of no use. when a chancre sloughs at the Lips of the Urethra it will close its orifice. when the urine is discharg’d there will perhaps be only a small stream or sometimes a total stoppage. the Urethra is considerably enlarged behind the place where it has stopp’d Take a very narrow bladed Lancet push it into the swell’d part of the Urethra. take then a Trocar and Canula, and leave the Canula in the Urethra and direct him to make water through it - 247 When a chancre is seated in the lips of the Urethra Structure of the Orifice is occasioned. a piece of bougie 2 inches long should be worn constantly for a month or more the passing of a bougie or the use of a caustic bougie is of no use in this Case Mercury is not to be given after the sloughing is cleansed. heal it up as a common sore. If you use Mercury as the constitution is supposed to be very irritable it will produce again the same appearance wait untill you find the Venereal Virus has affected another part. if it should then use the proper steps 22 The appearance of the first kind, is separation of skin with hemorrhage, the indication or cure are to stop the hemorrhage remove the coagulated blood from the surface tiring the edges, to bring them together and unite them by the first intention, pressure will in general stop the hemorrhage. if the divided artery is not very large, union by the first intention is effected in the following manner, a small portion of crasamentum adhering to the cellular membrane glews the edges together in a few hours a slight inflammation comes on which causes the vessels to elongate; their ends project into the interposd. blood which this becomes Vascular, in about 10 days the union is effected - the part produced is similar to that destroyed if the skin is divided it becomes skin if Tendon tendon is produced (instanced in a preparation of the tendon of a dog’s leg which is injected and is in the parts produced 248 If this does not succeed use the following powder. Rx Pulvis Sabinae: Cupri acet. (Verdigris) partis equalis M f Pulvis - apply it on the Warts. A saturated solution of sublimate in spirits gives pain afterwards but not at the time. Mercurial Ointment has removed a number not destroying them by its Mercurial power but by its irritating effect The yellow wash of the Hospital (Aq: Calcis and Hydrarg Muriat) the black wash (Aq Calcis & Calomel) - Treatment of the hard kind, Arsenic in powder upon the part of the Lotion : Rx Arsenic: pulv grii Aq Rosae ʒviÿ M f Lotio - the powder applied to surface only is best. the Lotion being applied to a greater surface is apt to effect the system: the whole of the wart separates in two days put a piece of Lint over it or it will cause the same sloughing from the foreskin a liniment is also used . Rx arenic ʒi Ungn. albi ℥i M. this is not so good as the powder as it runs about upon the Glans Sometimes by cutting them off a cure is effected - Chancres in Women. Its most common seat is in the inner side of the external Labiae. sometimes on the nymphae or externum Vaginae and Rectum. Treatment 249 use the Aq. Calcis and Calomel. give Mercury internally. sometimes sloughing as in the Male and from the same causes When it takes place in the Female it does not stop at the Pubis as in the Male but extends up the abdomen the region of the Pubis, and destroying such a surface as they die of irritation. Use Mercurial Ointment with Opium. the Nitrous aud Lotion page. to sloughing sores which would not yield to any thing else the following Liniment has made a Cure Rx Aq: Lithrarg: acetat : pulv Opii. Mil: Rosar os in ʒii Conserv: Rosar ℥i M p Linn. when they once begin to slough they very seldom stop till Death closes the scene. - Means to prevent the Venereal Disease Ablution with soap and water will prevent a chancre but not Gonorrhoea. the the following Lotion may be also used Rx Aq: Kali: purae 20 gtt Aq: Purae ℥i M p Lotio. If not used directly will answer no purpose — Bubo. Venereal Bubo generally tho' not always appear on that side of the Groin on which the Chancre is situated on the penis. generally single in each groin 50 If other Glands are a little enlargd. they do not increase in a good Constitution. when more than one Gland suppurates it shows a scrophulous [constitution] Habit - Symptoms are like those of a common Abscess except more nocturnal pain. Treatment 1st Cathartics to reduce the inflammation. then the Mercurial pill. apply the Emplast: sapon to the part. the Mercurial Ointment to be rubbd in. it is indifferent in which side it is used. Continue the Mercury untill the Gland is nearly of its natural size. When the Bubo does not yield to this treatment and the pain increases leave off the Mercury for three or four days otherwise the Bubo will suppurate. in these intervals give purgatives and Apply Leeches to the parts also the following Lotion. Rx Ammon muriat ʒi aquae ℥iv M. However a Bubo will suppurate. this known by its size and pain being increased and by the redness of the skin. Here use no Mercury but apply Empl Luth. Comp the Patient must live well and take the Bark. when the Bubo is opened use Mercury again - opening of a Bubo. As soon as fluctuation is perceived the Bubo should be opened If not large open it with a common Lancet 251 on the inferior and anterior part then poultice, and in three days again give Mercury. If the collection is large make an opining at each extremity of the Bubo — Bubo sometimes become very red. of a great size and hard. here abstain from Mercury for the constitution is irritable in this case. foment and poultice in order to bring on a suppuration as soon as there is the least fluctuation open and the swelling becomes absorbd. very soon. If the collection of matter is allowed to be great dreadful consequence will ensure - sometimes a bubo after opeining forms a sinus especially if the Bubo is large. when it is opened apply a Blistter to irritate the skin and inject into the sinus Rx Acid: Vitriol 2 gtt Aq:Rosae ℥i M p Ing also Tinct: Canth - also Hydrarg Mur grii Aq: ℥i M by these means inflammation is brought on and the sides of the sinus are glued together and the enlargement is dissipated - Indolent Bubo. sometimes after the suppuration and also after being opened. If after suppuration do 252 not open it but give Mercury for the absorption of the Matter. If after being opened this does not yield to large exhibition of Mercury and use of Caustic, lay aside all dressings &c and expose the part to the air In three or four days it becomes scabbd, and under which cicatrization will go on Sometimes a considerable number of Glands are enlarged from pouparts Ligament down to the second order, two, or three inches below this is Veneral but scrophula and Mercury does harm Give Tonics Sloughing Bubo this resembles sloughing chancre and occurs in the same irritable constitution and is follow? nearly by the same effects is opened- sloughing with much pain comes on but by the cessasion of the use of Mercury. inflammation abates. separation takes place. and the sore heals but from some triffling cause in a little time sloughing again comes on. In this manner the case goes on till by the repeated sloughing the Femoral Artery or Vein is opened and the Patient dies from haemorrhage - Local Applications. the black wash and if it disagrees vary its 253 proportions, should not this at last suceed apply the following Rx Unguent: Hyd: Nit ℥i pulv Opii ʒ1/2 M p Ungn or Rx Mil: Rosae Tinit: Opii : Aq: Lith Acet [illegible] ʒii Conr rosar ℥i M or Acid nitrosi 20 gtt Aqui 1 H M apply this warm and do not exceed the above strength. yeast poultice composed of a Tablespoonful of yeast & a pint of water. Also the carrot poultice one of the above applications will agree with one constitution and another with another. Give Bark with Acid : Vitriol Opium and Wine. If the wine increases the pules which is often from 120 to 130 in a minute. substitute Ale or porter. In a sloughing Bubo do not give Mercury till it has healed except Venereal symptoms in the constitution endanger life After the constitution is improv’d again is evaluated from the Bubo the Gland will project out and lie [like the Bubo] over the skin. Mercury here produces sloughing. give Tonics. applications Rx Argent: Nitrol ʒ1/2 - ʒi Aq : Rosae ℥i M p solutio vis die applicand - apply the blends 254 Wash after each time. with these applications the Bubo is brought level with the Skin and heals – Venereal Ulcers in the Throat . the Venereal poison is absorbed in the groin carried [carried] into the Blood and produces its first effects on the Throat. there are three parts so affected. the Throat, skin, and the bones; and in this order the Testicle is sometimes affected. In the Throat the Tonsil Glands are generally affected. This is the most favorable for only dryness of the mouth follows their destruction, Symptoms. a dry husky feel especially towards evening no pain except the parts are excoriated by swallowing Acids. Another part affected is the soft palate this sometimes takes place from a small Ulcer in the palate itself most frequently in an extension from the tonsils - Symptoms Liquids in swallowing run trough the Nose. when it reaches the bony palate there is a considerable exfoliation and the Uvula is destroyed - Another part is the Fauces at the back part of the Pharynx. Symptoms. the same as in the soft palate - Another part is the inside of the Pharynx. symptoms. no visible venereal symptoms Horseness so that you can scarcely hear the Patient speak. from irritation 255 of the Epyglottis. Coughing and expectoration of of Matter mixd with blood. no pain in the chest but in the Throat. There is great constitutional irritation and wasting of the Body from which the disease is frequently mistaken for Phthisis Pulmonalis. Treatment when in the Tonsils or Fauces the same kind of Treatment is proper. Rub in Mercury & give Hydrarg Muriat internally and use the following Gargles Rx Hydrarg: Muriat 2 gr Aq: font ℥i M dip a probe with Lint wound round it into this Gargle and apply it to the part- sometimes enlargements of the Tonsils are accompanied with scrophula dip the probe as above in the following Gargle Rx Acid Nitrosi 25 gtt Aquae 1 H M give also Mercury. If not Venereal give the Murialic Acid & Bark- should this not succeed puncture the tonsils 1/2 a dozen times and if scrophula use the Acid wash the enlargement soon disappears. if sloughing comes on leave off Mercury and apply p Boracae over the whole sloughing surface likewise mill: eruginis & Nit: Acid Gargle the constitutional treatment must be the same as in sloughing of the Penis & groin- Treatment in the soft palate the same as in the Tonsils. 256 Treatment in the Bony palate apply the following to the edges of the sore. Rx Acid Muriat 25 gtt Aq: fontan 1/2 H M this acts chemically on the bone and removes it without exfoliation - If in the Larynx give sublimate early and fumigate twice a Day Apply a Blister externally to abate the inflammation Venereal Eruptions are distinguished from other cutaneous eruption by their copper colour a brown crust over their surface and under this crust a sanious pus or serum. This eruption first appears on the Breast 2nd on the Face and very often crust and eruptions hang on the Hare and the head is sore. after other parts of the Body becomes affected. they are as large as half a Crown other times not larger than a flea bite. yet all possess the same copper colour and are attended with little pain except an itching sensation in the evening - the pain is great when the eruptions are large and have ulcerated Treatment. In addition to Mercurial frictions give sublimate internally. Local treatment is unnecessary except the eruption has ulcerated the crust of the eruption is the best covering taking this crust off disposes it to Ulcerate. If Ulceration has taken place with pain (and not unless that pain is very great) 257 apply sublimate and lime water. Rx Pulv: Opii 1 dram Ungn. Hydrarg: Mit ℥i M These eruptions sometimes became Phagadonic Ulcers most commonly situated in the Groin after Bubo they are so called from eating away the parts as they advance. Character A deep sore with the edges of the skin hanging over. the surrounding skin is of a copper colour inclining to a purple. Treatment Rx Argent: Nitral ʒi ad ʒÿ Aq: Pura ℥i M p Lotio wash the sore and surrounding edges with it till they become white every morning - also the Calomel & Aq: Calcis. to use the oxid of Mercury which settles at the bottoms by these means the worst kind of sores are cured. give the following Rx Pulv: Cinchonae . sarsaparilla aci ʒ1/2 M p Pulvis ter qutidce ex Vino Rub Allow the usual beverage of Wine & Spirits After the skin the bones become affected 1st the Bones of the nose: small chancres form upon the membrane of the nose, soreness across the bridge of the nose and pain upon pressure blowing the nose forces out scabs. after there is a discharge of blood & matter. the Breadth is offensive sometimes a considerable portions of bone separate at the vomer and os nasi: the osa nasi will sometimes come down the nostrils 23 produced as vascular as in the other parts) to this rule there are to exceptions, muscles if divided are not united by muscular but by tendinous substance; Glands when divided are united by an intervening substance which never becomes Glandular: in old persons the cartilage of the ribs if divided is united by bone, but in young person it is united by cartilage - union by the first intention will take place between other substances, for if the scalp is torn and replaced it will unite to the scull - the periosteum of the bone will do the same, skin will never unite to cartilage; it will grow together over it, and like a joint is furnishd. with synovia, how much so ever parts may be divided, they should never be separated for they will or may unite- It was the custom of old surgeons when a part had been much separated to cut it away this very much prohibited the cure, and when the bone was exposed as in injuries of the scalp, it produced very troublesome exfoliation - The following care prove 258 and at other times make an opening through the bridge and fall away. Timely attention prevents the latter. Treatment Rx acid : Muriat 1 gtt Aq: fontan 1 H M p Lothi The patient to pour a little of this on the Palm of the hand and sniff up his nose this cleans the sore and quickens exfoliation at the same time use the Mercurial plan To prevent external exfoliation which causes deformity, as soon as the skin becomes inflamed pass the forceps up the nostrils and bring away the loose os nasi: the nose sinks a little - Venereal Diseases in the Bones. Symptoms. Dull pain in the bone especially towards evening and increasing when warm in Bed. these nocturnal pains distinguish it from Rheumatism. soon after a prominence small and painful to the touch appears If the node is left to itself it goes on to suppuration, a glary fluid is formed, in it which by a long inflammation becomes purulent Existence of fluid is known by the redness of the skin. Matter forms in the Bone and not between the bone and periosteum Nodes are situated chiefly in the center of the Cylindrical bones. particularly those that are subject to Vississitudes of weather as the Tibia sometimes the clavicle and sternum. 259 Treatment. Besides the Mercurial plan local means are frequently necessary. soap plaisters to the part lessens the pain &c When there is much inflammation apply a Blister to the part before you give Mercury - nocturnal pains are lessened by wearing fleecy hosiery and woollen stockings during day - If a Node contains fluid do not be hasty to open it for exfoliation will ensue and the cure take up many months. if there is not inflammation the Glary fluid is absorbed by the use of Mercury and the periosteum again adheres to the bones - If suppuration has taken place leave it to Burst of its own accord. These effects in nodes are more frequent in the cranium than any other part: where tumours containing fluid form upon the cranium excite mercurial action quickly and if the skin is not red the fluid will be absorbed - Symptoms of Venereal Disease Universal pains in the Bones distinguished from Rheumatism by being more nocturnal not affecting the Joints like Rheumatism but the Bones: no nodes attend this pain Venereal Pains require a longer course of 260 Mercury than nodes. small moveable venereal tumours are found sometimes in the cellular membranes. in Various parts as large as small marble. They appear like Glands but are quite distant from their situation. there are nocturnal pains which are very difficult of cure. taking 9 weeks under mercury Another situation in the Testicles this is quite different to hernia humoralis in Gonorrhoea, it is an enlargement of one of Testicles- cure Mercury – sometimes in Venereal diseases there occurs after a clap a red line extending from the lips of the urethra along the rapha to the Anus, and has the appearance of Erysipelatous inflammation. Care by mercury Another spasms of the abductor muscles of the Eye drawing the Pupil to one side quite within the socket. Cure mercury – The Venereal disease may be contracted without the contact of the organs of Generation Venereal Matter to the scratch on the Finger produces a Chancre on the part with very Violent inflamation. the absorbents are inflamed to the Axilla. where a Gland becomes enlarged with constitutional irritation so as to endanger life the sore puts on a sloughing appearance 261 Treatment. Apply Aq: Calcis & Calomel. Subdue the inflammation by the antiphlogistic plan. and then give mercury - General remarks on the disease & on the effects of Mercury upon the Body. the Venereal disease only effects a few parts of the body viz the Urethra. the surface of the Glans penis. the first Gland in the Groin The Throat. the skin, and Bones. the Brain the different Viscera - and all the principal Vital organs are not [illegible] effected - Venereal symptoms are divided into primary and secondary. the Three primary are 1st. Gonorrhoea 2nd. Chancre. and 3rd Bubo - The Three secondary are 1st. Throat 2nd skin. and 3rd Bones. however Bubo is not always primary but where there has been no chancre. It is possible for a Bubo to be Venereal altho there has no disease upon the penis - Mr. Hunter has considered the Venereal complaint to be merely a local disease. that is unattended with Fever Mr. Cooper denies it and advances the following arguments. viz that there is a regular exacerbation every evening and that the pulse are quicker &c 2ndly that before 262 the appearance of the Venereal disease and even after he feels unwell having a feverish paroxysm every Evening - Mr. Hunter also says that a child at the Breast of a Woman having the Venereal disease cannot catch the infection, To this Mr. Cooper is Certain to the Contrary. some persons have not susceptibility to receive the Venereal disease altho they may have frequent connections with foul Women. some persons are susceptible only of the affection of gonorrhoea and no other form, as Chancre or Bubo. Persons who have been much on the Town escape the infection when at the same time a person from the country having connexion with some woman will catch the disease. In healthy constitution the Venereal disease is unattended with inflammation or very little: when there is much inflammation mercury disagrees and the disease is more difficult of cure. Mr. Cooper says that Gonorrhoea is not truly Venereal: chancre cannot produce Gonorrhoea nor Gonorrhoea chancres The Venereal Disease in the Throat often takes place without chancre or Bubo. the Poison frequently gets into the Blood and affect the Throat without affecting the 263 the Urethra or Groin- Matter taken from the Throat and inoculated, does not produce the Disease. the Matter by passing the absorbents becomes changed in its nature Matter from Bubo, will not produce Bubo - Effects of Mercury- Mercury effects a Fever in the constitution throughout. which action overpowers and at length destroys the Venereal action in the particular parts. Rule of Cure. The cure of Venereal Disease does not depend on the quantity of Mercury used nor upon the action it excites in a given time but upon the Action being supported for a length of time To Cure a Chancre the Mercurial Action should be kept up for three weeks. To Cure a Bubo from three to four weeks, none of the secondary symptoms are cured under 5 weeks. some of a peculiar habit require 11 or 12 weeks. The Patient should rub in from 12 or 14 times for a Bubo. 2 night, and missing one and sometimes every other night. chancre may be cured by nine times 2 nights and missing one - some persons require much more Mercury to affect the constitution than others some are 264 not affected at all. such persons are of an indolent and scrophulous habit in such cases when afflicted with scrophulous symptoms give the Patient Mercury. keep him warm and let him live upon a cow diet as Liquid Aliment &c. putting the feet in warm water will quicken the circulation - In summer Mercurial Action is sooner excited than it Winter - Also during friction it is a good plan for the Patient to immerse his Legs up to the knees in Water as hot as he can bear it. the warm bath quickens the Mercurial action - A Woman that gives suck cannot be salivated let the amount of Mercury be ever so great-. on the contrary some persons are very soon affected especially those of irritable habits and quick pulse Calomel :3 gr scammon 5 gr has been know to excite salivation, In stout and strong constitutions a 1 dram of Ungn. Hydrarg : fort rubbd in for two or three nights will excite mercurial action while those who seem thin and weak are not at all affected - those having a quick and small pulse are most easily affected, desist. from the use of Mercury when it 265 excites much Fever. there is always a slight chill down the back when it begins to act. if the pulse is quickened and there is a slight fever leave off its use likewise if there is much sweating for if it does it never affects the system. passes off and injures the health. Give Bark and Vitriolic Acid till the sweating ceases. some persons are very quickly salivated without effect on the constitution is they have no soreness of the gums nor swelling of the cheeks Country Air is proper for such persons. In London and in all large Towns there is frequently sloughings of the Venereal Sores which hinders The Cure - here leave of Mercury & give equal parts of Bark & Sarsaparilla, and a considerable quantity of opium. Country Air is the best. after you may give Mercury when the debility of the constitution is gone off - Forms of Mercury. the best is Mercurial friction. begin with Ungn. Merc fort as before directed till the Mouth is affected 266 and as soon as it is affected 1 dram every other night increasing on diminishing it according to the effect it produces on the constitution carry it on progressively untill it produces considerable effect towards the end. you may let the patient walk about for the first three weeks of the course, then let him lay by for a fortnight by this means you will obtain a permanent Cure Next the Blue Pill composed of iÿ grains of Quicksilver and 1/4 gr. of Opium this taken every night and morning Increase the dose if necessary : Opium prevents it from purging. Calomel & Hydrarg Muriate should not be given as they run off by the bowels &c- Calomel is only required when the Mouth is difficult to be effected. This form of Mercury agrees well with some and not with others - next Rx Hydrarg: Muriat grÿ vel 4 Sp. Aether Nit ℥ÿ M Capt. corhl i paru bis terve die. this produces a slow effect upon the system and at the same time improves the health - when the effects of Mercury continue and the salvation does not stop. Rx Argent: Nitrat gr ÿ Aq: Purae ℥iv M the mouth to be Gargled with a Tablespoonful of it. three times a Day its Astringency Braces the relaxd parts 267 The infusion of Roses cum Acid Nitrosi is also useful. at the same time give wine and expose the Body to cold air. the Patient should be careful of catching cold. Mercury has been said to pervade the system in such a quantity. that even the sweat. the saliva. the Urine and Blood contain’d it Mr. Cooper was very anxious to have these experiments tried and it is found by the most accurate chemical tests that it is not true. he took from the arm of a Person in a state of salivation 6g of Blood not the 560 part of a Grain was found in it- A quart of saliva was then tried in which there was not the smallest quantity found: also he took a quart of Urine and there was none there – the effect produced on the Gold in the Pocket is in consequence of the Mercury hanging upon the Patients hands, we may therefore conclude that its nature is altered from pervading the system- Exema Mercuriale This Disease has in some instances proved fatal- Symptoms. Eruption upon the Belly and Thighs. The Eye Lid sometimes inflamed when it affects the Bowels the Patient falls a Victim to the Diarrhoea sometimes 24 the practicability of uniting parts when they have been quite separated- A Gentn. well known by Mr. Cooper. was when a boy playing with a mastiff. the dog flew at him and caught hold of the lower part of his nose and tore it so that it only hung by the skin of the lower part, it was immediately replaced by straps of sticking Plaster being secured and supported, it united so well that the cicatrix is not to be easily perceivd A lady had the lower part of her nose nearly separated by her head being thrust through the widow of her carriage in which she was overturned, it was united by the adhesive plaster and as perfectly as the above case- parts quite separated will if put together will not only unite but grow after their union- Mr. Hunter made a whimsical experiment, he wishd. to try if inserting the Testes of a Cock in the body of a hen would produce any sexual alteration. he did so, and although they did not produce any 268 the whole body is covered. Debility is extreme These eruptions are covered with a crust giving out and odour. When the Patient stands up the crust falls upon the floor and appears as if bran had been scattered sometimes it only Partial upon the Thighs If you scrape off the crust there will be an extreme discharge from the sore. the scrotum is also affected - Treatment. Sulphur internally. Tonics warm Bath. Aq: Lith: Acet. comp has failed. The best mode is country Air Tonics. and the following Lotion Rx Hydrarg: Muriat gr ÿ Aq: Calcis ℥ÿ M fs Lotio this is the yellow wash on the Aqua Phagedonica. the Patient should be wash’d with it from head to foot. it Produces no Mercurial effect - Introductory Lecture Surgery consists in proper Remedies to external disorders, and in performance of Various Operation. It is divided into principles and Practicals - In simple Fractures the Surgeon ought to keep the parts in Opposition. and in Compound Fractures the extremities of the bones are exposed with a bruise, and sometimes splinters which must be carefully removed. It is necessary to bring the two edges together: but If you do not succeed you then promote discharge by warm applications: Granulations follow and the cavity fills up when parts are bruised a sloughing takes place. which requires particular attention. In these cases nature herself will do a great deal - Index Page On Accidents - 1 On the Progress of Inflammation - 8 On specific Inflammation - 13 On Wounds - 21 On Lacerated wounds - 29 On Mortification - 37 On Injuries of the Head - 43 On the effects of compression of the Brain - 49 On Trepanning - 53 On Cataract - 59 On Couching - 68 On Fistula Lachrymalis - 72 Wounds of the Throat - 76 Wounded Arteries - 78 Dtt. - Joints - 79 On Hydrocele - 81 On the Operation for Hydrocele - 86 On Dislocation of the Vertebrae - 91 Page Dislocation of the Clavicle - 92 Ditto of the shoulder - 93 Ditto of the Elbow - 95 Ditto of Wrist - 97 Ditto of the Hip Joint - 98 Ditto of the Patella - 101 Ditto of the knee Joint - 103 Ditto of the Ankle - 105 Incysted Tumours - 107 On diseases of the Testicle - 108 On Aneurism - 112 On Fistula in Ano - 121 On Amputation - 123 Ditto of the Metatarsal - 124 Ditto of the Leg - 125 Ditto of Thigh - 127 Ditto of the Wrist - 127 Ditto of the fore Arm - 128 Ditto of the shoulder Joint - 129 On Diseases of the Female Breasts - 130 On Hydatid Tumours in the Female Breast - 133 Page The Operation for Schirrus Breasts - 133 The Method of Introducing the Female Catheter - 134 The Method of Introducing the Male Catheter - 135 On Opening the Temporal Artery - 135 On Lithotomy - 136 Method of performing the Operation in Male - 138 Ditto in Female - 142 On Suspend Animation - 143 On submersion under Water - 143 Suspension - 143 Introduction of Noxious Air - 144 of Extraneous bodies - 145 Means of recovery - 146 Bronchotomy - 147 Operation for Suppression of Urine - 148 Of Calculi in the Urethra - 149 Cancer of the Penis - 153 Amputation of Dtt - 153 On the Hare Lip - 154 Page Operation for Hare Lip - 155 Of Nasal Polypi - 156 Operation for Dtt - 157 On Dropsy & the Method of Operating - 159 On Scrophula Character of Scrophulous Persons - Treatment - Tabes Mesenterica Scrophulous affections of the Joint - Treatment - Scrophulous Hip Joint Ulceration of ye Vertebrae Scrophulous Ophthalmia Testicle On Gunshot wounds Treatment Burns & Scalds Sprains - Fractures - Compound Fractures Wounds of Veins Page Wounds of nerves Wounds of Tendons - Wounds of the Abdomen Wounds of the small Intestines - Dtt. of the large Intestines Dtt. of the Liver Dtt. of the Gall Bladder Dtt. of the Spleen Dtt. of the Chest. Dtt. of the Lungs - Dtt. of the Heart. Tix. Doloreux - On Gonorrhoea The seat of Gonorrhoea Treatment - Stricture the seat of Stricture Treatment for Stricture Use of Caustic Bougie Spasmodic stricture Irritability extending to the Bladder - Bloody Urine Inflammation & enlargement of the Prostate Gland Treatment - Bleeding from the Urethra Chordee - Hernia Humoralis - Sympathetic Bubo - Impotence - Loss of testicle - Emissions & Impressions &c Gleet - Seat of Gleet - External: Gonorrhoea - Ophthalmia occasioned by Dtt. Gonorrhoea in Females Gleet in Females - Chancres Sympathetic Bubo Phymosis - Paraphymosis - On sloughing - Warts - Page Chancres in Women - Opening a Bubo - Indolent Bubo - Sloughing Bubo - Venerea Ulcers in the Throat - Page Venereal Eruptions. Dtt. Diseases in the Bones Symptoms of the Venereal Disease General remarks on Dtt - Exema Mercuriale - 25 change of that kind, yet they grew and were filled by an injection thrown into the surrounding part- the spur of a young cock being inserted into the comb will grow to the same size as on the Leg- A preparation was handed round the theatre in which a human tooth had been inserted into the comb of a cock and the periosteum of the Tooth was so firmly united that it may be forcibly pulled without any fear of the separation - A Tobacconist in the Borrough had the first joint of his finger cutt off, it was replaced by Mr. Lucas and the soft part united, the nail grew, but the Phalanx exfoliated at the Joint of the finger- soft parts will readily unite on account of their admitting the elongation of the vessels, but hard parts will not - Mr. L. Bell in his fist addition of his system of surgery ridiculed the idea of uniting separated parts, but being in London and seeing the instances above mentiond. he was convinced of the probability of uniting them and in the subsequent 26 editions of his surgery ingeniously confessed his error - A curious operation lately common among the natives of India proves how parts that have been divided may be united. It was the custom of Hydor Ally and his son Tippoo said to cut of the noses of their prisoners to remedy this defect a piece of wax nicely moulded to the shape of the nose is applied to the part and a piece of skin the size and shape sufficient to cover it is cut from from the forehead and is turnd. down over the wax nose, the upper side of the skin is placd. outwards, it is united to the forehead by a small slip left undivided and the edges are inserted into each of the artificial nose, the whole is firmly united in a short time, the strap on the forehead is divided and no one could distinguish the artificial nose from the natural one; the turban hiding the cicatrix on the forehead, the union by the first intention takes place sooner on the upper extremities than 27 in the lower, as the circulation is stronger in those parts, for the same reason it is more difficult in old persons where the circulation is weak the Vessels do not elongate - the impediments to the union by the first intention are irritability of constitution where suppuration takes place, introduction of extraneous bodies ligatures the division of many absorbents, as in transverse wounds of the groin where extravasated lymph prevents union of the parts by the first intention, to promote this union we should not open the parts after the first dressing for ten days or a Fortnight if they are not painfull. if they are exposed too soon inflammation comes on and the cure is protracted - of the importance of union by the first intention as soon as that is effected the danger is over, its quickness [illegible] takes place in as many days as the same wound be weeks in healing by the other means- in the old method of amputating when the Limb was cut 28 off strait, lint and flower applied to the stump the discharge was very great, suppuration frequently took place and the patients frequently died the present method of applying adhesive plaisters soon produces an union and it is very seldom that any bad effects follow amputation, the method of applying the adhesive plaister may be used whenever the Bone supports the parts as in the scalp, neck, longitudinal wounds of the limbs &c &c Wounds of the face if the muscles are divided require sutures as do wounds of the throat, triangular wounds of the extremities, deep transverse wounds of the muscles all require sutures are described in old books of surgery but only two are admitted in the present practice the interrupted and the pulled the first for the wound, above mention'd, and the last for long wounds of the abdomen we should always be carefull to introduce as few sutures as posible - 29 On Lacerated Wounds Lacerated wounds are very little different from the incised, they bleed less, extraneous bodies are frequently introducd., it is difficult to remove them, but necessary if parts are healed by the first intention without removeing them abcesses will ensue, A man had lacerated his scalp by a fall from a scaffold the part was laid over the scull and union took place, matter afterwards form,d in several places, and many small pebbles workd. out - Lacerations are most dangerous in the tendinous parts and frequently occasions lockd. jaws, attempt to produce union by the first intention but if inflamation comes on change your plan to poultices & - contusd. wounds are dangerous they disorganize the parts and hinder the circulation, blood is extravasated in the cellular membrane, inflamation & mortification 30 ensue, these wound are not to be united by the first intention - poultices should be applied to the wounds, and if sloughing comes on hot fomentation should also be applied, as they generally expedite the process of the sloughing, if the inflammation goes on Leeches should be applied, and the swelld. part of the limb should be bathed with St. brine; Camph, as the process of sloughing is attended with irritation, Bark &c should not be given. Opium given in saline draughts will give great relief when the inflamation has subsided, then Bark wine and strengthening remedies should be administerd, - We ought to observe where the process of sloughing is the effect of constitution and not accident, Bark may be given, as in this case it is not attended with irritation which accompanies it when from accident - Punctured wounds are the most dangerous, their effects arise from, two causes, the operation of the nerves and absorbents, but the most 31 common effects is inflamation of the absorbent vessels, the symptoms of this is great pain in the part, red lines extend up the limbs the auxilla enlarges, pulse becomes quick and hard the knees swell and become stiff, delirium comes on and the patient dies; - A young man a Pupil in the Hospital had opened the Body of a man, and in sewing it up he prickd. the tip of his finger, in the evening he complain,d of pain and applied a poultice during the night be became delirious the next day he was calmer, but ye following morning the symptoms returnd, and he died about two o Clock, - A man who had puncturd, his finger had suppuration come on in the axilla the discharge from which was so great that it killed him the effects are produced. by the inflammation spreading through a great number of the absorbents, as these cases have occurred frequently in the practice of dissection, it has been a common opinion that putridity 32 was absorbed, but it does not seem to arise from this but more from the sort of wound and constitution of the person puncturd. - this was the case with the person before mentiond, as the Body was opened before putrefaction came on, and we frequently find that the same symptoms occur from accident where absorption of any kind is impossible Mr. Lucas Surgeon at Guy's had all the symptoms and was very near loosing his life by pricking his finger with the point of a buckle, it was in consequence of putrid matter only, the absorbent vessels that receivd. it would be affected in this case a sharp instrument is thrust into the cellular membrane, where the mouths of many absorbents are lodged, it wounds some and the inflammation spreads along their internal surface, these effects takes place in the constitutions naturally irritable. in those who are intemperate, or those who by long confinement to the close and bad air 33 of the dissecting room have acquired a considerable degree of irritability- Putrid matter has been injected into the cellular membrane of animals, which only produces a swelling that is absorbd. in three days & that without any ill effect to the animal The treatment necessary for punctured wounds of this kind, is to dilate the wound apply a poultice to the part, a frequent application of Leeches- Mr. Cooper applied 31 at different times to the arm of patient the limb should be fomented after the application of Leeches, saline medicine should be given, Calomel & [E?t] Cath should be used and if there is a tendency to delirium opium should be given, many persons has been destroyed by stimulating medicines given in these cases. on supposition of putrid matter being absorbd. - Dr. Watts having mett with an accident of this kind, when the symptoms came on took wine very freely and died in 9 hours - Mr. Cooper when a young man dissecting a body at surgeon's hall punctured his thumb, the symptoms came on 34 and he at first pursued a lowering plan by the advice of a Physician who was an advocate for the stimulating plan, he took a few glasses of wine and on finding the symptoms increase he desisted had a very painfull Night, and the next morning found one of his knees swelld. and stiff, he applied a blister and before that relieved him stiffness and swelling came on in the other knee, had he taken a few glasses more wine it would have killd him - A Gentleman fond of dissecting, punctured his hand, on opening the body and being fearful of venereal infection, rubbd in a large quantity of mercurial ointment and died in a few hours- The nerves are most frequently injured by punctures of the slighter kind the punctures happen generally on the feet and hands, and one ever so slight as to be healed before the symptoms come on may produce a lockd. Jaw. Dr. Ludlow lately died of Lockd. Jaw 35 in consequence of running a thorn into one of his fingers, the first symptoms of Lockd. Jaw is a stiffness of the Mastoid muscles, the Jaw becomes lockd, and is generally more firmly so in the beginning of the disorder ; tinitus aurium and chilliness attends, the Joints are affected and cannot be freely bent, violent spasms of the back come on and the body is bent backwards, it affects the muscles of the abdomen, which are hard and do not yield to the touch, the cheeks and corner of the mouth are drawn upwards and the face is much wrinkled, the body becomes stiff, the muscles of respiration are lastly affected and the patient dies, but most frequently he is attackd. with convulsion fits, the intervals of which becomes shorter & shorter till they carry off the patient in lockd. Jaws there is little disposition to sleep, if he does sleep the Jaw relaxes but shuts closely on waking there is frequently a profuse cold perspiration 36 the body is costive little urine is made and the pulse is from 90 to 160, we have not a sufficient number of cases that have terminated successfully to point out in certain mode to proceed on, the warm bath does no good in this disorder, it may in warm climates, but will not in this, opium will not relieve the spasms. A man at Guys Hospital took the first night of his admission 360 drops in three doses the next morning be took 310, at several doses in the evening he took an ounce at one dose at eight o Clock and at 11 in the same evening he took half an ounce at one dose he died the same night the opiate produced no effect on the spams, Brandy and stimulants faild., the removal of the punctured parts has no effect after the symptoms are commenced Tobacco Glysters give temporary relief but weeken to much for repetition Digitalis was unsuccessfull two cases have been lately successfully treated in the Hospital. A man run a nail into his foot, a week after the symptoms came on and he was admitted into 37 the Hospital, the cold bath only was tried he was allowd. a small quantity of wine, when the spasms came on he went into the bath which constantly relievd him the spasms were thus kept down and he recovered – in the second case Tinct ferri:muriat having been successful in some spasmodic affections, it was determined to make a trial of it in lockd. Jaw- it was given in this case in such a quantity as to keep a constant nausea 60 drops was given every ten minutes, but on this making the mouth very sore it was discontinued, and took 5 grains of ferri Vitriol in its stead this kept up the nausea the spasms were restraind, and he recoverd, he went into the cold bath once but it increasd, the symptoms On Mortification Mortification or Gangrene are synonymous terms signifying the death of a part the rest of the body being sound spacetus 38 signifies the act of separation of the dead part from the living, the first symptoms are those of violent inflammations, great swelling skin florid red, violent pain with quick pulse, loss of rest, and delirium, after which the part suddenly becomes easy, small vesications appearing on its surface containing a sanious dark colour fluid, the skin under these vesications is dark purple and insensible, hiccup comes on partial flushing of the cheeks, and if the part is small the Patient may live, if large dies- When mortification is producd in consequence of exposure to cold only the symptoms are, the parts becomes benumd. feels swelld. when pressed, the inflamation arise when the part is warmed, there is very little pain or constitutional affection, the inflammation abates and returns three or four times before the mortification commences, but in colder countries, such 39 as Russia, the parts become at once perfectly white and sloughing off without any previous inflamation, Thus when the mortification has happened the next process is the separation of the dead part from the living or spacitation which begins first by the appearance of white prominent line between the dead and living part which is the rising of the cuticle under which is a small furrow containing a quantity of serous matter, this is the first sign of the cessation of mortification, the Groove is formed by the absorption of the living part, this gradually extends deeper through the cellular membrane and muscle, until the whole dead part is removed, granulations are thrown out from the living part of the groove, by which the dead parts becomes thrown off: the largest arteries in the Body under these circumstances become separated without any hemorrhage for it is prevented by the formation of coagulum 40 very high up in the sound artery – the separation is the same in all cases, from whatever cause the mortification arises: the predisposing cause is debility: by whatever means it is induced; as by continued fever a mortification is producd. of the Hips when laying in bed the same time with Compound Fracture if the constitution is good no such effects follow it is soon producd. in old people as the circulation is most languid - more common in the extremities than the trunk. they being so much further from the Heart. Tentons are more liable to it than muscles as their living power is much less, loss of blood when great especially of stumps when the limb has been previously removed on out of mortification The occasional causes of Mortification are inflammations violent bruises destroying the texture of the part, and a disease of the Heart as Hydros pectoris. means of prevention when it arises from high inflamation, leeches should be applied to the part. cathartics must 41 be administered, apply the poppy fomentation, and stale beer poultice, or wine Lees, or sps. of wine mix'd in the poultice. when the inflamation is a little abated, give Tinct of Opii & the Bark freely every two hours, which however must not be dependd. upon, if the pain becomes less and the pulse not full, wine may be allowed, but better not while there is much inflammation, unless the person has lived very free before, when the mortification has happend. you must give wine freely - opii gr ij every two hours, cinchonæ and confect: aromat or the Bolus with cayenne pepper, fomentations and stimulating poultices, untill the part is separated, which should not be used to long and should afterwards use Turpentine dressings as soon as you can, Amputation ought never to be performd, while mortification is going on nor till the patient has in some degree recoverd, the irritating effects of it on the constitution and never as soon as the mortification has ceased unless from the inconvenient length of the stumps. it is not at all necessary as the parts 42 will separate of themselves - the Bone shortest the muscles longer than it, and the skin the longest of all so as to form every good stump which will readily heal, - In the mortification which arises from cold - sps. wine and Camph should be applied in such a manner that evaporation can take place and the stimulus created by it, be moderated by the cold produced if this does not succeed moderately, warm poultices an fomentation must be used and in cold countries rub the part with snow which produces a certain warmth moderated by the melting of the snow, mortification of the Feet in old people who have lived very high, begins with pain in his ancle and along the top of the Foot, and a Toe or toes appear black, the upper part of the foot florid, red, and then turning black, extending sometimes up to the calf of the leg, it mostly confines itself to the toes, and then the patient generally does well, occurs chiefly in tall people 43 sometimes also from ossification of the arteries this generally arises in people who having livd. very freely are suddenly deprivd. of their nutriment in this state opium is the best remedy combind. with wine and Brandy and fomentations of milk and water- Injuries of the Head First symptoms of injuries happening to the Brain are nausea vomiting, loss of sense and voluntary motion, fœces pass off involuntary and so does the urine in the same manner as when injury is done to the spine - Bleeding from the nose and Ears, and sometimes vomiting of Blood, as it gets from the back of the fauces into the stomach - A labouring slow irregular intermitting pulse, pupil in some cases dilated, in others not, it is sometimes contracted, but then there generally is spicule of bone, driven in and irritating the brain, respiration is sometimes affected with apoplectic 44 terror convulsions sometimes takes place if light, but if there is injury receivd on one side of the Head there is hemoplegic . - strabismus is the consequence of it and deafness: These symptoms generally arise from two causes only 1st, concussion of the brain 2nd pressure on that organ causing inflammation on concussion of the brain - The first circumstance to be attended to is to distinguish concussion from compression in concussion the breathing is not at first affected, nor is the pulse, sleep is easy the effects of concussion have been thought to arise from the motion being so violent at to interrupt the circulation here, but it appears to arise from laceration of the fibres of the brain as appears by dissection, the part about being of a red colour, and a worm eaten appearance, in slight concussions an altered action of the circulation is produced preventing 45 Ideas being formed - Treatment. In slight cases of concussion sickness is of service we are to consider whether Emetics are to be used when other means have failed, the first thing that must be done is to bleed very copiously, and if the pulse are full bleed as long, and as often as twice a day for several days if necessary, so as to bring it to the natural standard, it is much better to take blood from the jugular or from the Temporal artery as it relieves more speedy than from any other part- in slight cases of concussion Leeches may be applied to the Temple, in concussion of the brain it is wonderfull what quantity of blood will be lost before the pulse is brought to its natural standard or the symptoms relieved - A man was admitted into St. Ths. Hospital May 12th 1803 for concussion of the brain he was bled on that day four different times 8 oz. 16 oz 16 oz - 10 oz - the 13th - 10 oz- 14th 12 oz 10th 12 oz 46 in consequence of intemperance he got worse on the 26th and was bled again twice 32 oz. on the 28th - 10oz - 30th 16 oz. June 1st 10 oz. and in the end perfectly recoverd. losing in the whole 152 oz of blood, this was done under Mr. Cooper, directions, and the blood was drawn by his apprentice - drastic purges should be given freely, antimonials to keep up a diaphoresis, Calomel & Pulv Antim ought to be given in preference to Pulv Ipecac:Comp, a blister to be applied to the whole scalp its use depends on withdrawing the blood from the brain, if incission has been made to search for [the] a Fracture we ought to apply a poultice to it, and procure a discharge then heal it directly, mix Ol. Terebinth in the poultice it has the same effect as a blister. no cordials as wine &c should be allowd, on any account. Trepaning here is totally useless and very dangerous, The opening of the 47 Jugular vein will often put a stop to it when it will fail from the arm, particularly in children, the opening of the Temporal Artery is very usefull, and in extremely young children Leeches are very useful, Partial symptoms occurring from the accident are very difficult of cure, so much so, as the most violent ones such as loss of recollection or Epileptic fits afterwards, these symptoms are also caused by slighter injures to the Head, but these may sometimes be moderated and relieved by a seton in the neck, a partial loss of hearing or sight is sometimes the consequence, and which have been cured by Electricity if applied early - loss of memory is almost always the consequence of it - A man was admitted into the Hospital for concussion of the brain and when he began to get better, spoke different language. in short he perfectly lost the English language, so that there was no person in the Hospital that could understand him 48 A woman who sold milk accidentally coming into the ward and on hearing him talk answerd. him, and it it was discoverd, that he had been talking Welsh, & it was a considerable time before he got his English again, this case tho' remarkable as to be scarcely creditd. all the surgeon in the Hospital well remember - A Gentn recievd. a blow on the forehead and was stunned, in consequence he when home and vomitted and felt relievd. by it, the next day he complaind. of pain in the Head the vomitting came on, and for many weeks continued vomitting once a day and was relieved. it at last got to twice and three times a day and continued - the Trephine was applied to examine the dura mater & was found perfectly sound and in a good state; he lost his reason and died soon after in consequence of this slight blow on the Head- This shews that it was wrong to perform the operation 49 On the effects of compression of the Brain Pressure may arise from three causes. 1st from extravasation of blood within the cranium 2dly. depression of bone in consequence of a Fracture 3rdly. the formation of matter in the brain. - 1st Extravasation of blood within the cranium. The symptoms do not come on directly but will in an hour or two, (in concussion the symptoms come on immediately)- the breathing is laborious, pulse full slow & irregular, Extravasation is always accompanied by a fracture: a simple fracture of the scull without any depression or symptoms of injury does not require trepanning or any thing but the antiphlogistic treatment but when there is depression the symptom, of pressure come on and in violence proportionate to the degree of pressure produced. A great depression may sometimes be felt in some of these accidents 50 Without any symptoms of pressure ensuing, but in this cases the depression is only of the external table, and therefore you should not trepan without symptoms of depression - . a great depression will also take place in young children without any fracture or harm as their bones are very soft. - If symptoms of injury to the brain come on or if with the depression there is an external wound then you should trepan for if in this case you do not inflamation of the dura mater will come on with delirium and will kill the patient, but if there is no external wound neither trepan no make an incission nor if a patient has a depression and external opening so that a portion of brain equal to the diminished space is removd. you need not trepan - A person who has once 51 had a concussion or compression is liable to have some of these symptoms come at a future period. he should therefore if possible keep himself quiet and loose from time to time small quantities of blood. Extravasation between the dura mater and Pia Mater or between the dura mater and bone requires trepanning to be performd., the quantity extravasated sometimes is very small and sometimes large but the dura mater is not to be opend. for it will yield when the bony support is taken away inflammation on the Brain from accident, generally comes on about the 10th day after the accident sometimes as soon as the seventh and even as late as the 21st it begins by pain in the Head on the injured side generally it pulsates if there is a wound the slough becomes brown and there is no discharge. the scalp about the injurd. part pits, it is an odematous swelling. the Patient is siezd. with frequent rigors followd by heat the Eye inflamd., cheeks flushed, pulse 52 quick and irregular, body costive, feet cold, and when matter is collecting on the dura mater or Brain, respiration becomes laborious as soon as these symptoms appear the patient ought to be trepanned, when the scalp is cut through, the Pericranium will be found to be detatched and on perforating you will find the matter between the dura Mater and the bone gush out as soon as you make an opening. be careful in puncturing the dura mater when you wish to see whether is matter is lodged between the membranes, it ought to be carefully obliquely. but even here the surgeon has often failed for it is situated sometimes at the basis of the scull and the case is renderd. irretrievable - Mr. C. never knew a case succeed where the dura Mater had been puncturd. for this purpose before you operate bleed freely. if compression accompanies fracture many hours ought not to elapse before the operation use purgative & VS - the object here is to take away the extravasated blood under the bone - 53 On Trepanning There are parts of the Head where Trepanning ought not to be performed as on the middle of the os frontis over its spine except in young subjects where there is none. above the Eye brows where the frontal sinusses are placed, nor over the coronal sagital suture, or lambdoidal sutures on account of the firm adhesion between the Dura mater and the suture, however it may be done here if absolutely necessary, the sagital suture has been objected to on account of wounding the longitudinal sinus. but that is of no consequence as a pledget of lint will most commonly stop the Haemorrhage, and the immediate discharge of blood from the part is often advantageous, the anterior & inferior angle of the os parietale one inch before the Ear has also been objected to as the Dura matrel artery passes throug a foramen in this angle of the bone and if cut was supposed to be dangerous, however the 54 Hemorrhage may be stoppd with a dossil of lint and it does not prove troublesome This angle of the bone is situated just above the zyogomatic arch — To be certain where the situation of the fracture is you ought to make a crucial incission over the suspected part and turn up the edges of the scalp and examine the bone beneath: if you find a fracture you must trace it by making a longitudinal incision slowly and carefully along its course. if a great separation has taken place take care your knife does not slip and injure the membranes - when the operation of trepanning is inevitable and determind, on, the instruments necessary are the scalpel, Rougine, perforator, Trephine, or instead of perforator, a Trephine with a central moveable pin to act as a perforator. and afterwards to fix the crown of the instrument to work steady, the elevator and Lenticular which is a very bad instrument as it separates so much 55 dura mater from the scull as to cause exfoliation, lastly a pair of forceps which are of no use till the bone is sawd. completely round and is loose, but as this is a very dangerous practice it is rarely employd. - After you have made your crucial incision you are to remove the pericranium which should not be separated further than it is necessary to admit the Trephine, for if you do separate more pericranium than you want an exfoliation will ensue, when you use the old instruments you must make a small hole in the cranium with the perforator into which the central pin in the crown of the trephine is to be applied and continued till you have made a grove sufficiently deep to make the saw work steadily & then to be removed otherwise will protrude beyond the teeth of the saw and perforate the membrane, now when the instruments are used you make the perforation and all with the central pin till you have 56 formed a sufficient grove to work the saw steadily; the screw the central pin up and the instrument will work as before. when the perforator is removed and grove deepens, you must frequently and carefully examine with the end of an eyed probe, in the operation you ought by no means to be hasty or you may slip thro, and if a surgeon has once done so he ought never to be suffered to operate again as it may so easily be prevented by attending to the following rules, after have been sometime sawing and when you are you ought frequently to change hands, to prevent the instrument from hitching you will find a small portion of blood come up by the sides of the Teeth of the saw which tells you that you have entered the diploe which is generally about two thirds through 57 the thickness of the bone, you must then proceed with still greater caution and examine the grove every turn or two of the as it is often extremely thin, as soon as you find the bone completely perforated at any one part then introduce the point of the Elevator under it and the circular portion as far as you can and raise it up gently- by using the elevator at this time you prevent any injury being done to the dura mater which will be avoided for the Teeth of the saw will not come in contact with it, and if at this time the bone will not yield, make another carefull turning or two of the circular saw not pressing so much on that part which is perforated- on raising up the piece of bone there will be roughness left on the scull which may be removd. by the elevator as easily as the Lenticular which ought never to be used, but if [they] it does remain it is not of the least importance. If when you have raisd the bone you find an extravasation which appears in 58 large quantity, another piece of bone ought to be taken out in its course so as to expose it rather than pass a probe or scoop under it- there is never any danger in Trepanning when you find extravasated matter under the bone as you will find the dura mater a great way separated from the bone- and when you have removd, the matter apply a poultice over it- In trepanning for depression of the scull the Instrument should be applied on two thirds of the sound bone and one third of the depressd. then pass the elevator under the depressd. portion and raise it up into its natural place resting on the opposite sound portion If any portion of the depressd bone lies under the sound piece that has been removd. it must be sawd. off or two pieces be removd. before you can raise the bone If there is any wound on the Brain endeavor to unite the external wound as soon as posible 59 by which you may probably cause an adhesion between the dura mater and scalp When in consequence of Fracture you find extravasation, and on operating you ought to leave the integuments open by introducing a dossil of Lint and apply poultices to facilitate the discharge of the extravasation- when Trepanning has been performd. for Fracture with depression & the the depressd portion has been elevated bring the edges of the integuments together and unite as much as possible by the first intention by which means you will prevent exfoliation - On Cataract It is an opacity of the crystaline lens or the capsule in which the humours is containd. both producing the same appearance and symptoms, the first symptoms to be noticd. are sparks appearing to the patient moving in the Eye and one of these spots 60 seem situated in the same place, 2nd dimness of sight 3rd. that the patient see’s better in the evening than in the day time, and which is a principal criterion you may Judge this disease by, and further on looking into the Eye you will perceive a pearly appearance, the whiteness does not always come at once sometimes by a speck, sometimes in many parts over the lens - in a strong light the pupil becomes so much contracted that all the rays are thrown on the opaque spot and in a weak light the pupil becomes so much dilated that the rays do not fall on the diseasd, spot which accts for the person seeing better in a weak light than a strong one - the Eye looks sometimes yellow like matter behind the pupil. A patient with a cataract never becomes perfectly blind so that he can always be able to 61 distinguish a small portion of light. The colour is generally uniform and sometimes streakd. which denotes the cataract to be soft or fluid, sometimes it is of a reddish brown or red and then it is difficult to determine whether it is a cataract or not - they vary in their consistence, sometimes quite solid and different degrees of firmness even the entire fluidity which is a rare circumstance The crystalline humour is met with in three states 1st solid and sometimes contain earth 2dly quite fluid and from that called milky cataract 3rdly. a part of each; it can be distinguishd. if solid you will see it streakd. & in cracks, in all children born with cataracts it is fluid or soon after born it is so. in all these cases it is only necessary to puncture it and let it out into the Eye - There is in families a disposition to form catararts so that this disease may in some degree be calld. hereditary - this is a most remarkable circumstance - [illegible] 62 A Gentleman under his knowledge had a cataract and his two Aunts, Father. Grandfather and Grandfather, Brother. had Cataract, many such cases came under his and Mr. Cline’s knowledge of the same kind - Cataract is sometimes loose and in general attachd. to the Vitrous humour when it arises from thickening of the capsule of the lens it may be judged of by the lens appearing much closer to the opening of the pupil, and like a membranous bag streakd, across the iris - the cause of it appears to be a slow continued inflamation in the capsule or the lens itself its structure has also been found completely alter'd and becoming ossified, medicine has generally faild. but you may try the Hydrarg Muriat & Electricity in slight cases - the removal of the cataract has been found the only sure cure when the crystaline humour becomes opaque it prevents the light passing to the optik nerve - there are two operations 63 1st Extraction. the other by putting needle into it and so open it to let the rays of light pass to the optic nerve - on Extraction the instrument used in this operation is a cornea knife which is shapd like a wedge and exactly like spear pointed lancet, the knife must gradually thicken from the point so as to completely fill the incision as it is made; to prevent the escape of the aquaues humour till the incision is made one edge of the knife must cut through its whole extent the other [over] about half an inch, the speculum formerly in use for fixing the Eye is now laid aside as it is to be fixd by the fingers pressing on the globe. 2d a small hook is used to scratch the capsule of the cristalizd. lens, or by a small instrument made like a very small Gum Lancet for infants 3rdly. a small silver scoop is also useful to remove any broken part of a cataract 4th a small pair of forceps to remove the capsule of the crystalizd. lens opaque - To prepare the patient for 64 this operation you ought to give him Calomel purges for some days previous as it will cause inflamation afterwards, convey a probe for some days under the Eye lid to ensure it to inflamation gradually, if the Patient is of a Plethoric habit Bleed, - The Patient should be placd. on a low chair. & the Surgeons Chair should be six inches higher. - Mr. Cooper thinks laying on a table till you have completed the section of the cornea, as soon as you have done this as the posture is unfavorable for the escape of the lens, the Patient should be directly raisd, up, the light of the room should fall obliquely on the Patient's eye for if strong the Iris contracts so much so that it is liable to be torn in the extraction and there is danger of forcing out the vitreous humour by the force you employ to force out the christalline - Mr. Ware is very particular in that respect and it 65 is owing to that he is so successful, the chair to have a back with a pillow behind and the patient being seated the Surgeon sitting opposite resting his elbow on his knee, The assistant is now to place himself and he is to draw back the edge of the eyelid with an handkerchief. to be careful in not pressing the Eye, but upon the bone, if he does he will prevent the operation from succeeding, the Surgeon with two fingers of the left hand is to hold down the under lid and with the other finger press the Globe of the Eye nigh the inner canthus into the transparent cornea a hair, a breadth before the opaque cornea just so far forwards to prevent wounding the iris - the point of the knife is the to be carried a little backwards to prevent its passing between the laminæ of the cornea, you are then to pass the knife quickly across the Eye and push it through the opposite part of the cornea which 66 should complete the section without drawing the knife back, as that would endanger the iris and loss of the aqueous humour as soon as this done the Eye should be directly closd,, and if there are two catarracts you should proceed with the same steps when the capsule of the Christaline [lenses] is found diseased after the extraction of the lens every portion of it should be immediately removd, by a very small pair of forceps it has been known to have been absorbed but that has happened very rarely - The difficulties in the operation are 1st some Eyes are so unsteady that it is almost imposible to confine them particularly those that are born so, 2nd. is when the knife is sometimes pressed between the laminae not the cornea, and therefore a sufficient opening is not made, you may think sometimes that the pupil does not move which will cause failure as afterwards the pupil will become considerably contracted & loose eye sight 67 before you perform the Operation look at the pupil to see whether it has the power of contraction, or whether it has what is called Gutta serena which you may easily perceive by holding a candle before the Eye and then he cannot see it. When the opacity before mentiond, takes place in the Christalized lens there is in this respect a different in opinion whether it is to be taken away or it will be absorbed by scratching. 99 out of 100 will remain opaque if the operation is not performed, and if it takes up 1/2 an hour or longer every capsule that is opaque ought to be extracted by a pair of forceps- the vitreous humour escapes frequently in consequence of irritation during the operation- supposing a quantity of milky fluid escapes you are not to suppose the operation is complete before you examine whether there is any opacity After the operation apply a linen rag over the eye dipped in equal parts of Brandy and Water - 68 the patient should be placed in a sitting posture in bed so that the Blood may not influence the part- to be kept extremely quiet, no light. & very low the Eye is not to be looked at –if very painful apply leeches, purgatives &c but if there is no pain no remedies is requird, - let the linen rag wett with Brandy and Water remain on three days then let the rag hang loose before the Eye and remain for some time taking care the light does not cause inflammation - On Couching Couching is called depression and carried to the inferior lateral part of the Eye with a needle. The patient is to be placd, in the same manner as in the Cataract the needle is to be put in the Centre of the pupil, the patient is to be in a chair and his head to be held 69 by an assistant the Eyelid to be held in the same way as in Cataract. The surgeon is to stand before the Patient with his hand resting on the temple, his Head to be a little inclind. so as not to prevent the light, the under Eyelid to be drawn by one finger and the Eye fixed by another, the operation consists as follows a needle (that was invented by Mr. Hays is best) is to be introduced first 16th of an inch behind where the transparent cornea joins with the opake and having done so instead of passing it transversely so as to cross the Eye, pass it into the center of the Eye, then the point is to be brought forward so as to see it behind the transparent cornea. that you have it upon the cataract let your instrument rest on the cataract - bring the Handle forwards & the point being by that means depressd, you will find the cataract passed from side to side - There are many objections that have been made against 70 Couching amongst the principal are that the Cataract is very apt to rise to its former place, and until Mr. Hay’s treatise upon the subject couching had almost ceased; yet this objection is not a real one as the operation may be performed several times and at last ultimately succeed. Mr. Hay’s perform it several times in one subject Another objection to this operation has been brought forward, that the needle would hurt the cornea retina &c, but this objection will not particularly hold good - when the capsule of the christaline lens is opake perform the operation of Extraction instead of couching – If the cataract is opake and is united to the iris couching ought not to be performd, The advantages of couching are 1st the ease and safety it is performed as you may see the step when the needle passes into the Eye, 2ndly. when it is 71 a fluid Cataract. this is one that there is great advantage over extraction as the humour will escape, in this case you are to pass the needle into the cristaline lens and tear a little - When children are born with cataracts, or have it soon after, the humour is always fluid the extreme mobility in the Eyes of Children prevents extraction from succeeding and therefore couching is preferred - it is necessary in young Children to use a Speculum under the upper Eyelid - A young Practitioner ought to begin with couching in preference to extraction – Mr. Cooper says that he has seen the Operation of Extraction performed may times but never successfully but once and that was by Mr. Ware 3 weeks ago- the Operation of Extraction ought to be performed only by those who have frequent opportunities - but those practitioners who have only an opportunity 3 or 4 in their life ought always to Couch 72 though extraction is certainly in another point of view to be preferrd. - On Fistula Lacrymalia This disease is divided in three stages 1st. It begins with a small tumor occurring at the corner of the Eye just below the tendon of the orbiculus muscle. As the Patient meets the wind the tears run over the cheek which side it happens. If you press the tumor you will perceive streams of mucus comming out of the Puncta Lachrymalia and dropping on the cheek, in this stage there is no pain felt and may remain for several years - in the 2nd stage it becomes red & inflamd in its first it is called uninflamd. in the 2nd it is called inflamd, and it its 3rd state ulcerated - If the Surgeon does noting it ulcerates & then tears getting into the cellular membrane it extends considerably down the rose. The 73 cause is generally from the venereal disease sometimes from scrophula. It has risen but that very rarely from cold small pox pustule in the part scarlatina anginosa - Treatment of the 1st stage When there is only a simple enlargement press on the tumor and empty it entirely, then inject white vitriol water into it by the puncture lachrymator first turning the Eyelid down introduce a briscle into the puncture as soon as you have done this introduce the syringe into the puncture by this means you throw it into the ductus adnasum, and by throwing it in the wash being admitted into the structurd. part and brace it - Sir Wm. Blizard recommend quicksilver to be sent into the sac- if the obstruction is not quite perfect it will do but if it is it will pass down the cheek Another method is to introduce a probe from the ductus adnasum into the lachrymal sac, but this requires in general more 74 resolution than the patient can exert In the 2nd stage it is necessary to open the sac as it is inflammatory. Feel for the margin of the orbit cut about half an inch below the tendon of orbicularis and 1/8 of an inch behind that ridge the cut into the Lachrymal sac The direction you are to cut by is the fibres of the tendon orbicularis, as soon as you have cut the lachrymal sac pass the probe into the ductus ad nasum if you find the obstruction is very strong order a poultice for 24 hours then try the probe and continue in the same manner from day to day as it may be a week or more before the stricture may give way- If after trying a fortnight without success a caustic bougie may be used- after you have succeeded in making a communication pass an instrument which is called stile into the ductus ad nasum to prevent it from closing and you are to leave it there 75 during the highly inflammatory state of the ductus ad nasum, do not leave it in but only pass a probe continually till the inflammation is gone off, as the stile will irritate and therefore order a poultice , if that does not decrease it then withdraw the stile for 24 hours. but it is necessary to continue the use of for 3 months at least- the 3rd an ulcerative state requires for its treatment somewhat of the same mode as the 2nd, when it is ulcerated it is much diminishd in size so that it is difficult unless you have a good anatomical knowledge to open it after cutting open the sac pass a trochar through the lachrymal sac on the os unguis break it down and thus pass it into the nose, this opening is very apt to close unless a bougie is worn for some months, to prevent which Mr. Cooper invented a cannula with the trocar which he leaves in, but so far as he 76 has seen the operation performed in this manner it has very rarely succeeded On Wounds of the Throat Wounds of the Throat have been frequently misunderstood and are in many books of surgery erroneously described on account of the complex Anatomical structure of the part not being attended to from the chin to the sternum is about nine inches, and may be divided into three equal parts, from the chin to the beginning of the larynx is about 3 inches The Tongue & its muscles fills up the front part of this space, the Pharynx the back part- wounds here pass through the tongue and its muscles into the pharynx - the next there inches reaches the whole length of the Larynx, here the Trachea is in front and esophagus behind it, the lobes of the Thyroid gland are united over it. the 77 carotid rtery lies on each side. The most common wound of the throat is in the first divition when the Tongue or its muscles are divided along with the Pharynx, the Breadth passes through the wound yet the air tube is not wounded. Air and Frothy blood passes from the wound. [of] food solid and liquid passes through the wound which proves the air tube is not injured if it was the food would be rejected with violent coughing. Bring the chin forwards, make five or six sutures and completely close the wound, adhesive plaisters is of no use, the sutures must not be passed deeper than the skin. solid food is easier swallowed than liquid. The Epiglottis not performing its office Liquids get into the Larynx and occasion Violent irritation. The patient should have a handkerchief dipt in Lemonade to keep in his mouth to prevent thirst - wounds of this kind 78 are not mortal but as they are generally made by persons who wish to try destroy themselves. They frequently irritate them and bring on bad effects - Wounds of the Arteries Wounds of the arteries requires much attention the symptoms of a wounded artery are blood of a florid red issuing per saltem corresponding with the action of the Heart. Fainting comes on immediately on receiving the wound; during the Fainting the Hamorrhage stops but as soon as the patient revives a little the Hamorrhage returns. They alternately faint and bleed till death ensues. if the artery is small the fainting effectually stops the Bleeding. The artery when wounded retracts and draws itself an inch or an inch & half above the wound. blood is extravasated into the cellular membrane which coagulates 79 presses on the mouth of the artery and stops it, the divided artery contracts as high as the first anastomosis branch. When an artery is thus stopt by pressure on the outside the Blood forms a coagulum within adheres to the coats of the artery and in time becomes vascular, the contraction of the Artery alone would not be adequate to stop the Hemorrhage without the pressure of the coagulum. When even a large artery is stopt if the constitution is good the circulation will be sufficently free not only to prevent mortification but to preserve a perfect use of the parts - On Wound Joints Wounds of the joint even when small are dangerous as a small one lays open an extensive surface the joint having a [se???ing] surface does not easily heal, the cartilage cannot through off matter but must be absorbed and granulation formed instead if Union by the first intention cannot be effected. The Synovia escaping from the wound will often hinder the union by the first intention. If 80 this does not take place in three or four days a violent and dangerous inflammation comes on. The constitutional symptoms runs high. Matter forms at the Joint in different parts, the abcess form and break one after another, protracts the cure and generally render the joint anchylose. In delicate constitutions Wounds of the Joints frequently terminate fatal. - In the treatment of these wounds the first object should be to unite them as soon as possible sutures must be applied in this but particular care must be taken that they pass no deeper than the skin. If deeper they are productive of much irritation likewise the edges must be still further united with the straps of adhesive plaister laid over the sutures afterwards a roller and the wound should not be opened as long as possible perfect use is necessary to the joints, that of the knee and frequently obliged to be opened to take out loose pieces of cartilage formed there - To perform this operation we must keep the cartilages steady by pressure 81 the skin should be drawn back a small incission made into the joint and the cartilage that is loose taken out by a tenaculum afterwards the skin should be drawn each way over the wound that the joint may be as little exposed as possible a suture should be made through the skin to secure it and the wound treated as above - On Hydrocele - By the term Hydrocele is meant an accumulation of water within the Tunica Vaginalis Testes which tunic is loosely reflected over the Testicle in the same manner as the pericardium is over the heart. This disease begins with a Tumour at the inferior part of the Testicle gradually extending round it, as the water accumulates it produces a tumor of pyramidal shape at which time it extends along the spermatic cord until it reaches the abdominal ring - It is seldom a painful disease till it becomes greatly distended the scrotum seldom appears red but generally transparent. In oder to discover its transparency grasp the Tumour at its posterior part 82 Place the patient in a dark room, a candle being placed opposite will discover its transparency. Another mark to distinguish this disease from any other is its fluctuation and the comparative lightness of the tumour Sometimes two tumours are formed one situated at the abdominal ring. The other in the scrotum which frequently deceives the surgeon who supposes it to be a Hernia The fluid contained within the tunic puts on a Variety of appearances it is generally of a nature similar to the serum of the blood sometimes purulent at other times mixed with the red particles of the blood When the Tunica Vaginalis is thick its transparency is destroyed and which generally takes place in tumours of long standing The tunic becomes ossified and which variety of appearances may mislead the most experienced Surgeon. There is often within the Tunic one or more cysts formed as large as a Chestnut the Testicle is commonly placed behind the tumour in Hydrocele if it were otherwise situated it would probably be wounded in 83 performing the Operation, therefore you should be at all times certain that it is so situated before you attempt to operate - In order to distinguish this disease from Hernia desire the patient to cough if it is a Hernia a distention of the tumour takes place but in hydrocele no such distention takes place but, it must be observd should the tumour extend to the abdominal ring some little distention will necessarily be produced from coughing by the action of the abdominal muscles. another mark is this. if it be Hernia and you attempt to raise the scrotum you will find that you can’t readily do it. but in hydroceles no such difficulty appears - Hydrocele may be distinguished from diseasd. Testicle by its weight. Figure and inflamed or red appearance. This disease is sometimes unfounded with hematocele this is an accumulation of blood within the Tunica Vaginalis, it is generally occasioned by a severe blow on the testicle and may be known by the former marks - The cause of this disease is an increased action of the vessels of the Tunica Vaginalis and not a disease of the 84 absorbents as was formerly supposed but these vessels are generally found enlarged hydrocele is said to be treated in a Palliative and radial way. if in the Palliative, all that is required is to draw off the water from time to time which may be done by a lancet or a small Trocar direct the instrument obliquely upwards at about two thirds the length of the tumour after the operation lay a small piece of adhesive plaister over the wound, It is frequently necessary to perform the operation three or four times a year the Trocar should be preferred, in performing this operation a small incision being first made through the integuments with a lancet & give tonics internally combined with mercury a strong solution of crude sal Ammon dissolved in Vinegar and applied to the part is often of service. It has been found that taking a considerable deal of exercise directly after the operation 85 has produced a Radical cure by bringing on a Violent inflammation by which a quantity of coagulated lymph was thrown out and produced an adhession of the tunics - Of the Radical method of cure this may be affected by the process of granulation or adhesion, the latter is to be preferred. - Of the mode of cure by the Seton recommend by Mr. Pott, this is also liable to objections as it occasions frequent but partial adhesion of the Tunic - in the Hydrocele of young children do not be in haste to operate before you have given every remedy a fair trial The operation by caustic is sometimes employed but this like the method adopted by Mr. Pott is liable to objections - The method of applying it is. take a piece of kali purum rub it round the surface to be cauterizd for the space of 10 minutes which will produce an eschar and the operation is finished. This method of operating has been known to fail even in the most experienced hands. in old people it should never be performed on acct. of 86 the inflammation which succeeds being often very Violent producing high symptoms of irritation and sometimes even Death - It is Mr. Cooper opinion that this method of operating should be entirely done away with - The best method of operating in Children is by taking a common needle the same as is used after amputation arm it with a few threads of silk, pass it through the Tunica Vaginalis in a longitudinal direction and at the same time obliquely draw the threads out at the opposite opening and leave them these by acting as an extraneous Body will produce inflammation and in consequence a Radical Cure will be obtained - On the operation for Hydrocele The method of Operating by Injection is in a more general use than any other. this operation is of old date, Sir J Earl improvd on this mode of operating - The instruments required for it is 1st a large and small Trocar for the child and adults, 2nd an elastic 87 Bottle with a turn cock, 3rd a Mixture of Red Wine (1 part water & 2 parts wine) but as Wine is liable to vary in strength the Vitrolated water is now used in the following preparations - Rx Vitriol albi ʒi aq:distillate 1 H ᵯ - with this solution the Elastic bottle is to be filled - make a small incision with a Lancet through the skin at the anterior part of the tumour, the introduce the trocar and cannula - inject a quantity of fluid sufficient only to be applied to the whole surface of the tunica vaginalis testes - this should be allowed to remain as long as the patient can bear. about 4 minutes on an average - When the patient complains of a little pain during the operation the greater will be the succeeding inflammation - and Vice Versa - a small quantity of fluid about 2 drams should be allowed to reaming in - the patient ought not to go to bed until he is obligd. to do so from the violence of the pain in the part and also in the loins - If several hours should elapse & little or no inflammation comes on Mr. Cline directs Wine to be given and taking the scrotum 88 in the hand and rubbing it. In 48 hours the swelling is generally as large as when the operation was performed, it feels solid and pitts on pressure with the finger the skin appears in ridges, you then know that the inflammation exists in a sufficient degree - In the course of a week the tumour begins to subside and in three weeks the patient is generally cured - If the testicle is slightly enlarged you are not to be deterrd from operating for by exciting a counter inflammation the swelling will probably subside - If the Tunica Vaginalsis is inflamed you will know by a bloody appearance of the water when drawn off. you must then use the Injection only half the strength before directed that is in proportion to ʒ1/2 to Hj - Mr. Cooper observes it is very wrong practice to inject a quantity of fluid equal to that which is drawn off, but recommend. if ℥vi or ℥viii of water is drawn off to inject not more than ℥iii or ℥iv of the solution - There is some danger attending this operation for if great care is not 89 used in introducing the cannula with in the tunica vaginalis the injection becomes extravasated into the surrounding cellular substance. the consequence is that the whole surface of the scrotum becomes black sloughs and in 8 or 10 days the patient dies from high constitutional irritation -In a child from 6 to 10 years of age this method of operating may be employed if the tumour is large but in those that are younger it should not be employed - Incision with the introduction of Flower or the seton should be had recourse to in these cases - of Incision - this may be considered as a dangerous operation and in which the symptoms in general run high, but its advantages are that it shows you readily the situation of the Testicle, it also shows you if any cysts are formed on the surface of the testicle - This operation should always be performed when any adhesion are found - if the testicle is found anteriorly the incision must be made on the natural part of the tumour. - 90 The advantages of injection are that when it is properly performed it is comparatively a mild operation. it may fail in the fist instance but if repeated will certainly succeed. and with the Vitriolic injection Mr. C has never known it to fail - but treated with the wine & water it has been known to return at the end of two years An Hydrocele of the spermatic cord may be known by a tumour forming at the abdominal ring - it may be easily mistaken for a Hernia as before observed by its projecting when the Patient cough but in this there is a want of transparency in the Tumour. in this the operation is to be preferred in doing this operate as for Hernia which must be done with great caution as the spermatic artery and veins sometimes run on the fore part of the tumour and the vas deferens behind - should any portion of testines adhere you are to desist as it would be useless to operate, this species of Hydrocele is sometimes contained 91 within an hernial sac in which case the operation by incision is to be preferrd. On Dislocation The vertebrae are so connected that no dislocation can take place without a fracture the consequence of which is the compression or division of the spinal marrow the total loss of sensation and use of the parts below where the accident has happened - in these cases the urine is evacuated by the catheter otherwise it will be liable to bust from the patient, being incapable of expelling the urine - the – the foeces pass of involuntary and when dissolution is about to take place the urine runs off in the same manner - If the fracture happens in the Lumbar Vertebrae the patient may live from 17 days to 3 weeks with some little exception - If in the Dorsal about a fortnight – If about the 6 or 7 cervical not more than a week : if in the 2 or 3 cervical not more than 40 hours. if in 92 Atlas or Dentaba the patient generally expires instantly - . The Clavicula is liable to be dislocated at both extremities the sternal end is sometimes thrown before the sternum in its fore and upper part. when the shoulders are drawn back it returns into its place - Treatment - The shoulders are to be drawn and kept back as much as possible by the stellate bandage which ought to be kept on for about 5 weeks The scapular extremities are sometimes dislocated from the processus acromion it the forms a considerable projection on the spin of the scapula. The shoulder on that side falls to the breast therefore from the sternum to that shoulder is less than from the sternum to the other - Treatment. The shoulders are to be drawn back as in the former at the same time the shoulder is to be raised by a sling. In these cases the pain that it produces by keeping the shoulders 93 sufficiently back is more than Patients will generally admit to and when told that it produces no inconvenience by being left to nature (except that of the incapability of the arm being stretched out so far as the other) they prefer rather to be subject to that little inconvenience than suffer the pain that is necessary for the proper Union of the ends of the bones, which is the reason that it seldom or ever cured - The shoulder. is liable to be dislocated in three different direction 1st downwards or into the axilla-the marks of this is the dislocated side is flatter than the other the arm cannot be raised to the Head and the lower edge of the pectoral muscle is raised above that of the opposite, by putting the finger into the axilla at the same time raising the arm the head of the bone may be plainly felt - Treatment if recently done apply a round towel obliquely from the arm pit of the dislocated side to the top of the opposite shoulder it is to be carried over and then to be fastened by a bandage 94 This extension is to be made above the level of the shoulder, upon the dislocated arm the extension is to be made gradually and kept up for a long time - about 5 or 10 minutes the arm will commonly be reduced - If the arm has been out a long time Poultices should be applied; making two or three attempts to reduce it one after another Another mode of reducing recent dislocation of this joint. Place the patient upon his back then put the heel of your foot into the axilla at the same time having hold of the arm make a strong pressure by the foot and gently turn the arm inwards In this way the arm will commonly slip in - The 2nd dislocation is forwards the Head of the bone being placed under the Pectoral muscle just below the clavicle. The patient is incapable of raising his arm to his head. When the head of the bone may be perceived moving under the pectoral muscle on the arm being rotated the dislocated side is flat - Treatment - 95 To be reduced either by pullies or by the Bandages as in the former - Pullies are best as a greater extension is required The 3rd. dislocation is when the Head is thrown backwards or into the scapula when a considerable Tumour appears on the spine of the scapula if the arm is rotated it can be felt - The same treatment as the first - this seldom happens - Dislocations of the Elbow Joint backwards when the Radius and Ulna are placed behind the Os humeri the coronoid process is placed in a hollow above the Articular surface of the Os humeri the Arm is a little bent - Treatment - Take the Arm in one hand and the forearm in the other. having the knee or some fixed part at the inner of the Joint the forearm being pulled downwards the bones will immediately slip in– 2ndly where the extremities of the bones are thrown [in] laterally, either internally or externally, the same Treatment is to be made use of here, but at the same time the Extension is made by an Assistant press the bones towards the Joint - 96 The Ulna is sometimes dislocated without the Radius, in the case the projection is not so great at the Elbow as when both are dislocated. The Reduction is the same sometime the coronary process is broken off by the irregular action of the muscles. the ulna loosing its support is dislocated backwards and appear in a projection at the back part of the Os humeri - The coronoid process is drawn up by the muscles on the forepart of the Os humeri. This is easily reduced but when the extension is taken off it resumes its place - sometimes the head of the Radius is separated from the Ulna and thrown into the hollow above the external condyle of the Os humeri here the arm is incapable of being either bent or strengthened but still returns supination and pronation - Treatment the best way of Reducing this is first to produce fainting by the warm Bath or Tobacco Glysters. the confining the Ulna by placing the foot to it at the same time forcibly and suddenly extend 97 the arm it is however very rarely reduced The wrist is liable to be dislocated in two different ways, backwards and forwards, it is easily reduced by making an extension of the Hand one way and the forearm the other - There is often a tumour appearing like a dislocation of the wrist which is occasioned by an accumulation of coaguable lymph from inflammation produced by a strain of the Tendons - Apply prepare and Mercurial Plaister to reduce the swelling and afterwards electrify it - There are small tumours frequently appearing at the wrist which is a collection of synovia in saculi Mucosi, these are called Glanglions. They commonly move with the Tendons but are sometimes perfectly fixd. and adhere to the ligaments - These ought never to be opened but are to be dispersed by breaking them which is done by bending the wrist and then they become tense when if struck hard will burst and disappear  Professor Fox. M.B. 1 Mr,, Cooper's Lectures on Surgery On the effects of accidents, and diseases on the constitution, and sympathy of diseases on it. Sympathy of diseases are those where one part feels pain in consequence of an injury inflicted on another; Irritation may be only sensation in a diseases, which may affect the action of parts.- A pain in the Loins follows an inflammation of the Testes, A stone in the urethra occasions pain in the Testes and high on the side- The knee is painfull when the Hip Joint is diseased, occasioned by the communication of the Sciatic nerve; therefore where the knee is very painfull, and there is no inflammation, we should be particular in our examination of the Hip Joint, as so many practioners have so frequently been mistaken in this case. - A disorder in the liver occasions 2 a pain in the shoulder, outside of the collar bone, also an itching of the nose and rectum takes place when the rectum is irritated; Dr. Hunter called them sympathetic dilutions but they can be dilusive only to the uninformd. - bad affections of the Liver and stone in the urethra produces only local pain - we cannot discriminate with such accuracy as on their sympathetic symptoms, the Testes becomes painfull in consequence of an inflamation of the Urethra: the glands of the groin will swell and inflame in consequence of the passing of a Bougie producing a sympathetic Bubo - an unexpected blow on the stomach the very trifling will sometimes occasion [the] Death: - A man was endeavouring to part two women fighting in the street received a blow from one of them on the stomach and instantly fell, and was supposed at first to have fainted, but was dead; on opening the body no particular appearance 3 of disease was found- A young healthy man received is slight blow by the back of the hand and fell immediately, Mr. Cooper and another of the Faculty tried the usual modes of inflating the lungs, warm bath &c in vain; on opening the body a small discolouration was found in the stomach where the blow had been given occasioned by extravasation between the coats of the stomach: in these cases the blow on the stomach occasioned a cessation of the action of the Diaphragma and stopd. inspiration - Almonds when eaten will with some people produce violent irritation of the Skin; - Sympathy of actions is where one part acts in consequence of Injuries done to another; Thus injuries of the Head, strictures of the Intestines produces vomiting When a stone is passing the Gallbladder vomiting is producd, as is likewise the case when the uterus is inflamed, in the effects of irritation all the functions of the Body are changed by partial injuries Thus in a Compound Fracture in 24 or 36 hours all the functions will be changed 4 in scrophulous habits the change may be rather slower;- we shall find pains in the back, loins, and Head in Fever; the action of the Heart is altered the pulse becoming quick hard and intermittent, the alimentary Canal is affected the Tongue is firrd., white when the degree of irritation is small, brown when it is great, sickness of the stomach takes place and constipation of the Bowels, perspiration is stopd. the nerves become affected sleep interrupted, delirium and subsultus tendinum follow; a profuse sweat will break out and then the symptoms abate, but in a short time they return with greater violence;- The Symptoms should be regulated and checkd,, their Violence depend on the importance of the part Injurd, - a very small wound of the Intestines, will occasion a cessation of the pulse, or make it so faint as scarcely to be perceived - in parts not so essential to the vital functions, the symptom depends on the size of the wound, and on the degree of vital power possessd. by the part. Thus wounds of the Tendons produce more irritation 5. for the tendons being less Vascular require a greater afford of nature to restore Injury - A man was kicked by a Horse on the Intestine there was no pulse felt in the wrist, and yet survivd. 12 hours - The smallest ulcer on the Lungs will produce more considerable effects to the constitution than the largest ulcer on the Legs or any other part - In accidents many things are to be considered. 1st the importance of parts injured. 2ly the extent of the Injury. 3ly. wheather the Vital powers are weak or strong the weaker the better; Symptoms depend greatly on the natural irritability of the constitution A man was brought into the Hospital with a Compound Fracture of the elbow. The bones of which were laid bare. his hand at the same time quite crushd, amputation was thought inevitable but the man refusd. to submit and the arm got well without much pain and without any bad symptoms except a small abcess on the upper part: a much less injury in a person of an irritable habit, would have producd. Mortification and Death - the signs of irritability are great pain, extended inflammation, fear of Death, restless and delirium; 6 Fat persons are generally irritable. intemperate persons have a very considerable degree of irritability; the passions of the mind has a great effect in all operations; and in accidents it is always proper to inspire the patient with hope: the passions that influences the Body are grief, anger and fear- Joy and hope produce stimulating and healthy effects= Grief fear and anger lower the actions of the Vital power, and retart recovery. Grief particularly effects the Liver and produces conjection of bile,. Fear has a more particular effect on the Constitution than the rest. Anger produces a quick hard pulse and influences the irritation of the mind on the Body. - Mr. Cooper attended a gentn. for a Chancre. it had a healthy appearance but suddenly became worse without any apparent cause, it afterwards went on well again & again became worse had frequent lapses of this kind; till at Mr. Cooper accidentally calling found the Gentleman in a Violent fit of Passion and on examining the chancre he found it considerable worse sloughing be 7 on removing him to another place where he was not exposd. to anything which could cause passion the Chancre was soon healed by the same means that had been used before tho the air of the place to which he was removed was not so healthy as where he first resided.- Fear will frequently occasion Death; where there would not have been any danger without - A man with a Simple Fracture of the thigh was brought to S. ThS. Hospital he was prepossesd. he should die, his fears were smiled at, but on the eighth he died there was no inflammation nor was there any union of the bone taken place - a lad 17 years of age died in a similar manner of a simple fracture - Mr. Pott was called to Gentleman of a very timid disposition, who had symptoms of stone, the nature of the complaint his Friends had carefully concealed from him. Mr. Pott made an examination (with the sound) and having found a stone and being ignorant of his timidity told him the case, and that he might be effectually relieved by an operation 98 The Os Femoris is liable to dislocation in four different directions - 1st upwards or into the dorsum of the Illium about two inches above the acetabulum the trocanter Major is turned forwards and the head backwards the foot inwards and the leg on that side is about 2 o 2 ½ inches shorter than the other the limb cannot be moved at the hip Joint being so strongly bound by the muscles - Treatment - Place the Patient on the opposite side to the dislocated one. the Pelvis is then to be fixed by carrying a girt between the scrotum and the Thigh of the dislocated side round to the outer part of the Pelvis and there to be fixd. to a pillar or some steady point. The dislocated Thight is to be brought over to about the middle of the oposide side a bandage then being fixd. above the knee which is to be kept bent. the extension to be made obliquely forwards and downwards. after this has been made for sometime and it does not succeed let 99 a bandage be put round the upper part of the Thigh which is to be so long as to admit the Head of an assistant through it he then is to place his hands upon the Pelvis to prevent its raising than gradually and forcibly raise himself- The head of the bone will be elevated over the brim of the acetabulum and will slip in. this elevation is to be made at the same time as the former extension. or it is sometimes reduced by pressing hard upon the Trocanter major while the extension is made 2nd, dislocation is downward or into the foramen ovale the leg in this is much longer the foot turned inwards. The knee separated at some distance from the other and the patient cannot bring it to the other - Treatment. place the Patient on his back carry a girt round the upper part of the thigh and fix it to a point as the former the limb being bent press upon the knee by the weight of the body inwards. by these means the bone will 100 generally be reduced. 3rd Dislocation into the Ischiatic notch. The leg is very little if any shorter the Toes turned in the knee Lying upon the other, and the heel separated at the distance from the other. Treatt. Place the Patient upon his side and fix the Pelvis bend the Thigh at right angle with the body the extension is then to be made in this direction at the same time bend the knee a little downwards. otherwise in making the extension the head of the thigh bone would be drawn below the acetabulum and pulled into the foramen ovale, therefore to prevent this the knee must be a little bent. the same bandage is to be used here as in the first to raise the head of the bone above the brim of the acetabulum 4th dislocation is forwards as upon the Pelvis. the Foot is turned out. the leg is nearly the same length by rotating the limb the head of the bone is seen moving in the usual situation of a Bubo Just at the middle of Pouparts ligament 101 treatment. Place the Patient upon his side, carry a Girt round the upper part of the Pelvis which is to be confined by a roller from the girt round the thigh a bandage is then to be put round the upper part of the thigh into which a pully is to be fastened. The extension to be made rather obliquely upwards - These Dislocations are to be careful distinguished from Fractures of the cervix of the femoris. this however happens generally in Old People. In these cases the Leg is shorter and the Foot turned out - Dislocations of the Patella 1st outwards when it becomes immoveably fixd, to any common force that is applied Treatment. The leg being already extended (for the Patint cannot bend it) put your hand to the outward edge of the Patella and then press it downwards and at the same time inwards 2nd. Dislocation Inwards when it is situated internally the reduction is the same as the former 102 3rd Dislocation upwards from the Ligament connecting it to the tibia being torn throug: the Patella is then drawn up two or three inches by the rectus muscle about the knee - Treatment A cushion is to be put at the upper part of the Patella and confined by a roller pressing above and below the knee. There is over the Patella between the skin and the Tendon a Bursa Mucosa which often becomes enlarged, and frequently in women who are much accustomed to kneel. The bursa inflames swells and often increases to a considerable size Treatment. the knee is to be bent as much as possible the the tumour will became tense and hard. and if struck two or three hard blows will generally disappear If this does not succeed make an incission the whole length of the tumour and dissect out the sac after which bring the edges of the wound together by plaster and treat as a common wound 103 If inflammation comes on poultice and fomentation are to be applied and also Leeches this operation does not produce such violent symptoms as if it had been left to suppurate Dislocation of the knee joint It is liable to be dislocated in four different directions 1st outwards. the head of the Tibia is thrown on the outer side of the Os Femoris Treatment. An extension is to be made in a straight direction at the same time pressing the bone inwards - 2nd dislocation Inwards which very rarely happens it requires the same treatment as the former 3rd Dislocation Backwards little extension is requisite to reduce this notwithstanding the injures which must happen from these dislocations yet the Joint generally recovers its proper function 4th Dislocation is when one of the cartilages becomes separated from the Tibia and 104 Os femoris and is resting upon the ends of the Tibia instead of the cartilages it produces but little deformity in the Joint. the knee cannot be straightened but allows of flexion. Treatment The limb is not to be attempted to be straightened but bend it back as much as possible towards the nates. This allows the Cartilage to return into its place the Leg may then be straightened and it will resume its proper place when this accident has once happened it is very liable to return the Joint therefore is to be straightened by bandages - There are loose cartilages sometimes forming in the cavity of the knee Joint, and on the outer part which produce great inconveniences, a person when walking is liable to fall down suddenly from the cartilage slipping between the extremities of the bone soon afterwards it will move and the person will be able to walk again. These are 105 to be removed by an operation. the Cartilage is to be pushed if possible to the outside of the Joint an incission is then to be made the whole length of the Cartilage - before the incission is made the integuments are to be drawn very much above the Cartilage. so that the external orifice shall not be even with that communicating with the Joint the incission being made the cartilage is to be extracted. If it does not come out readily it will be right to extract by a tenaculum. the edges of the wound are then to be brought together and confind. By sutures which more effectually prevents subsequent inflammations at the hazard of the Patients life or expose him to extreme pain by the formation of Matter and anchylosis - Dislocations of the Ancle The 1st and most frequent is the Joint being thrown forward on the upper part of the foot the lower end of the fibula remaining in its 106 place and of course must be broke the heel is much lengthened and the distance from the Toes to the end of the metatarsal bones much shortened Treatment. make an extension by putting the Tibia downwards. the Foot likewise extended, after this reduction the Limb should always be laid upon the heel till the parts are recovered otherwise a return of the accident is liable to take place. 2nd Inwards when the end of the Tibia is resting on the inner edges of the astragalus the over extremities of both bones being broke off a large tumour appears on the inner [crossed out] side of the ancle . Treatt. Take hold of the Foot with one hand and with the other hand keep the leg steady a very gentle extension is to be made at the same time let pressure be applied on the projecting bone, when reduced lay the limb on the outside. 3rd when the end, of the bones are thrown on the outside of the Tarsus. the maleolus externus 107 being broken off - Treatment to be the same as the former, and when reduced lay it on the outside - When a compound dislocation happens, the Tibia and Fibula broke appear externally and the Joint laid open, it is a question whether it will be bent to amputate or not. attempts ought to be made to save the limb. for amputation performed so early after the accident is generally productive to the Patient - if advanced in years the operation ought not to be performed as the living power is very weak in those - on the contrary if the Patient is under 40 years a chance ought to be given - On Incysted Tumours These don't require to be removed as they occasion but little inconvenience. if they are large and no considerable vessels near, you may treat them in the same manner as Hydrocele either by Seton or Injection- If small remove them by the knife but if any large vessels are situated near open the tumour with the lancet and inject a little 8 The gentleman replied that the operation would not be necessary, for the idea of having a a stone in the Bladder would kill him - Mr. Pott took his leave but observing a great attention in his countenance sent Dr. Harris to inquire after him the same evening & when he came the person was dead: - A Lady with a scirrous Breast of no great extent was much pressed by her Friends to submit to the operation she refusd. for a long time; but at length she consented: she said she did it in compliance with the wishes of her Friends but was sure she should not survive it. Mr. Cline performed it and nothing could be done in a better manner. The Lady was put in bed; her countenance sunk and she died very soon after; her prepossession was so strong that she ticketed her keys and disposd. of every thing in such manner, that the Family affair might not have any interruption - On the Progress of Inflammation The existence of inflammation is known by redness 108 of the white Vitriol solution - Children are particularly subject to the formation of these incysted tumours On Diseases of the Testicle The diseases rendering its removal necessary are four 1st. Hidated disease this begins in the extremities of the Epydidymus extends into the Body of the Testicle back towards the spermatic cord, it is never attended with much pain, it may therefore be mistaken for Hydrocele; It is not of a cancerous substance; is confined entirely to the Testicle and is of a very considerable size. This diseases generally occurs between the age of 20 and 30 and sometimes later in life - In order to distinguish this Disease from Hydrocele it is to be observed that it differs ins shape, but, is of the form of the Testicle is prominent before and flat on each side, secondly its weight 109 is very considerable, but its want of transparency is the best mark. This Disease is very liable to deceive even the more eminent of Surgeons: Mr. Pott and Mr. Cruckshank have both fallen into this error - If you have any doubt in your mind respecting the disease puncture the Tumour with a lancet, and if there is no water. proceed to treat it as a diseased Testicle. This disease is found to be collection of a number of cysts on the surface of the Testicle filled with a mucilaginous substance, these cysts vary in their size from a pea to a marble, after the Operation for this complaint the Patient in general does remarkable well - The 2nd complaint is the true schirrous Testicle which originates in the body of the Testicle and becomes as it were all at once hard and considerably enlarged, it the proceeds to the Epididymis and spermatic cord- it may be distinguished from all other diseases of the Testicle by its stony hardness, it is likewise attended with considerable pain, but not constant 110 triffling causes produces this disease. it is envisioned by a deposit of coagulable lymph becoming at length cartilaginous runs up the spermatic cord into the abdomen and produces the same disease in the Loins as that originally in the Testicle Before you operate examine if the spermatic cord is diseased for it is of no use to operate if it is, therefore you should operate as early as possible - There is another species of cancer in the Testicle which Mr. Cline calls the Pulpy cancer this is a much more dangerous disease it originates in the same manner as the former, but its effects are much more sooner destructive . In a few weeks this disease extends into the abdomen and renders any operation fruitless and generally in the course of 20 weeks proves fatal, its called the Pulpy cancer because when you feel it it seems like the Hydatid Testicle. great pain attends this disease and if a Lancet is pushed into the Tumour Blood flows out 111 a sallow countenance is another decisive mark of this complaint so that with a little attention this disease may be distinguished from any other. The Operation must be performed as soon as the Cancer is attended with pain. The Tumour formed in the Loins from this disease when allowd. to take its course is much larger than the schirrous amounting in some case to 11 or 12 pounds when it is cut in its early stage it appears like curdly coagulable Lymph, but in the latter stage like Brain broken down by Putrefaction - This disease has been known to extend to the thoracic duct so as to destroy its internal surface - The 3rd is that of suppuration in the testicles. This begins sometimes from venereal causes, leeches are to be applied with a strict Antiphlogistic regimen. Calomel also ought to be given to promote absorption it likewise arises frequently from scrophula. The abscess which is formed in the testicle being of a scrophulous nature - It may arise from a violent blow on the testicle slight febrile attack attend this complaint remitting often 112 for many days, but ultimately the operation will be found necessary. When the Testicle is cut into, a curdly abscess is found in its centre - A fungus on the surface of the Testicle has been supposd to require an Operation for its removal but all that is unnecessary, but make circular inception round the Fungus including a small portion of the surrounding skin - cut it off just as it springs from the Tunica albuginea. bring the edges of the wound together and unite them by sutures On Aneurism By the term Aneurism is meant a Tumour containing blood formed by the yielding of the coats of an Artery, and which tumour has generally a pulsatory motion corresponding to that of the artery of which it is placed These tumours when examined may be divided into 3 stages with regard to their symptoms - 1st, when the tumour is very small its pulsation is remarkable 113 strong and the fluid which it contains, can be made to disappear by pressing on the Artery between it and the Heart, but on the pressure being removed it instantly reappears. in this stage of the disease the Patient suffers but little pain except that he feels slight spasms about the part during the night - 2nd stage If the Tumour is very large you cannot press the blood out of it as before, as the Blood is at this time in a coagulated state and deposited in layers, but the skin remains undiscoloured although the pain is very considerable. in this state the tumour may remain for years especially if it be situated under a Fascia - but with regard to this point every thing depends on its situation. 3rd stage, when the Tumour is about to burst but prior to this taking place, the skin becomes of Brownish red color. after a time it cracks discharging a Bloody Icher it then becomes mortified where it had been red, and sloughs, its edges in separating opens 114 into the sac. The Hemorrhage sometimes destroys the Patient suddenly but this is comparatively a rare circumstance as the progress of its bursting is generally very slow. When the Tumour appears ready to slough Mr. Cline advises it to be bound down with adhesive Plaister which prevents its bursting as soon as it otherwise would - Aneurism is found to take place most frequently in the extending portions of the aorta & its arch which it forms towards the dorsal vertebrae, when it is thus situated it shows itself by forming a Tumor under the sternum or Cartilages of the Ribs When it takes place in the Arteri Innominata a Tumour is seen under the carotid artery in the neck. sometimes an aneurism is formed between the curvature of the Aorta and Diaphragm. then the Death of the Patient is occasioned by the Pressure of the Tumour on the Trachea and osaphagus into which last it generally bursts. When it is situated in the abdomen it produces various symptoms, the Foot 115 being regurgitated generally soon after it is taken into the stomach so that the Patient dies exhausted and in a manner starvd., it generally shows itself by a Tumour situated at the umbilicus - An aneurism is now and then forming in the aorta just when the emulgent arteries are passing off. in this case a Tumour is formed in the side of the spine and which Tumour has no pulsation, these Tumours have been mistaken for Lumber abcesses and opened without detriment to the Patient. but when we do this Mr. Cline advices the puncture to be very small, a difficulty of passing the urine and foeces are sometimes occasioned by these Tumours. On Dissection of Aneurisms you find the artery in general given way only on one side; The aorta has be been known to give entirely, but this is very rarely the case - This disease generally takes place between the age of 35 & 50 Tho sometimes at a more advanced age, one case which Mr. Cline had under his care 116 occurred in a patient only 24 years Pophlitic Aneurism differ from all others from its being liable to be produced by local causes, as Violent exertions &c independent of any constitutional affection and may occur at any period of life. The cause of Aneurism in any other part is that the cuticular or internal coat of the Artery inflames, thickens & destroys its Texture, by which it gives way from the impetus of the Blood passing through it. its external coat remaining unaltered To distinguish this disease from any other you may suppose that its pulsation is a certain criterion, but in this you may be mistaken ..... Tumours sometimes forms, for instance in the neck under the carotid artery which is running over its substance. if you feel this Tumour and find a pulsation you at first suppose that it is an aneurism but if you put your finger on each side the tumour you will find that it does not pulsate, and by this mark you can ascertain whether it is an 117 Aneurism or not, if it is one. by taking the Tumour and lifting it form its bed as much as possible you will find it to pulsate strongly. these therefore are circumstances highly necessary to keep in mind - by attention to diet &c these Patients may be kept alive for a considerable time. Calomel should be taken when any pain is felt in the Tumour and Leeches applied on some part little distance from it - The Operation for Aneurism as it was performed 20 years ago. The first step in the Operation was to secure the artery by Tourniquet. then an incision made the whole length of the Tumour the coagulated Blood became exposed, this being removed and the sac washed out with a sponge dipt in warm water. the mouth of the artery being [removed] laid open then the Tourniquet loosened a little, in order more readily to discover them a Probe is to be passed into the superior extremity of the artery and a ligature made on it about an inch above the Tumour the 9 swelling pain and heat, these are the diagnostic sign’s. Tumors arise from the different causes from distention of the Vessels; where there is much tension, serum is pourd. from the extremity of the cellular membrane, and sometimes coagulated lymph: the nerves are strecthed by expansion of the Vessels, this occasions pain which depends on the degree of inflamation, this may be perceivd in operations which produce sometimes a great degree of pain while others that take a great deal more time before they perform are not so painfull that was increased in inflammation Dr. Hunter doubted from experiments he made on animals he injected corros: sublim into the rectum of a dog and waiting 24 hours when the inflammation was at its height he introduced a thermometer and found that the natural heat was not increased, he tried the same experiment on the vagina of an Ass, in 12 hours when the inflammation was beginning he found the natural heat had fallen one degree, and when the inflammation was at its height the heat was at its natural standard. we may conclude that this circumstance takes place only 118 same was done in the inferior portion of the Artery about an inch below; the edges of the wound were then brought into contract (the ends of the ligature being brought out at the wound) and secured by sutures or adhesive plaisters which finished the operation. but in consequence of the Ligature being thrown off, after the operation frequently, it now entirely laid aside - The present method of performing this operation; make an incision the whole length of the tumour (it is a popliteal aneurism meant) in order to expose the sactorious muscle you are then to dissect it away on its outer edge, pull it on one side and the Fascia is laid bare which encloses the femoral artery vein & nerve which last is to be carefully avoided, the Vein is situated between the artery & bone you are then to cut through for the Fascia to such an extent as to admit an instrument passing freely under it & then pass the director under the artery and in so doing give it a slight lateral 119 motion so as early to tear through the the cellular membrane beneath it: you are then to take an eyed Probe arming it with a double Ligature, having a needle at each end, the Probe is then passed through, along the hollow of the director the director is then to be withdrawn the Ligatures being drawn to an equal length on each side the Probe may be cut away: you then separate the Ligatures about an inch from each other: securing the upper portion of the artery first the same must be done with the inferior portion of the artery; first tearing away away the cellular membrane, this being done, the needles are to be passd through the Coats of the artery and again secured, then bring the edges of the wound in contact with the ends of the Lignature hanging out of the wound and endeavor to heal it if possible by the 1st intention, hemorrhage has been known to ensure when the Ligature came away - In applying the adhesive plaster leave small interstice to allow the escape of matter, but donot apply a roller because by its prepare in the anastomosing branches of 120 of the artery it sometimes produces Hemorrhage. The Patient should be placed on his back with the knee slightly bent and a pillow placed under it The limb being wrapped in flannel as the Patient will complain of cold and unless proper care is taken mortification will ensue, In two or there days after the operation the heat in the affected limb in greater than in the other. If no hemorrhage comes on at first there is no danger till the ligatures come away, which they do sometimes as early as the 4 Day. at other times on the 17 or 23. at this time bring the edges of the wound in contact unless there is considerable suppuration and apply a roller. The consequence of this operation is that the Patient in general complains of a weakness in the Limb with a sense of coldness - In Aneurism of either the Posterior or Anterior Tibial Artery. The Femoral Artery should be secured in the middle of the Thigh in preference to the Ham. as here the Vessel is deeper seated. If the Brachial Artery be wounded in 121 Bleeding cut down on it and secure it above and below and divide it between the Ligatures - never apply a Ligature near an Aneurismal sac. as inflammation may extend to it, produce suppuration and destroy the Patient neither contegious to the Anasomosing branch of an Artery In aneurism of the Carotid, Posterior aural or Brachial Arteries Mr. Cline makes an incision on the sac. securing the Artery above and below as before directed & dissect the Tumour out &c - On Fistula in Ano This Disease in produced by and abscess forming itself in the Cellular substance surrounding the extremity of the Rectum or just by the verge of the anus. The sinus occasioned by this does not always confine itself to a straight direction. but sometimes extends nearly round the Anus - when the Fistula is one formed it seldom or ever heals itself It is because the the Rectum is constantly tearing the sides of the sinus on account of its contractile power, therefore to remedy this 122 The sinus must be entirely laid open This disease frequently attacks Patients after long continued Fevers, or disease of the Bowels or Liver, in this last case Calomel must be given before you attempt to operate. The Piles generally preceeds this Complaint - it is also a frequent attendant in Phthisis Pulmonalis, but it is of no use to Operate in these Patients as no cure will be obtained : Fistula is sometimes depending on local causes as costiveness &c sometimes from long continued exercise on Horseback & from Violent irritation of the Parts - The method of operating. Pass a probe up the sinus with a Finger of the other Hand previously dipt in oil into the Rectum by this you will distinguish if the sinus runs into the gutt then pass Potts Bistary along ye probe untill it meets the extremity of your Finger the lay it open through its whole extent, place a dip of dry lint into the wound after & continue this dressing till a cure is obtaind. - Fistula may sometimes be cured without any operation by Injecting the following 3 or 4 times a Day Rx Aq:Calcis ℥iv Hydrarg Muriate giv M and at the same time give Wards paste Rx Pulv: Enul : Campan Hi semen fenual dule Hip Piper negre H1/2 Pulver bene at adde sacchar et Milles a a Hi M sumat L.N.M vis vel ter in die - 123 On Amputation The first step necessary to be taken in this Operation is to apply the Tourniquet. If The Operation is to be performed below the knee it should be applied a little above the middle of the inner part of the Thigh as there the Artery requires less pressure - If the Operation is to be performed so high up on the Thigh that the Tourniquet cannot be applied pressure must be made on the Artery in the groin as it passes over the pubis by an assistant - When on the Arm apply the Tourniquet on the middle of the inner part of the Arm between the shoulder and Elbow (near the insertion of the Biceps Muscle called the Deltoid) - if very high an assistant must secure the Artery by pressing behind the Clavicle - On Amputation of the Fingers. in amputating the 2 or 3 joints make a circular incission a little above the Joint and then make a Longitudinal incision on each side as far as the Joint in order to leave a double Flap to cover the stump, then 124 pass your knife into the Joint and remove it cover the stump with integuments and apply adhesive plaisters. The first joint is amputated rather different. make an incision between the Fingers on each side which incision should meet on the back of the Hand, divide the Tendons on each side rather short. remove the Finger by cutting into the joint. Cover the stump with integuments and apply ample adhesive On amputation of the Metatarsal Bones In Performing this Operation save as much integuments as is required to cover the stump from the bottom of the Foot, then make a circular incision saw through the Tarsal bones bring the Flap over the stump, pass sutures thro' the integuments and cover them with ample adhesive and light dressings. the parts in general heal readily. In this operation half the Foot is only removed - On amputation below the knee with a flap according to Mr. Hay’s method is as follows. first measure the leg from the knee to the ancle 125 and take half the length as the spot where you are to take off the limb, next take off the circumference of the Leg, one third of which is to be the length of the Flap. The parts should then be markd. With Ink. the catlin is then thrust through the Limb at this place and carried down to 3 or 4 inches in the adult and brought out make a circular incision round the Limb draw up the integuments and cut thro' the muscles to the bone, pass the catlin between the bones to divide the interosseous ligament, and saw off the Bones turning the limb round so as to apply the saw on both bones at once. The Fibula should be sawd. through first. bring the Flap over the stump and pass sutures Mr. Hay makes use of eight in this operation The [am] patients who undergo amputation in these Hospitals suture can rarely be made use of by the advance of Mr. Allamon they are at one time used in the Hospitals but were found to occasion with great constitutional irritation and symptoms of Trismus 126 or lockd, jaw so that in two or three days they were obliged to be removed consequently adhesive Plasters was made use of with a compress of Lint, a cross cloth with the Roller, and the stump kept cool - The Present method. The distance below the knee where the incision is to be made is a hands breadth in the adult, in children about 3 Fingers below the joint of the Patella, or Rotula, make the first incision about 2 inches below the part at which the bone is to be sawn off, in order to save integuments to cover the stump: in Children about 1 ½ Inch divide the Fascia which binds down the muscles on each side of the bone, then draw the Integuments upwards next divide the muscles to the bone. turning the the edge of your knife rather obliquely towards the knee: pass the catlin between the bones and apply the saw as before directed bring the integuments over the stump, having secured the Tibialis anterior arteries and Intercostal artery apply ample adhesive Lint Roller cross cloth and give the Patient an anodyne - 126 Amputation above the knee Begin your circular incision as near as you can above the knee joint. but in case of white swelling be careful not to cut near the diseased part as a cure after the operation will be tedious. make a circular incision through the common integuments divide the Fascia on the Anterior and lateral parts of the Thigh to allow enough to be drawn up then divide the muscles to the bone inclining the knife a little upwards then saw the bone as high up as you can, the Tourniquet being slackend you must secure the Femoral Artery and a branch of the arterial profunda. in securing the this Artery be careful not to include the nerve bring the integuments over the stump and treat as before - Amputation at the wrist – In performing this operation save as much integuments as you require to cover the stump from the Palm of the Hand, feel for the extremity of the Radius and make an incision just at the root of the Thumb to some 10 in the internal parts of the Body, the surface is evidently hot to the touch and the heat occasiond. by the inflammation of blisters has in in a great number of experiments been found to exceed the natural heat from 4 to 7 degrees Inflammations are divided into common and specific common is that which arrives from wounds or spontaneously in a good constitution without any particular change of arterial action producing an effusion different from the common inflammation, it will cause four effects 1st. adhesion or resolution this is by coagulated lymph pourd. from the extremities of the blood vessels- it consolidates the parts a preparation of a Heart shews this in a very distinct manner, it is coverd. With a coat of coagulated lymph which gives the external surface a rough appearance- the 2nd. effect is suppuration, the vessels here pour out matter instead of coagulated lymph - 3rd effect is ulceration which is an absorption of the inflamd. part producd. by a violent action of the absorbents - 4th mortification in 128 depth make an Incision round the wrist so as to meet the Flap whether on the back or inside of the hand, dividing the Tendons completely draw back the integuments and insert the knife into Joint and remove. bring the Flap over the stump and endeavour as much as possible to heal by the first intention, there are two Arteries to be secured the Ulnal and Radial, but this last if in a Gun shot accident rarely requires to be secured Amputation of the Fore Arm This operation is more dangerous in diseased Habits, than the upper Arm as suppuration frequently takes place between the Tendons with high constitutional irritation Lock Jaw and Death - First make a circular incision through the common integuments dividing the Fascia on both sides the Arm, draw back the integuments as much as possible. next divide the muscles to the Bone inclining the edge of the knife obliquely upward, next divide the Interossious Ligament by passing the catlin between the Bones turn the Limb round and apply the saw 129 on both bones at once. when the Limb is removed three arteries must be secured Viz the Radial, Ulnai Intercostal. then proceed as before directed - Amputation of the Shoulder Joint with a flap - The first step necessary to be taken is to secure the Axillary Artery, when this is exposed pass a Director under and carry a needle armed with a ligature along the grove of the director and secure the vessel, next take hold of the Deltoid Muscle between your Finger and Thumb and carry your incision obliquely upwards towards the bone this leaves the Flap which is afterwards to cover the stump, then make a circular incision round the Bone, turn the head of the Humerus out of its socket & cut it away bring the Flap over the wound and endeavour to heal by the first intention. - 130 In Diseases of the Female Breast The first disease we sall speak of is the formation of Hydatis in the breast. similar to those occurring in the Testicle in the Male. in this Disease the Patient at first suffers but, trifling pain. In the early stage, the Breast feels as if small knots were placed under the skin of various sizes, when the disease has continued a long time, one of the Tumours increases in size, ulcerates, and discharges a Glary Fluid, and if more Tumours Ulcerate very troublesome sinusses ensue In the removal of these Tumours there is no danger, and when removd. do not return [or] this disease does not extend by absorption as in cancerous Tumours The next disease to be treated of is that of schirrous The symptoms of which are a discharge of Blood from the nipple. or an uneasy sensation in the Breast when the Arm is thrown back. Pain in the Breast shooting into the axilla, a Tumour formed of a remarkable hardness feeling like a marble under the skin. in an early stage the 131 Tumour is moveable. and the Patient suffers very severe pain at time but not constantly- If the woman is menstruating a Day or two Prior to this the Tumour enlarges and becomes more painful - it goes on gradually until it becomes of a considerable size, the Glands in the Axilla becomes affected, with a slight pricking in the skin forming a kind hollow over some part of the Tumour. when this is the case Dr. Cheston of Gloucester observes that no success will attend the Operation if performed; the skin also appears rather inflamed. one or two Glands under the edge of the Pectoral Muscle first becomes affected and the Glands above the axillary artery and Vein, the disease also extend, into the Chest. Tumours are formed opposite the middle of the Clavicle in this case all you can do is but palliatives - in case of adhesion to the Pectoral muscle only you may operate with advantage as a considerable portion of this muscle may be removed without detriment to the Patient If the Tumour is left to itself it ulcerates and discharges a bloody Ichor. these schirrous Tumours become sometimes entirely cartilaginous 132 Prior to the patient dying of this disease the arm of the affected side swells, becomes oedematous, acute pains are felt shooting from the axilla to the finger ends Patients sometimes die of a Cancer in a very curious manner, they complain of violent and unremitting pain in different parts of the Body. Opium tho given in large doses give but little relief and the Patient lives but a short time Mr. Cline related a case of a woman in Guy's Hospital, who had a cancer in both Breasts extending as low as the navel and not less than 50 small cancerous Tumours in different parts of the Body. the scalp in Particular she was attackd with difficulty of Breathing with violent pains in divers parts, high constitutional Irritation the Womand died. - The true schirrous generally takes place about the time when women cease to menstruate that is between 40 & 50. Old age is rarely subject to this disease - The Fungus Haematodes sometimes though rarely exists in the Breast, it is a disease similar to the pulpy cancer, which sometimes affects the Testicles in the Male and if you take a Lancet and make a puncture into the Tumour a fungus excrescence appears 133 like the Head of a cauliflower. when the Tumour bursts the patient survives but a short time. no advantage is to be [crossed out] gained by an operation as these Tumours will form again shortly – Women from the age of 16 to 24 or 25 are frequently the subject of Tumours in the Breasts which at first sight may be readily mistaken for a schirrus but this Tumour has no sensible limits when felt, appearing gradually to loose itself in the surrounding substance. but in the true schirrous you can readily discover its extent. it is accompanied with pain in the axilla shooting down the arm - It generally attack young women of strong Passions and delicate constitutions also young married women. The treatment in this disease is first to apply leeches to the part when the pain is Violent. apply a soap Plaister and over this apply the skin of some animal as is Hare, to keep up a degree of perspiration. which relieves the Pain and diminish the size of the Tumour give internally Ferri: Ammonia gr.v bis vix ter quotidie Gentle exercise on Horseback should also be recommended - In Performing the Operation for schirrus 134 Cancer makes your fist Incission in a semicircular direction over the upper part of the Tumour you then divide the Arteries which supply the Tumour with Blood, compression being made on these by an assistant, dissect out the Tumour so as to lay the Fibres of the Pectoral muscles. no ligatures are required bring the skin over the wound apply [Empt] adhesive & a Roller - The Method of Introducing ye Female Catheter The Patient lying on her back. feel with the forefinger of the left hand for the extremity of the Clitoris which having found carry your finger in a straight line one inch below, when you meet with the orifice of the meatus urinarius, then with your right hand you are gently to introduce the catheter. in introducing it elevate the point of the Catheter by depressing the Handle. The Cather should be somewhat more curved than usual as it then more readily takes the course of the meatus urinarius - 135 The Method of Introducing the Male Catheter - The Patient being placed on a Table. stand by his left side near the shoulder, introduce the catheter untill it reaches the neck of the bladder, the by depressing the Handle backwards so as to let it sink between the Patients Thigh. it elevates the point & the catheter readily passes into the Bladder - On Opening the Temporal Artery The best place for making an incision into this Artery is just as it emerges from the root of the Hair, make an oblique incision through the integuments in order to lay the artery bare. then make a small puncture in the side of the Artery - when you have taken away a sufficient quantity of Blood introduce the Lancet and divide the artery completely if it is not divided Haemorrhage will be continually recurring - 136 On Lithotomy First of the formation of Calculi in the kidneys their presence may be known by the Patient complaining of Pain in the Loins of a dull kind attended with sickness, and on rubbing the Back an uneasy sensation is produced in the side where the stone is lodged. after much exercise Blood is discharged with the urine. where these Calculi are passing along the Ureters the Patient complains of pain in the Thigh of the affected side, extending a little below the Groins in the course of the anterior Crural nerve and the Testicle is drawn up by the action of the Cremaster Muscle to the abdominal ring: Bloody urine is occasionally discharged Death sometimes takes place from a swelling of the abdomen coming on which fluxtuates, and on dissection is found to be an of the kindneys - The symptoms of stone in the Bladder are a cutting sensation at the extremity of the Penis, and when the Patient is discharging his urine it suddenly 137 stops. when the Bladder is nearly emptied itself there is frequent inclination to make water. with a disposition to go to stool at the same time, and when the symptoms run high the Foeces are often discharged involuntarily in any change of position. the Patient always feels pain, when much exercise has been used, mucus passes off with the urine. - If a stone has existed a long time purulent matter is discharged with urine from a disease in the Bladder - If this is unaccompanied with pain in the Loins you may safely operate: The Patient becomes frequently seizd. with violent shiverings like an intermittent succeeded by heat with profuse sweating, spasms of the abdominal muscles and the contagious parts, but the degree of irritability is not proportioned to the size of the stone, as a large stone frequently produces less irritation than a small one Dr. Franklin the Philosopher in America was the subject of the Disease. The size of calculi are various. there is a stone in Mr. Foriter's Possession surgeon to Guy’s Hospital which weighs ℥xxv and of a remarkable compact Texture there is another in the Library of Trinity College Cambridge which weighs ℥xiv & 11 which the circulation cease and the parts require to be separated from each other or Death must ensue.- symptoms of the [state] first state an uniform swelling the skin uninflamd, with a dull equal and constant pain, parts easily pit, in hernia humoralis these symptoms are very perceptible, in the sound state the skin is red however deep the inflammation the most certain criterion is a softness in the middle surrounded by hardness – A man in the Hospital with symptoms of a diseasd. Liver had a Tumor on the side with the appearance of softness surrounded with hardness, it was opend, and a great quantity of matter was dischargd. the abcess was so deep that probe would but part reach the bottom. The pain in this state is variable and darting- the 3rd state has “gnawing pain which marks the action of the absorbents, the skin becomes thin the cuticle loses its color and becomes white it separates, when the matter is dischargd, Ulceration ceases - in the 4th state there is excessive 138 is nearly as large as that weighting ℥xxv The largest stone Mr. Cooper ever saw extract weighd. ℥iv1/2 ounces - In extracting a small stone from the Bladder the flat forceps are preferable - The circumstance necessary to be attended to previous to performing the operation are to observe if the Patient is in good health, for if a pain is felt in the Loins a disease of the Kidneys in all probability exists, give two or three purgatives in the week previous to the operation. and morning before give a purgative Enema. if the Patient is plethoric VS - To Perform this Operation. Place your Patient on a Table of convenient height & having properly secured the Hands and Feet the perineum being shaved, make your incision beginning immediately under the Arch of the Pubis carrying it opposite to the middle of the Anus, this incision lay bare the accelerator urine and bulb of the urethra. this last is divided in making your second incision and sometimes the internal Pudendal Artery (but this is not so likely to happen when the cutting Gorget is used as when you use ye blunt 139 Gorget) In making your second incision you carry it into the Grove of the staff. and keeping your scalpel there to serve as a disector for the Gorgett, and before you withdraw the staff ascertain clearly that it is open throughout its extent having done this remove it, and feel for the stone with your Finger or Forceps having ascertain its situation, pass your Forceps along the Gorget, and having taken firm hold of the stone. remove the Gorget, and in extracting the stone give your Forceps a slight lateral motion which tends greatly to facilitate the extraction of the stone - the staff when you cut into it should be held nearly perpendicular, so that in making your first incision you can’t feel the staff - If the stone is containd. within a sacculus, you are directed to use Potts Bistoury and dilate it. Ricketty children have frequently the Tuberositus of the Ischia so close together, as not to allow the passage of the stone, in this case you must endeavour to break the stone. the case however generally proves fatal. If you succeed in breaking the stone, introduce 140 the flat forceps in preference to the scoop Mr. C observes it is a wron practice to inject any fluid to wash assay the particle of stone- In Norfolk this disease is more frequent than elsewhere. in Norfolk and Norwich Hospitals above 300 stones are collected, and of those Patients operated on, about two fifteen die on an average in these Hospitals according to Mr. C estimate about one in 13 die of this operation Mr. Cline in the first 24 cases he Operated on lost none after that he lost three successively. Mr. Cooper in in the first 24 cases he operated on lost one. which Patient was a very young Child and died of Convulsions. therefore it is more dangerous to Operate in young Children than old people In those Children who labour under Tabes Mesenterica this operation should never be performed, as they stand no chance of recovering, Age makes but little difference in this respect Mr. C Operated on a Gentn. 82 years old who recovered in a short time 141 In order to stop Haemorrhage from the Pudendal Artery. press on for about 10 minutes with your Finger but dont introduce Lint. for in this case the pressure applied is often incomplete and the Blood escapes into the Bladder producing shiverings &c. after the Operation apply superficial dressings - Mr. Cooper thinks there is no occasion for any- If there is a considerable discharge it is a favourable Symptom. If otherwise the abdomen becomes painfull, then you are to apply the Leeches with fomentations of Chamomile Flower & Spts. and when it can be had the warm Bath - In 14 or 20 hours after the Operation a little urine is discharged by the Penis, when you are to bring the Thighs together, and secure them by Ligatures, if the external wounds does not heal in 17 or 20 days pass Bougies up the Urethra - In the Patients who wont submit to this Operation as Palliatives you may employ Alkalies give aq: mephitic for common drink & the following may be taken with advantage twice a Day - Rx carbonate of Potash ʒ1/2 aq 1/2 ♏︎ the PA sapon may be given with advantage - Women are less liable to this disease than men as the meatus urinarius in them 142 is short and a stone of a considerable size will frequently pass of itself, a women who has once been operated on never after requires the Gorget - In Performing this Operation in the Female. Having the necessary preparations Sound the Patient with a small male Catheter in order to discover the calculus, this done introduce another sound with the grove turned downwards the pass the back of the Gorget into the Grove of the staff, and carry it into the Bladder, then withdraw the staff and carry your Finger into the Bladder to fee for the stone, having discovered its situation introduce the Forceps along the Gorget, withdraw the Gorget as before directed, and laying hold of the stone (which is generally found in a hollow immediately over the vagina) extract it using a slight lateral motion in the extraction &c NB Mr. C. observes young women wish to have this operation performed on then for what reason he cannot tell, but believes it to be a species of insanity, these women have generally diseased ovaries - 143 On suspended Animation The causes giving rise to suspended Animation are Submersion, Suspension, Noxious Airs Extraneous Bodies, and Tumours pressing on the Trachea - Submersion Under Water In this case the animal does not die from water getting into the air cells of the Lungs, but from the exclusion of the Air from the Lungs, the blood is rendered incapable of undergoing that change which fits for the purpose of Respiration and Life- It is found from experiment that very little water is found or containd in the Lungs and not more than three or four Ounces generally in the stomach - Mr. Coleman observes that the Blood accumulating in the right side of the Heart is impeded in its passage to the left, but Mr. Cooper differs in Opinion and says that the Blood is not impeded in its Passage but diminished in quantity Suspension It was generally supposed that apoplexy was the effect of suspension, but that is an idea erroneous for if there happens 144 any congestion in the Head it is only within the Vessels themselves which cannot produce this effect. Persons that are hanged die precisely under the same circumstance as in drowning, for if you take an animal and make an aperture into the Trachea below the cord, and a pipe being introduced into it the Animal will live for many hours. It was supposed by some that the Vertebrae suffered and the medulla spinallis became compressed but this like the former opinion is erroneous Vide Coleman on Suspended Animation Introduction of Noxious Air As Hydrogen Gas, Carbonic Acid Gas. these act as Poisons by their effect on the Nervous System & thereby destroy life, a Frog may be kept alive for three hours under water but if Carbonic Acid Gas be employed it will die in 8 or 10 minutes. If Animals are immersed in Hydrogen Gas and taken out just before the functions of Life is [destroyed] cease they will recover for a time but in general die in a few hours with convulsive symptoms. In those who 145 are destroyed by the Mephitic Gas emitted from charcoal or Carbonic Acid Gas - In the Brewers Vatts it is found that the temperature of their of their Bodies is far above the standard and continues so for many hours after Death has taken place - From this fatal exposure scarce any person is ever recovered as it acts as a direct poison when applied to the Lungs, and not as some gasses merely by the exclusion of the respirable part of Atmosphere Air - Extraneous Bodies introduced into the Larynx produces suffocation in this case the Patient dies suddenly generally: sometimes not for many hours, and it has happened where they have lived for 3 weeks, an obstruction is produced in the Larynx by substances in eating dipping under the epiglottis, where it may kill instantly or by the irritation it may cause which when it happens after swallowing a substance great difficulty of Breathing is caused with a Violent Cough – Emetics have been known to eject the substance by their action, which should be used strong The throwing up of a piece of coagulable lymph in Cynanche trachealis is a frequent cause 146 for this complaint, sometimes also from swelling of the Glotis and Epiglotis in Angina Scarlatina, also from an abcess arising on the Cartilages of the Larynx from pressure and irritation Means of Recovery In infants just born, and no symptoms of respiration, bring them to the fire or put them into warm water inflate the Lungs employ friction with hot flannels – If an adult under submersion or suspension warm Bath. Opening the Jugular Veins taking away not more than one or two ounces of Blood, inflate the Lungs by means of a pair of bellows pressing at the same time upon the Chest for the purpose of producing artificial respiration. pour spirits down the Throat probably some of it may pass into the Trachea, and if it excits any emotion it will be the means of recovering him - Electricity is but seldom employd. with advantage as circumstances occur to render it inadmissible. when you have inflate the Lungs, and left side of the Heart begins to Act emply friction with warm flannels, some use salt. in case 147 of suspended animation from the inhalation of Noxious Airs do not take away Blood but heat it as under submersion and suspension When any Extraneous Body is Lodged in the Larynx never use a probeing for its removal but pass your finger under the epiglottis and endeavor to extract it before you attempt any operation If you cannot succeed in that way give a smart Emetic: there has been instances where it has proved effectual. if neither of these succeed set about performing the Operation as follows - Bronchotomy This is the most unsuccessful Operation in Surgery It was once performed by Mr. Andrie with successes and which is the only instance on record Mr. Sharp recommends to make an incision of an Inch in length at the ring of the Trachea half way between the Cricoid Cartilage, and the Sternum, this Incision lays bare the Trachea, you are then to pass the front of your scalpel through the substance of the Trachea between the ring, but this plan of Operating is by no means advisable, as the Thyroidal vein becomes divided and the Blood 12 acute pain, vesications arises containing sanous serum the parts under the vesication is of a brownish red this procedes gradually, delirium takes place when mortification takes place in consequence of accident, singultus comes on, the stomach and Bowels are affected, much air is expeld, constipation takes place, the pulse are in general quick and pain varies according to the importance of the parts affected; when the limbs are the seat of the disorder [it is] they are quick and hard when in the abdomen they are exceeding small sometimes full in the first stage they are slow in inflammations of the Lungs & rises on venesection and becomes more like a natural pulse in inflammation of the Heart the pulse is tense beating work a jerk like a broad wire: in inflammation of the brain the pulse is full and slow: if there is much effusion on the brain, the blood when inflamd, is much thinner and separates into three parts, and takes a longer time to regulate and the red particles are not sustained by the lymph, the Blood becomes cuppd on both 148 gushes into the Treache and suffocates the Patient - Mr. Cooper recommends the incision to be made between the Thyroid & Cricoid cartilages, and a probe to be introduced to push the extraneous body into the Throat in this manner you avoid the Thyroidal Vein and it is an Operation that ought to be performed without fear - Mr. Coleman recommends to make an incision on the Thyroid Cartilage but this Mr. Cooper objects to there not being room left sufficient for the Passage of the Air from the Trachea from the elasticity of this Cartilage and sometimes it being met with in an ossified state On the Operation for Suppression of Urine The best method of performing this is about the Pubis. First make an incision one Inch in length as near the Pubis as possible, feeling for the Symphisis Pubis then pass a Trocar & Canula directly downward towards the Bladder the length of the Trocar & Canula should be 4 inches the Canula should be rather longer than it is generally used as the urine is apt to be extravasated, the coats of the Bladder receding from it as the 149 urine passes off then fix the Cannula by strings to the abdomen- it should not be allowed to remain in more than 2 Days when it should be withdrawn and a shorter one introduced if necessary: even this method of operating is liable to objections as it generally brings on disease of the Bladder from irritation Mr. Cooper recommends an incision to be made into the membranous part of the urethra as it depends chiefly on a stricture in that part : there generally occur about 2 or 3 inches from the Bladder or 7 Inches from the lips of the Urethra - The incision is to be made with a Lancet made straight and this is to be thrust through the Tumour in the perineum into the Bladder - Of Calculi in the Urethra The presence of calculi in the Urethra may be known by the Patients complaining of cutting sensation at the lips of the Urethra a sudden suppression of Urine and if a Catheter is used to surgeon hears it strike against the stone If the stone is lodged two or three inches within the passage make an incision through the Urethra upon the stone keeping 150 it at the same time steady between your Finger and Thumb, and taking care that your external incision is larger than the internal: this done extract the stone with a dissecting hook: the wound will heal by granulation: you must not attempt to heal by the first intention for obvious reasons - When the Calculus is situated directly opposite the Scrotum it is not to be distinctly felt : it is more difficult to extract, and likewise endangers a sloughing of the Penis by the urine extravasating itself within the surrounding cellular [membrane] substance therefore it is recommended to push back the stone in perineo, where it is less difficult to extract. If you intend to operate in its first situation (viz directly opposite the scrotum) make your incision from 1 ½ Inch to 2 Inches through the integuments covering the stone to allow the Urine to escape freely after the Operation and extract the Calculus with the forceps or dissecting hook- In Children this Operation is not so dangerous - 151 apply poultices to the wound, and heal by granulation as before observed - the next situation of Calculus we shall speak of is at the Prostate gland which of itself will sometimes produce Calculi different from those found in the Bladder or Kidneys. before you attempt any operation in this case give the Patient a few hours to wait, for there has been instances of the urine accumulating behind it and forming by his efforts to void his urine from its situation, and it being in consequence expelled with the Urine. but Mr. Cooper advises at the same time Bougie to be introduced as far as the stone, and suffer to remain there as long as the patient can bear it, when it being withdrawn and the Patient desired to void the contents of the Bladder, the stone will in all probability pass off along with it, but if a Fistula in perineo attends this complaint this will not happen but the stone will make its way through the Perineum If after you have tried this plan of treatment and gain no advantage you must proceed to operate as follows 152 First pass a staff along the Urethra untill you distinctly feel it resting on the stone pressing it into the Perineum so as to feel, then cut, make an incision with a scalpel into the point of the staff within its grove pass a probe into it and push it along the Urethra (over the stone) towards the Bladder beyond the stone this done extend the incision with a Phymoses knife untill the extremity of the stone where you may readily extract it with your Finger or a fine pair of forceps. after Treatment as before directed - If a stone is situated at the membranous part of the Urethra with a stricture, it must be removed make an incision through the perineum and extract it with forceps A stone lodged in the Meatus Urinarius of the Female seldom requires any operation for its removal , but it sometimes produces Ulceration, and part of the stone being lodged in the meatus and the other in the Vagina - you must introduce a pair of forceps break off that part in the vagina and afterwards remove the other portion within the meatus urinarius Mr. C. saw this operation performd. on a woman who had previously a 153 very difficult Labour and it was found that one portion of the stone communicated with the other by a narrow neck - On Amputation of the Penis The Penis is subject to two species of cancer First the Watery Cancer so called from its first appearance being similar to that of a Venereal Wart this increases to a considerable size resembling a Cauliflower this Ulcerates and destroys the Penis the Urine is discharged by many orifaces and the Patient suffers excruciating Pain 154 saving of integuments as the corpora Cavernosa recede considerably, and besides that the integuments are more diseased than the Body of the Penis. when the wound begins to granulate you must introduce a bougie, and suffered to remain there, if it induces a discharge from the Urethra it must be only occasionally introduced (viz) two or three times a day if this is not strictly attended to much mischief will ensue- On the Hare Lip Children are frequently born with a deficiency in the formation of the Lips and which forms is its resemblance to a Hares Lip. it has been denominated by surgical writers Labia Leborino this deficiency extend sometimes through the palate to the Uvula. in this case the Operation is more difficult If there is a fissure in the Velum pendulum Palati only it produces a nasal pronunciation of sound. The hare lip exists sometimes on both sides in this case you must succeed with one operation before you attempt the other 155 If this Operation is to be performed in a Child its age is to be first considered Mr. C advises the Operation never to be performed until the Child is two or three years old, there are two reasons for this, in the first place if very early performed it generally prove unsuccessfull, and secondly if delicate Children it proves dangerous. the Lip from the violent irritation it occasions brings on Diarrhea Convulsions &c - Operation Pass the point of a Lancet through the skin of the Lip, extending your incision first upwards towards the fissure and then downwards towards the edge of the Lip so as to make it a recent wound this done on both sides, pass the first suture through the middle of the red part of the Lip and the second half way between the first and the nose exactly; the sutures are then to be tied, you are to bring the cheeks together and apply in a day or two a slip of Empl adhesive across the Lip from the Angle of the Jaw on one side to the opposite angle, this is to remain for 10 days. and if any excoriation is produced by 156 it. first apply a slip of Lint & the empl adhesive over it - If it is a double Hare Lip there is always a projecting portion of bone if in the Adult, this is to be removed by the bone forceps, in young Children it is of no material consequence - In this Operation, the Labial Artery is divided and in order to stop the haemorrhage you are to pass the Lower suture so as to include the Artery if possible and which is not very difficult to accomplish: The Middle Suture must be taken away on the 4th day - and the lower one on the 5th . In Children leave the Ligatures to Ulcerate of themselves, for the inflammation which they produce is trifling, but still keep adhesive plaster over the lip - On Nasal Polypi These Polipi which arise from the Pituitary membrane of the nose, are sometimes found transparent, at other times of an Amber colour, they are found depending by a narrow neck, are easily movable and are contained within a thin Bladder they are not very sensible and but slightly vascular, Patients under 157 this disease complain that when the weather is moist the nose feels stopd up, so that they cannot readily breath, and if they have a a cold the nostrill on the affected side seems stopt up, while the other remains free, they are sometimes found branching and at other times to contain a Hydatid Operation If the Polypus appear at the nose. place the Patient in a clear light and examine with a probe where the neck of the Polypus is attached. it generally to the septum nasi. then introduce a pair of pointed Forceps, take hold of the neck of the Polypus and by a sudden jerk extract it a small portion of bone sometimes is brought with and which is a describable circumstance if not they are very liable to return in a few months Polypi sometimes occur of an Hydatid kind filling up the cavity of the nostril completely and when you attempt to extract them they break under the forceps so that you can’t remove them in this way they contain a small quantity of fluid, they occasion swelling of the 13 sides which is a stronger sign of inflammation than buff, - on Specific Inflamation Specific inflammation is where the arterial action is changed, and the effusion is different from those already described, those in the Gout. the skin is inflamd, but chalky matter is deposited on the Joints instead of lymph - in cancer and schirrous where the disposition is on a peculiar nature. the discharge is very different from pus. small pox erisipelatous fever. Angina scarlatina are specific inflammations. Inflammation is salutary if it does not precede to too great a length; granulation could not be affected without an inflammation of the surface of a wounded part - if matter forms in the interior part it could not get out without a process of ulceration - Bone exposed to accident must always remain so did inflamation produce exfoliation. Inflammation therefore should be suppressd, its symptoms are to be attended to and regulated, weakness is the predisposing cause of spontaneous inflammation 158 cheeks, Ulcerate and destroy the nose producing violent constitutional irritation which puts a period to the Patients sufferings. This Disease is not of a cancerous nature, An Injection of Hydrar: Muriat & aq:Calci is recommended A Cancerous Polypus sometimes occurs between the age of 40 & 80 it’s colour livid & when touched bleed profusely it is attended with a shootin pain thru the Head, sometimes extends through the ductus a nasum and forms a Tumour just opposite to the Lachrymal sac - Treatment - use Injections with Tinct:Opii & give opium muriatae On Dropsy & Method of Operating Dropsy of the abdomen is of two kind. First Ascites which is an accumulation of water within the Cavity of the [abdomen] Peritoneum or Encysted when the water is collected in the Ovaria, or in an Hydatid on its surface - I ascites the water gradually accumulates upwards untill it reaches the navel, when there is but a 159 small quantity of water an undulating motion is felt by the Patient in charge of posture, this Disease produces an accumulation of water in the extremities which there takes the name of Anasarca if it is accompanied with difficulty of Breathing much danger is to be apprehend Ascites is generally the effect of a Diseased Liver, sometimes from the omentum or spleen becoming hard and enlarged, the Tabes Mesenteria is sometimes a cause of this disease, and especially the abuse of spirit Liquors, from it producing a great determination of Blood to the Viscera: whatever hurries the circulation is a frequent cause on Dissecting those who die of this disease the Peritoneum is in general found studded with Patches of coagulable Lymph - Encysted Dropsy caused from an accumulation of serous fluid in the Cavity of the Ovaria. it becomes considerably enlarged before the Patient is aware of the Disease existing forming a large Tumour on one side of the abdomen there is at this time on the Museum 160 of St. Thomas, Hospital, an ovarium which contained 12 Gallons and one Pint of water purchasd. from Dr. Poles collection by Mr. Cooper in General they contain from 20 to 30 Pints The Water is sometimes accumulated in many cysts, therefore it is not advisable to operate early - The fluid which these enlarged ovaries contain, differs much at various times, at first it appears like the serum of the Blood the next time it appears glary & Tenuious as the White of an Egg after which it seems like pus & Hydatis is found in it; the fluctuation in this Disease is not to be distinct as in ascites - water is more & there discharged by the the urethra & vagina Operation Have the Patient in a Chair with a sheet thrown round the abdomen, and confind. there having made an incision with a Lancet one Inch below the navel in the course of the Linia Alba introduce a large Trocar and Canula after the water is evacuated close the wound with Empl adhesive Very Carefully. This operation maybe performed at the navel or an Inch above it if the Tumour is high - If the operation is performed Low down the Bladder should be previously emptied - It requires to be often repeated 161 Scrophula Scrophula is an inflammatory disease accompanied with great debility, all the processes are attempted as in common inflammation but they are slow & imperfect. The adhesive process instead of taking place in a few hours as in common inflammation is sometimes weeks, and there is not that kind of adhesion as in inflammation: the coagulable Lymph is soft and imperfect the Suppuration stage is slow and imperfect. the pus is like a serous fluid mixd with curd like matter Ulceration is also very slow. there is evidence of fluctuation long before the abscess breaks when opened the edges of the skin are curled at the ends and turn inwards, not opposite to one another and considerable scars are produced Scrophulous complaints occur at different periods of life first there is a scrophulous enlargement of mesenteric gland in very young Children called Tabes Mesenterica, at two years of Age the glands of the neck becomes enlarged next from 6 to 12 years there are generally the different white swellings in the Joints about Puberty Phithisis Pulmonatis occurs & generally continues to 35 years of age about the same time lumber abscesses take place upon the spine and also in the Loins and groin. From 20 to 23 the Testicle becomes scrophulous 162 there is no pain, great enlargement & hardness, this extends to the vesicule seminal and Prostrate Gland - Scrophulous Opthalmia occurs at any Period under 35 years, An enlargement of the Prostrate Gland in old age is said to be scrophulous but doubtful, Truly scruphulous complaint are rare after 35 years - Exceptions - Character of Scruphulous Persons Distinguishing mark, Then skin, delicate constitution, light florid complexion light in general, fixed colour in the cheeks you may see the Veins distinctly under the skin usually about the neck and Temples. the hair hangs straight, pliable fine light and sometimes very dark. upper lips much the thickest and projecting over the lower, Scruphulous Children are liable to diseased secretions behind the Ears producing and enlargement of the Glands of the neck - No disease is hereditary Every constitution is liable to scrophula when exposed to particular causes. no Child is born with scrophula but only with that disposition to it like its parents and their disposition must be acted upon by the same existing causes before the disease is produced the Disposition is hereditary but not the disease. Predisposing Causes Weakness generally the effects of some Fever - scrophula frequently occurs after the inoculation of 163 the Variolae prior to the introduction of the inoculation for the small pox into this country scrophula was not so frequent[ly] as it was afterwards, but since the introduction of vaccination scrophula is not frequent as it was. also caused after the Fever produced by Mercury- the most common cause is Angina Scarlatina, the more Violent the Scarlatina the less Violent the scrophula &c close confined situations and scanty nourishment - The treatment consists in restoring the tone of the Arteries and in the formation of better Blood. Begin with enriching the Blood Good Nourishment must be kept up - 3 Glasses of Wine for a Child out of arms per day. Scarcely any Vegetable Food should be given. Meat at breakfast again before dinner & at dinner the Child should never fast long: nutritive food in as small a compass as possible; Exercise with other Children frequently but not to fatigue Good Air. On this plan you must place more dependence than Medical treatment Medicine steel and Gentian combind with Bark. If inflammation is going on give the following Rx Hydrarg Muriat gr 1/8 Tinct. Cinchone 164 Comp 1 dram bis terve die sumendus ex vino rubro. This is particularly beneficial in scrophulous ophthalmia. The above is a dose for a Child, it produces absorption of scrophulous enlargement prior to the formation of abscess - scrophulous Diseases of the Absorbent Glands - In the Glands of the neck an amount of the exposed state of the face and ears inflammation is produced the almonds of the Ears are said to come down inflammation takes place on the mucus membrane of the nose; with these scrophulous enlargement of the Glands of the neck: there is but a slight degree of pain: remain for a long time in a very indolent state, then with no obvious cause on a sudden go to suppuration which is shewn by the redness of the skin afterwards of a purple colour and when the Glands Ulcerates the edges turn in the Granulations or flacid & glassy and take great length of time to heal. sometimes the Tumours produce fatal consequences by pressing on the Larynx obstructing Breathing and from taking sufficient nourishment. likewise pressing on the Jugular vein and occasioning apoplexy - 165 The plan of treatment proper in these cases If you are called in at an early period of the enlargement it is best to apply aq Lith Acet: comp and to give purges of calomel If there is any considerable pain apply Leeches repeatedly and prevent suppuratoin if possible endeavour to keep the inflammation under Medicines Rx Hydrarg Muriat & 1/8 Tint: Cinchone ʒi bis terve die. If the pain & inflammation is great the Tint: Cinchone should be left but, where it does not ammount to suppuration it will promote the action of the Absorbent Vessels- When the Tumour is of a very indolent kind use the soap plaister. If in the early stage the Emph sapon and flannel put over with rest and Calomel purges will cause a cure in a few days. If suppuration takes place after all the means you have tried, as soon as there is any fluctuation open the abscess - If in the Female be a little particular for fear of making a mark - make your incision with a Lancet transversly into the abscess - after it is opened 166 apply the following Lotion Rx Zinci Vitriole gr xÿ Aq: Rose ℥viÿ ᵯ If it checks the discharge too much, mix it up with Bread as a poultice which is the only alteration found necessary- It requires daily attention to prevent it from closing by passing the probe in - The reason scars are so frequent after these abscesses is the skin is suffered to get diseased before the opening is made and the edges of the skin is drawn into puckers Earthy matter is discharged from some of these abscesses sometimes and are more difficult to cure. use the following Rx Ferri Ammon. ʒi Cerat alt ʒi M Ung Rx Ferri Rubigo ʒi Ung & Albi 1 ounce M. or the Martiat Cerate - When granulation is risen near or quite to the skin use white Vitriol or the Vitriolic Acid wash Lime Water or the following Ointment Rx gum: Elemi 2 ounces Milt Commun ℥i or Tercl ℥1/2 Adipis scilla ℥i ᵯ f Ungm to every half ounces of this ointment udde pulv Ammon prop ʒii ᵯ f Ung. The Glands about of the bronchiae are often affected and the Patient cough up a considerable quantity of Earthy matter - they become enlarged & adhere to the bronchiae - 167 Tabes Mesenterica This is a common disease in Children at a very early Period of life attributed by their Parents to worms, but the real cause is an enlargement of the Mesenteric gland these Glands are placed between the Thoracic duct and intestines, by the enlargement of these Glands nutrition is prevented from going into the intestines in a proper manner. the Child makes a chyle as usual but passes it off by stool which is supposed by their ignorant Parents to be worms. The Chyle not getting into the Blood the Wasting of the Body is extreme appetite very irregular. enlargement of the belly: picking of the nose &c Treatment Rx Calomel gr iÿ Pulv e scummon gr v M f Pulv this is to be repeated every five days - In all diseases of Children Mr. C. always recommends the above powder except in those which are considered specific in themselves: such as Hooping Cough: small pox measles &c. as he wishes to produce vomiting and purging – do not depend on Calomel 14 on which account the Legs especially of old persons are most apt to ulcerate, their circulation being slower than that of rest of the Body Intemperance weakens and produces a great disposition to inflammation, for the same reason persons who take too much exercise immediately after they have recoverd. from Fevers are liable to suppurations near the knee Blisters are liable to produce sloughs after Typhus Fever or Measles - The occasional causes of inflammation are those that change the action of the Blood Vessels of a part. thus in Fevers the Blood is pumpd. too fast through the arterial system if it meets with a weak part congestion takes place and an increasd. action of the part is set up to take up the congestion, - the sudden application of cold to parts in a healed state stop these suppurations and a large quantity of blood is impelld to the part to keep up the resistance of these vessels that had been constringed by the cold - violent exercise produces an increasd. circulation 168 alone. if in a very delicate habit use Rhubarb with it at the same time the Vinum Ferri a Teaspoonful in a Tablespoonful of Red Wine three or four times a Day. Nutritive food in small compass and entirely on meat, not vegetable Air and exercise without fatigue. Empl Litharg Comp on Empl fix Burgand on the surface of the abdomen is very usefull - This disease if suffered to go on too long or treated improperly will terminate in Dropsy. and even after the disease itself has been cured it has been necessary to draw off the water. abscesses have been produced and large tumours of earthy matter also - Scrophulous affection of the Joints white swelling called so because the skin remains of its natural colour. symptoms at first, a stiffness is felt with slight pain: then in a few days an enlargement of the Joint begins: this continues for a length of time, & as there 169 is not much pain it does not execute alarm after being sometime in this indolent state a sudden change takes place a general Chilliness, pain and suppuration in the part, the slightest Jar of the Joint causes exquisite pain. when matter has begun to form it goes on increasing in quantity suppuration takes place below the Joint If it is at the Knee it will be 6 inches below and sometimes a little above when the abscess is opened the process of ulceration is very slow - the dishcharg will continue for a length of time for 2 years unless some active means are used to prevent it - Appearance on dissection. under the skin a quantity of Fat is found under which the common capsular Ligament is considerably thickened, the Vascular Ligaments from whence the synovia is secreted are particularly affected: the Cartilages are in part absorbed sometimes wholly so Bones throwing out spicule in several different parts with holes in them- If when it has made any 170 progress and ultimately cured it is anchylosed. Treatment supposing it only stiffness with slight degree of pain Rest. Rx Linim Ammon. Spt Vini camph [an] ℥1/2 Antim Tart 1 dram rub in 1 dram every night and morning on the part affected. in three days there will appear an eruption like the small pox: and if the Linim Camph is omitted the eruption will appear as in Henerial - It is preferable to the use of Blisters & Ungn. Sabina tho the Blister may effect a cure there is always left a greater contraction of the Joint with weakness and Lameness After using the liniment for 3 days apply a common poultice which is to be kept on for 3 days renewing it occasionally at which time the Liniment is to be used again - Another form which is used – Rx Antim Tart ʒiÿ Ungn. Sperm Coli ℥i 1 H f Ungn -this produces a more irritable eruption but the former is far preferable give Hydrary & Tinct Cinchona. If much pain it is usual to apply Leeches but these produce 171 weakness in the part which ought therefore to be avoided if possible - Rx hydrard Muriat combind. with opium to produce nausea answers well - A considerable quantity of opium is sometimes required to be given to prevent pain- the following is the form to give at night Rx Calomel prop gr i Pati: Opii gr 1/2 Ferri Vitriol gr 1/2 M Omni nosta sumendus - The Vinegar poultice is also used. it produces an eruption in about 3 days. it has not so good an effect as the Liniment the Emp Lith the Empl pix Burgand are good applications Emplast Epispast & savn Ointment is in common use - The best means of Restoring the Joint, if you have subdued the inflammation use friction with frequent motion but not too quick nor begin too soon. If suppuration takes place in the Joint no means can prevent it from taking its course. therefore it is best to encourage it, and to bring it on speedily give Tonic Medicines and use warm applications to the part after it has been opened inject the following into the [sinus] Rx Acid Vitriol ʒi aq Purce ℥vi throw this into the joint 172 Put a Blister over the Joint and dress it with savin Ointment, in time the inflammation will be lessened and the discharge but a stop to- Surgeons have several times performed amputation unnecessarily in this disease, It is never necessary unless there are the most powerful hectic symptoms, never suffer it to be amputated though the Patient may be lame the whole of his life - the weakness which the Amputation occasions in that particular constitution will probably prevent the stump from healing and it is a great chance if some other part is not affected - Disease of the Hip Joint. Pain in the knee is the first symptom. If you fix the Thigh bend and extend the knee it will give no pain in the knee, but if you take the Leg and raise it up towards the Body you will cause pain extending to the knee. in walking the Patient turns his Toes out - the Toes can turn in but triffle. The Joint does not feel round but flat - the disease limb appears longer than the sound one, as the Head 173 of the bone is thrust out a little from the Acetabulum by an effusion of coagulable lymph into the acetabulum, the nates of the diseased side is one inch below the opposite - If you turn the Patient on his face there is a fold in the groin by pouparts Ligament while the opposite groin is straight from the lengthening of the Leg at last the limb becomes shorter, so that the head of the Thigh bone becomes diminished greatly and the Acetabulum becomes lengthened upwards: it is one or two inches shorter. If suppuration has taken place they never recover with less than one inch shortening of the limb. Abscesses sometimes break opposite the Trocanter Major, there has been a Case in the Hospital of these Ulcerating the coats of the Femoral Artery and causing Death from Hamorrhage - Treatment. this should be undertaken as early as possible. give the Hydrary Muriat cum Tinct. Cinchona so as to excite nausea this will often diminish the pain in the knee apply Leeches. if very painfull use the following on the Hip Joint Rx Linim: Amon: Camph ℥i Antim Tart ʒÿ M rub in 1 dram nocta manque, and continue untill Pimples are produced. order Rest let the Patient use 174 Crutches and no motion of the limb be employed whatsoever. if you do not succeed in this plan early, make an Issue with Kali purum about the size of a shilling on each side of the Trochanter Major: this is preferable to a Blister with the Ungn Sabina, these Issues should be kept open for six Months or more: untill the pain in the knee has ceased - If abcesses are formed from the Joint let them take their own course. if they are opened the inflammation will extend upwards and the whole of the Joint will become inflamed - should the Patient recover fast he should be in haste to use the limb as he may bring on the disease again. and ought to continue the crutches for some time after. the cavity of the acetabulum becoming absorbed the head of the Thigh bone passes into the pelvis, and by its irritation destroys life or produces abscesses bursting into the Rectum and kills him also. if in a woman the abcess burt into the Vagina and may recover - Ulceration of the vertebrae. This complaint begins with a pain in the affected part soon after there is a projection of one 175 of the spinous processes, which becomes detached and the spine suddenly forms an angle, weakness in the lower extremities so that he often falls down suddenly when sitting he draws his heels under his seat. during the night spasms of the muscles of the lower extremities at length producing a paralytic affection, but the muscles are not relaxed, but spasmodically affected - the Vertebrae press on the spinal marrow and produce irritation: the Bladder [find] looses its retention power as does the Rectum. If the cervical vertebrae are affected, the patient has no use of his Arms or Legs, the Head only being free from disease. in some Case as many as four or five of the Vertebrae has been destroyed and yet recovered, sometimes there is a considerable abcess forming in the fore part of the spine adheres to the Lungs burst, and is discharged by coughing - Treatment setons or Issues by the side of the Vertebrae. Issues are most affectual but setons are most convenient these Issues must be kept open for 12 months or more and sometimes two years. but it depends on the Relief afforded if sufficient irritation irritation is not made dip the pea in unguent cantharid - 176 When a Cure is affected it is with an Anchylosis of the Vertebrae so that the spine never after becomes straight yet the spinel marrow does not become compressd. The constitutional treatment should be the same as before directed as Hydrar Muriat & Tinct Cinchona - Psoas and Lumber Abcesses, these are singular to the last symptoms. Pain in the Loins for months before there is any appearance of disease. a small Tumour in the Groin where Bubo appears, which dilates in Coughing as in Hernia. this Tumour extends downwards and is of a considerable size. this sometimes form two las one on each side the Femoral Artery and Vein, the tumour at length bursts and discharges from H1/2 to Hi of Matter three or four days after: much Fever is excited and hectic symptoms come on, night sweats chilliness succeeded by heat. and the case soon terminates fatally - On Dissection the Origin is found to be from the Spine and the Matter Ulcerates through the Psoas muscle to the Thigh under pouparts Ligament. it destroys the Ligaments of the spine where it is situated and the Psoas Muscle become hollowed 177 Treatment. Excite irritation at the part where the Patient complains of pain. make Issues and keep them open for a month or six weeks before you have any thing to do with the abscess, then you are next to consider the propriety of opening the abscess. Mr. Abernethy consider making a puncture into it is advantageous to let the matter out gradually - as this diminishes the constitutional irritation pass a Lancet at the part where the abscess feels rather thick introduce it from the side and make an oblige incision as you have a larger fur pure of the escape of the matter which is generally mixd with clots which must be removed by a probe, then lay a puic of lint over the wound. and over that Empl adhesivim - as the Matter accumulates you must repeat the Operation not suffering much matter to collect - Scrophulous Ophthalmia. This produces very quickly opacity of the cornea even in a few days, give Hydrarg Muriat with the Decoct. Cinchona & Tinct. Cinchona, if the Eye is irritable apply. Rx Hydrang Muriat gÿ Aq: Calcis ℥vi Tinct: Opii ʒÿ Aq Pura ℥i M or Rx Aq: Litharg acet 30 gtt Zinic Vitriol giv Aq: Pura ℥iv this forms the acetate of Lime 15 and congestion takes place in any weak part as before mentiond, - The division of Blood Vessels is the most frequent cause of inflammation. the division of an artery stops its circulation and the neighbouring arteries throw more Blood on the part to keep up a due circulation:- Laceration contusions &c are the existing cause of inflammation: extraneous bodies Gunshot Wounds and ligatures occasion more or less inflammation according to the irritability of the system. Proximate causes the state of the part which produces the symptoms, it has been supposd, that the Blood when in an inflamd, state, was thicker and would not pass through the smaller branches of the arteries, which made the arteries push with great force to get it through, this is now found to be a false idea, the Blood when inflamd. is much thinner, Dr. Cullen thought that inflammations was occasiond, by spasms of the arteries, the contraction of which obstructed the passage of the blood, that the neighbouring arteries pushed with more force to obtain one if the Blood was thus returnd. it would 178 which is to be introduced between the Eye lids: give Calomel. In scrophulous testis give. Calomel to affect the Mouth and Mercurial poultices must be applied It generally occurs in people from 20 to 22 years of Age. It is not attended with much pain and one Testicle is affected which soon extends to the other On Gunshot Wounds Any wound produced by a substance entering the body with great Velocity is of the same consequence as Gunshot wounds The Gunshot Wounds differ from common wounds in their being much more intense extraneous substance most frequently loose and having a sinous tendency during cure. They are divided into two kinds 1st When the Ball is passed through part of the Body: 2nd when they continue to lodge. they require different mode of treatment, the former much the simplest, the surface of the wound is covered by a thick slough as if 179 caustic had been used in consequence of the velocity with which the Ball has passed in the wound where the Ball has passed through there is always less haemorrhage than from incised wound: for the first four days the Patient complains of great pain a Glutinous substance issuing out of the wound. untill the sixth day there is no appearance of suppuration and when it begins it is in consequence of separation of eschar not completed till the tenth day or a fortnight; when the eschar has separated it forms a sinus, unless the Ball has struck a bone no pain is produced but if it has then it communicates a shock to the Body if there is no sinus formed it then goes on as any other common wound Treatment. Bleeding is highly essential in Gunshot Wounds at first to prevent inflammation and afterwards when it is come on the Bowels are to be kept regular, but in these there is the same objections as in Fractures: doses of opium with saline medicines every four hours to keep the patient comatose state to alley the irritability of mind and prevent 180 the locked Jaw, regimen to be the same in moderation. Poultices not only upon the wounded part but upon the whole Limb if there is not much Haemorrhage. but if there is use cold spirituous Lotions with Vinegar. the poultice to be used till suppuration happens, as slough often came away during the cure. the best method of separating them is by the injection of warm waters into the sinuses not using any force. scarify the edges of the wound at the time of inflammation if you have not the opportunity of applying leeches, and do this occasionally as you find inflammation coming on sometimes the inflammation is so great as to produce mortification. there is no discharge from the wound. Apply leeches about the part scarify so as in some degree to dilate the wound with fomentations, & vinegar poultice. The sinus has sometimes been very difficult to heal, make an incision between the two orifices and divide the sinus then it will probably heal. if it does not then pass 181 a Bougie with stimulated ointment on 2nd. Gunshot Wounds, with the Ball lodged. when the Ball and extraneous bodies remain lodged in the parts. Pass a probe or a long bougie into the wound and search for the Ball and if you can feel it attempt its extraction, or if it has passed nearly thro so that you can feel it under the skin you mat cut so as to take it out, but not otherwise, for it is not proper to make extensive incisions to follow them as it is well known that Balls sometimes remain for years in the Body without any disagreeable effect being produced - and from their curious course it is often impossible to find them, and as they pass a long way to make a large incision will be very dangerous for they have been known to enter the middle of the forearm and pass out at the neck, also to enter at the scorbiculus cordis and pass out at the back part by the spinous process of the Vertebrae going round the out sides of the ribs. if the Ball is left and does not form cyst it generally produces inflammation which will ovation the expulsion of it in time 182 therefore it is much better not to cut to far for it- Gunshot Wounds of Arteries Arteries when divided by a Ball Bleed much less than if incised because it leaves a fringe of cellular membrane. and the tone is lost. but still there is considerable danger, even if it has passed near an artery as it will cause the coats to slough & the Patient will die from Haemorrhage when passed near an Artery apply a tourniquet, for if it does not Bleed at first. still it will Bleed, In tying an Artery from a Gunshot Wound it should be done high up from the divided or contused parts as they will soon separate or mortify - the Patient if there is a wound near the Artery should be directed how to manage the tourniquet in case of haemorrhage - Gunshot Wounds of the Abdomen If a Ball passed directly through the abdomen it is fatal in a few hours as it must pass through many folds of the intestines - Bleeding & remedies 183 against inflammations must be used. Opium freely: when shot through the stomach in general die in 30 hours and when through the intestines in 24 hours - an intestine may be wounded and the patient may recover. Gunshot wounds of the Liver spleen or Kidneys Mr. C has not seen Gunshot wounds through the Chest into the Lungs are not so dangerous as incised many instances are occurring, when recovery has been affected when there has been considerable injury, these require only simple mode of treatment. Perfect rest, bleeding very freely, - more danger ensues frequently from bits of cloth & being carried in with the Ball than from the Ball itself causing so much irritation, but it is never necessary to make incisions to take them out for the wound will heal from where the Balls enters and will Ulcerate externally towards the extraneous body. thus closing at the part furthest from the Ball and gradually opening to it silk clothing is safer in this respect as it is not so soon separated and carried in - 184 Gunshot Wound of the Heart are instantly fatal. wounds of the Brain are fatal, yet when only the skull is depressed the Patient may do well after trepanning; the Ball has been known to enter and do through the Othmoidal & Sphenoidal sinus and have not proved fatal nor done any injury to the Brain Compound Fractures occasioned by Gunshot wounds are much worse accidents then when happening from other causes : and consequently more difficult in their treatment as the Bones become much more splintered in these it is necessary to dilate all the wounds, to extract all loose portions of bone for if they remain the Patient will die of the consequent discharge, but if removed tho the limb will be shortened, he will commonly do as well as in other compound Fractures and perhaps render the operation of amputation unnecessary - If the Ball passes near or through a Joint so as to splinter the Joint as in the Ancle, Knee, or Elbow, it is very dangerous much more so than Compound Fractures from other causes, it is necessary to amputate, but it is much better to wait and see whether the wound is of such a nature as to Create symptomatic Fever, and the to consider 185 whether the Patient will be able to bear that Fever if you think the latter it is much better to wait till that has subsided before you begin to Operate. Dr. Babington was Surgeon sometime ago on board a ship, after an engagement 24 were amputated in consequence of [a] Gunshot wounds 21 died soon after and three lived to go to a Hospital where one of the three died after so that two only lived when probably if their limbs had not been amputated till the symptomatic fever had subsided some (if not many) of their lives might have been saved - Burns and Scalds The effects of Burns and scalds are of three different kinds. 1st Vesications of the Cuticle 2nd separation of the Cuticle so as to expose the cutis to a great extent and 3rd Destruction of the cuticle and cutis so as to occasion sloughing these three states require different mode of treatment - in the 1st state when the cuticle is detached in the form of a Blister though extensive it is not dangerous. if the cuticle is over it such burns will always do well under this kind of treatment Rx Aq Litharg: acetat. g xxxÿ Zinc Vitriole gr iv Aq Pura ℥iv M Spt. Vini: Camph is a good 186 application. but the following is the best Lotion to prevent the separation of the Cuticle Rx Spt. Vini Rut. Acet communis part equalis ᵯ - In the second stage. It is most dangerous with the cuticle separated and without the life of the cutis being destroyed. The patient soon dies (though the sore in some cases may be extremely small) let you follow what plan you will: for the extremities of the nerves are exposed and occasions such a Violent degree of constitutional invitation that in a few hours it terminates fatally. sometimes the Diaphragma becomes affected breathing Laborious with spams & in this state a solution of opium will moderate the pain, but as it produces costiveness it out to be guarded against Lime Water and Linseed Oil is a good application to allay the pain and heat at first, but it produces a great discharge from the part, and may also produce pectis symptoms, therefore to not continue its use long - in Consequence of what has been written about spirits of Turpentine in this state of burns M. C had been induced to give it a fair trial. It produces excessive pain and very often extensive sores In a Case now in Guy’s Hospital A Man’s Legs were both equally burnt. to one Leg he applied 187 the Aq Litharg : acetat &c and to the other spirit Terebinth. The Leg which was dressd with the Aq: Lith. &c is completely well and then is on the other a very extensive sore- the danger in this second state is not all over when the immediate symptoms cease for a very profuse discharge will sometimes follow if the surface is large. but this may be restraind. by applying the Lotion of the Aq: Lith: acet &c as before recommended on Lint over the surface it also quickens the formation of cuticle - In the 3rd state when the true skin's life is destroyed it is not so quickly fatal as when the cutis is sensible, the constitution does not become affected for several days, but probably will when it begins to slough: If you do not Judge it proper to amputate you must use fomentation & poultices. When large surfaces have lost their cuticle it is a long time before granulation forms but if you use the Linn Vitriolate & Aq Lith Lotion, granulation will form in a few hours - Sprains. A Laceration of a Ligament, the best mode is to apply the following lotion Rx ammon: muriat ʒi Aq: Ammon Acet. ℥vi M Lotion. if there is 16 Change color; the redness of inflammation proves it does not, it likewise proves that vessels are not lessend, which must be the case if Dr. Cullen's hypothesis was true; The Blood Vessels are distended on the inflamd. part but their actions is not increasd. the arteries near the inflamd. part have a stronger pulsation, but are not distended, the distention is occasiond, beyond particles being pressed into the small vessels, that before only containd. white ones, thus it may be stated that there is always distention without increasd, action of the inflam part increased action without distention on the surrounding parts - to ascertain this Mr. Cooper put a young Frog (as their circulation may be easily seen) with a microscope he applied a stimulus to a part, and in a few minutes saw a red particle forced into the artery on that part it passed into the veins and at every pulsation of the Heart, fresh red particles were forced in till the vessels were filled with them 188 inflammation apply Leeches: put on a bandage as soon as the inflammation will allow: the Patient must be kept quiet four days or the Ligament will be torn through again by walking - a light Bandage should be used if he lay by a month or six weeks it will be difficult to walk a little exercise about the third or fourth day is necessary - Fractures Fractures are divided into simple & Compound called simple when the extremities of the bone are not exposed: there may be wound tho we may call it simple the exposure of the ends make the destruction 189 bone in the Body requires different spaces of time, depending on their size, as the Radius and Ulna will unite in three weeks The tibia never under 5 weeks and in very old people never under 7 or 8 weeks the large Bones in general, as the os femur and Humeri require 5 or 6 weeks before a firm union takes place. Simple Fractures are seldom dangerous to life except under certain circumstance. as a great depression of mind in very old age - Simple Fracture of the Tibia is ascertained by feeling along the skin. or by holding the foot in one hand and rotating it gently, passing the other hand along the bone untill you discover the crepitus when ascertained a slight extension is necessary to replace the bone in contact. but if the muscles oppose much by spasm you must not attempt replacement by force, but foment and poultices a day or two till it is subsided, when it may be readily replaced. You mush then apply the many tailed bandaged over the whole limb: this bandage is better than a long roller, for as the limb will afterwards swell the bandage 190 may be entirely loosed without disturbing the position of the Limb. if there is not excoriation of the skin or much swelling you had better put a rag dipped in aq: Ammon Acet under the Bandage. If excoriation has been produced then the aq. Lith: comp is preferable; over the bandage the whale bone splints are the best, as one set can be adapted to either Limb, and are known in the shops by the name of Martins splints - The posture. The Leg to be laid on the outside, knee a little bent the foot a little raised and supported by or pillow - The Fibula when broken is not commonly about three inches above the ankle and cannot be felt exept by rotating the Limb the other hand gradually feeling up the outside of the Leg untill you discover the crepitus, it is generally connected with a sprain of the ancle and is often mistakes for it rendering the Patient always lame 191 of the Leg with one hand, and rotating it: at the same time feeling along the Os Femoris carefully. when you arrive at the Fracture you will distinguish the crepitus: or by placing one hand on Trochanter Major & rotating the Leg with the other. If there is any Fracture the motion of the Leg will not be obeyed by the Trochanter. Treatment. Apply the many tailed bandage over the Limb, then three splints lined with wool, one before and one on each side. the Position of the Limb should be the Leg resting on the heel rolling a pillow up and laying it under the Ham so as to raise up and bend the knee - Fracture of the Clavicle may be known by tracing the bone with a finger from the sternum towards the scapula, you will find the bone sunk down at the fracture: Treatment. assistant must put the shoulders as much back as possible to bring the fractured ends in a line. then raise the arm so as to keep the clavicle in its place, then apply the stillate bandage (along roller) pass under both 192 axilla &c. not press on the broken extremity of the Clavicle for it would render the Fracture Compound. apply Emplast sapon under it. The shoulder is to be elevated in a sling, during the Cure no use of the Arm is to be allowed. The best mode of elevating the shoulder is to carry it close to the side and bind it down by a lon roller. the just support the arm in a sling - Fracture of the Os Humeri is distinguished easily by feeling the bone. A long roller should be applied round the arm then two splints one before & one behind will answer equally well when made of thick pasteboard, these are to be confined by another roller passed round the Limb in the opposite direction to the first ie. one from without inwards the other from within outwards which prevend. an appearance of twist of the Bone after. The position of the Arm should be hanging by the side supported by a sling on a pillow If in a very plethoric person he should be confined to bed for little while as very great swelling of the arm & forearm is likely to ensue 193 Fracture of the Radius & Ulna requires the same treatment as fracture of the Os Humeri- Fracture of the Radius only generally happens from falls in running - about two inches above the wrist known rotating the hand and applying the other hand along the Radius the fractured end of the bone generally protrudes among the tendons of the fingers so as to impede their motion - Treatment. the same as fracture of the Radius and Ulna to be suspended in a sling on a pillow - Fracture of the Ribs are ascertained by applying the finger to the part where the pain is and when the Patient Coughs a kind of grating sensation is perceived from the ends of the bones rubbing attended with pain Treatment it is necessary to hinder any motion of the ribs, therefore they must be bound very tight with a double headed flannel roller so that respiration is to go on by the Diaphragma - If the Lungs are wounded it is known by the Emphysima the bandage must be applied as before and a number of punctures made above and below it to let the Air escape. this 194 Accident generally gets well in about three weeks or a month unless in very old people - Fracture of the Sternum is a very similar accident to the former and is easily ascertained the lowest end of the bone generally lays under the upper, therefore the union is often irregular - Treatment the same as in Fractured Ribs. in both Bleeding is necessary - Fracture of the Lower Jaw, this happens generally at the symphysis from blows on the angle. The best bandage is leather sling with four heads. The sling being put under the lower Jaw the four ends carried over the head & brought down again and carried under the chin. Liquid food only must be allowed during the Cure - Another method of curing this Fracture is by passing a wire between the Teeth (2 on each side) twisting the ends firmly together this method must only be employed when the Teeth are firm Fractures of the Flat Bones unite exactly in the same way as cylindrical ones ie. by cartilage gradually becoming ossified thus in the skull where if 195 the bones could be brought together would unite gradually and equally as well as others but in these bones where a piece of any size is removed the place is not again filled up except by ligamentous substance - Fractures of the Patella happens generally from falls. the different portions of the bones become divided the upper one being drawn up the Thigh from three to six inches by the muscles inserted into it. the person becomes instantly lame if the pieces are not brought in contact the union is by Ligament but if brought in contact the Union is by bone. Treatment. you must bring down the upper portion in contact with the Lower by extending the Leg and pushing down the piece gradually from day to day as it cannot be done at once but will be done generally in about a week. If the bones is not brought in contact the Ligamentous union will be four or five months and the Patient is always to falls as that Limb is much weaker than the the other from the length of Ligament the patient should begin to move the limb gently after 1 month 196 Fracture of the Olecranon, is generally broke of about an Inch from the upper part and the portion of bone becomes drawn up about 2 inches high, the union as in the patella is either by Ligament or bone, Ligament when the Bones are not brought in contact. but bone when they are; to bring then in contact you must gradually and daily press the upper portion down till they come together. the arm must then be kept extended and a small square cushion laid just above the process which is to bound down by a roller. After the third week the arm must be gently moved every day to prevent anchylosis. - Fracture of the Os Calcis or other bones where large tendons are inserted unite them in the same manner as Fractures of the olecranon Fractures will sometimes not unite at all this happens from some peculiarity of constitution. there are no particular symptoms by which you can foretell it if appears to arise from a languor of constitution so that there is not sufficient inflammation produce to unite the separated parts 197 only Ligamentous substance without ossification. It has been recommended to cut off the two extremities of the bones and keeping the external wound open for some time this but rarely succeeds - If the muscles are affected with at a fracture give large doses of opium Tinct: Opii 30 gtt mane et Meridie et 4x nota hora somni with wine and a free use of spirits. Compound Fractures A Compound Fracture is when a bone is broken and there is at the same time an external wound communicating with the Fracture the wound is generally occasioned by the end of the bone. sometimes there is a haemorrhage. in twelve hours after the fracture there is a discharge of bloody serum much tension and great symptomatic Fever which continues from four to six days when the discharge becomes purulent and granulation arise from the sides and soon after from all the cavity which fills it up and the wound heals The greater degree of danger in compound than simple fracture arises from the greater degree 17 in the same manner great number of vessels were filled that could not be seen before their distention was produced. - the action of the vessels were not increased in this part but in the surrounding parts. The pulsation was much increasd, - Mortification takes place when a part is amputated in an inflamd, state, the living powers are to weak to support it - distention is not confind. to the part at first inflamd. it gradually increases and the whole brachial artery will become enlargd. in consequence of an inflamd. hand: if inflammation extends to a very great degree, the Heart will become enlargd. in which case the pulse will be scarcely perceptible, in case of very extensive inflammation constitutional treatment is necessary, particularly bleeding, this Mr. Cooper thinks is too much laid aside, but there is no occasion to bleed if the constitution is not affected - Blood should be removed quickly, if some degree of faintness is producd, it will be more effectual. 198 of inflammation and suppuration produced. and requires twelve or thirteen weeks to Cure when a simple one require only four or five - Treatment. Extension must be made at both end of the Limbs to bring the parts in opposition not using much force as it is not very material to have it done directly. if there is any haemorrhage apply dry Lint no Ligatures should be used if you can possibly avoid: if there should be tension apply poultice for the first few days. but if not attempt Union by the first intension with a linen rag (thin) in the Blood which comes from the wound. over it apply the many tailed bandage and over which put the splints. (Martins)- If the Fracture happens to the leg it must be laid on the most favorable position for dressing the Wound. if in the Thigh the same bandage is necessary as in the Simple fracture and the same position. the same application in the Upper extremity as in the simple fracture. the only difference is to wrap up the Limb in the rag with with the Blood from the wound. Get 199 the external wound to unite of possible by the first intention, always attempt it as it relieves the patient from great danger. unless there are very great Bruises then you must poultice - Much inflammation often comes on about the fourth day with great pain. loss of sleep stoppage of the discharge the parts about very much swelled. Air coming from the part when pressed the wound appearing dark pulse quick and small, with delirium. Blisters arising on the part with mortification killing in 24 hour - Treatment apply six or eight leeches to the part, general Bleeding im proper. poultice of beer grounds over the wound. Opium freely- Bark 1 dram 2ly poris and let the patient take freely of wine. Porter or Brandy according to the Habit he has been accustomed to live. The less medium the better internally so as to relax the Bowels. these means when employed early will generally prevent the Mortification - Mortification sometimes comes on in old people without any previous pain cheaply in old drunken people: this soon extends a great way and often proves fatal 200 In the reduction or replacement of the bone. when it cannot be done by extension. the most preferable mode is of the bone is not much denuded of its periosteum is to enlarge the wound. but if it is you should saw off the end which is denuded, but this is rarely necessary. if this happens to the Tibia, and the Fibula not broken it must not be sawn off on any amount as the ends of the bone will then be so far distant that no union well ever be effected When a large Artery happens to be divided which occurs oftenest in the Leg the Anterior tibial artery, and the Arteries of the Arms, you should not amputate hastily but cut down on the divided portions and take them up, then treat the fracture as before. A want of union will sometimes arises from a bad constitution and from exfoliating pieces of bone being enclosed. when a Compound Fracture extends unto a Joint it renders it a much more dangerous accident as the suppuration extends into it. Locked jaw coming on &c - Cases that require Amputation 1st when a bone is fractured in numerous pieces and the removal of which will cause such deficiency as will render the Limb 201 useless afterwards - 2ndly The division of a large Artery when it cannot be easily secured, as the posterior tibial Artery and when they are taken up high the Patient generally dies of mortification, but in the Branchial Artery as it is easily got at take it up and try to cure the fracture likewise in the fore arm - 3rdly when a large Joint is opened as the Knee or Ankle, but at the Elbow it should not be done hastily as the use has been sometimes recovered 4ly when the lacerations are very extensive though the fracture be not but should not be amputated hastily as great recoveries are founded to happen - 5ly It has been recommended where locked Jaw has come on - but the removal of the part is useless as it does not appear to relieve the disease at all - Young people often do well under accidents of this kind, when old ones dies - if the patient, Constitution is very irritable Amputation must be performed sooner than in one that is cool and patiently suffering. for in these delirium always follows quickly 202 the upper extremity may be amputated earlier than the lower. Mr. Cooper thinks that amputation in general succeeds better when performed after the patient has recovered from the symptomatic Fever than early if his constitution appears likely to sustain the first symptoms of irritation. - Wounds of Veins - These wounds are but of little importance with regard to the haemorrhage as they can be easily stopped. a wound in the Axillary Vein can be easily stopped with a dossel of Lint. so also the femoral Vein. the greatest danger of them arises from the inflammation of their internal coats the symptoms of which are a stiffness in the limb and part where the wound is and when occasioned from bleeding in the arm a difficulty of extending it. a swelling from the wounded part up the skin the size of a quil of a red colour: an abcess forms nigh the part with Violent shiverings and the matter with great difficulty gets to the skin, before are abscess breaks another forms higher up and often a third above that, when it breaks into the vein 203 then it proves fatal soon. these effects have by different authors been thought to arise from a wound of a Nerve, Tendon or Fascia. Treatment to be pursued is when the inflammation appears to apply leeches to the part & poultice - If these should not abate the inflammation quickly they best mode is to cut through the inflamed part down on the Vein and cut it across it may be done with a Lancet and afterwards compress the Bleeding Vein Wounds of the Nerves - On the division of a nerve the part to which it is distributed becomes senseless, yet the involuntary actions will go on in it as before, a Blister will rise in the usual time on it, and an Ulcer will granulate through not quite so quickly. for a few days after the division, the heat of the part will be greater than where the nerve is entire. as 78 in the entire part and 86 in the senseless part but after a few weeks it becomes much colder. a small branch is sometimes divided in Bleeding. it only causes a sharp pain at the time and a numbness at the fore part of the arm 204 for a month, but it is of no consequence further than that sometimes divided by the ends of fractured bones causing a numbness of the Limb below. When nerves have been divided after sometime they reunite by forming a sort of ganglion or knot at the divided part, and the powers of the part becomes gradually restored, this is also found where the ends of the nerves have been purposely separated. if the divided branch is very small the sense will begin again in three weeks if large from 4 to 8 months or if very large as the sciatic nerve at the Hip two years - Electricity quickens the restoration of sensation and motion: when a nerve is tied and remains undivided it generally kills the patient if large by producing violent pain and irritation & quickness of the pulse. If a nerve that has been cut through has been included in a Ligature as in a stump. the effects produced are according to the patient, constitution in some no ill consequence ensue, in others Violent and Universal spasms Treatment. when exposed lay the extremities in contact only and they will unite. 205 Wounds of Tendons The Tendo Achillis is often accidentally divided or cut across after which the Heel falls down and the upper portion of the divided tendon is drawn up within its thicken an Inch Treatment. Elevate the heel as much as possible by a high heel shoe with a strap extending up the Leg from the back part [of the] which is to be bound in with roller and applied round the calf of the Leg to hinder the spams of the gastrocnemii muscle: no pressure should be made at the divided portion as it will cause an adhesion of the Tendon to the bones and lameness ever after - The dressings are to be lint spread with carat simplex just laid on, if this plan is pursued the Tendon will readily unite and the patient walk with the shoe in ten days, no suture must be used. This tendon is often lacerated by great exertions in walking & ramming. the treatment is exactly the same. The patient may be allowed to walk as soon as the inflammation has a little subsided. it becomes completely united in 3 weeks and height of the shoe heel must be 206 gradually diminished. Partial laceration of the fibres of the tendo Achillis or of the Gastrocnemii: muscle is words accident than either of the former. It happens generally by a false step. the sensation at the time is as if the part was struck by a stone. Where the fibers are ruptured a depression can be felt and an Ecchymosis follows. This injury causes Lameness for years or for ever, if the person walks much on it for sometime after [a] high heeld shoe should be used for sometime with a bandage on the Gastrocnemii muscle for the reason before mentioned and in this manner the part will frequently recover itself in about three weeks or a months time - Wounds of the Abdomen These are of two kinds. Those where the Viscera are wounded. and those where they are not . If no Viscera is wounded, the wound is no otherwise dangerous than from its extent, or the protrution of the intestines which becomes strangulated by pressure 207 When the stomach is wounded the countenance collapses this person becomes insensible, the pulse cannot be felt. blood is vomited up mixd. with the contents of the Stomach, and liquids when swallowed come out at the wound, when this has happened no food should be taken either Liquid or Solid for a week or ten days, the Patient should be nourished by Clysters of Broth in which 120 drops of Tinct: Opii should be put three times a day to retain them after which a small quantity of Jelly may be taken for the space of a week and then solid food Wounds in the small Intestines are accompanied by the same symptoms as Wounds of the Stomach except that the Vomiting is without blood the same Treatment is necessary, but if it protrudes at the external wound, if partially wounded longitudinally and the intestines is seen externally it is right to pass the interrupted suture in it, the stiches only half an inch as under, then return the Intestines just within the Cavity leaving the ends of the Ligatures hanging out 18 There is but one objection to a large orifice it is apt to inflame. Venesection maybe used not only when the pulse is full and hard, but even when there is a weak thready pulse, as that will frequently rise after bleeding, of this we have frequent instances after amputation where the Patient is sinking very fast. if the stump bleeds the pulse rises and he gets better. the same effect take place in the bleeding of a compound fracture: it has been the custom to give bark & wine in these cases of slowness, but it is injudicious as they irritate too much in cases of incipient inflammation; taking [place] away blood in small quantities, will frequently stop its progress and not weaken so much as taking a large quantity at once, which should never be done but, in very extensive inflammation: when there is a very irritable jerking pulse, but if arising from a slight cause we should not bleed as it will only weaken. purgatives relieve by evacuation 208 then unite the Eternal wound by sutures which should not pierce the Peritoneum in eight days gentle efforts are to be made to bring away the ligatures of the Intestines - Wounds of the large Intestines may be known by the escape of the true foeces from the wound which should be treated the same as the former except that the nourishment must be given by milk only by the mouth instead of Clysters, as it will not make so much foeces. When any wound is made into the Cavity of the Abdomen and there is much haemorrhage the wound should not be closed till the haemorrhage ceases, for if Blood is extravasated into the Cavity of the Abdomen it is certainly fatal and not any great degree of inflammation is excited by leaving the wound open as long as twelve hours Wound of the Liver. This is not a fatal accident unless the wound is large a quantity of venous blood is discharged mixd. with bilious matter If the external wound is closed directly a quantity of this matter is extravasated in the abdomen; it should therefore be kept 209 open – lacerations without external wounds are fatal and it is not an uncommon accident. the abdomen swells to an enormous size and the Patient dies in a few hours Wounds of the Gall Bladder. Fatal in about 40 hours known by a discharge of bile Wounds of the Spleen. Although this is a viscus that may be removed from the Body without injury yet the most trifling wound of it is fatal, as great haemorrhage into the Cavity of the Abdomen follows. attended with such an inflammation as destroys the Patient indeed Blood when in any way extravasated in the abdomen proves fatal Wounds of the Chest. These are of two kinds. those which injure , and those which do not injure the contained Viscera: when only a wound is through the parts which contain the Viscera it may be known by the Lungs protruding when the patient expires and in the rushing in of Air at the aperture when he inspires. the wound must be united by sutures & covered with adhesive Plaisters to exclude the air and over them the applications of a roller. the opening closes inside by adhesion of the Lungs 210 Wounds of the Lungs. In these the breathing becomes difficult. coughing and vomiting of blood florid and frothy. with much haemorrhage externally and Emphysema. If the haemorrhage is not stopped you must bleed the patient till it does in general to 20 oz and when it is stopped you must close the external wound as before and the plaister applied, also the roller if the difficulty of Breathing does not prevent it. The Patient should have 20 drops of Tinct: Opii every three hours after. speaking should be avoided. these means will prevent immediate danger, but inflammations comes on sometimes on the fourth or fifth day after the accident which renders it necessary to take away large and repeated quantities of blood. Another danger is haemorrhage happening many days after the accident. when the external wound is healed it is shown by difficulty of breathing coming on without pain: the wound must then be opened again: when the Emphysema is very great small punctures may be made round the Wound not further than 6 inches off. Wound of the Heart & Pericardium are universally fatal as they have no opportunity of healing or uniting because of the Perpetual Motion of the Heart - 211 Of the Tix Doloreux This is the most painful disease the human Body is liable to it produces no disorganization of part. The pain during the fit is compared to a flash of lightning darting through the part with a vibrating or undulating feel in the part. an effect may be brought on from the most trivial causes: the nerves subject to this painful affection are the suborbitary: the ophthalmic branch of the 5th pair. The dental, the pes anserinus of the 7th pair. The nerves distributed to the Tongue & tonsil gland, sometimes the par vagum. the radial and the Anterior tibial nerve ... To Perform the Operation when the suborbitary nerve is affected (which is oftener affected than any other) make an incision with a Phymosis knife 1/2 an inch below the edge of the orbit and divide the nerve near the suborbitary foramen: the incision is to be made about 3/4 of an inch passing the cheek over the knife with the fingers which divides the nerve and the Patient feels a numbness in the upper Lip: the suborbitary artery being also divided. it is necessary to make a pressure on it with the finger for 5 minutes The complaint is very liable to recur in a few months after the operation from the reunion of the nerve. Lord Carlile & Capt Elliot in the navy have undergone this Operation with complete success - 212 As palliative remedies in affections of this nerve. salt held in the mouth and cicuta given internally have proved useful though never wholly effectual - In affection of the Anterior Tibial nerve apply a Caustic upon the part to produce an eschar, this is to be kept open by the introduction of a pea On Gonorrhoea The symptoms of this disease are an Itching sensation near the fraenum generally about the fifth day after impure Coition and on Examining the lips of the Urethra. they appear of a florid colour. on pressare a drop of mucus appears, in a few hours some pain is felt in making water. as the inflammation increases the discharge becomes yellowish, and when it is at its height it is of a greenish yellow colour mixd with blood erections are frequent, proceeding from irritation and is attended with considerable pain. after the pressure appears oedematous producing Phymosis and the dorsum penis when pressed on by ye Fingers feels knotted ie, the absorbents. then the glands of the Groin become enlarged. these symptoms decline if the constitution is very irritable. the will complain of a weighty sensations in - Posines - 213 near the membranous part of the Urethra. frequent inclination to make water, at this time the Testicle frequently enlarges, more especially if he is exposed to cold: the Urine passes in two or more streams as in stricture of the Urethra. If the discharge is of a white colour the inflammation is inconsiderable if it is yellow it is more extensive and if mixd with blood and the lip of the Urethra are excoriated inflammation run very high the appearance of this disease is uncertain sometimes in 24 hours and in others as long as 3 weeks - when the disease is protracted as it generally is in scrophulous habits the cure is more difficult. sometime there will be every Symptom of Gonorrhea present without any discharge The seat. of this disease in a lacuna Just an inch from the lips of the Urethra opposite the fraenum this lacuna is inflamed and in a virulent Gonorrhea the inflammation will extend to the neck of the Bladder and streaks of coagulable Lymph are discharged with urine It has been supposed that an Ulcer exists in the Urethra. but this very scarcely the case, and then only when the lacuna suppurates and bursts. The Progress of Gonorrhea is arrested by an attack of Fever when to all appearance it entirely ceases but as soon as the fever is subdued it returns with unbated violence 214 Treatment. Mercury given to effect the mouth does much mischief by its irritating effect, but mercurial purges may prove serviceable. If a patient has had several Gonorrhoea he is much easier cured than if it is was the first time. In a first Gonorrhoea the inflammation gradually extends for the first ten days, and if at this time you use astringent injections. you will in all probability produce hernia humoralis, or a stricture. If the Urethra will be the consequence. In order to lessen the inflammation give the following - Rx magnes Vitriol ʒÿ Nitri Puri ℈i P.G Arab: ʒ1/2 ᵯ pulv bis vel ter die ex Aq sumed As a purgative in some habits Calomel with Ext. Cath: proves useful. When the ardor Urina is very considerable give the following Rx Aq: Kali: purae gr xv ad xx Ext. Cicuta g iv Mist e: Camph ʒÿ M Haustus. the warm bath is a good remedy soda water is useful after taking the the powder or the following. Rx Kali: Carbonat ʒ1/2 Aqua H1/2 this should be drank mixd with milk it is of a diuretic nature. Local remedies: Rx ol: olii: opt ℥i Pul. Opii ʒ1/2 m. Tinct: Opii ʒÿ Aq: Purae ʒiv ᵯ the Penis should be shaked in warm water frequently for ten minutes. when the inflammation from very high apply a leech or two to the lips of the urethra 215 and the Patient should drink freely of then Gruel or Barley water. When the inflammation has a little subsided use the following injection Rx Aud: Vitriol gr i Aq: Rose ℥i or gr iÿ to ℥ÿ or Aq Vitrol: Albi gr i Aq: Rose ℥i sometimes gr iv to ℥ÿ may be used when the inflammation is nearly abated direct the use of Rx Zinci: Vitr gr iv Aq: Lith Acet 30 gutte Aq: Rose ℥iv M [if] injectio. in this injection a decomposition take place forming an acetate of Zinc, or the following is equally useful. Rx Zinci Acetat gr vi Aq. ℥iv aceti ʒi M - This preparation Mr. C objects to as by its astringent power it is liable to produce strictures - The following is a slow but a sure remedy- Rx Calomel ppr. ʒi Aq Calcis ʒiv M Inject. - The strength of the injection may be determind. by the constitution of the Patient and it ought to be changed every two or three days, they should four or five times in the day and in the night of awake in injecting he is to press under the symphisis pubis so that the injection may not pass further than two or three inches within the passage It should be thrown up with a little force the Elastic bottle syringe is the most convenient for this purpose - In some habits a Gleet will take place after the Inflammatory Symptoms have subsided for which give the following Rx Bals: Cobail ʒi (VO) q's aud Vitriol 4 gtt aqua cinnam ℥ÿ M g Haustus or Rx Bals: Cobail ℥i (VO) [illegible] 216 Aud: Vitriol 20 gtt Aq: Cininam ℥iv M Caps cochl amp tres vel quater in die, when there remains a discharge like the white of Eggs. use the Injection with the acet of Zinc. The Bals Cobail is apt to throw out an eruption on the skin like nettle and which take place in some people after eating Mussels but this disappears by the use of purgatives - the face swells with a troublesome Itching - Consequences of Gonorrhea. Strictures of the Urethra divided into two kinds. permanent and Spasmodic, there is likewise a stricture of mix'd kind, the symptoms of the most common kind are increase of inflammation on discharge of Urine when in Bed frequent inclination to make water a question necessary to ask- this precedes an alteration of size and appearance of the stream which is diminished, and instead of coming out in a round, stream it is broad and sometimes spiral- The most common effect is two or more streams, and when the complaint has been for sometime it will almost stop, and at length either from cold or something very triffling a retention of Urine is occasioned. There is a glary fluid discharge from the Urethra which stains like white of Egg: if guilty of Excess of yellow colour in consequence of inflammation but no Ulcer - The Bladder is affected and thickened with a weight above the Pubis, it’s contracting causes a 217 painful sensation at the upper part of the Pubis. pain of the Loins extending down the Thighs from perineum. Venumd sensation in direction of the crural nerves are the symptoms of the common state. it will produce Fistula in Perineo- The manner it is produced there is an enlargement of the Urethra between the stricture and the Bladder. The occasions a corresponding enlargement of the lacunae. The lacunae in consequence of the collection of Urine and being distended at length bursts. and the urine becomes extravasated between the cellular membrane: every time he makes water there is a great collection and after matter is produced - it depends much on the part where the strictures is formed. Bladder becomes thickened in consequence of stricture where it is existed for considerable time. the Urine becomes like whey being mixd. with Coagulable lymph, the irritations which it occasions the Constitution is mistaken for an intermittent sometimes with rigors & hot pungent skin relieved by sweating and so indeed do the symptoms give away to the use of Bark Kidneys become affected. An enlargement of the Pelvis and infundibule, and wasting of its substance when it continues long a suppuration of the Pelvis of the kidneys takes place so that the whole of the Urinary organ becomes diseased in Consequence - Seat of Stricture it is 7 inches within 19 and lesson the irritation of the Bowels by carrying off any foreign matter that may remain therein Calomel & Extl Cathl. produces this effect the most efficacious- saline purges tho' they occasion plentifull evacutions have not so good an effect - The 3rd mode of stopping inflammation is to excite perspiration - the warm bath relieves inflammation especially of the chronic kind, warm water applied to the feet in bottles or Bladders, are to be used to excite perspiration and hot diluent drink open the pores as soon as they are received into the stomach: in weak irritable inflammations, the Hydrarg. Muriat. in the dose of 16th part of a Grain given three times a day with Decoct sarsaparilla comp: in Decoct Cinchona is of great service. A Girl at Guy's Hospital had lost the use of one Eye by inflamation and the Cornea of the other opacity, many remedies had been tried without effect. it was supposd. a lost case by the use of Hydrarg. Muriat. The inflammation was stoppd. and the opacity of the corner 218 the Urethra. the length of the Urethra is 9 Inches, 2 Inches from the Bladder where Cowper Glands terminates. Which part is always a little naturally contracted. sometimes there are two strictures one an Inch behind the other they differ in length being from 1/8 to half an Inch. There are likewise many in the same Person. and some very near the orifice of the Urethra: description of stricture there are three kinds met with on dissection the first and most common is as if a cord was tied round the part: the 2nd kind is of a considerable length as if there was a broad round ribbon. difficult to cure. requires the use of bougies several times. The 3rd is a membranous band forming a cross the Urethra and sometimes several at the membranous part of the Urethra. There is also a species of are elastic kind in which if you pass a very small Bougie it will resist. but will not a large one. it will not sometimes yield to the passage of Urine. it is dangerous in this kind to make use of Caustic bougie. The cause is from an inflammation of the Urethra from whatever cause that may arise. Mr. Hunter says it does not arise from Gonorrhoea because he has found it in Boys, but the frequency 219 that it follows Gonorrhoea shows this disease is brought on in Consequence of it, but it is more the more of treating it than the Complaint itself that produces. the use of Astringent injection in the highly inflammatory state of Gonorrhoea extending it down the Urethra to where the stricture is situated. riding on Horseback & hard drinking - Method of Treating - The first thing a surgeon is to take a Bougie of the size of the passage. tho Patient Sensation may lead him to suppose it is opposite the frenum. when you have got a Bougie to the size keep increasing the size as the Patient can bear it - If not able to introduce a small bougie, bend it and give it the form of the Urethra. it may be softend by the fire. When there is discharge like common mucus stricture is to be suspected. The Elastic Bougies do not answer so well as the common ones. but Mr. Smith Covent Garden flexible bougies are usefull. Catgut Bougies are seldom used. the have one advantage that of swelling after they have been in a short time and thus dilating the stricture. if there is suppuration of Urine instead of the Catgut use the flexible bougie but this is not so certain a the common Catheter 220 A Catheter of the Natural size will generally where a bougie of a smaller size will not. It is not to be depended on for a Cure but only as a relief to draw off the water - On Caustic Bougie. when a common bougie cannot be passed through the stricture and when a small one does not enlarge the diameter of the stricture and give relief. then it is necessary to have recourse to the Caustic Bougie. Dr. Hunter revised this Practice and instead of a Bougie he conveyed a Caustic up the Urethra in a silver Cannula pushing it forwards untill it arrived at the stricture, but the Bougie is more convenient when the Caustic is inserted at the end of it. a soft Bougie larger than that containing the caustic should be passed first in order to dilate the Urethra as far as the stricture If the Urethra is not distended by this means the caustic will touch it and cause a contraction and will also bring on an haemorrhage. the caustic should not be suffered to project beyond the end of the Bougie. at first application it should only touch the stricture and be immediately withdrawn, after it may be suffered to remain in the Urethra against the stricture for ½ a minute but never longer. the surgeon should proceed cautiously that he may know what degree of irritability the Patient can bear. If 221 the Caustic Bougie remains in the part too long it will inflame and cause a suppuration of Urine Use it twice or three times a week. the slough occasioned by it seldom separates in less than 3 days. if applied oftener the Caustic acts upon the Slough produced. the day before. the Bougie should be of the size of the staff used in the operation of Lithotomy. The Caustic Bougie in strictures have been used with very good effect. and no doubt many lives saved. In a case of stricture under Mr. Coopers care that had continued two years and caused a fistula in perineo. the application of the caustic only 8 times destroyed the stricture and cured the fistula - In general the application must be repeated in proportion to the length of time the compliant has been standing In another case Mr. C. applied the Caustic 104 times. but this stricture had continued 14 years and at length cured by the application. The time it will take to cure is so uncertain that it is wrong to promise any time. The Patient always experiences instant relief but not a certain permanent cure. and if a common bougie or Catheter is not passed from time to time it will return in two or three months Though it has a general good effect. it is liable to inconvenience but in those most 222 Likely to happen when injudiciously used, one is Haemorrhage form the Urethra. Mr. Cooper was called to a Case where after the application of Caustic bougie Blood was discharged and a small pulsatory tumor was found in the Urethra. pressure did not stop the Bleeding and it appeared that the Artery of bulb was divided the tumor was opened, the blood collected in it was discharged. and a compress of Lint introduced into the incision stopd the bleeding for several days. The Gentn was at this time very weak - as soon as he recoverd his strength a little the haemorrhage returned and distended the Scrotum: the blood was again discharged and the hamorrhaege stoped by a compress of Lint: as it returned again Mr. C only supposed the artery of the bulb only half divided and found it in this state divided at quite with a Lancet, this stopt the haemorrhage but the Patient was so weak that he died in a short time after - Another inconvenience is the formation of a false passage. when a Caustic bougie has been used without relieving the Patient. it may be supposed that the Caustic has acted upon a neighboring part instead of the stricture. in this case a large bougie must be used whose end will not enter the false 223 passage but it is a far better way to pass a a piece of caustic in a catheter with the end cut off: this at first will go into the false passage, but if it is then drawn back and passed straight forward it will go to the stricture (it may be easily felt when in the false passage). When drawn back the point of the Catheter should be elevatd before it is passed forward - The Edges of the Catheter round the caustic should be defended by a thin coat of wax to prevent injury to the Urethra - Another inconvenience is the bursting of the Urethra, this will sometimes happen after caustic has been used and the symptoms of stricture very much relieved by: When the Urethra bursts the urine will insinuate itself into the perineum & scrotum and must be discharged by incision If the patient has not a very good constitution it generally proves Fatal - If a Caustic Bougie is kept in for more than a minute it will bring on suppression of Urine on the Treatment of Fistula in Perineo brought on in consequence of stricture. This abcess will take place even as far as opposite the Fraenum it then requires the same Treatment as in perineo, and when it has 224 extended into the scrotum it is particularly necessary as soon as you have found out the complaint to make an opening into it the earlier the better. The urine accumulates in the Cellular Membrane the skin becomes diseased. and so much so in perineo that unless it is opened it gives much pain. The Caustic Bougie must be used for that purpose. there are some whose Urethra is so irritable that the Caustic Bougie will bring on such irritation that it is dangerous to use it. In these Cases use the Catheter. it is to be kept in constantly. only to take it out for 10 minutes twice a week to clean. The Patient should always make water through the Catheter and not suffered to come the natural way if it does it will keep increasing the extravasation. by attending to these rules the aperture soon closes and in about 3 weeks a complete cure is affected. Mr. C has invented a screw to screw on the other. that is should not run down the Thigh. and to prevent the Catheter from [running down] slipping into the Bladder. there is a stop to the top If there is extravasation in the scrotum it is particularly necessary to attend to these rules. Sudden bursting of the Urethra behind the stricture the Urine becomes 225 extravasated in the scrotum and perineum at the time of being at stool or from other causes make an incision into the part by pushing a Lancet to where the Urethra has busted and let the Urine run out at the orifice. as soon as you have cut down upon the rupturd. part, pass in your fingers. let the inflammation be ever so great provided there is not a very great extravasation in the scrotum it will generally give way to this operation. This Rupture of the Urethra arises sometimes from accident it is to be treated in the same manner - Spasmodic Stricture. A sudden suppression of Urine so as not to be able to discharge a single drop of Urine. This sometimes accompanies the permanent stricture after it has existed some years it is an inflammation of the muscular fibres which surround the membranous part of the Urethra. Cause extended inflammation in walking there appears to be a collection of water there with Spasms upon the muscular fibres, extreme pain which is generally relieved by passing a Bougie but it is very difficulty to do it. for when it is passed. the part by the stricture resists it and force is of no use. let the Bougie rest gently against the stricture for several minutes accustom the Urethra to its use and in a little time, it will slip suddenly into the Bladder. 226 Sometimes the bougie will not succeed then you should have recourse to the Catheter which will always succeed: the common are of a large size. In the introduction of it it may be necessary to change the posture of the Patient. slight causes has been relieved by the warm bath. sitting in a common tub of warm water is the best way - Medicines does not give relief. Opium does not relieve the stricture. prefer a small dose of Antim Tart. to create a nausea, If Opium is given join it with Calomel. If an uneasy irritation of the neck of the Bladder and the patient has a constant desire to void his Urine, give the Hydrarg Muriat cum Decoct: Cinchona. If accompanied with a high degree of inflammation extending into the adjoining muscles. take 14 ounces of Blood from the Arm and apply Leeches to the part. apply a poultice composd of 1/3 mustard 2/3 Flower this will bring on a redness and give relief, this is to be preferred to Blisters as they will prevent the Patient from walking for sometime after. give a Pill composed of Ext Cicuta and Camphor, after Bleeding inject an Anodyne Enema. which will answer a good purpose as it will act on the muscles - Irritability extending to the Bladder occasions constant desire to make water. Open the Bowels, when evacuants have failed, and indeed has every other Medicine. The following remedy which was discoverd lately has never been known to fail 227 and always gives instant relief: make a small Pill from 1/4 to 2 grains of Ext. of Opium. this to be introduced by the Urethra (with the help of bougie or Catheter) into the Bladder where it becomes readily dissolved - It is wrong to use Bals Cobail if there is much inflammation — If a Discharge of [Urine] Blood with the urine. use the following Rx Opii 1 1/2 gr Cicuta gr iÿ Camphor gr ÿ M f Pilul. Calom may be added to prevent caustiveness Inflammation & Enlargement of the Prostrate Glands- The Prostrate Glands is of diseased by a simple inflammation in Gonorrhoea. more frequently so in old People who have indulged very free in Venereal Actions. it begins with a sensation of weight in the perineum occasioned by its enlargement. This also accasions it to press on the rectum and obstruct the Passage of the foeces- a frequent inclination to make water. and is not able to pass it without they kneel and their Legs wide assunder They generally void their foeces at the time of making water- a pain is felt at the end of the Urethra like that occasioned by a stone. The Urine is sometimes of a Whey colour and when suppressd is of a chocolate colour very offensive looking as if it came from a mortified surface- When thus enlarged the prostrate may be distinctly felt by the Rectum 20 diminished: irritability should be lessoned by medicines which act on the nerves as Opium Cicutæ &c, of the local treatment where inflammation is superficial we may apply cold lotions which diminishes it by restraining the vessels that are distended Lead is one of the best as it has a particular effect on the nerves. the application of Spirits by the cold they produce in evaporation constringes the vessels; other may be applied till the parts are frozen - if these application should not relieve the inflammation Leeches may be applied and the bleeding kept up as long as possible, and the cold applications returnd. to after the bleeding. Fomentations and poultices if not applied very hot will not promote suppuration but when the matter is formd. will bring it forward more speedily when inflamation is very deeply seated, it is servicable external inflammation by means of stimulating Plasters 228 On Dissection it is found to be divided into three tumours. one on each side and one behind between it and the Bladder. The valvular projection of the Prostrate pressing one of the tumours upon the Urethra and occasions the stoppage of the water - If the Prostrate is inflamed on passing your finger up the rectum it will cause much pain which goes on sometimes to be production of matter. the Urethra is three times its natural size that in passing the Catheter a surgeon is often deceiv'd thinking he has got into the Bladder as it may be turned to either side without resistance its length from 1 1/2 to inches more than common - this state of the Prostrate is the effects of growth in old men, or of simple inflammation from Gonorrhoea. in this last case it often suppurates or bursts of itself or is burst in passing a Catheter. This at once relieves the suppression - Treatment Take a large Catheter ½ or 2 Inches longer than the common size which is bent towards the end suddenly. When passed as far as the Gland it must be lifted over the tumour by depressing the handle between the Thighs elevate the point over the Prostrate and pass it into the Bladder. if pushed strait on. it would Rupture the Patient. the Catheter is 229 to be left in the Bladder. The French elastic Catheter is best as it does not soften and become rough like the English Elastic Catheter in three or four days it should be withdrawn to try of the passage is restored if not it must be introduced again - the Bladder is sometime so irritable as it will not bear the Catheter to be left in under this state the Patient generally dies - During the Use of the Catheter the Hydrarg Muriat may be given in Decoct. Cynchonae Soda Water has also a good effect in taking off the irritability of the Bladder or Rx [Sali] Carbonat: ʒ1/2 Pulv. Uva Ursi ℈i Ag Pura ℥iÿ Capt Cochl / major sepi et lactes - most dependence on Hydrarg: Murriat for Permanent relief . Bleeding from the Urethra in Consequence of Gonorrhea - this take place when the inflammation runs high and generally offords some degree of relief but is rather alarming to the Patient. tho it serves to lessen the inflammation. but sometimes a large Vessel is ruptured. and much Blood is discharged and in a very short time ye Blood will run back into the Bladder and be discharged from it in the same manner as the Urine The hemorrhaege generally takes place in the Membranous part of the Urethra. it is wrong to use Bougies - Treatment to find its situation pressure should be made along the Course of the Urethra it is best to begin at the Anus and pass along the 230 perineum to the Scrotum. when its situation is found pressure with the finger for 10 or 15 minutes will stop the hemorrhage. In irritable Habits it is sometimes very troublesome and will not stop by pressure with the finger contined pressure is required and it is best made by binding a Roller up with a [illustration] bandage on the perineum Chordee is a very troublsome symptom caused by imperfect erection making the Penis to be crooked to one side. pain very Violent it feels sometimes as if cord was passed along the under part of the Penis. it usually comes on when warm in Bed. it is caused by inflammation attendant on Gonorrhoea which throws out an effusion of coagulable lymph into the corpus spongiosum and cavernosum. and adhesion is produced in some of the cells which are in consequence glued together and prevents complete erection. a knot is generally felt where the obstruction is. there is sometimes another sort where the erection will be complete. we may call a cordee of two kinds. Viz Simple inflammatory or inflammatory with effusion. The pain is so very Violent that he is obliged to get out of bed and lie down with the part on some cold place. As the best Palliative remedy the Patient may apply a bottle of cold water between the Thighs. Treatment in the first place. 231 purgatives to reduce the inflammation give the following Rx Calomel 2 gr Opii gr i1/2 Cicuta gr iÿ Camphor gr ii M Piled hora somni sumendus this will take off the irritation and prevent the imperfect erection in the day time to take the aq. Kali: pine & Soda Water deaden the irritation of the parts. Local Applins. soak the Penis in warm water and apply a poultice during the night if the inflammation is considerable apply Leeches on each side of the Glans Penis - When the Cordee is gone off the knot may still remain. but may be dispersed by the Camphoratic Merc. Ointment - Hernia Humoralis is an inflammation of the Epididymus more than the body of the Testicles this begins with an uneasy sensation in perineo with inflammation appearing to extend to the neck of the Bladder, pain is then felt in the Spermatic cord. and the Heat extends to the Epididymus which at first appears swelled and afterwards to a considerable degree. when the Testicle becomes affected, the scotum is always much so by a remarkable florid redness, its Vessel, distended on pressure great pain. The spinous process of the ilium & the loins are also affected with pain - causes. This is not as has been thought a sympathetic affection. It is an inflammation beginning at the 232 opening of the seminal ducts in the Urethra and extending along the spermatic cord to the Epididymus. The most common cases is the use of injections in the inflammatory state of Gonorrhoea at that time even when the inflammatory state is subsidded. yet if there is pain in perines. Injections should not be used for they will cause inflammation to spread up the Urethra and produce this effect This inflammation is often brought on by the passing of a Bougie. to prevent such effects the parts should be suspended, during its use and so they ought during the Cure of Gonorrhoea cold water injected for a Gleet has occasioned a hernia hummoralis - Treatment the testis are to be well suspended by a Trap (the common bag Trap is very improper) Calomel purges if it is a slight affection this will be sometimes sufficient. If you find the inflammation continue use fomentations but first apply Leeches. Aq. Ammon: Acet as a Lotion. to be kept in a recumbent posture for this blood is sitting in those parts on account of its Vascularity V.S. in Brachio is sometimes necessary more than once. Sal. Amn and Acetum will sometimes relieve the inflammation but if it will not speedily do it it will excoriate the scrotum. poultices and fomentation are to be preferd 233 after the Leeches - If connected with pain in perineo Bleeding is necessary. Emollients in preference to astringents The Testicle will sometimes enlarge & suppurate in consequence of Hernia Hummoralis fomentations are necessary - make a free opening into the part. give the Bark and in general the patient will recover rather speedily but often when suppuration takes place it arises from a scrophulous Constitution. there is but little pain a long time before it points. and a Curdy substance is discharged a quantity of semen is [discharge] emitted from its Orifice. Inject into the sinus the following with an intention of causing a slight inflammation and promote union of the parts rx Zinic: Vitriol gr iv. Aq: Rosae ℥iv M vel Rx Acid: Vitriol gr ÿ Aq: Rosae ℥ÿ ℥ÿ M f Inject there is a fungus projecting from its orifice like Cauliflower of the size of half a Crown it is unnecessary to remove the Testicle sprinkle powderd. blue Vitriol over the Fungus or take it off with a knife and Join the edges of the skin with sutures, draw it over the sinus and it will heal. After the inflammation has subsided there will probably remain an uneasy hardness of the Epididymus. the best 234 external application is a piece of old silk over the scrotum it causes a copious perspiration and in consequence lessons the hardness and enlargement. this has a greater effect than the Ungn. Hydrarg fort Calomel ppr. externally - Emetics are not improper this enlargd, and hardend. state of the Epydidimus is often the source of much uneasiness to the Patient as he is apt to suppose it will lessen the virile power. but it has not such effect Sympathetic Bubo occurs during the inflammatory state of Gonorrhoea: when you find more than one Gland in the Groin enlarged never use Mercury as you are to believe it sympathetic. many of the Glands in the groin are affected. Simply by the application of Aq: Ammon acet and purges they will give way- they never suppurate unless by the use of mercurials which will occasion an increase of inflammation. Apply emplast: sulfur to the part affected - Impotency is in consequence of Gonorrhoea in some cases - Loss of Testicle. This was formerly considered a loss of Virile power. but it is not the case sometimes in consequence of disease. The testicle will become completely absorbed. if you see the other Testes begin in the same way. though the advice is by no means moral, his only resource is to have frequent connection with women 235 Mr. Cooper mentions a remarkable case of a man Castrated 22nd March 99 in June 22. 1802 having frequent emisions afterwards but at length they subsided, but he had erections. at command - [If the Tes] If both Testes are taken away the beard does no grow - Impotence is produced by loss of the retentive power of the semen. tho Vesicular seminatis loose their power of retention: the semen is dischargd. while he is at stool without erection. this brings on great degree of debility and the parts are incapable afterwards of doing their office. this particularly happens if the Body is in a Costive state. The following form has been found very useful. Rx Gum Oliban ℈i Myrrh ℈ii Ferri [pro?ef]: ℈1/2 Bals:Canud qt M Pilul 20 Capti 3 ter quotidie. at the same time the Bark should be given and the cold bath used. - The next cause of impotence is an irritability of the Vesicula seminalis. causing a discharge of semen by whatever excited Venereal ideas as the sight of a fine Woman. or touching the Penis. as soon as the Patient is warm in bed he has imperfect erections and emissions. which bring on great debility and even impair the mental faculties. Tonics only increase the irritability sedatives are the only remedies to be depended on the Path composed of Opium: Cicuta and camphor succeed the best - 236 Emissions during the night alarm some men but provided they do not occur oftener than once in a week or 10 days he not be under any apprehension as it can only then be called natural. If it occurs frequently a Yoke should be put on the Penis (Composd. Of elastic Gum) is the best. this gives a painful sensation when an imperfect erection comes on, Wakes the patient and thus ye discharge is prevented - Treatment- Cold Both and Pilulce Cicuta- Impressions on the Mind- when a person think himself incapable of coition, supposing a wasting of one Testicle from hernia humoralis &c will impede his power: his fears in this case will render him incapable. but if he can overcome his fears he will find that he has sufficient however - Dr. Hunter advised a person in this state to lie by the side of a very fine woman seven nights and to attempt to have any connection with her untill the end of that period. When he promisd, him that he would have power. this he bound himself to observe that after the 4th or 5th night his were passions were so much excited that he acted with effect and got cured - Stricture in the Urethra will occasion impotence in a case under Mr. Cooper, are the powers had gradually abated during two years, at first pain and difficulty was felt in the emission of the semen, at last it 237 it was totally obstructed passing backwards into the Bladder, and no erection from these circumstance and by a slight Gleet. Mr. Cooper was led to suspect a stricture, this he destroyd. by a Caustic bougie and the Virile powers soon returned. Gleet is a discharge continuing after the affection of Gonorrhoea has ceased Glary in general like white of egg; by irritation produced either by walking dancing riding it becomes yellow and sanous will influence the Urethra so much that a cordee will be produced and very difficult to distinguish from Gonorrhoea. the seat of a Gleet is in the same place as Gonorrhoea, but the lacuna magna is more particularly affected. generally accompanied with a stricture it is difficult to determine when Gonorrhoea ceases and gleets begins. The longest period Mr. C ever knew it infectious was after 5 month and 3 days - Treatment by the use of injections and bougies- Rx Hydrarg Muriat gr i Spt Vini Ten: ℥i Aq: Rosae ℥xÿ M Inject: their strength should seldom be exceeded. If stronger it will inflame the Urethra and cause hernia humoralis. Rx Liqur Cupri: Ammon: grx Aq: Rosae ℥i M [illegible] is particularly recommended. Combine the use of injections with bougie, which you are to introduce three times a week. injections 21 as good an application as any for this purpose is an ointment composd. of ʒÿ antimon Tartar and ℈i of Hogs Lard, which rubd. on the skin produces considerable vesication. Ungm. Hellebore Ungm. Sabrina are used with same intent a Vinegar poultice is frequently of use in inflammation of the Joints when irritation fails poultices will sometimes relieve, soap plaisters by keeping up perspiration are usefull in deep seated inflamations of the Joints, if the parts are in an indolent state, stimulation is necessary, and where inflammation is removed a Tonic plan externally and internally should be used On Wounds Wounds are Violent separations of the skin, and sometimes connected with the Parts beneath, if the parts beneath are divided, and the skin is not. it is not to be considerd. as a wound, - wounds are divided into four kinds 1st. the simple incised 2nd the lacerated 3rd, the puncturd. which is the most dangerous. 4th the contusd., - when the parts are disorganisd. 238 produce stricture. Bougie create a discharge the Injections diminish the discharge and Bougies the stricture. Rx Bals: Cobail ℥i spt. Aether: Nitrosi ℥i M Caht M 40 Cochl; parva ter quotidie - when there is Gleet with stricture use the Bougie oftener & Rx Pulv: Cynchone ℥i Bals: Cobail: gr1/2 Elactn. Caht Cochl 1 parva bis quotidie Mercury does no good in Gonorrhoea but Mr. C knew of one exception in a Gleet & stricture A gentlemen had a Gonorrohea after several months of Gleet and stricture and trying all other remedies, it gave way to the following Rx Hydrarg: nitrat gr i spt. Aether Nitrosi ℥i M Capt Cochl 1 Min vis die - An obstinate Gleet is often brought on by an abscess in one of the Lacunae alternately collecting and bursting: it may be felt on the outside of the Urethra. the Caustic bougie should be used to destroy it. An abscess in the lacunae has been known to bring an hectic symptoms and destroy life - External Gonorrhoea takes place at the External part, only at the Glands, from the Glandula ordoriferia near the fraenum frequently attended with Phymosis. An injection with Rx Calomel prop ʒi Aq: Calies ℥iv M Injection [gr] Rx Aq: Litharg : Acet: 30 gutte Tinc: Opii ʒi Aq Rosae ℥iv M Inject. as Phymosis almost always attends : apply spt. Vini : Camph & Aq Pinae to the Penis 239 Gonorrhea in Women. is a disease which affects the nymphae. and extends to the Glands of the Os externum of the Vagina. when it effects the Meatus Urinarius and occasions a great discharge from the lacunae like that from the Urethra in Men. on account of the shortness of the Meatus Urinarius the external coat of the Bladder is affected. this causes an incontinence of Urine. the Bladder contracts as soon as a very small quantity of water is collected - Pain is more excruciating in the Females than in men. the Glands of the Groin very generally become inflamed forming the sympathetic Bubo. Treatment – at first fomentations should be used: at the same time it will be proper to give purgatives. When the inflammn is subsided use the following Injection Rx Alum: 1 dram Decoct: Cynchona 2 H M It is a good way to keep a sponge with this Injection in the Orifice. All the other Injections mentiond. for the Male are proper - Gleet in Females in very common: it is difficult to say when it has commenced. the discharge may be like the White of Egg. yet it may infect - It will appear that a woman may give the Infection & not know of it herself 240 Treatment, the same as in Gonorrhoea sympathetic Bubo is not Venereal tho it sometimes suppurates: Mercury is very improper these Buboes seldom suppurates when Mercury is not given. If usd. they always do - when irritation is the cause several Glands enlarge. but when a Bubo is occasioned by Gl absorption of Venereal poison. Seldom more then one is enlarged - Treatment- The application of Leeches to the part using the Aq: Ammon: acet as a lotion. and purgatives. when inconvenient to the patient to use Lotions a soap Plaister will prevent suppuration - Chancre. milder form. This is an Ulcer occasioned by the application of Veneral poison to the Cuticle. on its first appearance there is an Itching in the part arising from a small pimple which breaks & discharges, leaves a deep Cavity. edges ragged and very [deep] thick with efflorescence & redness round with tumour. it is a point of importance to distinguish Chancre from simple excoriation. attend to the following circumstance. on taking it up between the Finger & Thumb a hardness is perceived like half a Pea. and excoriation is more superficial & no hardness to be felt 241 Chancre in its progress has much the appearance of a pustule in the small poxs - the time of its appearance after coition is uncertain. being as early as 24 hours and as late as 6 weeks. It attacks different parts, most commonly the Glans & prepuce. it caus Phymosis by thickening the skin. it also attacks the fraenum and commonly destroys it. this is the worst species as it very soon makes a hole through. even if the Patient washes immediately after connection the Poison lodges in the hollow of the fraenum and remain there. on the margin of the prepuce chancre is certain to form Phymosis. they sometimes form in the orifice of the Urethra and produce stricture when on the skin of the penis they have the appearance of wart. and also on the Scrotum occasioned by hanging down of the Penis after impure coitions - no Gonorrhoea accompanies chancre and when both are receivd. together chancre appears after Gonorrhoea has gone off - Treatment. It is to be supposed that Caustic will destroy the whole. if small it may do, this is desirable if the chancre attacks the fraenum. but although the sore will heal it does not necessary follow that it will prevent the symptoms. Give Mercury so as to affect the mouth: [O use] the following Rx 242 Rx Calomel prop ʒi Aq: Calcis ℥iv M : the time necessary to cure is about 3 weeks. give Morning for ten days after disappearance of the Cancre. Unctuos applications are very improper and have a tendency to inflame Calomel sprinkled on the sore is sometimes of service but will in general inflame and cause a deep slough. Red precipitate is a good application when the part is very focal and looks black it may be sprinkled or mix’d with Conser Rosae vel Cynosbat - sometimes after mercury has been use for sometime the Chancre appears stationary apply the following Rx argent Nitrat 1 dram Aq Rosae 1 ounce M once a day use this & constantly wash it with the Aq: Calcis & Calomel solution or if you find it indolent you may apply the Argent Nitrat every 24 hours it will cause a dry scab to form over it, under this a skin will be produced and heal it over. in the most lenient kind of [Mercury] canires it is absolutely necessary to give mercury to prevent the Venereal Virus from again breaking out and probably attack the Throat - Phymosis occasioned most frequently by Chancre on the external margin and sometimes in the Corona Glands. if taking mercury immediately desist from its use. it shews a weakly constitution with irritability. the best plan 243 is to order the lotion with Aq: Calcis & Calomel ℥iv if the pain is severe add Tinit: Opii ʒiÿ this will bring on a healthy state of the sore when the inflammation is subsided. then return to the mercury. suspend the penis towards the abdomen with rags round it will with the Lotion. this plan will sooner reduce the inflammation than any other. sometimes Phymosis will not go off when inflammation has subsided. then use fomentations. for they will absorb it and reduce it. the Mercurial Oint will produce the same effect. if these will not succeed then perform the operation which is very simple - make an incision upon the upper part of the penis. pass a director between the Glans & prepuce make a division with the Phymosis Knife midway between the extremity and the Corona Glands. the prepuce drawn back as much as possible before the operation is performed. make a small incision of the inner parts afterwards. this produces no deformity the Bleeding is very slight apply dry Lint. in healing it keep the skin back behind the Corona Glandis & apply poultices - when the skin is drawn behind the Corona Glandis it is called Paraphymosis. both the prepuce & Glans become swelled and inflamed - an 244 effusion of coagulable lymph into them is taking place, in order to reduce the swelling as much as you can. apply at first a cold Lotion with Aq: Litharg: Acet Comp with Spt Vini the evaporation of the spirits producing a greater degree of cold. but it is much better to proceed at once to the reduction it is wrong to perform even any operation. Take the Glans penis with in the palm of the Hand squeeze it so that it will become quite flacid. by the pressure it forces the blood back. but your fingers over and under the penis bring the integuments forward. and pressing the Glans backwards. so as to push it within the prepuce. A poultice is to be put on the part. It is alarming if attended with Chancre and is not quickly reduced. for it will cause Mortification & sloughing Chancre in an irritable constitution instead of mercury having a good effect. it will make it worse, and the Lotion recommended will be hurtful and Penis lost in consequence. A Chancre itself does not destroy the penis but by inflammation with succeeding sloughing together with high constitutional irritation pulse from 120 to 130 Symptoms are the Patient cannot sleep the part swelled the edges look discolord a sign of approaching Mortification 245 this sloughing extends more along the skin than the body of the penis. it will in general soon cause the whole sloughing of the penis untill it reaches the pubis; If you donot arrest the progress at the beginning it will be of no use - abstain from the use of Mercury if you see any considerable degree of inflammation, and attend to the constitution - do not fear the Penis being destroyed - In this sloughing state of the Penis it has been a custom to use fomentations and Poultices, but it will go on worse if any poultice is used. the following is the best A Tablespoonful of Yeast mixd up with Linseed meal - use also the following Rx Calomel: prop: ʒi1/2 Aq: Calcis ℥iv M there is in this a precipitation taking and which is the oxid of mercury. shake the bottle and tun the mouth upon the tip of your finger, the powder will be deposited on it. apply it on the surface of the sloughing sore- Rx acid: Nitros 30 gtt Aq: Fontan 2 H: M p Lotio. this may be injected under the prepuce even with Phymosis. this is as strong as the Penis is able to bear. check the irritability of the constitution with opium. Bark & sarsaparilla 246 give porter & wine. but in this you must be carefull, and regulate it by the heat of the skin - to put a stop to the bleeding sores dip Lint in ol: Tereb. press it for 4 or 5 minutes but where the Vessel is very large use a needle and Ligature. it is surprising with what good effect this may be used. no degree of irritation will be occasioned by it and the sore will heal in the same manner as if not there - The Urethra bursts from sloughing sometimes with a hole opposite the fraenum if a very small part treat is as a hare lip pare the edges and introduce a hollow bougie to prevent the urine from coming through then pass a suture through the hole. If 1/3 of the Urethra is burst it will be of no use. when a chancre sloughs at the Lips of the Urethra it will close its orifice. when the urine is discharg’d there will perhaps be only a small stream or sometimes a total stoppage. the Urethra is considerably enlarged behind the place where it has stopp’d Take a very narrow bladed Lancet push it into the swell’d part of the Urethra. take then a Trocar and Canula, and leave the Canula in the Urethra and direct him to make water through it - 247 When a chancre is seated in the lips of the Urethra Structure of the Orifice is occasioned. a piece of bougie 2 inches long should be worn constantly for a month or more the passing of a bougie or the use of a caustic bougie is of no use in this Case Mercury is not to be given after the sloughing is cleansed. heal it up as a common sore. If you use Mercury as the constitution is supposed to be very irritable it will produce again the same appearance wait untill you find the Venereal Virus has affected another part. if it should then use the proper steps 22 The appearance of the first kind, is separation of skin with hemorrhage, the indication or cure are to stop the hemorrhage remove the coagulated blood from the surface tiring the edges, to bring them together and unite them by the first intention, pressure will in general stop the hemorrhage. if the divided artery is not very large, union by the first intention is effected in the following manner, a small portion of crasamentum adhering to the cellular membrane glews the edges together in a few hours a slight inflammation comes on which causes the vessels to elongate; their ends project into the interposd. blood which this becomes Vascular, in about 10 days the union is effected - the part produced is similar to that destroyed if the skin is divided it becomes skin if Tendon tendon is produced (instanced in a preparation of the tendon of a dog’s leg which is injected and is in the parts produced 248 If this does not succeed use the following powder. Rx Pulvis Sabinae: Cupri acet. (Verdigris) partis equalis M f Pulvis - apply it on the Warts. A saturated solution of sublimate in spirits gives pain afterwards but not at the time. Mercurial Ointment has removed a number not destroying them by its Mercurial power but by its irritating effect The yellow wash of the Hospital (Aq: Calcis and Hydrarg Muriat) the black wash (Aq Calcis & Calomel) - Treatment of the hard kind, Arsenic in powder upon the part of the Lotion : Rx Arsenic: pulv grii Aq Rosae ʒviÿ M f Lotio - the powder applied to surface only is best. the Lotion being applied to a greater surface is apt to effect the system: the whole of the wart separates in two days put a piece of Lint over it or it will cause the same sloughing from the foreskin a liniment is also used . Rx arenic ʒi Ungn. albi ℥i M. this is not so good as the powder as it runs about upon the Glans Sometimes by cutting them off a cure is effected - Chancres in Women. Its most common seat is in the inner side of the external Labiae. sometimes on the nymphae or externum Vaginae and Rectum. Treatment 249 use the Aq. Calcis and Calomel. give Mercury internally. sometimes sloughing as in the Male and from the same causes When it takes place in the Female it does not stop at the Pubis as in the Male but extends up the abdomen the region of the Pubis, and destroying such a surface as they die of irritation. Use Mercurial Ointment with Opium. the Nitrous aud Lotion page. to sloughing sores which would not yield to any thing else the following Liniment has made a Cure Rx Aq: Lithrarg: acetat : pulv Opii. Mil: Rosar os in ʒii Conserv: Rosar ℥i M p Linn. when they once begin to slough they very seldom stop till Death closes the scene. - Means to prevent the Venereal Disease Ablution with soap and water will prevent a chancre but not Gonorrhoea. the the following Lotion may be also used Rx Aq: Kali: purae 20 gtt Aq: Purae ℥i M p Lotio. If not used directly will answer no purpose — Bubo. Venereal Bubo generally tho' not always appear on that side of the Groin on which the Chancre is situated on the penis. generally single in each groin 50 If other Glands are a little enlargd. they do not increase in a good Constitution. when more than one Gland suppurates it shows a scrophulous [constitution] Habit - Symptoms are like those of a common Abscess except more nocturnal pain. Treatment 1st Cathartics to reduce the inflammation. then the Mercurial pill. apply the Emplast: sapon to the part. the Mercurial Ointment to be rubbd in. it is indifferent in which side it is used. Continue the Mercury untill the Gland is nearly of its natural size. When the Bubo does not yield to this treatment and the pain increases leave off the Mercury for three or four days otherwise the Bubo will suppurate. in these intervals give purgatives and Apply Leeches to the parts also the following Lotion. Rx Ammon muriat ʒi aquae ℥iv M. However a Bubo will suppurate. this known by its size and pain being increased and by the redness of the skin. Here use no Mercury but apply Empl Luth. Comp the Patient must live well and take the Bark. when the Bubo is opened use Mercury again - opening of a Bubo. As soon as fluctuation is perceived the Bubo should be opened If not large open it with a common Lancet 251 on the inferior and anterior part then poultice, and in three days again give Mercury. If the collection is large make an opining at each extremity of the Bubo — Bubo sometimes become very red. of a great size and hard. here abstain from Mercury for the constitution is irritable in this case. foment and poultice in order to bring on a suppuration as soon as there is the least fluctuation open and the swelling becomes absorbd. very soon. If the collection of matter is allowed to be great dreadful consequence will ensure - sometimes a bubo after opeining forms a sinus especially if the Bubo is large. when it is opened apply a Blistter to irritate the skin and inject into the sinus Rx Acid: Vitriol 2 gtt Aq:Rosae ℥i M p Ing also Tinct: Canth - also Hydrarg Mur grii Aq: ℥i M by these means inflammation is brought on and the sides of the sinus are glued together and the enlargement is dissipated - Indolent Bubo. sometimes after the suppuration and also after being opened. If after suppuration do 252 not open it but give Mercury for the absorption of the Matter. If after being opened this does not yield to large exhibition of Mercury and use of Caustic, lay aside all dressings &c and expose the part to the air In three or four days it becomes scabbd, and under which cicatrization will go on Sometimes a considerable number of Glands are enlarged from pouparts Ligament down to the second order, two, or three inches below this is Veneral but scrophula and Mercury does harm Give Tonics Sloughing Bubo this resembles sloughing chancre and occurs in the same irritable constitution and is follow? nearly by the same effects is opened- sloughing with much pain comes on but by the cessasion of the use of Mercury. inflammation abates. separation takes place. and the sore heals but from some triffling cause in a little time sloughing again comes on. In this manner the case goes on till by the repeated sloughing the Femoral Artery or Vein is opened and the Patient dies from haemorrhage - Local Applications. the black wash and if it disagrees vary its 253 proportions, should not this at last suceed apply the following Rx Unguent: Hyd: Nit ℥i pulv Opii ʒ1/2 M p Ungn or Rx Mil: Rosae Tinit: Opii : Aq: Lith Acet [illegible] ʒii Conr rosar ℥i M or Acid nitrosi 20 gtt Aqui 1 H M apply this warm and do not exceed the above strength. yeast poultice composed of a Tablespoonful of yeast & a pint of water. Also the carrot poultice one of the above applications will agree with one constitution and another with another. Give Bark with Acid : Vitriol Opium and Wine. If the wine increases the pules which is often from 120 to 130 in a minute. substitute Ale or porter. In a sloughing Bubo do not give Mercury till it has healed except Venereal symptoms in the constitution endanger life After the constitution is improv’d again is evaluated from the Bubo the Gland will project out and lie [like the Bubo] over the skin. Mercury here produces sloughing. give Tonics. applications Rx Argent: Nitrol ʒ1/2 - ʒi Aq : Rosae ℥i M p solutio vis die applicand - apply the blends 254 Wash after each time. with these applications the Bubo is brought level with the Skin and heals – Venereal Ulcers in the Throat . the Venereal poison is absorbed in the groin carried [carried] into the Blood and produces its first effects on the Throat. there are three parts so affected. the Throat, skin, and the bones; and in this order the Testicle is sometimes affected. In the Throat the Tonsil Glands are generally affected. This is the most favorable for only dryness of the mouth follows their destruction, Symptoms. a dry husky feel especially towards evening no pain except the parts are excoriated by swallowing Acids. Another part affected is the soft palate this sometimes takes place from a small Ulcer in the palate itself most frequently in an extension from the tonsils - Symptoms Liquids in swallowing run trough the Nose. when it reaches the bony palate there is a considerable exfoliation and the Uvula is destroyed - Another part is the Fauces at the back part of the Pharynx. Symptoms. the same as in the soft palate - Another part is the inside of the Pharynx. symptoms. no visible venereal symptoms Horseness so that you can scarcely hear the Patient speak. from irritation 255 of the Epyglottis. Coughing and expectoration of of Matter mixd with blood. no pain in the chest but in the Throat. There is great constitutional irritation and wasting of the Body from which the disease is frequently mistaken for Phthisis Pulmonalis. Treatment when in the Tonsils or Fauces the same kind of Treatment is proper. Rub in Mercury & give Hydrarg Muriat internally and use the following Gargles Rx Hydrarg: Muriat 2 gr Aq: font ℥i M dip a probe with Lint wound round it into this Gargle and apply it to the part- sometimes enlargements of the Tonsils are accompanied with scrophula dip the probe as above in the following Gargle Rx Acid Nitrosi 25 gtt Aquae 1 H M give also Mercury. If not Venereal give the Murialic Acid & Bark- should this not succeed puncture the tonsils 1/2 a dozen times and if scrophula use the Acid wash the enlargement soon disappears. if sloughing comes on leave off Mercury and apply p Boracae over the whole sloughing surface likewise mill: eruginis & Nit: Acid Gargle the constitutional treatment must be the same as in sloughing of the Penis & groin- Treatment in the soft palate the same as in the Tonsils. 256 Treatment in the Bony palate apply the following to the edges of the sore. Rx Acid Muriat 25 gtt Aq: fontan 1/2 H M this acts chemically on the bone and removes it without exfoliation - If in the Larynx give sublimate early and fumigate twice a Day Apply a Blister externally to abate the inflammation Venereal Eruptions are distinguished from other cutaneous eruption by their copper colour a brown crust over their surface and under this crust a sanious pus or serum. This eruption first appears on the Breast 2nd on the Face and very often crust and eruptions hang on the Hare and the head is sore. after other parts of the Body becomes affected. they are as large as half a Crown other times not larger than a flea bite. yet all possess the same copper colour and are attended with little pain except an itching sensation in the evening - the pain is great when the eruptions are large and have ulcerated Treatment. In addition to Mercurial frictions give sublimate internally. Local treatment is unnecessary except the eruption has ulcerated the crust of the eruption is the best covering taking this crust off disposes it to Ulcerate. If Ulceration has taken place with pain (and not unless that pain is very great) 257 apply sublimate and lime water. Rx Pulv: Opii 1 dram Ungn. Hydrarg: Mit ℥i M These eruptions sometimes became Phagadonic Ulcers most commonly situated in the Groin after Bubo they are so called from eating away the parts as they advance. Character A deep sore with the edges of the skin hanging over. the surrounding skin is of a copper colour inclining to a purple. Treatment Rx Argent: Nitral ʒi ad ʒÿ Aq: Pura ℥i M p Lotio wash the sore and surrounding edges with it till they become white every morning - also the Calomel & Aq: Calcis. to use the oxid of Mercury which settles at the bottoms by these means the worst kind of sores are cured. give the following Rx Pulv: Cinchonae . sarsaparilla aci ʒ1/2 M p Pulvis ter qutidce ex Vino Rub Allow the usual beverage of Wine & Spirits After the skin the bones become affected 1st the Bones of the nose: small chancres form upon the membrane of the nose, soreness across the bridge of the nose and pain upon pressure blowing the nose forces out scabs. after there is a discharge of blood & matter. the Breadth is offensive sometimes a considerable portions of bone separate at the vomer and os nasi: the osa nasi will sometimes come down the nostrils 23 produced as vascular as in the other parts) to this rule there are to exceptions, muscles if divided are not united by muscular but by tendinous substance; Glands when divided are united by an intervening substance which never becomes Glandular: in old persons the cartilage of the ribs if divided is united by bone, but in young person it is united by cartilage - union by the first intention will take place between other substances, for if the scalp is torn and replaced it will unite to the scull - the periosteum of the bone will do the same, skin will never unite to cartilage; it will grow together over it, and like a joint is furnishd. with synovia, how much so ever parts may be divided, they should never be separated for they will or may unite- It was the custom of old surgeons when a part had been much separated to cut it away this very much prohibited the cure, and when the bone was exposed as in injuries of the scalp, it produced very troublesome exfoliation - The following care prove 258 and at other times make an opening through the bridge and fall away. Timely attention prevents the latter. Treatment Rx acid : Muriat 1 gtt Aq: fontan 1 H M p Lothi The patient to pour a little of this on the Palm of the hand and sniff up his nose this cleans the sore and quickens exfoliation at the same time use the Mercurial plan To prevent external exfoliation which causes deformity, as soon as the skin becomes inflamed pass the forceps up the nostrils and bring away the loose os nasi: the nose sinks a little - Venereal Diseases in the Bones. Symptoms. Dull pain in the bone especially towards evening and increasing when warm in Bed. these nocturnal pains distinguish it from Rheumatism. soon after a prominence small and painful to the touch appears If the node is left to itself it goes on to suppuration, a glary fluid is formed, in it which by a long inflammation becomes purulent Existence of fluid is known by the redness of the skin. Matter forms in the Bone and not between the bone and periosteum Nodes are situated chiefly in the center of the Cylindrical bones. particularly those that are subject to Vississitudes of weather as the Tibia sometimes the clavicle and sternum. 259 Treatment. Besides the Mercurial plan local means are frequently necessary. soap plaisters to the part lessens the pain &c When there is much inflammation apply a Blister to the part before you give Mercury - nocturnal pains are lessened by wearing fleecy hosiery and woollen stockings during day - If a Node contains fluid do not be hasty to open it for exfoliation will ensue and the cure take up many months. if there is not inflammation the Glary fluid is absorbed by the use of Mercury and the periosteum again adheres to the bones - If suppuration has taken place leave it to Burst of its own accord. These effects in nodes are more frequent in the cranium than any other part: where tumours containing fluid form upon the cranium excite mercurial action quickly and if the skin is not red the fluid will be absorbed - Symptoms of Venereal Disease Universal pains in the Bones distinguished from Rheumatism by being more nocturnal not affecting the Joints like Rheumatism but the Bones: no nodes attend this pain Venereal Pains require a longer course of 260 Mercury than nodes. small moveable venereal tumours are found sometimes in the cellular membranes. in Various parts as large as small marble. They appear like Glands but are quite distant from their situation. there are nocturnal pains which are very difficult of cure. taking 9 weeks under mercury Another situation in the Testicles this is quite different to hernia humoralis in Gonorrhoea, it is an enlargement of one of Testicles- cure Mercury – sometimes in Venereal diseases there occurs after a clap a red line extending from the lips of the urethra along the rapha to the Anus, and has the appearance of Erysipelatous inflammation. Care by mercury Another spasms of the abductor muscles of the Eye drawing the Pupil to one side quite within the socket. Cure mercury – The Venereal disease may be contracted without the contact of the organs of Generation Venereal Matter to the scratch on the Finger produces a Chancre on the part with very Violent inflamation. the absorbents are inflamed to the Axilla. where a Gland becomes enlarged with constitutional irritation so as to endanger life the sore puts on a sloughing appearance 261 Treatment. Apply Aq: Calcis & Calomel. Subdue the inflammation by the antiphlogistic plan. and then give mercury - General remarks on the disease & on the effects of Mercury upon the Body. the Venereal disease only effects a few parts of the body viz the Urethra. the surface of the Glans penis. the first Gland in the Groin The Throat. the skin, and Bones. the Brain the different Viscera - and all the principal Vital organs are not [illegible] effected - Venereal symptoms are divided into primary and secondary. the Three primary are 1st. Gonorrhoea 2nd. Chancre. and 3rd Bubo - The Three secondary are 1st. Throat 2nd skin. and 3rd Bones. however Bubo is not always primary but where there has been no chancre. It is possible for a Bubo to be Venereal altho there has no disease upon the penis - Mr. Hunter has considered the Venereal complaint to be merely a local disease. that is unattended with Fever Mr. Cooper denies it and advances the following arguments. viz that there is a regular exacerbation every evening and that the pulse are quicker &c 2ndly that before 262 the appearance of the Venereal disease and even after he feels unwell having a feverish paroxysm every Evening - Mr. Hunter also says that a child at the Breast of a Woman having the Venereal disease cannot catch the infection, To this Mr. Cooper is Certain to the Contrary. some persons have not susceptibility to receive the Venereal disease altho they may have frequent connections with foul Women. some persons are susceptible only of the affection of gonorrhoea and no other form, as Chancre or Bubo. Persons who have been much on the Town escape the infection when at the same time a person from the country having connexion with some woman will catch the disease. In healthy constitution the Venereal disease is unattended with inflammation or very little: when there is much inflammation mercury disagrees and the disease is more difficult of cure. Mr. Cooper says that Gonorrhoea is not truly Venereal: chancre cannot produce Gonorrhoea nor Gonorrhoea chancres The Venereal Disease in the Throat often takes place without chancre or Bubo. the Poison frequently gets into the Blood and affect the Throat without affecting the 263 the Urethra or Groin- Matter taken from the Throat and inoculated, does not produce the Disease. the Matter by passing the absorbents becomes changed in its nature Matter from Bubo, will not produce Bubo - Effects of Mercury- Mercury effects a Fever in the constitution throughout. which action overpowers and at length destroys the Venereal action in the particular parts. Rule of Cure. The cure of Venereal Disease does not depend on the quantity of Mercury used nor upon the action it excites in a given time but upon the Action being supported for a length of time To Cure a Chancre the Mercurial Action should be kept up for three weeks. To Cure a Bubo from three to four weeks, none of the secondary symptoms are cured under 5 weeks. some of a peculiar habit require 11 or 12 weeks. The Patient should rub in from 12 or 14 times for a Bubo. 2 night, and missing one and sometimes every other night. chancre may be cured by nine times 2 nights and missing one - some persons require much more Mercury to affect the constitution than others some are 264 not affected at all. such persons are of an indolent and scrophulous habit in such cases when afflicted with scrophulous symptoms give the Patient Mercury. keep him warm and let him live upon a cow diet as Liquid Aliment &c. putting the feet in warm water will quicken the circulation - In summer Mercurial Action is sooner excited than it Winter - Also during friction it is a good plan for the Patient to immerse his Legs up to the knees in Water as hot as he can bear it. the warm bath quickens the Mercurial action - A Woman that gives suck cannot be salivated let the amount of Mercury be ever so great-. on the contrary some persons are very soon affected especially those of irritable habits and quick pulse Calomel :3 gr scammon 5 gr has been know to excite salivation, In stout and strong constitutions a 1 dram of Ungn. Hydrarg : fort rubbd in for two or three nights will excite mercurial action while those who seem thin and weak are not at all affected - those having a quick and small pulse are most easily affected, desist. from the use of Mercury when it 265 excites much Fever. there is always a slight chill down the back when it begins to act. if the pulse is quickened and there is a slight fever leave off its use likewise if there is much sweating for if it does it never affects the system. passes off and injures the health. Give Bark and Vitriolic Acid till the sweating ceases. some persons are very quickly salivated without effect on the constitution is they have no soreness of the gums nor swelling of the cheeks Country Air is proper for such persons. In London and in all large Towns there is frequently sloughings of the Venereal Sores which hinders The Cure - here leave of Mercury & give equal parts of Bark & Sarsaparilla, and a considerable quantity of opium. Country Air is the best. after you may give Mercury when the debility of the constitution is gone off - Forms of Mercury. the best is Mercurial friction. begin with Ungn. Merc fort as before directed till the Mouth is affected 266 and as soon as it is affected 1 dram every other night increasing on diminishing it according to the effect it produces on the constitution carry it on progressively untill it produces considerable effect towards the end. you may let the patient walk about for the first three weeks of the course, then let him lay by for a fortnight by this means you will obtain a permanent Cure Next the Blue Pill composed of iÿ grains of Quicksilver and 1/4 gr. of Opium this taken every night and morning Increase the dose if necessary : Opium prevents it from purging. Calomel & Hydrarg Muriate should not be given as they run off by the bowels &c- Calomel is only required when the Mouth is difficult to be effected. This form of Mercury agrees well with some and not with others - next Rx Hydrarg: Muriat grÿ vel 4 Sp. Aether Nit ℥ÿ M Capt. corhl i paru bis terve die. this produces a slow effect upon the system and at the same time improves the health - when the effects of Mercury continue and the salvation does not stop. Rx Argent: Nitrat gr ÿ Aq: Purae ℥iv M the mouth to be Gargled with a Tablespoonful of it. three times a Day its Astringency Braces the relaxd parts 267 The infusion of Roses cum Acid Nitrosi is also useful. at the same time give wine and expose the Body to cold air. the Patient should be careful of catching cold. Mercury has been said to pervade the system in such a quantity. that even the sweat. the saliva. the Urine and Blood contain’d it Mr. Cooper was very anxious to have these experiments tried and it is found by the most accurate chemical tests that it is not true. he took from the arm of a Person in a state of salivation 6g of Blood not the 560 part of a Grain was found in it- A quart of saliva was then tried in which there was not the smallest quantity found: also he took a quart of Urine and there was none there – the effect produced on the Gold in the Pocket is in consequence of the Mercury hanging upon the Patients hands, we may therefore conclude that its nature is altered from pervading the system- Exema Mercuriale This Disease has in some instances proved fatal- Symptoms. Eruption upon the Belly and Thighs. The Eye Lid sometimes inflamed when it affects the Bowels the Patient falls a Victim to the Diarrhoea sometimes 24 the practicability of uniting parts when they have been quite separated- A Gentn. well known by Mr. Cooper. was when a boy playing with a mastiff. the dog flew at him and caught hold of the lower part of his nose and tore it so that it only hung by the skin of the lower part, it was immediately replaced by straps of sticking Plaster being secured and supported, it united so well that the cicatrix is not to be easily perceivd A lady had the lower part of her nose nearly separated by her head being thrust through the widow of her carriage in which she was overturned, it was united by the adhesive plaster and as perfectly as the above case- parts quite separated will if put together will not only unite but grow after their union- Mr. Hunter made a whimsical experiment, he wishd. to try if inserting the Testes of a Cock in the body of a hen would produce any sexual alteration. he did so, and although they did not produce any 268 the whole body is covered. Debility is extreme These eruptions are covered with a crust giving out and odour. When the Patient stands up the crust falls upon the floor and appears as if bran had been scattered sometimes it only Partial upon the Thighs If you scrape off the crust there will be an extreme discharge from the sore. the scrotum is also affected - Treatment. Sulphur internally. Tonics warm Bath. Aq: Lith: Acet. comp has failed. The best mode is country Air Tonics. and the following Lotion Rx Hydrarg: Muriat gr ÿ Aq: Calcis ℥ÿ M fs Lotio this is the yellow wash on the Aqua Phagedonica. the Patient should be wash’d with it from head to foot. it Produces no Mercurial effect - Introductory Lecture Surgery consists in proper Remedies to external disorders, and in performance of Various Operation. It is divided into principles and Practicals - In simple Fractures the Surgeon ought to keep the parts in Opposition. and in Compound Fractures the extremities of the bones are exposed with a bruise, and sometimes splinters which must be carefully removed. It is necessary to bring the two edges together: but If you do not succeed you then promote discharge by warm applications: Granulations follow and the cavity fills up when parts are bruised a sloughing takes place. which requires particular attention. In these cases nature herself will do a great deal - Index Page On Accidents - 1 On the Progress of Inflammation - 8 On specific Inflammation - 13 On Wounds - 21 On Lacerated wounds - 29 On Mortification - 37 On Injuries of the Head - 43 On the effects of compression of the Brain - 49 On Trepanning - 53 On Cataract - 59 On Couching - 68 On Fistula Lachrymalis - 72 Wounds of the Throat - 76 Wounded Arteries - 78 Dtt. - Joints - 79 On Hydrocele - 81 On the Operation for Hydrocele - 86 On Dislocation of the Vertebrae - 91 Page Dislocation of the Clavicle - 92 Ditto of the shoulder - 93 Ditto of the Elbow - 95 Ditto of Wrist - 97 Ditto of the Hip Joint - 98 Ditto of the Patella - 101 Ditto of the knee Joint - 103 Ditto of the Ankle - 105 Incysted Tumours - 107 On diseases of the Testicle - 108 On Aneurism - 112 On Fistula in Ano - 121 On Amputation - 123 Ditto of the Metatarsal - 124 Ditto of the Leg - 125 Ditto of Thigh - 127 Ditto of the Wrist - 127 Ditto of the fore Arm - 128 Ditto of the shoulder Joint - 129 On Diseases of the Female Breasts - 130 On Hydatid Tumours in the Female Breast - 133 Page The Operation for Schirrus Breasts - 133 The Method of Introducing the Female Catheter - 134 The Method of Introducing the Male Catheter - 135 On Opening the Temporal Artery - 135 On Lithotomy - 136 Method of performing the Operation in Male - 138 Ditto in Female - 142 On Suspend Animation - 143 On submersion under Water - 143 Suspension - 143 Introduction of Noxious Air - 144 of Extraneous bodies - 145 Means of recovery - 146 Bronchotomy - 147 Operation for Suppression of Urine - 148 Of Calculi in the Urethra - 149 Cancer of the Penis - 153 Amputation of Dtt - 153 On the Hare Lip - 154 Page Operation for Hare Lip - 155 Of Nasal Polypi - 156 Operation for Dtt - 157 On Dropsy & the Method of Operating - 159 On Scrophula Character of Scrophulous Persons - Treatment - Tabes Mesenterica Scrophulous affections of the Joint - Treatment - Scrophulous Hip Joint Ulceration of ye Vertebrae Scrophulous Ophthalmia Testicle On Gunshot wounds Treatment Burns & Scalds Sprains - Fractures - Compound Fractures Wounds of Veins Page Wounds of nerves Wounds of Tendons - Wounds of the Abdomen Wounds of the small Intestines - Dtt. of the large Intestines Dtt. of the Liver Dtt. of the Gall Bladder Dtt. of the Spleen Dtt. of the Chest. Dtt. of the Lungs - Dtt. of the Heart. Tix. Doloreux - On Gonorrhoea The seat of Gonorrhoea Treatment - Stricture the seat of Stricture Treatment for Stricture Use of Caustic Bougie Spasmodic stricture Irritability extending to the Bladder - Bloody Urine Inflammation & enlargement of the Prostate Gland Treatment - Bleeding from the Urethra Chordee - Hernia Humoralis - Sympathetic Bubo - Impotence - Loss of testicle - Emissions & Impressions &c Gleet - Seat of Gleet - External: Gonorrhoea - Ophthalmia occasioned by Dtt. Gonorrhoea in Females Gleet in Females - Chancres Sympathetic Bubo Phymosis - Paraphymosis - On sloughing - Warts - Page Chancres in Women - Opening a Bubo - Indolent Bubo - Sloughing Bubo - Venerea Ulcers in the Throat - Page Venereal Eruptions. Dtt. Diseases in the Bones Symptoms of the Venereal Disease General remarks on Dtt - Exema Mercuriale - 25 change of that kind, yet they grew and were filled by an injection thrown into the surrounding part- the spur of a young cock being inserted into the comb will grow to the same size as on the Leg- A preparation was handed round the theatre in which a human tooth had been inserted into the comb of a cock and the periosteum of the Tooth was so firmly united that it may be forcibly pulled without any fear of the separation - A Tobacconist in the Borrough had the first joint of his finger cutt off, it was replaced by Mr. Lucas and the soft part united, the nail grew, but the Phalanx exfoliated at the Joint of the finger- soft parts will readily unite on account of their admitting the elongation of the vessels, but hard parts will not - Mr. L. Bell in his fist addition of his system of surgery ridiculed the idea of uniting separated parts, but being in London and seeing the instances above mentiond. he was convinced of the probability of uniting them and in the subsequent 26 editions of his surgery ingeniously confessed his error - A curious operation lately common among the natives of India proves how parts that have been divided may be united. It was the custom of Hydor Ally and his son Tippoo said to cut of the noses of their prisoners to remedy this defect a piece of wax nicely moulded to the shape of the nose is applied to the part and a piece of skin the size and shape sufficient to cover it is cut from from the forehead and is turnd. down over the wax nose, the upper side of the skin is placd. outwards, it is united to the forehead by a small slip left undivided and the edges are inserted into each of the artificial nose, the whole is firmly united in a short time, the strap on the forehead is divided and no one could distinguish the artificial nose from the natural one; the turban hiding the cicatrix on the forehead, the union by the first intention takes place sooner on the upper extremities than 27 in the lower, as the circulation is stronger in those parts, for the same reason it is more difficult in old persons where the circulation is weak the Vessels do not elongate - the impediments to the union by the first intention are irritability of constitution where suppuration takes place, introduction of extraneous bodies ligatures the division of many absorbents, as in transverse wounds of the groin where extravasated lymph prevents union of the parts by the first intention, to promote this union we should not open the parts after the first dressing for ten days or a Fortnight if they are not painfull. if they are exposed too soon inflammation comes on and the cure is protracted - of the importance of union by the first intention as soon as that is effected the danger is over, its quickness [illegible] takes place in as many days as the same wound be weeks in healing by the other means- in the old method of amputating when the Limb was cut 28 off strait, lint and flower applied to the stump the discharge was very great, suppuration frequently took place and the patients frequently died the present method of applying adhesive plaisters soon produces an union and it is very seldom that any bad effects follow amputation, the method of applying the adhesive plaister may be used whenever the Bone supports the parts as in the scalp, neck, longitudinal wounds of the limbs &c &c Wounds of the face if the muscles are divided require sutures as do wounds of the throat, triangular wounds of the extremities, deep transverse wounds of the muscles all require sutures are described in old books of surgery but only two are admitted in the present practice the interrupted and the pulled the first for the wound, above mention'd, and the last for long wounds of the abdomen we should always be carefull to introduce as few sutures as posible - 29 On Lacerated Wounds Lacerated wounds are very little different from the incised, they bleed less, extraneous bodies are frequently introducd., it is difficult to remove them, but necessary if parts are healed by the first intention without removeing them abcesses will ensue, A man had lacerated his scalp by a fall from a scaffold the part was laid over the scull and union took place, matter afterwards form,d in several places, and many small pebbles workd. out - Lacerations are most dangerous in the tendinous parts and frequently occasions lockd. jaws, attempt to produce union by the first intention but if inflamation comes on change your plan to poultices & - contusd. wounds are dangerous they disorganize the parts and hinder the circulation, blood is extravasated in the cellular membrane, inflamation & mortification 30 ensue, these wound are not to be united by the first intention - poultices should be applied to the wounds, and if sloughing comes on hot fomentation should also be applied, as they generally expedite the process of the sloughing, if the inflammation goes on Leeches should be applied, and the swelld. part of the limb should be bathed with St. brine; Camph, as the process of sloughing is attended with irritation, Bark &c should not be given. Opium given in saline draughts will give great relief when the inflamation has subsided, then Bark wine and strengthening remedies should be administerd, - We ought to observe where the process of sloughing is the effect of constitution and not accident, Bark may be given, as in this case it is not attended with irritation which accompanies it when from accident - Punctured wounds are the most dangerous, their effects arise from, two causes, the operation of the nerves and absorbents, but the most 31 common effects is inflamation of the absorbent vessels, the symptoms of this is great pain in the part, red lines extend up the limbs the auxilla enlarges, pulse becomes quick and hard the knees swell and become stiff, delirium comes on and the patient dies; - A young man a Pupil in the Hospital had opened the Body of a man, and in sewing it up he prickd. the tip of his finger, in the evening he complain,d of pain and applied a poultice during the night be became delirious the next day he was calmer, but ye following morning the symptoms returnd, and he died about two o Clock, - A man who had puncturd, his finger had suppuration come on in the axilla the discharge from which was so great that it killed him the effects are produced. by the inflammation spreading through a great number of the absorbents, as these cases have occurred frequently in the practice of dissection, it has been a common opinion that putridity 32 was absorbed, but it does not seem to arise from this but more from the sort of wound and constitution of the person puncturd. - this was the case with the person before mentiond, as the Body was opened before putrefaction came on, and we frequently find that the same symptoms occur from accident where absorption of any kind is impossible Mr. Lucas Surgeon at Guy's had all the symptoms and was very near loosing his life by pricking his finger with the point of a buckle, it was in consequence of putrid matter only, the absorbent vessels that receivd. it would be affected in this case a sharp instrument is thrust into the cellular membrane, where the mouths of many absorbents are lodged, it wounds some and the inflammation spreads along their internal surface, these effects takes place in the constitutions naturally irritable. in those who are intemperate, or those who by long confinement to the close and bad air 33 of the dissecting room have acquired a considerable degree of irritability- Putrid matter has been injected into the cellular membrane of animals, which only produces a swelling that is absorbd. in three days & that without any ill effect to the animal The treatment necessary for punctured wounds of this kind, is to dilate the wound apply a poultice to the part, a frequent application of Leeches- Mr. Cooper applied 31 at different times to the arm of patient the limb should be fomented after the application of Leeches, saline medicine should be given, Calomel & [E?t] Cath should be used and if there is a tendency to delirium opium should be given, many persons has been destroyed by stimulating medicines given in these cases. on supposition of putrid matter being absorbd. - Dr. Watts having mett with an accident of this kind, when the symptoms came on took wine very freely and died in 9 hours - Mr. Cooper when a young man dissecting a body at surgeon's hall punctured his thumb, the symptoms came on 34 and he at first pursued a lowering plan by the advice of a Physician who was an advocate for the stimulating plan, he took a few glasses of wine and on finding the symptoms increase he desisted had a very painfull Night, and the next morning found one of his knees swelld. and stiff, he applied a blister and before that relieved him stiffness and swelling came on in the other knee, had he taken a few glasses more wine it would have killd him - A Gentleman fond of dissecting, punctured his hand, on opening the body and being fearful of venereal infection, rubbd in a large quantity of mercurial ointment and died in a few hours- The nerves are most frequently injured by punctures of the slighter kind the punctures happen generally on the feet and hands, and one ever so slight as to be healed before the symptoms come on may produce a lockd. Jaw. Dr. Ludlow lately died of Lockd. Jaw 35 in consequence of running a thorn into one of his fingers, the first symptoms of Lockd. Jaw is a stiffness of the Mastoid muscles, the Jaw becomes lockd, and is generally more firmly so in the beginning of the disorder ; tinitus aurium and chilliness attends, the Joints are affected and cannot be freely bent, violent spasms of the back come on and the body is bent backwards, it affects the muscles of the abdomen, which are hard and do not yield to the touch, the cheeks and corner of the mouth are drawn upwards and the face is much wrinkled, the body becomes stiff, the muscles of respiration are lastly affected and the patient dies, but most frequently he is attackd. with convulsion fits, the intervals of which becomes shorter & shorter till they carry off the patient in lockd. Jaws there is little disposition to sleep, if he does sleep the Jaw relaxes but shuts closely on waking there is frequently a profuse cold perspiration 36 the body is costive little urine is made and the pulse is from 90 to 160, we have not a sufficient number of cases that have terminated successfully to point out in certain mode to proceed on, the warm bath does no good in this disorder, it may in warm climates, but will not in this, opium will not relieve the spasms. A man at Guys Hospital took the first night of his admission 360 drops in three doses the next morning be took 310, at several doses in the evening he took an ounce at one dose at eight o Clock and at 11 in the same evening he took half an ounce at one dose he died the same night the opiate produced no effect on the spams, Brandy and stimulants faild., the removal of the punctured parts has no effect after the symptoms are commenced Tobacco Glysters give temporary relief but weeken to much for repetition Digitalis was unsuccessfull two cases have been lately successfully treated in the Hospital. A man run a nail into his foot, a week after the symptoms came on and he was admitted into 37 the Hospital, the cold bath only was tried he was allowd. a small quantity of wine, when the spasms came on he went into the bath which constantly relievd him the spasms were thus kept down and he recovered – in the second case Tinct ferri:muriat having been successful in some spasmodic affections, it was determined to make a trial of it in lockd. Jaw- it was given in this case in such a quantity as to keep a constant nausea 60 drops was given every ten minutes, but on this making the mouth very sore it was discontinued, and took 5 grains of ferri Vitriol in its stead this kept up the nausea the spasms were restraind, and he recoverd, he went into the cold bath once but it increasd, the symptoms On Mortification Mortification or Gangrene are synonymous terms signifying the death of a part the rest of the body being sound spacetus 38 signifies the act of separation of the dead part from the living, the first symptoms are those of violent inflammations, great swelling skin florid red, violent pain with quick pulse, loss of rest, and delirium, after which the part suddenly becomes easy, small vesications appearing on its surface containing a sanious dark colour fluid, the skin under these vesications is dark purple and insensible, hiccup comes on partial flushing of the cheeks, and if the part is small the Patient may live, if large dies- When mortification is producd in consequence of exposure to cold only the symptoms are, the parts becomes benumd. feels swelld. when pressed, the inflamation arise when the part is warmed, there is very little pain or constitutional affection, the inflammation abates and returns three or four times before the mortification commences, but in colder countries, such 39 as Russia, the parts become at once perfectly white and sloughing off without any previous inflamation, Thus when the mortification has happened the next process is the separation of the dead part from the living or spacitation which begins first by the appearance of white prominent line between the dead and living part which is the rising of the cuticle under which is a small furrow containing a quantity of serous matter, this is the first sign of the cessation of mortification, the Groove is formed by the absorption of the living part, this gradually extends deeper through the cellular membrane and muscle, until the whole dead part is removed, granulations are thrown out from the living part of the groove, by which the dead parts becomes thrown off: the largest arteries in the Body under these circumstances become separated without any hemorrhage for it is prevented by the formation of coagulum 40 very high up in the sound artery – the separation is the same in all cases, from whatever cause the mortification arises: the predisposing cause is debility: by whatever means it is induced; as by continued fever a mortification is producd. of the Hips when laying in bed the same time with Compound Fracture if the constitution is good no such effects follow it is soon producd. in old people as the circulation is most languid - more common in the extremities than the trunk. they being so much further from the Heart. Tentons are more liable to it than muscles as their living power is much less, loss of blood when great especially of stumps when the limb has been previously removed on out of mortification The occasional causes of Mortification are inflammations violent bruises destroying the texture of the part, and a disease of the Heart as Hydros pectoris. means of prevention when it arises from high inflamation, leeches should be applied to the part. cathartics must 41 be administered, apply the poppy fomentation, and stale beer poultice, or wine Lees, or sps. of wine mix'd in the poultice. when the inflamation is a little abated, give Tinct of Opii & the Bark freely every two hours, which however must not be dependd. upon, if the pain becomes less and the pulse not full, wine may be allowed, but better not while there is much inflammation, unless the person has lived very free before, when the mortification has happend. you must give wine freely - opii gr ij every two hours, cinchonæ and confect: aromat or the Bolus with cayenne pepper, fomentations and stimulating poultices, untill the part is separated, which should not be used to long and should afterwards use Turpentine dressings as soon as you can, Amputation ought never to be performd, while mortification is going on nor till the patient has in some degree recoverd, the irritating effects of it on the constitution and never as soon as the mortification has ceased unless from the inconvenient length of the stumps. it is not at all necessary as the parts 42 will separate of themselves - the Bone shortest the muscles longer than it, and the skin the longest of all so as to form every good stump which will readily heal, - In the mortification which arises from cold - sps. wine and Camph should be applied in such a manner that evaporation can take place and the stimulus created by it, be moderated by the cold produced if this does not succeed moderately, warm poultices an fomentation must be used and in cold countries rub the part with snow which produces a certain warmth moderated by the melting of the snow, mortification of the Feet in old people who have lived very high, begins with pain in his ancle and along the top of the Foot, and a Toe or toes appear black, the upper part of the foot florid, red, and then turning black, extending sometimes up to the calf of the leg, it mostly confines itself to the toes, and then the patient generally does well, occurs chiefly in tall people 43 sometimes also from ossification of the arteries this generally arises in people who having livd. very freely are suddenly deprivd. of their nutriment in this state opium is the best remedy combind. with wine and Brandy and fomentations of milk and water- Injuries of the Head First symptoms of injuries happening to the Brain are nausea vomiting, loss of sense and voluntary motion, fœces pass off involuntary and so does the urine in the same manner as when injury is done to the spine - Bleeding from the nose and Ears, and sometimes vomiting of Blood, as it gets from the back of the fauces into the stomach - A labouring slow irregular intermitting pulse, pupil in some cases dilated, in others not, it is sometimes contracted, but then there generally is spicule of bone, driven in and irritating the brain, respiration is sometimes affected with apoplectic 44 terror convulsions sometimes takes place if light, but if there is injury receivd on one side of the Head there is hemoplegic . - strabismus is the consequence of it and deafness: These symptoms generally arise from two causes only 1st, concussion of the brain 2nd pressure on that organ causing inflammation on concussion of the brain - The first circumstance to be attended to is to distinguish concussion from compression in concussion the breathing is not at first affected, nor is the pulse, sleep is easy the effects of concussion have been thought to arise from the motion being so violent at to interrupt the circulation here, but it appears to arise from laceration of the fibres of the brain as appears by dissection, the part about being of a red colour, and a worm eaten appearance, in slight concussions an altered action of the circulation is produced preventing 45 Ideas being formed - Treatment. In slight cases of concussion sickness is of service we are to consider whether Emetics are to be used when other means have failed, the first thing that must be done is to bleed very copiously, and if the pulse are full bleed as long, and as often as twice a day for several days if necessary, so as to bring it to the natural standard, it is much better to take blood from the jugular or from the Temporal artery as it relieves more speedy than from any other part- in slight cases of concussion Leeches may be applied to the Temple, in concussion of the brain it is wonderfull what quantity of blood will be lost before the pulse is brought to its natural standard or the symptoms relieved - A man was admitted into St. Ths. Hospital May 12th 1803 for concussion of the brain he was bled on that day four different times 8 oz. 16 oz 16 oz - 10 oz - the 13th - 10 oz- 14th 12 oz 10th 12 oz 46 in consequence of intemperance he got worse on the 26th and was bled again twice 32 oz. on the 28th - 10oz - 30th 16 oz. June 1st 10 oz. and in the end perfectly recoverd. losing in the whole 152 oz of blood, this was done under Mr. Cooper, directions, and the blood was drawn by his apprentice - drastic purges should be given freely, antimonials to keep up a diaphoresis, Calomel & Pulv Antim ought to be given in preference to Pulv Ipecac:Comp, a blister to be applied to the whole scalp its use depends on withdrawing the blood from the brain, if incission has been made to search for [the] a Fracture we ought to apply a poultice to it, and procure a discharge then heal it directly, mix Ol. Terebinth in the poultice it has the same effect as a blister. no cordials as wine &c should be allowd, on any account. Trepaning here is totally useless and very dangerous, The opening of the 47 Jugular vein will often put a stop to it when it will fail from the arm, particularly in children, the opening of the Temporal Artery is very usefull, and in extremely young children Leeches are very useful, Partial symptoms occurring from the accident are very difficult of cure, so much so, as the most violent ones such as loss of recollection or Epileptic fits afterwards, these symptoms are also caused by slighter injures to the Head, but these may sometimes be moderated and relieved by a seton in the neck, a partial loss of hearing or sight is sometimes the consequence, and which have been cured by Electricity if applied early - loss of memory is almost always the consequence of it - A man was admitted into the Hospital for concussion of the brain and when he began to get better, spoke different language. in short he perfectly lost the English language, so that there was no person in the Hospital that could understand him 48 A woman who sold milk accidentally coming into the ward and on hearing him talk answerd. him, and it it was discoverd, that he had been talking Welsh, & it was a considerable time before he got his English again, this case tho' remarkable as to be scarcely creditd. all the surgeon in the Hospital well remember - A Gentn recievd. a blow on the forehead and was stunned, in consequence he when home and vomitted and felt relievd. by it, the next day he complaind. of pain in the Head the vomitting came on, and for many weeks continued vomitting once a day and was relieved. it at last got to twice and three times a day and continued - the Trephine was applied to examine the dura mater & was found perfectly sound and in a good state; he lost his reason and died soon after in consequence of this slight blow on the Head- This shews that it was wrong to perform the operation 49 On the effects of compression of the Brain Pressure may arise from three causes. 1st from extravasation of blood within the cranium 2dly. depression of bone in consequence of a Fracture 3rdly. the formation of matter in the brain. - 1st Extravasation of blood within the cranium. The symptoms do not come on directly but will in an hour or two, (in concussion the symptoms come on immediately)- the breathing is laborious, pulse full slow & irregular, Extravasation is always accompanied by a fracture: a simple fracture of the scull without any depression or symptoms of injury does not require trepanning or any thing but the antiphlogistic treatment but when there is depression the symptom, of pressure come on and in violence proportionate to the degree of pressure produced. A great depression may sometimes be felt in some of these accidents 50 Without any symptoms of pressure ensuing, but in this cases the depression is only of the external table, and therefore you should not trepan without symptoms of depression - . a great depression will also take place in young children without any fracture or harm as their bones are very soft. - If symptoms of injury to the brain come on or if with the depression there is an external wound then you should trepan for if in this case you do not inflamation of the dura mater will come on with delirium and will kill the patient, but if there is no external wound neither trepan no make an incission nor if a patient has a depression and external opening so that a portion of brain equal to the diminished space is removd. you need not trepan - A person who has once 51 had a concussion or compression is liable to have some of these symptoms come at a future period. he should therefore if possible keep himself quiet and loose from time to time small quantities of blood. Extravasation between the dura mater and Pia Mater or between the dura mater and bone requires trepanning to be performd., the quantity extravasated sometimes is very small and sometimes large but the dura mater is not to be opend. for it will yield when the bony support is taken away inflammation on the Brain from accident, generally comes on about the 10th day after the accident sometimes as soon as the seventh and even as late as the 21st it begins by pain in the Head on the injured side generally it pulsates if there is a wound the slough becomes brown and there is no discharge. the scalp about the injurd. part pits, it is an odematous swelling. the Patient is siezd. with frequent rigors followd by heat the Eye inflamd., cheeks flushed, pulse 52 quick and irregular, body costive, feet cold, and when matter is collecting on the dura mater or Brain, respiration becomes laborious as soon as these symptoms appear the patient ought to be trepanned, when the scalp is cut through, the Pericranium will be found to be detatched and on perforating you will find the matter between the dura Mater and the bone gush out as soon as you make an opening. be careful in puncturing the dura mater when you wish to see whether is matter is lodged between the membranes, it ought to be carefully obliquely. but even here the surgeon has often failed for it is situated sometimes at the basis of the scull and the case is renderd. irretrievable - Mr. C. never knew a case succeed where the dura Mater had been puncturd. for this purpose before you operate bleed freely. if compression accompanies fracture many hours ought not to elapse before the operation use purgative & VS - the object here is to take away the extravasated blood under the bone - 53 On Trepanning There are parts of the Head where Trepanning ought not to be performed as on the middle of the os frontis over its spine except in young subjects where there is none. above the Eye brows where the frontal sinusses are placed, nor over the coronal sagital suture, or lambdoidal sutures on account of the firm adhesion between the Dura mater and the suture, however it may be done here if absolutely necessary, the sagital suture has been objected to on account of wounding the longitudinal sinus. but that is of no consequence as a pledget of lint will most commonly stop the Haemorrhage, and the immediate discharge of blood from the part is often advantageous, the anterior & inferior angle of the os parietale one inch before the Ear has also been objected to as the Dura matrel artery passes throug a foramen in this angle of the bone and if cut was supposed to be dangerous, however the 54 Hemorrhage may be stoppd with a dossil of lint and it does not prove troublesome This angle of the bone is situated just above the zyogomatic arch — To be certain where the situation of the fracture is you ought to make a crucial incission over the suspected part and turn up the edges of the scalp and examine the bone beneath: if you find a fracture you must trace it by making a longitudinal incision slowly and carefully along its course. if a great separation has taken place take care your knife does not slip and injure the membranes - when the operation of trepanning is inevitable and determind, on, the instruments necessary are the scalpel, Rougine, perforator, Trephine, or instead of perforator, a Trephine with a central moveable pin to act as a perforator. and afterwards to fix the crown of the instrument to work steady, the elevator and Lenticular which is a very bad instrument as it separates so much 55 dura mater from the scull as to cause exfoliation, lastly a pair of forceps which are of no use till the bone is sawd. completely round and is loose, but as this is a very dangerous practice it is rarely employd. - After you have made your crucial incision you are to remove the pericranium which should not be separated further than it is necessary to admit the Trephine, for if you do separate more pericranium than you want an exfoliation will ensue, when you use the old instruments you must make a small hole in the cranium with the perforator into which the central pin in the crown of the trephine is to be applied and continued till you have made a grove sufficiently deep to make the saw work steadily & then to be removed otherwise will protrude beyond the teeth of the saw and perforate the membrane, now when the instruments are used you make the perforation and all with the central pin till you have 56 formed a sufficient grove to work the saw steadily; the screw the central pin up and the instrument will work as before. when the perforator is removed and grove deepens, you must frequently and carefully examine with the end of an eyed probe, in the operation you ought by no means to be hasty or you may slip thro, and if a surgeon has once done so he ought never to be suffered to operate again as it may so easily be prevented by attending to the following rules, after have been sometime sawing and when you are you ought frequently to change hands, to prevent the instrument from hitching you will find a small portion of blood come up by the sides of the Teeth of the saw which tells you that you have entered the diploe which is generally about two thirds through 57 the thickness of the bone, you must then proceed with still greater caution and examine the grove every turn or two of the as it is often extremely thin, as soon as you find the bone completely perforated at any one part then introduce the point of the Elevator under it and the circular portion as far as you can and raise it up gently- by using the elevator at this time you prevent any injury being done to the dura mater which will be avoided for the Teeth of the saw will not come in contact with it, and if at this time the bone will not yield, make another carefull turning or two of the circular saw not pressing so much on that part which is perforated- on raising up the piece of bone there will be roughness left on the scull which may be removd. by the elevator as easily as the Lenticular which ought never to be used, but if [they] it does remain it is not of the least importance. If when you have raisd the bone you find an extravasation which appears in 58 large quantity, another piece of bone ought to be taken out in its course so as to expose it rather than pass a probe or scoop under it- there is never any danger in Trepanning when you find extravasated matter under the bone as you will find the dura mater a great way separated from the bone- and when you have removd, the matter apply a poultice over it- In trepanning for depression of the scull the Instrument should be applied on two thirds of the sound bone and one third of the depressd. then pass the elevator under the depressd. portion and raise it up into its natural place resting on the opposite sound portion If any portion of the depressd bone lies under the sound piece that has been removd. it must be sawd. off or two pieces be removd. before you can raise the bone If there is any wound on the Brain endeavor to unite the external wound as soon as posible 59 by which you may probably cause an adhesion between the dura mater and scalp When in consequence of Fracture you find extravasation, and on operating you ought to leave the integuments open by introducing a dossil of Lint and apply poultices to facilitate the discharge of the extravasation- when Trepanning has been performd. for Fracture with depression & the the depressd portion has been elevated bring the edges of the integuments together and unite as much as possible by the first intention by which means you will prevent exfoliation - On Cataract It is an opacity of the crystaline lens or the capsule in which the humours is containd. both producing the same appearance and symptoms, the first symptoms to be noticd. are sparks appearing to the patient moving in the Eye and one of these spots 60 seem situated in the same place, 2nd dimness of sight 3rd. that the patient see’s better in the evening than in the day time, and which is a principal criterion you may Judge this disease by, and further on looking into the Eye you will perceive a pearly appearance, the whiteness does not always come at once sometimes by a speck, sometimes in many parts over the lens - in a strong light the pupil becomes so much contracted that all the rays are thrown on the opaque spot and in a weak light the pupil becomes so much dilated that the rays do not fall on the diseasd, spot which accts for the person seeing better in a weak light than a strong one - the Eye looks sometimes yellow like matter behind the pupil. A patient with a cataract never becomes perfectly blind so that he can always be able to 61 distinguish a small portion of light. The colour is generally uniform and sometimes streakd. which denotes the cataract to be soft or fluid, sometimes it is of a reddish brown or red and then it is difficult to determine whether it is a cataract or not - they vary in their consistence, sometimes quite solid and different degrees of firmness even the entire fluidity which is a rare circumstance The crystalline humour is met with in three states 1st solid and sometimes contain earth 2dly quite fluid and from that called milky cataract 3rdly. a part of each; it can be distinguishd. if solid you will see it streakd. & in cracks, in all children born with cataracts it is fluid or soon after born it is so. in all these cases it is only necessary to puncture it and let it out into the Eye - There is in families a disposition to form catararts so that this disease may in some degree be calld. hereditary - this is a most remarkable circumstance - [illegible] 62 A Gentleman under his knowledge had a cataract and his two Aunts, Father. Grandfather and Grandfather, Brother. had Cataract, many such cases came under his and Mr. Cline’s knowledge of the same kind - Cataract is sometimes loose and in general attachd. to the Vitrous humour when it arises from thickening of the capsule of the lens it may be judged of by the lens appearing much closer to the opening of the pupil, and like a membranous bag streakd, across the iris - the cause of it appears to be a slow continued inflamation in the capsule or the lens itself its structure has also been found completely alter'd and becoming ossified, medicine has generally faild. but you may try the Hydrarg Muriat & Electricity in slight cases - the removal of the cataract has been found the only sure cure when the crystaline humour becomes opaque it prevents the light passing to the optik nerve - there are two operations 63 1st Extraction. the other by putting needle into it and so open it to let the rays of light pass to the optic nerve - on Extraction the instrument used in this operation is a cornea knife which is shapd like a wedge and exactly like spear pointed lancet, the knife must gradually thicken from the point so as to completely fill the incision as it is made; to prevent the escape of the aquaues humour till the incision is made one edge of the knife must cut through its whole extent the other [over] about half an inch, the speculum formerly in use for fixing the Eye is now laid aside as it is to be fixd by the fingers pressing on the globe. 2d a small hook is used to scratch the capsule of the cristalizd. lens, or by a small instrument made like a very small Gum Lancet for infants 3rdly. a small silver scoop is also useful to remove any broken part of a cataract 4th a small pair of forceps to remove the capsule of the crystalizd. lens opaque - To prepare the patient for 64 this operation you ought to give him Calomel purges for some days previous as it will cause inflamation afterwards, convey a probe for some days under the Eye lid to ensure it to inflamation gradually, if the Patient is of a Plethoric habit Bleed, - The Patient should be placd. on a low chair. & the Surgeons Chair should be six inches higher. - Mr. Cooper thinks laying on a table till you have completed the section of the cornea, as soon as you have done this as the posture is unfavorable for the escape of the lens, the Patient should be directly raisd, up, the light of the room should fall obliquely on the Patient's eye for if strong the Iris contracts so much so that it is liable to be torn in the extraction and there is danger of forcing out the vitreous humour by the force you employ to force out the christalline - Mr. Ware is very particular in that respect and it 65 is owing to that he is so successful, the chair to have a back with a pillow behind and the patient being seated the Surgeon sitting opposite resting his elbow on his knee, The assistant is now to place himself and he is to draw back the edge of the eyelid with an handkerchief. to be careful in not pressing the Eye, but upon the bone, if he does he will prevent the operation from succeeding, the Surgeon with two fingers of the left hand is to hold down the under lid and with the other finger press the Globe of the Eye nigh the inner canthus into the transparent cornea a hair, a breadth before the opaque cornea just so far forwards to prevent wounding the iris - the point of the knife is the to be carried a little backwards to prevent its passing between the laminæ of the cornea, you are then to pass the knife quickly across the Eye and push it through the opposite part of the cornea which 66 should complete the section without drawing the knife back, as that would endanger the iris and loss of the aqueous humour as soon as this done the Eye should be directly closd,, and if there are two catarracts you should proceed with the same steps when the capsule of the Christaline [lenses] is found diseased after the extraction of the lens every portion of it should be immediately removd, by a very small pair of forceps it has been known to have been absorbed but that has happened very rarely - The difficulties in the operation are 1st some Eyes are so unsteady that it is almost imposible to confine them particularly those that are born so, 2nd. is when the knife is sometimes pressed between the laminae not the cornea, and therefore a sufficient opening is not made, you may think sometimes that the pupil does not move which will cause failure as afterwards the pupil will become considerably contracted & loose eye sight 67 before you perform the Operation look at the pupil to see whether it has the power of contraction, or whether it has what is called Gutta serena which you may easily perceive by holding a candle before the Eye and then he cannot see it. When the opacity before mentiond, takes place in the Christalized lens there is in this respect a different in opinion whether it is to be taken away or it will be absorbed by scratching. 99 out of 100 will remain opaque if the operation is not performed, and if it takes up 1/2 an hour or longer every capsule that is opaque ought to be extracted by a pair of forceps- the vitreous humour escapes frequently in consequence of irritation during the operation- supposing a quantity of milky fluid escapes you are not to suppose the operation is complete before you examine whether there is any opacity After the operation apply a linen rag over the eye dipped in equal parts of Brandy and Water - 68 the patient should be placed in a sitting posture in bed so that the Blood may not influence the part- to be kept extremely quiet, no light. & very low the Eye is not to be looked at –if very painful apply leeches, purgatives &c but if there is no pain no remedies is requird, - let the linen rag wett with Brandy and Water remain on three days then let the rag hang loose before the Eye and remain for some time taking care the light does not cause inflammation - On Couching Couching is called depression and carried to the inferior lateral part of the Eye with a needle. The patient is to be placd, in the same manner as in the Cataract the needle is to be put in the Centre of the pupil, the patient is to be in a chair and his head to be held 69 by an assistant the Eyelid to be held in the same way as in Cataract. The surgeon is to stand before the Patient with his hand resting on the temple, his Head to be a little inclind. so as not to prevent the light, the under Eyelid to be drawn by one finger and the Eye fixed by another, the operation consists as follows a needle (that was invented by Mr. Hays is best) is to be introduced first 16th of an inch behind where the transparent cornea joins with the opake and having done so instead of passing it transversely so as to cross the Eye, pass it into the center of the Eye, then the point is to be brought forward so as to see it behind the transparent cornea. that you have it upon the cataract let your instrument rest on the cataract - bring the Handle forwards & the point being by that means depressd, you will find the cataract passed from side to side - There are many objections that have been made against 70 Couching amongst the principal are that the Cataract is very apt to rise to its former place, and until Mr. Hay’s treatise upon the subject couching had almost ceased; yet this objection is not a real one as the operation may be performed several times and at last ultimately succeed. Mr. Hay’s perform it several times in one subject Another objection to this operation has been brought forward, that the needle would hurt the cornea retina &c, but this objection will not particularly hold good - when the capsule of the christaline lens is opake perform the operation of Extraction instead of couching – If the cataract is opake and is united to the iris couching ought not to be performd, The advantages of couching are 1st the ease and safety it is performed as you may see the step when the needle passes into the Eye, 2ndly. when it is 71 a fluid Cataract. this is one that there is great advantage over extraction as the humour will escape, in this case you are to pass the needle into the cristaline lens and tear a little - When children are born with cataracts, or have it soon after, the humour is always fluid the extreme mobility in the Eyes of Children prevents extraction from succeeding and therefore couching is preferred - it is necessary in young Children to use a Speculum under the upper Eyelid - A young Practitioner ought to begin with couching in preference to extraction – Mr. Cooper says that he has seen the Operation of Extraction performed may times but never successfully but once and that was by Mr. Ware 3 weeks ago- the Operation of Extraction ought to be performed only by those who have frequent opportunities - but those practitioners who have only an opportunity 3 or 4 in their life ought always to Couch 72 though extraction is certainly in another point of view to be preferrd. - On Fistula Lacrymalia This disease is divided in three stages 1st. It begins with a small tumor occurring at the corner of the Eye just below the tendon of the orbiculus muscle. As the Patient meets the wind the tears run over the cheek which side it happens. If you press the tumor you will perceive streams of mucus comming out of the Puncta Lachrymalia and dropping on the cheek, in this stage there is no pain felt and may remain for several years - in the 2nd stage it becomes red & inflamd in its first it is called uninflamd. in the 2nd it is called inflamd, and it its 3rd state ulcerated - If the Surgeon does noting it ulcerates & then tears getting into the cellular membrane it extends considerably down the rose. The 73 cause is generally from the venereal disease sometimes from scrophula. It has risen but that very rarely from cold small pox pustule in the part scarlatina anginosa - Treatment of the 1st stage When there is only a simple enlargement press on the tumor and empty it entirely, then inject white vitriol water into it by the puncture lachrymator first turning the Eyelid down introduce a briscle into the puncture as soon as you have done this introduce the syringe into the puncture by this means you throw it into the ductus adnasum, and by throwing it in the wash being admitted into the structurd. part and brace it - Sir Wm. Blizard recommend quicksilver to be sent into the sac- if the obstruction is not quite perfect it will do but if it is it will pass down the cheek Another method is to introduce a probe from the ductus adnasum into the lachrymal sac, but this requires in general more 74 resolution than the patient can exert In the 2nd stage it is necessary to open the sac as it is inflammatory. Feel for the margin of the orbit cut about half an inch below the tendon of orbicularis and 1/8 of an inch behind that ridge the cut into the Lachrymal sac The direction you are to cut by is the fibres of the tendon orbicularis, as soon as you have cut the lachrymal sac pass the probe into the ductus ad nasum if you find the obstruction is very strong order a poultice for 24 hours then try the probe and continue in the same manner from day to day as it may be a week or more before the stricture may give way- If after trying a fortnight without success a caustic bougie may be used- after you have succeeded in making a communication pass an instrument which is called stile into the ductus ad nasum to prevent it from closing and you are to leave it there 75 during the highly inflammatory state of the ductus ad nasum, do not leave it in but only pass a probe continually till the inflammation is gone off, as the stile will irritate and therefore order a poultice , if that does not decrease it then withdraw the stile for 24 hours. but it is necessary to continue the use of for 3 months at least- the 3rd an ulcerative state requires for its treatment somewhat of the same mode as the 2nd, when it is ulcerated it is much diminishd in size so that it is difficult unless you have a good anatomical knowledge to open it after cutting open the sac pass a trochar through the lachrymal sac on the os unguis break it down and thus pass it into the nose, this opening is very apt to close unless a bougie is worn for some months, to prevent which Mr. Cooper invented a cannula with the trocar which he leaves in, but so far as he 76 has seen the operation performed in this manner it has very rarely succeeded On Wounds of the Throat Wounds of the Throat have been frequently misunderstood and are in many books of surgery erroneously described on account of the complex Anatomical structure of the part not being attended to from the chin to the sternum is about nine inches, and may be divided into three equal parts, from the chin to the beginning of the larynx is about 3 inches The Tongue & its muscles fills up the front part of this space, the Pharynx the back part- wounds here pass through the tongue and its muscles into the pharynx - the next there inches reaches the whole length of the Larynx, here the Trachea is in front and esophagus behind it, the lobes of the Thyroid gland are united over it. the 77 carotid rtery lies on each side. The most common wound of the throat is in the first divition when the Tongue or its muscles are divided along with the Pharynx, the Breadth passes through the wound yet the air tube is not wounded. Air and Frothy blood passes from the wound. [of] food solid and liquid passes through the wound which proves the air tube is not injured if it was the food would be rejected with violent coughing. Bring the chin forwards, make five or six sutures and completely close the wound, adhesive plaisters is of no use, the sutures must not be passed deeper than the skin. solid food is easier swallowed than liquid. The Epiglottis not performing its office Liquids get into the Larynx and occasion Violent irritation. The patient should have a handkerchief dipt in Lemonade to keep in his mouth to prevent thirst - wounds of this kind 78 are not mortal but as they are generally made by persons who wish to try destroy themselves. They frequently irritate them and bring on bad effects - Wounds of the Arteries Wounds of the arteries requires much attention the symptoms of a wounded artery are blood of a florid red issuing per saltem corresponding with the action of the Heart. Fainting comes on immediately on receiving the wound; during the Fainting the Hamorrhage stops but as soon as the patient revives a little the Hamorrhage returns. They alternately faint and bleed till death ensues. if the artery is small the fainting effectually stops the Bleeding. The artery when wounded retracts and draws itself an inch or an inch & half above the wound. blood is extravasated into the cellular membrane which coagulates 79 presses on the mouth of the artery and stops it, the divided artery contracts as high as the first anastomosis branch. When an artery is thus stopt by pressure on the outside the Blood forms a coagulum within adheres to the coats of the artery and in time becomes vascular, the contraction of the Artery alone would not be adequate to stop the Hemorrhage without the pressure of the coagulum. When even a large artery is stopt if the constitution is good the circulation will be sufficently free not only to prevent mortification but to preserve a perfect use of the parts - On Wound Joints Wounds of the joint even when small are dangerous as a small one lays open an extensive surface the joint having a [se???ing] surface does not easily heal, the cartilage cannot through off matter but must be absorbed and granulation formed instead if Union by the first intention cannot be effected. The Synovia escaping from the wound will often hinder the union by the first intention. If 80 this does not take place in three or four days a violent and dangerous inflammation comes on. The constitutional symptoms runs high. Matter forms at the Joint in different parts, the abcess form and break one after another, protracts the cure and generally render the joint anchylose. In delicate constitutions Wounds of the Joints frequently terminate fatal. - In the treatment of these wounds the first object should be to unite them as soon as possible sutures must be applied in this but particular care must be taken that they pass no deeper than the skin. If deeper they are productive of much irritation likewise the edges must be still further united with the straps of adhesive plaister laid over the sutures afterwards a roller and the wound should not be opened as long as possible perfect use is necessary to the joints, that of the knee and frequently obliged to be opened to take out loose pieces of cartilage formed there - To perform this operation we must keep the cartilages steady by pressure 81 the skin should be drawn back a small incission made into the joint and the cartilage that is loose taken out by a tenaculum afterwards the skin should be drawn each way over the wound that the joint may be as little exposed as possible a suture should be made through the skin to secure it and the wound treated as above - On Hydrocele - By the term Hydrocele is meant an accumulation of water within the Tunica Vaginalis Testes which tunic is loosely reflected over the Testicle in the same manner as the pericardium is over the heart. This disease begins with a Tumour at the inferior part of the Testicle gradually extending round it, as the water accumulates it produces a tumor of pyramidal shape at which time it extends along the spermatic cord until it reaches the abdominal ring - It is seldom a painful disease till it becomes greatly distended the scrotum seldom appears red but generally transparent. In oder to discover its transparency grasp the Tumour at its posterior part 82 Place the patient in a dark room, a candle being placed opposite will discover its transparency. Another mark to distinguish this disease from any other is its fluctuation and the comparative lightness of the tumour Sometimes two tumours are formed one situated at the abdominal ring. The other in the scrotum which frequently deceives the surgeon who supposes it to be a Hernia The fluid contained within the tunic puts on a Variety of appearances it is generally of a nature similar to the serum of the blood sometimes purulent at other times mixed with the red particles of the blood When the Tunica Vaginalis is thick its transparency is destroyed and which generally takes place in tumours of long standing The tunic becomes ossified and which variety of appearances may mislead the most experienced Surgeon. There is often within the Tunic one or more cysts formed as large as a Chestnut the Testicle is commonly placed behind the tumour in Hydrocele if it were otherwise situated it would probably be wounded in 83 performing the Operation, therefore you should be at all times certain that it is so situated before you attempt to operate - In order to distinguish this disease from Hernia desire the patient to cough if it is a Hernia a distention of the tumour takes place but in hydrocele no such distention takes place but, it must be observd should the tumour extend to the abdominal ring some little distention will necessarily be produced from coughing by the action of the abdominal muscles. another mark is this. if it be Hernia and you attempt to raise the scrotum you will find that you can’t readily do it. but in hydroceles no such difficulty appears - Hydrocele may be distinguished from diseasd. Testicle by its weight. Figure and inflamed or red appearance. This disease is sometimes unfounded with hematocele this is an accumulation of blood within the Tunica Vaginalis, it is generally occasioned by a severe blow on the testicle and may be known by the former marks - The cause of this disease is an increased action of the vessels of the Tunica Vaginalis and not a disease of the 84 absorbents as was formerly supposed but these vessels are generally found enlarged hydrocele is said to be treated in a Palliative and radial way. if in the Palliative, all that is required is to draw off the water from time to time which may be done by a lancet or a small Trocar direct the instrument obliquely upwards at about two thirds the length of the tumour after the operation lay a small piece of adhesive plaister over the wound, It is frequently necessary to perform the operation three or four times a year the Trocar should be preferred, in performing this operation a small incision being first made through the integuments with a lancet & give tonics internally combined with mercury a strong solution of crude sal Ammon dissolved in Vinegar and applied to the part is often of service. It has been found that taking a considerable deal of exercise directly after the operation 85 has produced a Radical cure by bringing on a Violent inflammation by which a quantity of coagulated lymph was thrown out and produced an adhession of the tunics - Of the Radical method of cure this may be affected by the process of granulation or adhesion, the latter is to be preferred. - Of the mode of cure by the Seton recommend by Mr. Pott, this is also liable to objections as it occasions frequent but partial adhesion of the Tunic - in the Hydrocele of young children do not be in haste to operate before you have given every remedy a fair trial The operation by caustic is sometimes employed but this like the method adopted by Mr. Pott is liable to objections - The method of applying it is. take a piece of kali purum rub it round the surface to be cauterizd for the space of 10 minutes which will produce an eschar and the operation is finished. This method of operating has been known to fail even in the most experienced hands. in old people it should never be performed on acct. of 86 the inflammation which succeeds being often very Violent producing high symptoms of irritation and sometimes even Death - It is Mr. Cooper opinion that this method of operating should be entirely done away with - The best method of operating in Children is by taking a common needle the same as is used after amputation arm it with a few threads of silk, pass it through the Tunica Vaginalis in a longitudinal direction and at the same time obliquely draw the threads out at the opposite opening and leave them these by acting as an extraneous Body will produce inflammation and in consequence a Radical Cure will be obtained - On the operation for Hydrocele The method of Operating by Injection is in a more general use than any other. this operation is of old date, Sir J Earl improvd on this mode of operating - The instruments required for it is 1st a large and small Trocar for the child and adults, 2nd an elastic 87 Bottle with a turn cock, 3rd a Mixture of Red Wine (1 part water & 2 parts wine) but as Wine is liable to vary in strength the Vitrolated water is now used in the following preparations - Rx Vitriol albi ʒi aq:distillate 1 H ᵯ - with this solution the Elastic bottle is to be filled - make a small incision with a Lancet through the skin at the anterior part of the tumour, the introduce the trocar and cannula - inject a quantity of fluid sufficient only to be applied to the whole surface of the tunica vaginalis testes - this should be allowed to remain as long as the patient can bear. about 4 minutes on an average - When the patient complains of a little pain during the operation the greater will be the succeeding inflammation - and Vice Versa - a small quantity of fluid about 2 drams should be allowed to reaming in - the patient ought not to go to bed until he is obligd. to do so from the violence of the pain in the part and also in the loins - If several hours should elapse & little or no inflammation comes on Mr. Cline directs Wine to be given and taking the scrotum 88 in the hand and rubbing it. In 48 hours the swelling is generally as large as when the operation was performed, it feels solid and pitts on pressure with the finger the skin appears in ridges, you then know that the inflammation exists in a sufficient degree - In the course of a week the tumour begins to subside and in three weeks the patient is generally cured - If the testicle is slightly enlarged you are not to be deterrd from operating for by exciting a counter inflammation the swelling will probably subside - If the Tunica Vaginalsis is inflamed you will know by a bloody appearance of the water when drawn off. you must then use the Injection only half the strength before directed that is in proportion to ʒ1/2 to Hj - Mr. Cooper observes it is very wrong practice to inject a quantity of fluid equal to that which is drawn off, but recommend. if ℥vi or ℥viii of water is drawn off to inject not more than ℥iii or ℥iv of the solution - There is some danger attending this operation for if great care is not 89 used in introducing the cannula with in the tunica vaginalis the injection becomes extravasated into the surrounding cellular substance. the consequence is that the whole surface of the scrotum becomes black sloughs and in 8 or 10 days the patient dies from high constitutional irritation -In a child from 6 to 10 years of age this method of operating may be employed if the tumour is large but in those that are younger it should not be employed - Incision with the introduction of Flower or the seton should be had recourse to in these cases - of Incision - this may be considered as a dangerous operation and in which the symptoms in general run high, but its advantages are that it shows you readily the situation of the Testicle, it also shows you if any cysts are formed on the surface of the testicle - This operation should always be performed when any adhesion are found - if the testicle is found anteriorly the incision must be made on the natural part of the tumour. - 90 The advantages of injection are that when it is properly performed it is comparatively a mild operation. it may fail in the fist instance but if repeated will certainly succeed. and with the Vitriolic injection Mr. C has never known it to fail - but treated with the wine & water it has been known to return at the end of two years An Hydrocele of the spermatic cord may be known by a tumour forming at the abdominal ring - it may be easily mistaken for a Hernia as before observed by its projecting when the Patient cough but in this there is a want of transparency in the Tumour. in this the operation is to be preferred in doing this operate as for Hernia which must be done with great caution as the spermatic artery and veins sometimes run on the fore part of the tumour and the vas deferens behind - should any portion of testines adhere you are to desist as it would be useless to operate, this species of Hydrocele is sometimes contained 91 within an hernial sac in which case the operation by incision is to be preferrd. On Dislocation The vertebrae are so connected that no dislocation can take place without a fracture the consequence of which is the compression or division of the spinal marrow the total loss of sensation and use of the parts below where the accident has happened - in these cases the urine is evacuated by the catheter otherwise it will be liable to bust from the patient, being incapable of expelling the urine - the – the foeces pass of involuntary and when dissolution is about to take place the urine runs off in the same manner - If the fracture happens in the Lumbar Vertebrae the patient may live from 17 days to 3 weeks with some little exception - If in the Dorsal about a fortnight – If about the 6 or 7 cervical not more than a week : if in the 2 or 3 cervical not more than 40 hours. if in 92 Atlas or Dentaba the patient generally expires instantly - . The Clavicula is liable to be dislocated at both extremities the sternal end is sometimes thrown before the sternum in its fore and upper part. when the shoulders are drawn back it returns into its place - Treatment - The shoulders are to be drawn and kept back as much as possible by the stellate bandage which ought to be kept on for about 5 weeks The scapular extremities are sometimes dislocated from the processus acromion it the forms a considerable projection on the spin of the scapula. The shoulder on that side falls to the breast therefore from the sternum to that shoulder is less than from the sternum to the other - Treatment. The shoulders are to be drawn back as in the former at the same time the shoulder is to be raised by a sling. In these cases the pain that it produces by keeping the shoulders 93 sufficiently back is more than Patients will generally admit to and when told that it produces no inconvenience by being left to nature (except that of the incapability of the arm being stretched out so far as the other) they prefer rather to be subject to that little inconvenience than suffer the pain that is necessary for the proper Union of the ends of the bones, which is the reason that it seldom or ever cured - The shoulder. is liable to be dislocated in three different direction 1st downwards or into the axilla-the marks of this is the dislocated side is flatter than the other the arm cannot be raised to the Head and the lower edge of the pectoral muscle is raised above that of the opposite, by putting the finger into the axilla at the same time raising the arm the head of the bone may be plainly felt - Treatment if recently done apply a round towel obliquely from the arm pit of the dislocated side to the top of the opposite shoulder it is to be carried over and then to be fastened by a bandage 94 This extension is to be made above the level of the shoulder, upon the dislocated arm the extension is to be made gradually and kept up for a long time - about 5 or 10 minutes the arm will commonly be reduced - If the arm has been out a long time Poultices should be applied; making two or three attempts to reduce it one after another Another mode of reducing recent dislocation of this joint. Place the patient upon his back then put the heel of your foot into the axilla at the same time having hold of the arm make a strong pressure by the foot and gently turn the arm inwards In this way the arm will commonly slip in - The 2nd dislocation is forwards the Head of the bone being placed under the Pectoral muscle just below the clavicle. The patient is incapable of raising his arm to his head. When the head of the bone may be perceived moving under the pectoral muscle on the arm being rotated the dislocated side is flat - Treatment - 95 To be reduced either by pullies or by the Bandages as in the former - Pullies are best as a greater extension is required The 3rd. dislocation is when the Head is thrown backwards or into the scapula when a considerable Tumour appears on the spine of the scapula if the arm is rotated it can be felt - The same treatment as the first - this seldom happens - Dislocations of the Elbow Joint backwards when the Radius and Ulna are placed behind the Os humeri the coronoid process is placed in a hollow above the Articular surface of the Os humeri the Arm is a little bent - Treatment - Take the Arm in one hand and the forearm in the other. having the knee or some fixed part at the inner of the Joint the forearm being pulled downwards the bones will immediately slip in– 2ndly where the extremities of the bones are thrown [in] laterally, either internally or externally, the same Treatment is to be made use of here, but at the same time the Extension is made by an Assistant press the bones towards the Joint - 96 The Ulna is sometimes dislocated without the Radius, in the case the projection is not so great at the Elbow as when both are dislocated. The Reduction is the same sometime the coronary process is broken off by the irregular action of the muscles. the ulna loosing its support is dislocated backwards and appear in a projection at the back part of the Os humeri - The coronoid process is drawn up by the muscles on the forepart of the Os humeri. This is easily reduced but when the extension is taken off it resumes its place - sometimes the head of the Radius is separated from the Ulna and thrown into the hollow above the external condyle of the Os humeri here the arm is incapable of being either bent or strengthened but still returns supination and pronation - Treatment the best way of Reducing this is first to produce fainting by the warm Bath or Tobacco Glysters. the confining the Ulna by placing the foot to it at the same time forcibly and suddenly extend 97 the arm it is however very rarely reduced The wrist is liable to be dislocated in two different ways, backwards and forwards, it is easily reduced by making an extension of the Hand one way and the forearm the other - There is often a tumour appearing like a dislocation of the wrist which is occasioned by an accumulation of coaguable lymph from inflammation produced by a strain of the Tendons - Apply prepare and Mercurial Plaister to reduce the swelling and afterwards electrify it - There are small tumours frequently appearing at the wrist which is a collection of synovia in saculi Mucosi, these are called Glanglions. They commonly move with the Tendons but are sometimes perfectly fixd. and adhere to the ligaments - These ought never to be opened but are to be dispersed by breaking them which is done by bending the wrist and then they become tense when if struck hard will burst and disappear  Professor Fox. M.B. 1 Mr,, Cooper's Lectures on Surgery On the effects of accidents, and diseases on the constitution, and sympathy of diseases on it. Sympathy of diseases are those where one part feels pain in consequence of an injury inflicted on another; Irritation may be only sensation in a diseases, which may affect the action of parts.- A pain in the Loins follows an inflammation of the Testes, A stone in the urethra occasions pain in the Testes and high on the side- The knee is painfull when the Hip Joint is diseased, occasioned by the communication of the Sciatic nerve; therefore where the knee is very painfull, and there is no inflammation, we should be particular in our examination of the Hip Joint, as so many practioners have so frequently been mistaken in this case. - A disorder in the liver occasions 2 a pain in the shoulder, outside of the collar bone, also an itching of the nose and rectum takes place when the rectum is irritated; Dr. Hunter called them sympathetic dilutions but they can be dilusive only to the uninformd. - bad affections of the Liver and stone in the urethra produces only local pain - we cannot discriminate with such accuracy as on their sympathetic symptoms, the Testes becomes painfull in consequence of an inflamation of the Urethra: the glands of the groin will swell and inflame in consequence of the passing of a Bougie producing a sympathetic Bubo - an unexpected blow on the stomach the very trifling will sometimes occasion [the] Death: - A man was endeavouring to part two women fighting in the street received a blow from one of them on the stomach and instantly fell, and was supposed at first to have fainted, but was dead; on opening the body no particular appearance 3 of disease was found- A young healthy man received is slight blow by the back of the hand and fell immediately, Mr. Cooper and another of the Faculty tried the usual modes of inflating the lungs, warm bath &c in vain; on opening the body a small discolouration was found in the stomach where the blow had been given occasioned by extravasation between the coats of the stomach: in these cases the blow on the stomach occasioned a cessation of the action of the Diaphragma and stopd. inspiration - Almonds when eaten will with some people produce violent irritation of the Skin; - Sympathy of actions is where one part acts in consequence of Injuries done to another; Thus injuries of the Head, strictures of the Intestines produces vomiting When a stone is passing the Gallbladder vomiting is producd, as is likewise the case when the uterus is inflamed, in the effects of irritation all the functions of the Body are changed by partial injuries Thus in a Compound Fracture in 24 or 36 hours all the functions will be changed 4 in scrophulous habits the change may be rather slower;- we shall find pains in the back, loins, and Head in Fever; the action of the Heart is altered the pulse becoming quick hard and intermittent, the alimentary Canal is affected the Tongue is firrd., white when the degree of irritation is small, brown when it is great, sickness of the stomach takes place and constipation of the Bowels, perspiration is stopd. the nerves become affected sleep interrupted, delirium and subsultus tendinum follow; a profuse sweat will break out and then the symptoms abate, but in a short time they return with greater violence;- The Symptoms should be regulated and checkd,, their Violence depend on the importance of the part Injurd, - a very small wound of the Intestines, will occasion a cessation of the pulse, or make it so faint as scarcely to be perceived - in parts not so essential to the vital functions, the symptom depends on the size of the wound, and on the degree of vital power possessd. by the part. Thus wounds of the Tendons produce more irritation 5. for the tendons being less Vascular require a greater afford of nature to restore Injury - A man was kicked by a Horse on the Intestine there was no pulse felt in the wrist, and yet survivd. 12 hours - The smallest ulcer on the Lungs will produce more considerable effects to the constitution than the largest ulcer on the Legs or any other part - In accidents many things are to be considered. 1st the importance of parts injured. 2ly the extent of the Injury. 3ly. wheather the Vital powers are weak or strong the weaker the better; Symptoms depend greatly on the natural irritability of the constitution A man was brought into the Hospital with a Compound Fracture of the elbow. The bones of which were laid bare. his hand at the same time quite crushd, amputation was thought inevitable but the man refusd. to submit and the arm got well without much pain and without any bad symptoms except a small abcess on the upper part: a much less injury in a person of an irritable habit, would have producd. Mortification and Death - the signs of irritability are great pain, extended inflammation, fear of Death, restless and delirium; 6 Fat persons are generally irritable. intemperate persons have a very considerable degree of irritability; the passions of the mind has a great effect in all operations; and in accidents it is always proper to inspire the patient with hope: the passions that influences the Body are grief, anger and fear- Joy and hope produce stimulating and healthy effects= Grief fear and anger lower the actions of the Vital power, and retart recovery. Grief particularly effects the Liver and produces conjection of bile,. Fear has a more particular effect on the Constitution than the rest. Anger produces a quick hard pulse and influences the irritation of the mind on the Body. - Mr. Cooper attended a gentn. for a Chancre. it had a healthy appearance but suddenly became worse without any apparent cause, it afterwards went on well again & again became worse had frequent lapses of this kind; till at Mr. Cooper accidentally calling found the Gentleman in a Violent fit of Passion and on examining the chancre he found it considerable worse sloughing be 7 on removing him to another place where he was not exposd. to anything which could cause passion the Chancre was soon healed by the same means that had been used before tho the air of the place to which he was removed was not so healthy as where he first resided.- Fear will frequently occasion Death; where there would not have been any danger without - A man with a Simple Fracture of the thigh was brought to S. ThS. Hospital he was prepossesd. he should die, his fears were smiled at, but on the eighth he died there was no inflammation nor was there any union of the bone taken place - a lad 17 years of age died in a similar manner of a simple fracture - Mr. Pott was called to Gentleman of a very timid disposition, who had symptoms of stone, the nature of the complaint his Friends had carefully concealed from him. Mr. Pott made an examination (with the sound) and having found a stone and being ignorant of his timidity told him the case, and that he might be effectually relieved by an operation 98 The Os Femoris is liable to dislocation in four different directions - 1st upwards or into the dorsum of the Illium about two inches above the acetabulum the trocanter Major is turned forwards and the head backwards the foot inwards and the leg on that side is about 2 o 2 ½ inches shorter than the other the limb cannot be moved at the hip Joint being so strongly bound by the muscles - Treatment - Place the Patient on the opposite side to the dislocated one. the Pelvis is then to be fixed by carrying a girt between the scrotum and the Thigh of the dislocated side round to the outer part of the Pelvis and there to be fixd. to a pillar or some steady point. The dislocated Thight is to be brought over to about the middle of the oposide side a bandage then being fixd. above the knee which is to be kept bent. the extension to be made obliquely forwards and downwards. after this has been made for sometime and it does not succeed let 99 a bandage be put round the upper part of the Thigh which is to be so long as to admit the Head of an assistant through it he then is to place his hands upon the Pelvis to prevent its raising than gradually and forcibly raise himself- The head of the bone will be elevated over the brim of the acetabulum and will slip in. this elevation is to be made at the same time as the former extension. or it is sometimes reduced by pressing hard upon the Trocanter major while the extension is made 2nd, dislocation is downward or into the foramen ovale the leg in this is much longer the foot turned inwards. The knee separated at some distance from the other and the patient cannot bring it to the other - Treatment. place the Patient on his back carry a girt round the upper part of the thigh and fix it to a point as the former the limb being bent press upon the knee by the weight of the body inwards. by these means the bone will 100 generally be reduced. 3rd Dislocation into the Ischiatic notch. The leg is very little if any shorter the Toes turned in the knee Lying upon the other, and the heel separated at the distance from the other. Treatt. Place the Patient upon his side and fix the Pelvis bend the Thigh at right angle with the body the extension is then to be made in this direction at the same time bend the knee a little downwards. otherwise in making the extension the head of the thigh bone would be drawn below the acetabulum and pulled into the foramen ovale, therefore to prevent this the knee must be a little bent. the same bandage is to be used here as in the first to raise the head of the bone above the brim of the acetabulum 4th dislocation is forwards as upon the Pelvis. the Foot is turned out. the leg is nearly the same length by rotating the limb the head of the bone is seen moving in the usual situation of a Bubo Just at the middle of Pouparts ligament 101 treatment. Place the Patient upon his side, carry a Girt round the upper part of the Pelvis which is to be confined by a roller from the girt round the thigh a bandage is then to be put round the upper part of the thigh into which a pully is to be fastened. The extension to be made rather obliquely upwards - These Dislocations are to be careful distinguished from Fractures of the cervix of the femoris. this however happens generally in Old People. In these cases the Leg is shorter and the Foot turned out - Dislocations of the Patella 1st outwards when it becomes immoveably fixd, to any common force that is applied Treatment. The leg being already extended (for the Patint cannot bend it) put your hand to the outward edge of the Patella and then press it downwards and at the same time inwards 2nd. Dislocation Inwards when it is situated internally the reduction is the same as the former 102 3rd Dislocation upwards from the Ligament connecting it to the tibia being torn throug: the Patella is then drawn up two or three inches by the rectus muscle about the knee - Treatment A cushion is to be put at the upper part of the Patella and confined by a roller pressing above and below the knee. There is over the Patella between the skin and the Tendon a Bursa Mucosa which often becomes enlarged, and frequently in women who are much accustomed to kneel. The bursa inflames swells and often increases to a considerable size Treatment. the knee is to be bent as much as possible the the tumour will became tense and hard. and if struck two or three hard blows will generally disappear If this does not succeed make an incission the whole length of the tumour and dissect out the sac after which bring the edges of the wound together by plaster and treat as a common wound 103 If inflammation comes on poultice and fomentation are to be applied and also Leeches this operation does not produce such violent symptoms as if it had been left to suppurate Dislocation of the knee joint It is liable to be dislocated in four different directions 1st outwards. the head of the Tibia is thrown on the outer side of the Os Femoris Treatment. An extension is to be made in a straight direction at the same time pressing the bone inwards - 2nd dislocation Inwards which very rarely happens it requires the same treatment as the former 3rd Dislocation Backwards little extension is requisite to reduce this notwithstanding the injures which must happen from these dislocations yet the Joint generally recovers its proper function 4th Dislocation is when one of the cartilages becomes separated from the Tibia and 104 Os femoris and is resting upon the ends of the Tibia instead of the cartilages it produces but little deformity in the Joint. the knee cannot be straightened but allows of flexion. Treatment The limb is not to be attempted to be straightened but bend it back as much as possible towards the nates. This allows the Cartilage to return into its place the Leg may then be straightened and it will resume its proper place when this accident has once happened it is very liable to return the Joint therefore is to be straightened by bandages - There are loose cartilages sometimes forming in the cavity of the knee Joint, and on the outer part which produce great inconveniences, a person when walking is liable to fall down suddenly from the cartilage slipping between the extremities of the bone soon afterwards it will move and the person will be able to walk again. These are 105 to be removed by an operation. the Cartilage is to be pushed if possible to the outside of the Joint an incission is then to be made the whole length of the Cartilage - before the incission is made the integuments are to be drawn very much above the Cartilage. so that the external orifice shall not be even with that communicating with the Joint the incission being made the cartilage is to be extracted. If it does not come out readily it will be right to extract by a tenaculum. the edges of the wound are then to be brought together and confind. By sutures which more effectually prevents subsequent inflammations at the hazard of the Patients life or expose him to extreme pain by the formation of Matter and anchylosis - Dislocations of the Ancle The 1st and most frequent is the Joint being thrown forward on the upper part of the foot the lower end of the fibula remaining in its 106 place and of course must be broke the heel is much lengthened and the distance from the Toes to the end of the metatarsal bones much shortened Treatment. make an extension by putting the Tibia downwards. the Foot likewise extended, after this reduction the Limb should always be laid upon the heel till the parts are recovered otherwise a return of the accident is liable to take place. 2nd Inwards when the end of the Tibia is resting on the inner edges of the astragalus the over extremities of both bones being broke off a large tumour appears on the inner [crossed out] side of the ancle . Treatt. Take hold of the Foot with one hand and with the other hand keep the leg steady a very gentle extension is to be made at the same time let pressure be applied on the projecting bone, when reduced lay the limb on the outside. 3rd when the end, of the bones are thrown on the outside of the Tarsus. the maleolus externus 107 being broken off - Treatment to be the same as the former, and when reduced lay it on the outside - When a compound dislocation happens, the Tibia and Fibula broke appear externally and the Joint laid open, it is a question whether it will be bent to amputate or not. attempts ought to be made to save the limb. for amputation performed so early after the accident is generally productive to the Patient - if advanced in years the operation ought not to be performed as the living power is very weak in those - on the contrary if the Patient is under 40 years a chance ought to be given - On Incysted Tumours These don't require to be removed as they occasion but little inconvenience. if they are large and no considerable vessels near, you may treat them in the same manner as Hydrocele either by Seton or Injection- If small remove them by the knife but if any large vessels are situated near open the tumour with the lancet and inject a little 8 The gentleman replied that the operation would not be necessary, for the idea of having a a stone in the Bladder would kill him - Mr. Pott took his leave but observing a great attention in his countenance sent Dr. Harris to inquire after him the same evening & when he came the person was dead: - A Lady with a scirrous Breast of no great extent was much pressed by her Friends to submit to the operation she refusd. for a long time; but at length she consented: she said she did it in compliance with the wishes of her Friends but was sure she should not survive it. Mr. Cline performed it and nothing could be done in a better manner. The Lady was put in bed; her countenance sunk and she died very soon after; her prepossession was so strong that she ticketed her keys and disposd. of every thing in such manner, that the Family affair might not have any interruption - On the Progress of Inflammation The existence of inflammation is known by redness 108 of the white Vitriol solution - Children are particularly subject to the formation of these incysted tumours On Diseases of the Testicle The diseases rendering its removal necessary are four 1st. Hidated disease this begins in the extremities of the Epydidymus extends into the Body of the Testicle back towards the spermatic cord, it is never attended with much pain, it may therefore be mistaken for Hydrocele; It is not of a cancerous substance; is confined entirely to the Testicle and is of a very considerable size. This diseases generally occurs between the age of 20 and 30 and sometimes later in life - In order to distinguish this Disease from Hydrocele it is to be observed that it differs ins shape, but, is of the form of the Testicle is prominent before and flat on each side, secondly its weight 109 is very considerable, but its want of transparency is the best mark. This Disease is very liable to deceive even the more eminent of Surgeons: Mr. Pott and Mr. Cruckshank have both fallen into this error - If you have any doubt in your mind respecting the disease puncture the Tumour with a lancet, and if there is no water. proceed to treat it as a diseased Testicle. This disease is found to be collection of a number of cysts on the surface of the Testicle filled with a mucilaginous substance, these cysts vary in their size from a pea to a marble, after the Operation for this complaint the Patient in general does remarkable well - The 2nd complaint is the true schirrous Testicle which originates in the body of the Testicle and becomes as it were all at once hard and considerably enlarged, it the proceeds to the Epididymis and spermatic cord- it may be distinguished from all other diseases of the Testicle by its stony hardness, it is likewise attended with considerable pain, but not constant 110 triffling causes produces this disease. it is envisioned by a deposit of coagulable lymph becoming at length cartilaginous runs up the spermatic cord into the abdomen and produces the same disease in the Loins as that originally in the Testicle Before you operate examine if the spermatic cord is diseased for it is of no use to operate if it is, therefore you should operate as early as possible - There is another species of cancer in the Testicle which Mr. Cline calls the Pulpy cancer this is a much more dangerous disease it originates in the same manner as the former, but its effects are much more sooner destructive . In a few weeks this disease extends into the abdomen and renders any operation fruitless and generally in the course of 20 weeks proves fatal, its called the Pulpy cancer because when you feel it it seems like the Hydatid Testicle. great pain attends this disease and if a Lancet is pushed into the Tumour Blood flows out 111 a sallow countenance is another decisive mark of this complaint so that with a little attention this disease may be distinguished from any other. The Operation must be performed as soon as the Cancer is attended with pain. The Tumour formed in the Loins from this disease when allowd. to take its course is much larger than the schirrous amounting in some case to 11 or 12 pounds when it is cut in its early stage it appears like curdly coagulable Lymph, but in the latter stage like Brain broken down by Putrefaction - This disease has been known to extend to the thoracic duct so as to destroy its internal surface - The 3rd is that of suppuration in the testicles. This begins sometimes from venereal causes, leeches are to be applied with a strict Antiphlogistic regimen. Calomel also ought to be given to promote absorption it likewise arises frequently from scrophula. The abscess which is formed in the testicle being of a scrophulous nature - It may arise from a violent blow on the testicle slight febrile attack attend this complaint remitting often 112 for many days, but ultimately the operation will be found necessary. When the Testicle is cut into, a curdly abscess is found in its centre - A fungus on the surface of the Testicle has been supposd to require an Operation for its removal but all that is unnecessary, but make circular inception round the Fungus including a small portion of the surrounding skin - cut it off just as it springs from the Tunica albuginea. bring the edges of the wound together and unite them by sutures On Aneurism By the term Aneurism is meant a Tumour containing blood formed by the yielding of the coats of an Artery, and which tumour has generally a pulsatory motion corresponding to that of the artery of which it is placed These tumours when examined may be divided into 3 stages with regard to their symptoms - 1st, when the tumour is very small its pulsation is remarkable 113 strong and the fluid which it contains, can be made to disappear by pressing on the Artery between it and the Heart, but on the pressure being removed it instantly reappears. in this stage of the disease the Patient suffers but little pain except that he feels slight spasms about the part during the night - 2nd stage If the Tumour is very large you cannot press the blood out of it as before, as the Blood is at this time in a coagulated state and deposited in layers, but the skin remains undiscoloured although the pain is very considerable. in this state the tumour may remain for years especially if it be situated under a Fascia - but with regard to this point every thing depends on its situation. 3rd stage, when the Tumour is about to burst but prior to this taking place, the skin becomes of Brownish red color. after a time it cracks discharging a Bloody Icher it then becomes mortified where it had been red, and sloughs, its edges in separating opens 114 into the sac. The Hemorrhage sometimes destroys the Patient suddenly but this is comparatively a rare circumstance as the progress of its bursting is generally very slow. When the Tumour appears ready to slough Mr. Cline advises it to be bound down with adhesive Plaister which prevents its bursting as soon as it otherwise would - Aneurism is found to take place most frequently in the extending portions of the aorta & its arch which it forms towards the dorsal vertebrae, when it is thus situated it shows itself by forming a Tumor under the sternum or Cartilages of the Ribs When it takes place in the Arteri Innominata a Tumour is seen under the carotid artery in the neck. sometimes an aneurism is formed between the curvature of the Aorta and Diaphragm. then the Death of the Patient is occasioned by the Pressure of the Tumour on the Trachea and osaphagus into which last it generally bursts. When it is situated in the abdomen it produces various symptoms, the Foot 115 being regurgitated generally soon after it is taken into the stomach so that the Patient dies exhausted and in a manner starvd., it generally shows itself by a Tumour situated at the umbilicus - An aneurism is now and then forming in the aorta just when the emulgent arteries are passing off. in this case a Tumour is formed in the side of the spine and which Tumour has no pulsation, these Tumours have been mistaken for Lumber abcesses and opened without detriment to the Patient. but when we do this Mr. Cline advices the puncture to be very small, a difficulty of passing the urine and foeces are sometimes occasioned by these Tumours. On Dissection of Aneurisms you find the artery in general given way only on one side; The aorta has be been known to give entirely, but this is very rarely the case - This disease generally takes place between the age of 35 & 50 Tho sometimes at a more advanced age, one case which Mr. Cline had under his care 116 occurred in a patient only 24 years Pophlitic Aneurism differ from all others from its being liable to be produced by local causes, as Violent exertions &c independent of any constitutional affection and may occur at any period of life. The cause of Aneurism in any other part is that the cuticular or internal coat of the Artery inflames, thickens & destroys its Texture, by which it gives way from the impetus of the Blood passing through it. its external coat remaining unaltered To distinguish this disease from any other you may suppose that its pulsation is a certain criterion, but in this you may be mistaken ..... Tumours sometimes forms, for instance in the neck under the carotid artery which is running over its substance. if you feel this Tumour and find a pulsation you at first suppose that it is an aneurism but if you put your finger on each side the tumour you will find that it does not pulsate, and by this mark you can ascertain whether it is an 117 Aneurism or not, if it is one. by taking the Tumour and lifting it form its bed as much as possible you will find it to pulsate strongly. these therefore are circumstances highly necessary to keep in mind - by attention to diet &c these Patients may be kept alive for a considerable time. Calomel should be taken when any pain is felt in the Tumour and Leeches applied on some part little distance from it - The Operation for Aneurism as it was performed 20 years ago. The first step in the Operation was to secure the artery by Tourniquet. then an incision made the whole length of the Tumour the coagulated Blood became exposed, this being removed and the sac washed out with a sponge dipt in warm water. the mouth of the artery being [removed] laid open then the Tourniquet loosened a little, in order more readily to discover them a Probe is to be passed into the superior extremity of the artery and a ligature made on it about an inch above the Tumour the 9 swelling pain and heat, these are the diagnostic sign’s. Tumors arise from the different causes from distention of the Vessels; where there is much tension, serum is pourd. from the extremity of the cellular membrane, and sometimes coagulated lymph: the nerves are strecthed by expansion of the Vessels, this occasions pain which depends on the degree of inflamation, this may be perceivd in operations which produce sometimes a great degree of pain while others that take a great deal more time before they perform are not so painfull that was increased in inflammation Dr. Hunter doubted from experiments he made on animals he injected corros: sublim into the rectum of a dog and waiting 24 hours when the inflammation was at its height he introduced a thermometer and found that the natural heat was not increased, he tried the same experiment on the vagina of an Ass, in 12 hours when the inflammation was beginning he found the natural heat had fallen one degree, and when the inflammation was at its height the heat was at its natural standard. we may conclude that this circumstance takes place only 118 same was done in the inferior portion of the Artery about an inch below; the edges of the wound were then brought into contract (the ends of the ligature being brought out at the wound) and secured by sutures or adhesive plaisters which finished the operation. but in consequence of the Ligature being thrown off, after the operation frequently, it now entirely laid aside - The present method of performing this operation; make an incision the whole length of the tumour (it is a popliteal aneurism meant) in order to expose the sactorious muscle you are then to dissect it away on its outer edge, pull it on one side and the Fascia is laid bare which encloses the femoral artery vein & nerve which last is to be carefully avoided, the Vein is situated between the artery & bone you are then to cut through for the Fascia to such an extent as to admit an instrument passing freely under it & then pass the director under the artery and in so doing give it a slight lateral 119 motion so as early to tear through the the cellular membrane beneath it: you are then to take an eyed Probe arming it with a double Ligature, having a needle at each end, the Probe is then passed through, along the hollow of the director the director is then to be withdrawn the Ligatures being drawn to an equal length on each side the Probe may be cut away: you then separate the Ligatures about an inch from each other: securing the upper portion of the artery first the same must be done with the inferior portion of the artery; first tearing away away the cellular membrane, this being done, the needles are to be passd through the Coats of the artery and again secured, then bring the edges of the wound in contact with the ends of the Lignature hanging out of the wound and endeavor to heal it if possible by the 1st intention, hemorrhage has been known to ensure when the Ligature came away - In applying the adhesive plaster leave small interstice to allow the escape of matter, but donot apply a roller because by its prepare in the anastomosing branches of 120 of the artery it sometimes produces Hemorrhage. The Patient should be placed on his back with the knee slightly bent and a pillow placed under it The limb being wrapped in flannel as the Patient will complain of cold and unless proper care is taken mortification will ensue, In two or there days after the operation the heat in the affected limb in greater than in the other. If no hemorrhage comes on at first there is no danger till the ligatures come away, which they do sometimes as early as the 4 Day. at other times on the 17 or 23. at this time bring the edges of the wound in contact unless there is considerable suppuration and apply a roller. The consequence of this operation is that the Patient in general complains of a weakness in the Limb with a sense of coldness - In Aneurism of either the Posterior or Anterior Tibial Artery. The Femoral Artery should be secured in the middle of the Thigh in preference to the Ham. as here the Vessel is deeper seated. If the Brachial Artery be wounded in 121 Bleeding cut down on it and secure it above and below and divide it between the Ligatures - never apply a Ligature near an Aneurismal sac. as inflammation may extend to it, produce suppuration and destroy the Patient neither contegious to the Anasomosing branch of an Artery In aneurism of the Carotid, Posterior aural or Brachial Arteries Mr. Cline makes an incision on the sac. securing the Artery above and below as before directed & dissect the Tumour out &c - On Fistula in Ano This Disease in produced by and abscess forming itself in the Cellular substance surrounding the extremity of the Rectum or just by the verge of the anus. The sinus occasioned by this does not always confine itself to a straight direction. but sometimes extends nearly round the Anus - when the Fistula is one formed it seldom or ever heals itself It is because the the Rectum is constantly tearing the sides of the sinus on account of its contractile power, therefore to remedy this 122 The sinus must be entirely laid open This disease frequently attacks Patients after long continued Fevers, or disease of the Bowels or Liver, in this last case Calomel must be given before you attempt to operate. The Piles generally preceeds this Complaint - it is also a frequent attendant in Phthisis Pulmonalis, but it is of no use to Operate in these Patients as no cure will be obtained : Fistula is sometimes depending on local causes as costiveness &c sometimes from long continued exercise on Horseback & from Violent irritation of the Parts - The method of operating. Pass a probe up the sinus with a Finger of the other Hand previously dipt in oil into the Rectum by this you will distinguish if the sinus runs into the gutt then pass Potts Bistary along ye probe untill it meets the extremity of your Finger the lay it open through its whole extent, place a dip of dry lint into the wound after & continue this dressing till a cure is obtaind. - Fistula may sometimes be cured without any operation by Injecting the following 3 or 4 times a Day Rx Aq:Calcis ℥iv Hydrarg Muriate giv M and at the same time give Wards paste Rx Pulv: Enul : Campan Hi semen fenual dule Hip Piper negre H1/2 Pulver bene at adde sacchar et Milles a a Hi M sumat L.N.M vis vel ter in die - 123 On Amputation The first step necessary to be taken in this Operation is to apply the Tourniquet. If The Operation is to be performed below the knee it should be applied a little above the middle of the inner part of the Thigh as there the Artery requires less pressure - If the Operation is to be performed so high up on the Thigh that the Tourniquet cannot be applied pressure must be made on the Artery in the groin as it passes over the pubis by an assistant - When on the Arm apply the Tourniquet on the middle of the inner part of the Arm between the shoulder and Elbow (near the insertion of the Biceps Muscle called the Deltoid) - if very high an assistant must secure the Artery by pressing behind the Clavicle - On Amputation of the Fingers. in amputating the 2 or 3 joints make a circular incission a little above the Joint and then make a Longitudinal incision on each side as far as the Joint in order to leave a double Flap to cover the stump, then 124 pass your knife into the Joint and remove it cover the stump with integuments and apply adhesive plaisters. The first joint is amputated rather different. make an incision between the Fingers on each side which incision should meet on the back of the Hand, divide the Tendons on each side rather short. remove the Finger by cutting into the joint. Cover the stump with integuments and apply ample adhesive On amputation of the Metatarsal Bones In Performing this Operation save as much integuments as is required to cover the stump from the bottom of the Foot, then make a circular incision saw through the Tarsal bones bring the Flap over the stump, pass sutures thro' the integuments and cover them with ample adhesive and light dressings. the parts in general heal readily. In this operation half the Foot is only removed - On amputation below the knee with a flap according to Mr. Hay’s method is as follows. first measure the leg from the knee to the ancle 125 and take half the length as the spot where you are to take off the limb, next take off the circumference of the Leg, one third of which is to be the length of the Flap. The parts should then be markd. With Ink. the catlin is then thrust through the Limb at this place and carried down to 3 or 4 inches in the adult and brought out make a circular incision round the Limb draw up the integuments and cut thro' the muscles to the bone, pass the catlin between the bones to divide the interosseous ligament, and saw off the Bones turning the limb round so as to apply the saw on both bones at once. The Fibula should be sawd. through first. bring the Flap over the stump and pass sutures Mr. Hay makes use of eight in this operation The [am] patients who undergo amputation in these Hospitals suture can rarely be made use of by the advance of Mr. Allamon they are at one time used in the Hospitals but were found to occasion with great constitutional irritation and symptoms of Trismus 126 or lockd, jaw so that in two or three days they were obliged to be removed consequently adhesive Plasters was made use of with a compress of Lint, a cross cloth with the Roller, and the stump kept cool - The Present method. The distance below the knee where the incision is to be made is a hands breadth in the adult, in children about 3 Fingers below the joint of the Patella, or Rotula, make the first incision about 2 inches below the part at which the bone is to be sawn off, in order to save integuments to cover the stump: in Children about 1 ½ Inch divide the Fascia which binds down the muscles on each side of the bone, then draw the Integuments upwards next divide the muscles to the bone. turning the the edge of your knife rather obliquely towards the knee: pass the catlin between the bones and apply the saw as before directed bring the integuments over the stump, having secured the Tibialis anterior arteries and Intercostal artery apply ample adhesive Lint Roller cross cloth and give the Patient an anodyne - 126 Amputation above the knee Begin your circular incision as near as you can above the knee joint. but in case of white swelling be careful not to cut near the diseased part as a cure after the operation will be tedious. make a circular incision through the common integuments divide the Fascia on the Anterior and lateral parts of the Thigh to allow enough to be drawn up then divide the muscles to the bone inclining the knife a little upwards then saw the bone as high up as you can, the Tourniquet being slackend you must secure the Femoral Artery and a branch of the arterial profunda. in securing the this Artery be careful not to include the nerve bring the integuments over the stump and treat as before - Amputation at the wrist – In performing this operation save as much integuments as you require to cover the stump from the Palm of the Hand, feel for the extremity of the Radius and make an incision just at the root of the Thumb to some 10 in the internal parts of the Body, the surface is evidently hot to the touch and the heat occasiond. by the inflammation of blisters has in in a great number of experiments been found to exceed the natural heat from 4 to 7 degrees Inflammations are divided into common and specific common is that which arrives from wounds or spontaneously in a good constitution without any particular change of arterial action producing an effusion different from the common inflammation, it will cause four effects 1st. adhesion or resolution this is by coagulated lymph pourd. from the extremities of the blood vessels- it consolidates the parts a preparation of a Heart shews this in a very distinct manner, it is coverd. With a coat of coagulated lymph which gives the external surface a rough appearance- the 2nd. effect is suppuration, the vessels here pour out matter instead of coagulated lymph - 3rd effect is ulceration which is an absorption of the inflamd. part producd. by a violent action of the absorbents - 4th mortification in 128 depth make an Incision round the wrist so as to meet the Flap whether on the back or inside of the hand, dividing the Tendons completely draw back the integuments and insert the knife into Joint and remove. bring the Flap over the stump and endeavour as much as possible to heal by the first intention, there are two Arteries to be secured the Ulnal and Radial, but this last if in a Gun shot accident rarely requires to be secured Amputation of the Fore Arm This operation is more dangerous in diseased Habits, than the upper Arm as suppuration frequently takes place between the Tendons with high constitutional irritation Lock Jaw and Death - First make a circular incision through the common integuments dividing the Fascia on both sides the Arm, draw back the integuments as much as possible. next divide the muscles to the Bone inclining the edge of the knife obliquely upward, next divide the Interossious Ligament by passing the catlin between the Bones turn the Limb round and apply the saw 129 on both bones at once. when the Limb is removed three arteries must be secured Viz the Radial, Ulnai Intercostal. then proceed as before directed - Amputation of the Shoulder Joint with a flap - The first step necessary to be taken is to secure the Axillary Artery, when this is exposed pass a Director under and carry a needle armed with a ligature along the grove of the director and secure the vessel, next take hold of the Deltoid Muscle between your Finger and Thumb and carry your incision obliquely upwards towards the bone this leaves the Flap which is afterwards to cover the stump, then make a circular incision round the Bone, turn the head of the Humerus out of its socket & cut it away bring the Flap over the wound and endeavour to heal by the first intention. - 130 In Diseases of the Female Breast The first disease we sall speak of is the formation of Hydatis in the breast. similar to those occurring in the Testicle in the Male. in this Disease the Patient at first suffers but, trifling pain. In the early stage, the Breast feels as if small knots were placed under the skin of various sizes, when the disease has continued a long time, one of the Tumours increases in size, ulcerates, and discharges a Glary Fluid, and if more Tumours Ulcerate very troublesome sinusses ensue In the removal of these Tumours there is no danger, and when removd. do not return [or] this disease does not extend by absorption as in cancerous Tumours The next disease to be treated of is that of schirrous The symptoms of which are a discharge of Blood from the nipple. or an uneasy sensation in the Breast when the Arm is thrown back. Pain in the Breast shooting into the axilla, a Tumour formed of a remarkable hardness feeling like a marble under the skin. in an early stage the 131 Tumour is moveable. and the Patient suffers very severe pain at time but not constantly- If the woman is menstruating a Day or two Prior to this the Tumour enlarges and becomes more painful - it goes on gradually until it becomes of a considerable size, the Glands in the Axilla becomes affected, with a slight pricking in the skin forming a kind hollow over some part of the Tumour. when this is the case Dr. Cheston of Gloucester observes that no success will attend the Operation if performed; the skin also appears rather inflamed. one or two Glands under the edge of the Pectoral Muscle first becomes affected and the Glands above the axillary artery and Vein, the disease also extend, into the Chest. Tumours are formed opposite the middle of the Clavicle in this case all you can do is but palliatives - in case of adhesion to the Pectoral muscle only you may operate with advantage as a considerable portion of this muscle may be removed without detriment to the Patient If the Tumour is left to itself it ulcerates and discharges a bloody Ichor. these schirrous Tumours become sometimes entirely cartilaginous 132 Prior to the patient dying of this disease the arm of the affected side swells, becomes oedematous, acute pains are felt shooting from the axilla to the finger ends Patients sometimes die of a Cancer in a very curious manner, they complain of violent and unremitting pain in different parts of the Body. Opium tho given in large doses give but little relief and the Patient lives but a short time Mr. Cline related a case of a woman in Guy's Hospital, who had a cancer in both Breasts extending as low as the navel and not less than 50 small cancerous Tumours in different parts of the Body. the scalp in Particular she was attackd with difficulty of Breathing with violent pains in divers parts, high constitutional Irritation the Womand died. - The true schirrous generally takes place about the time when women cease to menstruate that is between 40 & 50. Old age is rarely subject to this disease - The Fungus Haematodes sometimes though rarely exists in the Breast, it is a disease similar to the pulpy cancer, which sometimes affects the Testicles in the Male and if you take a Lancet and make a puncture into the Tumour a fungus excrescence appears 133 like the Head of a cauliflower. when the Tumour bursts the patient survives but a short time. no advantage is to be [crossed out] gained by an operation as these Tumours will form again shortly – Women from the age of 16 to 24 or 25 are frequently the subject of Tumours in the Breasts which at first sight may be readily mistaken for a schirrus but this Tumour has no sensible limits when felt, appearing gradually to loose itself in the surrounding substance. but in the true schirrous you can readily discover its extent. it is accompanied with pain in the axilla shooting down the arm - It generally attack young women of strong Passions and delicate constitutions also young married women. The treatment in this disease is first to apply leeches to the part when the pain is Violent. apply a soap Plaister and over this apply the skin of some animal as is Hare, to keep up a degree of perspiration. which relieves the Pain and diminish the size of the Tumour give internally Ferri: Ammonia gr.v bis vix ter quotidie Gentle exercise on Horseback should also be recommended - In Performing the Operation for schirrus 134 Cancer makes your fist Incission in a semicircular direction over the upper part of the Tumour you then divide the Arteries which supply the Tumour with Blood, compression being made on these by an assistant, dissect out the Tumour so as to lay the Fibres of the Pectoral muscles. no ligatures are required bring the skin over the wound apply [Empt] adhesive & a Roller - The Method of Introducing ye Female Catheter The Patient lying on her back. feel with the forefinger of the left hand for the extremity of the Clitoris which having found carry your finger in a straight line one inch below, when you meet with the orifice of the meatus urinarius, then with your right hand you are gently to introduce the catheter. in introducing it elevate the point of the Catheter by depressing the Handle. The Cather should be somewhat more curved than usual as it then more readily takes the course of the meatus urinarius - 135 The Method of Introducing the Male Catheter - The Patient being placed on a Table. stand by his left side near the shoulder, introduce the catheter untill it reaches the neck of the bladder, the by depressing the Handle backwards so as to let it sink between the Patients Thigh. it elevates the point & the catheter readily passes into the Bladder - On Opening the Temporal Artery The best place for making an incision into this Artery is just as it emerges from the root of the Hair, make an oblique incision through the integuments in order to lay the artery bare. then make a small puncture in the side of the Artery - when you have taken away a sufficient quantity of Blood introduce the Lancet and divide the artery completely if it is not divided Haemorrhage will be continually recurring - 136 On Lithotomy First of the formation of Calculi in the kidneys their presence may be known by the Patient complaining of Pain in the Loins of a dull kind attended with sickness, and on rubbing the Back an uneasy sensation is produced in the side where the stone is lodged. after much exercise Blood is discharged with the urine. where these Calculi are passing along the Ureters the Patient complains of pain in the Thigh of the affected side, extending a little below the Groins in the course of the anterior Crural nerve and the Testicle is drawn up by the action of the Cremaster Muscle to the abdominal ring: Bloody urine is occasionally discharged Death sometimes takes place from a swelling of the abdomen coming on which fluxtuates, and on dissection is found to be an of the kindneys - The symptoms of stone in the Bladder are a cutting sensation at the extremity of the Penis, and when the Patient is discharging his urine it suddenly 137 stops. when the Bladder is nearly emptied itself there is frequent inclination to make water. with a disposition to go to stool at the same time, and when the symptoms run high the Foeces are often discharged involuntarily in any change of position. the Patient always feels pain, when much exercise has been used, mucus passes off with the urine. - If a stone has existed a long time purulent matter is discharged with urine from a disease in the Bladder - If this is unaccompanied with pain in the Loins you may safely operate: The Patient becomes frequently seizd. with violent shiverings like an intermittent succeeded by heat with profuse sweating, spasms of the abdominal muscles and the contagious parts, but the degree of irritability is not proportioned to the size of the stone, as a large stone frequently produces less irritation than a small one Dr. Franklin the Philosopher in America was the subject of the Disease. The size of calculi are various. there is a stone in Mr. Foriter's Possession surgeon to Guy’s Hospital which weighs ℥xxv and of a remarkable compact Texture there is another in the Library of Trinity College Cambridge which weighs ℥xiv & 11 which the circulation cease and the parts require to be separated from each other or Death must ensue.- symptoms of the [state] first state an uniform swelling the skin uninflamd, with a dull equal and constant pain, parts easily pit, in hernia humoralis these symptoms are very perceptible, in the sound state the skin is red however deep the inflammation the most certain criterion is a softness in the middle surrounded by hardness – A man in the Hospital with symptoms of a diseasd. Liver had a Tumor on the side with the appearance of softness surrounded with hardness, it was opend, and a great quantity of matter was dischargd. the abcess was so deep that probe would but part reach the bottom. The pain in this state is variable and darting- the 3rd state has “gnawing pain which marks the action of the absorbents, the skin becomes thin the cuticle loses its color and becomes white it separates, when the matter is dischargd, Ulceration ceases - in the 4th state there is excessive 138 is nearly as large as that weighting ℥xxv The largest stone Mr. Cooper ever saw extract weighd. ℥iv1/2 ounces - In extracting a small stone from the Bladder the flat forceps are preferable - The circumstance necessary to be attended to previous to performing the operation are to observe if the Patient is in good health, for if a pain is felt in the Loins a disease of the Kidneys in all probability exists, give two or three purgatives in the week previous to the operation. and morning before give a purgative Enema. if the Patient is plethoric VS - To Perform this Operation. Place your Patient on a Table of convenient height & having properly secured the Hands and Feet the perineum being shaved, make your incision beginning immediately under the Arch of the Pubis carrying it opposite to the middle of the Anus, this incision lay bare the accelerator urine and bulb of the urethra. this last is divided in making your second incision and sometimes the internal Pudendal Artery (but this is not so likely to happen when the cutting Gorget is used as when you use ye blunt 139 Gorget) In making your second incision you carry it into the Grove of the staff. and keeping your scalpel there to serve as a disector for the Gorgett, and before you withdraw the staff ascertain clearly that it is open throughout its extent having done this remove it, and feel for the stone with your Finger or Forceps having ascertain its situation, pass your Forceps along the Gorget, and having taken firm hold of the stone. remove the Gorget, and in extracting the stone give your Forceps a slight lateral motion which tends greatly to facilitate the extraction of the stone - the staff when you cut into it should be held nearly perpendicular, so that in making your first incision you can’t feel the staff - If the stone is containd. within a sacculus, you are directed to use Potts Bistoury and dilate it. Ricketty children have frequently the Tuberositus of the Ischia so close together, as not to allow the passage of the stone, in this case you must endeavour to break the stone. the case however generally proves fatal. If you succeed in breaking the stone, introduce 140 the flat forceps in preference to the scoop Mr. C observes it is a wron practice to inject any fluid to wash assay the particle of stone- In Norfolk this disease is more frequent than elsewhere. in Norfolk and Norwich Hospitals above 300 stones are collected, and of those Patients operated on, about two fifteen die on an average in these Hospitals according to Mr. C estimate about one in 13 die of this operation Mr. Cline in the first 24 cases he Operated on lost none after that he lost three successively. Mr. Cooper in in the first 24 cases he operated on lost one. which Patient was a very young Child and died of Convulsions. therefore it is more dangerous to Operate in young Children than old people In those Children who labour under Tabes Mesenterica this operation should never be performed, as they stand no chance of recovering, Age makes but little difference in this respect Mr. C Operated on a Gentn. 82 years old who recovered in a short time 141 In order to stop Haemorrhage from the Pudendal Artery. press on for about 10 minutes with your Finger but dont introduce Lint. for in this case the pressure applied is often incomplete and the Blood escapes into the Bladder producing shiverings &c. after the Operation apply superficial dressings - Mr. Cooper thinks there is no occasion for any- If there is a considerable discharge it is a favourable Symptom. If otherwise the abdomen becomes painfull, then you are to apply the Leeches with fomentations of Chamomile Flower & Spts. and when it can be had the warm Bath - In 14 or 20 hours after the Operation a little urine is discharged by the Penis, when you are to bring the Thighs together, and secure them by Ligatures, if the external wounds does not heal in 17 or 20 days pass Bougies up the Urethra - In the Patients who wont submit to this Operation as Palliatives you may employ Alkalies give aq: mephitic for common drink & the following may be taken with advantage twice a Day - Rx carbonate of Potash ʒ1/2 aq 1/2 ♏︎ the PA sapon may be given with advantage - Women are less liable to this disease than men as the meatus urinarius in them 142 is short and a stone of a considerable size will frequently pass of itself, a women who has once been operated on never after requires the Gorget - In Performing this Operation in the Female. Having the necessary preparations Sound the Patient with a small male Catheter in order to discover the calculus, this done introduce another sound with the grove turned downwards the pass the back of the Gorget into the Grove of the staff, and carry it into the Bladder, then withdraw the staff and carry your Finger into the Bladder to fee for the stone, having discovered its situation introduce the Forceps along the Gorget, withdraw the Gorget as before directed, and laying hold of the stone (which is generally found in a hollow immediately over the vagina) extract it using a slight lateral motion in the extraction &c NB Mr. C. observes young women wish to have this operation performed on then for what reason he cannot tell, but believes it to be a species of insanity, these women have generally diseased ovaries - 143 On suspended Animation The causes giving rise to suspended Animation are Submersion, Suspension, Noxious Airs Extraneous Bodies, and Tumours pressing on the Trachea - Submersion Under Water In this case the animal does not die from water getting into the air cells of the Lungs, but from the exclusion of the Air from the Lungs, the blood is rendered incapable of undergoing that change which fits for the purpose of Respiration and Life- It is found from experiment that very little water is found or containd in the Lungs and not more than three or four Ounces generally in the stomach - Mr. Coleman observes that the Blood accumulating in the right side of the Heart is impeded in its passage to the left, but Mr. Cooper differs in Opinion and says that the Blood is not impeded in its Passage but diminished in quantity Suspension It was generally supposed that apoplexy was the effect of suspension, but that is an idea erroneous for if there happens 144 any congestion in the Head it is only within the Vessels themselves which cannot produce this effect. Persons that are hanged die precisely under the same circumstance as in drowning, for if you take an animal and make an aperture into the Trachea below the cord, and a pipe being introduced into it the Animal will live for many hours. It was supposed by some that the Vertebrae suffered and the medulla spinallis became compressed but this like the former opinion is erroneous Vide Coleman on Suspended Animation Introduction of Noxious Air As Hydrogen Gas, Carbonic Acid Gas. these act as Poisons by their effect on the Nervous System & thereby destroy life, a Frog may be kept alive for three hours under water but if Carbonic Acid Gas be employed it will die in 8 or 10 minutes. If Animals are immersed in Hydrogen Gas and taken out just before the functions of Life is [destroyed] cease they will recover for a time but in general die in a few hours with convulsive symptoms. In those who 145 are destroyed by the Mephitic Gas emitted from charcoal or Carbonic Acid Gas - In the Brewers Vatts it is found that the temperature of their of their Bodies is far above the standard and continues so for many hours after Death has taken place - From this fatal exposure scarce any person is ever recovered as it acts as a direct poison when applied to the Lungs, and not as some gasses merely by the exclusion of the respirable part of Atmosphere Air - Extraneous Bodies introduced into the Larynx produces suffocation in this case the Patient dies suddenly generally: sometimes not for many hours, and it has happened where they have lived for 3 weeks, an obstruction is produced in the Larynx by substances in eating dipping under the epiglottis, where it may kill instantly or by the irritation it may cause which when it happens after swallowing a substance great difficulty of Breathing is caused with a Violent Cough – Emetics have been known to eject the substance by their action, which should be used strong The throwing up of a piece of coagulable lymph in Cynanche trachealis is a frequent cause 146 for this complaint, sometimes also from swelling of the Glotis and Epiglotis in Angina Scarlatina, also from an abcess arising on the Cartilages of the Larynx from pressure and irritation Means of Recovery In infants just born, and no symptoms of respiration, bring them to the fire or put them into warm water inflate the Lungs employ friction with hot flannels – If an adult under submersion or suspension warm Bath. Opening the Jugular Veins taking away not more than one or two ounces of Blood, inflate the Lungs by means of a pair of bellows pressing at the same time upon the Chest for the purpose of producing artificial respiration. pour spirits down the Throat probably some of it may pass into the Trachea, and if it excits any emotion it will be the means of recovering him - Electricity is but seldom employd. with advantage as circumstances occur to render it inadmissible. when you have inflate the Lungs, and left side of the Heart begins to Act emply friction with warm flannels, some use salt. in case 147 of suspended animation from the inhalation of Noxious Airs do not take away Blood but heat it as under submersion and suspension When any Extraneous Body is Lodged in the Larynx never use a probeing for its removal but pass your finger under the epiglottis and endeavor to extract it before you attempt any operation If you cannot succeed in that way give a smart Emetic: there has been instances where it has proved effectual. if neither of these succeed set about performing the Operation as follows - Bronchotomy This is the most unsuccessful Operation in Surgery It was once performed by Mr. Andrie with successes and which is the only instance on record Mr. Sharp recommends to make an incision of an Inch in length at the ring of the Trachea half way between the Cricoid Cartilage, and the Sternum, this Incision lays bare the Trachea, you are then to pass the front of your scalpel through the substance of the Trachea between the ring, but this plan of Operating is by no means advisable, as the Thyroidal vein becomes divided and the Blood 12 acute pain, vesications arises containing sanous serum the parts under the vesication is of a brownish red this procedes gradually, delirium takes place when mortification takes place in consequence of accident, singultus comes on, the stomach and Bowels are affected, much air is expeld, constipation takes place, the pulse are in general quick and pain varies according to the importance of the parts affected; when the limbs are the seat of the disorder [it is] they are quick and hard when in the abdomen they are exceeding small sometimes full in the first stage they are slow in inflammations of the Lungs & rises on venesection and becomes more like a natural pulse in inflammation of the Heart the pulse is tense beating work a jerk like a broad wire: in inflammation of the brain the pulse is full and slow: if there is much effusion on the brain, the blood when inflamd, is much thinner and separates into three parts, and takes a longer time to regulate and the red particles are not sustained by the lymph, the Blood becomes cuppd on both 148 gushes into the Treache and suffocates the Patient - Mr. Cooper recommends the incision to be made between the Thyroid & Cricoid cartilages, and a probe to be introduced to push the extraneous body into the Throat in this manner you avoid the Thyroidal Vein and it is an Operation that ought to be performed without fear - Mr. Coleman recommends to make an incision on the Thyroid Cartilage but this Mr. Cooper objects to there not being room left sufficient for the Passage of the Air from the Trachea from the elasticity of this Cartilage and sometimes it being met with in an ossified state On the Operation for Suppression of Urine The best method of performing this is about the Pubis. First make an incision one Inch in length as near the Pubis as possible, feeling for the Symphisis Pubis then pass a Trocar & Canula directly downward towards the Bladder the length of the Trocar & Canula should be 4 inches the Canula should be rather longer than it is generally used as the urine is apt to be extravasated, the coats of the Bladder receding from it as the 149 urine passes off then fix the Cannula by strings to the abdomen- it should not be allowed to remain in more than 2 Days when it should be withdrawn and a shorter one introduced if necessary: even this method of operating is liable to objections as it generally brings on disease of the Bladder from irritation Mr. Cooper recommends an incision to be made into the membranous part of the urethra as it depends chiefly on a stricture in that part : there generally occur about 2 or 3 inches from the Bladder or 7 Inches from the lips of the Urethra - The incision is to be made with a Lancet made straight and this is to be thrust through the Tumour in the perineum into the Bladder - Of Calculi in the Urethra The presence of calculi in the Urethra may be known by the Patients complaining of cutting sensation at the lips of the Urethra a sudden suppression of Urine and if a Catheter is used to surgeon hears it strike against the stone If the stone is lodged two or three inches within the passage make an incision through the Urethra upon the stone keeping 150 it at the same time steady between your Finger and Thumb, and taking care that your external incision is larger than the internal: this done extract the stone with a dissecting hook: the wound will heal by granulation: you must not attempt to heal by the first intention for obvious reasons - When the Calculus is situated directly opposite the Scrotum it is not to be distinctly felt : it is more difficult to extract, and likewise endangers a sloughing of the Penis by the urine extravasating itself within the surrounding cellular [membrane] substance therefore it is recommended to push back the stone in perineo, where it is less difficult to extract. If you intend to operate in its first situation (viz directly opposite the scrotum) make your incision from 1 ½ Inch to 2 Inches through the integuments covering the stone to allow the Urine to escape freely after the Operation and extract the Calculus with the forceps or dissecting hook- In Children this Operation is not so dangerous - 151 apply poultices to the wound, and heal by granulation as before observed - the next situation of Calculus we shall speak of is at the Prostate gland which of itself will sometimes produce Calculi different from those found in the Bladder or Kidneys. before you attempt any operation in this case give the Patient a few hours to wait, for there has been instances of the urine accumulating behind it and forming by his efforts to void his urine from its situation, and it being in consequence expelled with the Urine. but Mr. Cooper advises at the same time Bougie to be introduced as far as the stone, and suffer to remain there as long as the patient can bear it, when it being withdrawn and the Patient desired to void the contents of the Bladder, the stone will in all probability pass off along with it, but if a Fistula in perineo attends this complaint this will not happen but the stone will make its way through the Perineum If after you have tried this plan of treatment and gain no advantage you must proceed to operate as follows 152 First pass a staff along the Urethra untill you distinctly feel it resting on the stone pressing it into the Perineum so as to feel, then cut, make an incision with a scalpel into the point of the staff within its grove pass a probe into it and push it along the Urethra (over the stone) towards the Bladder beyond the stone this done extend the incision with a Phymoses knife untill the extremity of the stone where you may readily extract it with your Finger or a fine pair of forceps. after Treatment as before directed - If a stone is situated at the membranous part of the Urethra with a stricture, it must be removed make an incision through the perineum and extract it with forceps A stone lodged in the Meatus Urinarius of the Female seldom requires any operation for its removal , but it sometimes produces Ulceration, and part of the stone being lodged in the meatus and the other in the Vagina - you must introduce a pair of forceps break off that part in the vagina and afterwards remove the other portion within the meatus urinarius Mr. C. saw this operation performd. on a woman who had previously a 153 very difficult Labour and it was found that one portion of the stone communicated with the other by a narrow neck - On Amputation of the Penis The Penis is subject to two species of cancer First the Watery Cancer so called from its first appearance being similar to that of a Venereal Wart this increases to a considerable size resembling a Cauliflower this Ulcerates and destroys the Penis the Urine is discharged by many orifaces and the Patient suffers excruciating Pain 154 saving of integuments as the corpora Cavernosa recede considerably, and besides that the integuments are more diseased than the Body of the Penis. when the wound begins to granulate you must introduce a bougie, and suffered to remain there, if it induces a discharge from the Urethra it must be only occasionally introduced (viz) two or three times a day if this is not strictly attended to much mischief will ensue- On the Hare Lip Children are frequently born with a deficiency in the formation of the Lips and which forms is its resemblance to a Hares Lip. it has been denominated by surgical writers Labia Leborino this deficiency extend sometimes through the palate to the Uvula. in this case the Operation is more difficult If there is a fissure in the Velum pendulum Palati only it produces a nasal pronunciation of sound. The hare lip exists sometimes on both sides in this case you must succeed with one operation before you attempt the other 155 If this Operation is to be performed in a Child its age is to be first considered Mr. C advises the Operation never to be performed until the Child is two or three years old, there are two reasons for this, in the first place if very early performed it generally prove unsuccessfull, and secondly if delicate Children it proves dangerous. the Lip from the violent irritation it occasions brings on Diarrhea Convulsions &c - Operation Pass the point of a Lancet through the skin of the Lip, extending your incision first upwards towards the fissure and then downwards towards the edge of the Lip so as to make it a recent wound this done on both sides, pass the first suture through the middle of the red part of the Lip and the second half way between the first and the nose exactly; the sutures are then to be tied, you are to bring the cheeks together and apply in a day or two a slip of Empl adhesive across the Lip from the Angle of the Jaw on one side to the opposite angle, this is to remain for 10 days. and if any excoriation is produced by 156 it. first apply a slip of Lint & the empl adhesive over it - If it is a double Hare Lip there is always a projecting portion of bone if in the Adult, this is to be removed by the bone forceps, in young Children it is of no material consequence - In this Operation, the Labial Artery is divided and in order to stop the haemorrhage you are to pass the Lower suture so as to include the Artery if possible and which is not very difficult to accomplish: The Middle Suture must be taken away on the 4th day - and the lower one on the 5th . In Children leave the Ligatures to Ulcerate of themselves, for the inflammation which they produce is trifling, but still keep adhesive plaster over the lip - On Nasal Polypi These Polipi which arise from the Pituitary membrane of the nose, are sometimes found transparent, at other times of an Amber colour, they are found depending by a narrow neck, are easily movable and are contained within a thin Bladder they are not very sensible and but slightly vascular, Patients under 157 this disease complain that when the weather is moist the nose feels stopd up, so that they cannot readily breath, and if they have a a cold the nostrill on the affected side seems stopt up, while the other remains free, they are sometimes found branching and at other times to contain a Hydatid Operation If the Polypus appear at the nose. place the Patient in a clear light and examine with a probe where the neck of the Polypus is attached. it generally to the septum nasi. then introduce a pair of pointed Forceps, take hold of the neck of the Polypus and by a sudden jerk extract it a small portion of bone sometimes is brought with and which is a describable circumstance if not they are very liable to return in a few months Polypi sometimes occur of an Hydatid kind filling up the cavity of the nostril completely and when you attempt to extract them they break under the forceps so that you can’t remove them in this way they contain a small quantity of fluid, they occasion swelling of the 13 sides which is a stronger sign of inflammation than buff, - on Specific Inflamation Specific inflammation is where the arterial action is changed, and the effusion is different from those already described, those in the Gout. the skin is inflamd, but chalky matter is deposited on the Joints instead of lymph - in cancer and schirrous where the disposition is on a peculiar nature. the discharge is very different from pus. small pox erisipelatous fever. Angina scarlatina are specific inflammations. Inflammation is salutary if it does not precede to too great a length; granulation could not be affected without an inflammation of the surface of a wounded part - if matter forms in the interior part it could not get out without a process of ulceration - Bone exposed to accident must always remain so did inflamation produce exfoliation. Inflammation therefore should be suppressd, its symptoms are to be attended to and regulated, weakness is the predisposing cause of spontaneous inflammation 158 cheeks, Ulcerate and destroy the nose producing violent constitutional irritation which puts a period to the Patients sufferings. This Disease is not of a cancerous nature, An Injection of Hydrar: Muriat & aq:Calci is recommended A Cancerous Polypus sometimes occurs between the age of 40 & 80 it’s colour livid & when touched bleed profusely it is attended with a shootin pain thru the Head, sometimes extends through the ductus a nasum and forms a Tumour just opposite to the Lachrymal sac - Treatment - use Injections with Tinct:Opii & give opium muriatae On Dropsy & Method of Operating Dropsy of the abdomen is of two kind. First Ascites which is an accumulation of water within the Cavity of the [abdomen] Peritoneum or Encysted when the water is collected in the Ovaria, or in an Hydatid on its surface - I ascites the water gradually accumulates upwards untill it reaches the navel, when there is but a 159 small quantity of water an undulating motion is felt by the Patient in charge of posture, this Disease produces an accumulation of water in the extremities which there takes the name of Anasarca if it is accompanied with difficulty of Breathing much danger is to be apprehend Ascites is generally the effect of a Diseased Liver, sometimes from the omentum or spleen becoming hard and enlarged, the Tabes Mesenteria is sometimes a cause of this disease, and especially the abuse of spirit Liquors, from it producing a great determination of Blood to the Viscera: whatever hurries the circulation is a frequent cause on Dissecting those who die of this disease the Peritoneum is in general found studded with Patches of coagulable Lymph - Encysted Dropsy caused from an accumulation of serous fluid in the Cavity of the Ovaria. it becomes considerably enlarged before the Patient is aware of the Disease existing forming a large Tumour on one side of the abdomen there is at this time on the Museum 160 of St. Thomas, Hospital, an ovarium which contained 12 Gallons and one Pint of water purchasd. from Dr. Poles collection by Mr. Cooper in General they contain from 20 to 30 Pints The Water is sometimes accumulated in many cysts, therefore it is not advisable to operate early - The fluid which these enlarged ovaries contain, differs much at various times, at first it appears like the serum of the Blood the next time it appears glary & Tenuious as the White of an Egg after which it seems like pus & Hydatis is found in it; the fluctuation in this Disease is not to be distinct as in ascites - water is more & there discharged by the the urethra & vagina Operation Have the Patient in a Chair with a sheet thrown round the abdomen, and confind. there having made an incision with a Lancet one Inch below the navel in the course of the Linia Alba introduce a large Trocar and Canula after the water is evacuated close the wound with Empl adhesive Very Carefully. This operation maybe performed at the navel or an Inch above it if the Tumour is high - If the operation is performed Low down the Bladder should be previously emptied - It requires to be often repeated 161 Scrophula Scrophula is an inflammatory disease accompanied with great debility, all the processes are attempted as in common inflammation but they are slow & imperfect. The adhesive process instead of taking place in a few hours as in common inflammation is sometimes weeks, and there is not that kind of adhesion as in inflammation: the coagulable Lymph is soft and imperfect the Suppuration stage is slow and imperfect. the pus is like a serous fluid mixd with curd like matter Ulceration is also very slow. there is evidence of fluctuation long before the abscess breaks when opened the edges of the skin are curled at the ends and turn inwards, not opposite to one another and considerable scars are produced Scrophulous complaints occur at different periods of life first there is a scrophulous enlargement of mesenteric gland in very young Children called Tabes Mesenterica, at two years of Age the glands of the neck becomes enlarged next from 6 to 12 years there are generally the different white swellings in the Joints about Puberty Phithisis Pulmonatis occurs & generally continues to 35 years of age about the same time lumber abscesses take place upon the spine and also in the Loins and groin. From 20 to 23 the Testicle becomes scrophulous 162 there is no pain, great enlargement & hardness, this extends to the vesicule seminal and Prostrate Gland - Scrophulous Opthalmia occurs at any Period under 35 years, An enlargement of the Prostrate Gland in old age is said to be scrophulous but doubtful, Truly scruphulous complaint are rare after 35 years - Exceptions - Character of Scruphulous Persons Distinguishing mark, Then skin, delicate constitution, light florid complexion light in general, fixed colour in the cheeks you may see the Veins distinctly under the skin usually about the neck and Temples. the hair hangs straight, pliable fine light and sometimes very dark. upper lips much the thickest and projecting over the lower, Scruphulous Children are liable to diseased secretions behind the Ears producing and enlargement of the Glands of the neck - No disease is hereditary Every constitution is liable to scrophula when exposed to particular causes. no Child is born with scrophula but only with that disposition to it like its parents and their disposition must be acted upon by the same existing causes before the disease is produced the Disposition is hereditary but not the disease. Predisposing Causes Weakness generally the effects of some Fever - scrophula frequently occurs after the inoculation of 163 the Variolae prior to the introduction of the inoculation for the small pox into this country scrophula was not so frequent[ly] as it was afterwards, but since the introduction of vaccination scrophula is not frequent as it was. also caused after the Fever produced by Mercury- the most common cause is Angina Scarlatina, the more Violent the Scarlatina the less Violent the scrophula &c close confined situations and scanty nourishment - The treatment consists in restoring the tone of the Arteries and in the formation of better Blood. Begin with enriching the Blood Good Nourishment must be kept up - 3 Glasses of Wine for a Child out of arms per day. Scarcely any Vegetable Food should be given. Meat at breakfast again before dinner & at dinner the Child should never fast long: nutritive food in as small a compass as possible; Exercise with other Children frequently but not to fatigue Good Air. On this plan you must place more dependence than Medical treatment Medicine steel and Gentian combind with Bark. If inflammation is going on give the following Rx Hydrarg Muriat gr 1/8 Tinct. Cinchone 164 Comp 1 dram bis terve die sumendus ex vino rubro. This is particularly beneficial in scrophulous ophthalmia. The above is a dose for a Child, it produces absorption of scrophulous enlargement prior to the formation of abscess - scrophulous Diseases of the Absorbent Glands - In the Glands of the neck an amount of the exposed state of the face and ears inflammation is produced the almonds of the Ears are said to come down inflammation takes place on the mucus membrane of the nose; with these scrophulous enlargement of the Glands of the neck: there is but a slight degree of pain: remain for a long time in a very indolent state, then with no obvious cause on a sudden go to suppuration which is shewn by the redness of the skin afterwards of a purple colour and when the Glands Ulcerates the edges turn in the Granulations or flacid & glassy and take great length of time to heal. sometimes the Tumours produce fatal consequences by pressing on the Larynx obstructing Breathing and from taking sufficient nourishment. likewise pressing on the Jugular vein and occasioning apoplexy - 165 The plan of treatment proper in these cases If you are called in at an early period of the enlargement it is best to apply aq Lith Acet: comp and to give purges of calomel If there is any considerable pain apply Leeches repeatedly and prevent suppuratoin if possible endeavour to keep the inflammation under Medicines Rx Hydrarg Muriat & 1/8 Tint: Cinchone ʒi bis terve die. If the pain & inflammation is great the Tint: Cinchone should be left but, where it does not ammount to suppuration it will promote the action of the Absorbent Vessels- When the Tumour is of a very indolent kind use the soap plaister. If in the early stage the Emph sapon and flannel put over with rest and Calomel purges will cause a cure in a few days. If suppuration takes place after all the means you have tried, as soon as there is any fluctuation open the abscess - If in the Female be a little particular for fear of making a mark - make your incision with a Lancet transversly into the abscess - after it is opened 166 apply the following Lotion Rx Zinci Vitriole gr xÿ Aq: Rose ℥viÿ ᵯ If it checks the discharge too much, mix it up with Bread as a poultice which is the only alteration found necessary- It requires daily attention to prevent it from closing by passing the probe in - The reason scars are so frequent after these abscesses is the skin is suffered to get diseased before the opening is made and the edges of the skin is drawn into puckers Earthy matter is discharged from some of these abscesses sometimes and are more difficult to cure. use the following Rx Ferri Ammon. ʒi Cerat alt ʒi M Ung Rx Ferri Rubigo ʒi Ung & Albi 1 ounce M. or the Martiat Cerate - When granulation is risen near or quite to the skin use white Vitriol or the Vitriolic Acid wash Lime Water or the following Ointment Rx gum: Elemi 2 ounces Milt Commun ℥i or Tercl ℥1/2 Adipis scilla ℥i ᵯ f Ungm to every half ounces of this ointment udde pulv Ammon prop ʒii ᵯ f Ung. The Glands about of the bronchiae are often affected and the Patient cough up a considerable quantity of Earthy matter - they become enlarged & adhere to the bronchiae - 167 Tabes Mesenterica This is a common disease in Children at a very early Period of life attributed by their Parents to worms, but the real cause is an enlargement of the Mesenteric gland these Glands are placed between the Thoracic duct and intestines, by the enlargement of these Glands nutrition is prevented from going into the intestines in a proper manner. the Child makes a chyle as usual but passes it off by stool which is supposed by their ignorant Parents to be worms. The Chyle not getting into the Blood the Wasting of the Body is extreme appetite very irregular. enlargement of the belly: picking of the nose &c Treatment Rx Calomel gr iÿ Pulv e scummon gr v M f Pulv this is to be repeated every five days - In all diseases of Children Mr. C. always recommends the above powder except in those which are considered specific in themselves: such as Hooping Cough: small pox measles &c. as he wishes to produce vomiting and purging – do not depend on Calomel 14 on which account the Legs especially of old persons are most apt to ulcerate, their circulation being slower than that of rest of the Body Intemperance weakens and produces a great disposition to inflammation, for the same reason persons who take too much exercise immediately after they have recoverd. from Fevers are liable to suppurations near the knee Blisters are liable to produce sloughs after Typhus Fever or Measles - The occasional causes of inflammation are those that change the action of the Blood Vessels of a part. thus in Fevers the Blood is pumpd. too fast through the arterial system if it meets with a weak part congestion takes place and an increasd. action of the part is set up to take up the congestion, - the sudden application of cold to parts in a healed state stop these suppurations and a large quantity of blood is impelld to the part to keep up the resistance of these vessels that had been constringed by the cold - violent exercise produces an increasd. circulation 168 alone. if in a very delicate habit use Rhubarb with it at the same time the Vinum Ferri a Teaspoonful in a Tablespoonful of Red Wine three or four times a Day. Nutritive food in small compass and entirely on meat, not vegetable Air and exercise without fatigue. Empl Litharg Comp on Empl fix Burgand on the surface of the abdomen is very usefull - This disease if suffered to go on too long or treated improperly will terminate in Dropsy. and even after the disease itself has been cured it has been necessary to draw off the water. abscesses have been produced and large tumours of earthy matter also - Scrophulous affection of the Joints white swelling called so because the skin remains of its natural colour. symptoms at first, a stiffness is felt with slight pain: then in a few days an enlargement of the Joint begins: this continues for a length of time, & as there 169 is not much pain it does not execute alarm after being sometime in this indolent state a sudden change takes place a general Chilliness, pain and suppuration in the part, the slightest Jar of the Joint causes exquisite pain. when matter has begun to form it goes on increasing in quantity suppuration takes place below the Joint If it is at the Knee it will be 6 inches below and sometimes a little above when the abscess is opened the process of ulceration is very slow - the dishcharg will continue for a length of time for 2 years unless some active means are used to prevent it - Appearance on dissection. under the skin a quantity of Fat is found under which the common capsular Ligament is considerably thickened, the Vascular Ligaments from whence the synovia is secreted are particularly affected: the Cartilages are in part absorbed sometimes wholly so Bones throwing out spicule in several different parts with holes in them- If when it has made any 170 progress and ultimately cured it is anchylosed. Treatment supposing it only stiffness with slight degree of pain Rest. Rx Linim Ammon. Spt Vini camph [an] ℥1/2 Antim Tart 1 dram rub in 1 dram every night and morning on the part affected. in three days there will appear an eruption like the small pox: and if the Linim Camph is omitted the eruption will appear as in Henerial - It is preferable to the use of Blisters & Ungn. Sabina tho the Blister may effect a cure there is always left a greater contraction of the Joint with weakness and Lameness After using the liniment for 3 days apply a common poultice which is to be kept on for 3 days renewing it occasionally at which time the Liniment is to be used again - Another form which is used – Rx Antim Tart ʒiÿ Ungn. Sperm Coli ℥i 1 H f Ungn -this produces a more irritable eruption but the former is far preferable give Hydrary & Tinct Cinchona. If much pain it is usual to apply Leeches but these produce 171 weakness in the part which ought therefore to be avoided if possible - Rx hydrard Muriat combind. with opium to produce nausea answers well - A considerable quantity of opium is sometimes required to be given to prevent pain- the following is the form to give at night Rx Calomel prop gr i Pati: Opii gr 1/2 Ferri Vitriol gr 1/2 M Omni nosta sumendus - The Vinegar poultice is also used. it produces an eruption in about 3 days. it has not so good an effect as the Liniment the Emp Lith the Empl pix Burgand are good applications Emplast Epispast & savn Ointment is in common use - The best means of Restoring the Joint, if you have subdued the inflammation use friction with frequent motion but not too quick nor begin too soon. If suppuration takes place in the Joint no means can prevent it from taking its course. therefore it is best to encourage it, and to bring it on speedily give Tonic Medicines and use warm applications to the part after it has been opened inject the following into the [sinus] Rx Acid Vitriol ʒi aq Purce ℥vi throw this into the joint 172 Put a Blister over the Joint and dress it with savin Ointment, in time the inflammation will be lessened and the discharge but a stop to- Surgeons have several times performed amputation unnecessarily in this disease, It is never necessary unless there are the most powerful hectic symptoms, never suffer it to be amputated though the Patient may be lame the whole of his life - the weakness which the Amputation occasions in that particular constitution will probably prevent the stump from healing and it is a great chance if some other part is not affected - Disease of the Hip Joint. Pain in the knee is the first symptom. If you fix the Thigh bend and extend the knee it will give no pain in the knee, but if you take the Leg and raise it up towards the Body you will cause pain extending to the knee. in walking the Patient turns his Toes out - the Toes can turn in but triffle. The Joint does not feel round but flat - the disease limb appears longer than the sound one, as the Head 173 of the bone is thrust out a little from the Acetabulum by an effusion of coagulable lymph into the acetabulum, the nates of the diseased side is one inch below the opposite - If you turn the Patient on his face there is a fold in the groin by pouparts Ligament while the opposite groin is straight from the lengthening of the Leg at last the limb becomes shorter, so that the head of the Thigh bone becomes diminished greatly and the Acetabulum becomes lengthened upwards: it is one or two inches shorter. If suppuration has taken place they never recover with less than one inch shortening of the limb. Abscesses sometimes break opposite the Trocanter Major, there has been a Case in the Hospital of these Ulcerating the coats of the Femoral Artery and causing Death from Hamorrhage - Treatment. this should be undertaken as early as possible. give the Hydrary Muriat cum Tinct. Cinchona so as to excite nausea this will often diminish the pain in the knee apply Leeches. if very painfull use the following on the Hip Joint Rx Linim: Amon: Camph ℥i Antim Tart ʒÿ M rub in 1 dram nocta manque, and continue untill Pimples are produced. order Rest let the Patient use 174 Crutches and no motion of the limb be employed whatsoever. if you do not succeed in this plan early, make an Issue with Kali purum about the size of a shilling on each side of the Trochanter Major: this is preferable to a Blister with the Ungn Sabina, these Issues should be kept open for six Months or more: untill the pain in the knee has ceased - If abcesses are formed from the Joint let them take their own course. if they are opened the inflammation will extend upwards and the whole of the Joint will become inflamed - should the Patient recover fast he should be in haste to use the limb as he may bring on the disease again. and ought to continue the crutches for some time after. the cavity of the acetabulum becoming absorbed the head of the Thigh bone passes into the pelvis, and by its irritation destroys life or produces abscesses bursting into the Rectum and kills him also. if in a woman the abcess burt into the Vagina and may recover - Ulceration of the vertebrae. This complaint begins with a pain in the affected part soon after there is a projection of one 175 of the spinous processes, which becomes detached and the spine suddenly forms an angle, weakness in the lower extremities so that he often falls down suddenly when sitting he draws his heels under his seat. during the night spasms of the muscles of the lower extremities at length producing a paralytic affection, but the muscles are not relaxed, but spasmodically affected - the Vertebrae press on the spinal marrow and produce irritation: the Bladder [find] looses its retention power as does the Rectum. If the cervical vertebrae are affected, the patient has no use of his Arms or Legs, the Head only being free from disease. in some Case as many as four or five of the Vertebrae has been destroyed and yet recovered, sometimes there is a considerable abcess forming in the fore part of the spine adheres to the Lungs burst, and is discharged by coughing - Treatment setons or Issues by the side of the Vertebrae. Issues are most affectual but setons are most convenient these Issues must be kept open for 12 months or more and sometimes two years. but it depends on the Relief afforded if sufficient irritation irritation is not made dip the pea in unguent cantharid - 176 When a Cure is affected it is with an Anchylosis of the Vertebrae so that the spine never after becomes straight yet the spinel marrow does not become compressd. The constitutional treatment should be the same as before directed as Hydrar Muriat & Tinct Cinchona - Psoas and Lumber Abcesses, these are singular to the last symptoms. Pain in the Loins for months before there is any appearance of disease. a small Tumour in the Groin where Bubo appears, which dilates in Coughing as in Hernia. this Tumour extends downwards and is of a considerable size. this sometimes form two las one on each side the Femoral Artery and Vein, the tumour at length bursts and discharges from H1/2 to Hi of Matter three or four days after: much Fever is excited and hectic symptoms come on, night sweats chilliness succeeded by heat. and the case soon terminates fatally - On Dissection the Origin is found to be from the Spine and the Matter Ulcerates through the Psoas muscle to the Thigh under pouparts Ligament. it destroys the Ligaments of the spine where it is situated and the Psoas Muscle become hollowed 177 Treatment. Excite irritation at the part where the Patient complains of pain. make Issues and keep them open for a month or six weeks before you have any thing to do with the abscess, then you are next to consider the propriety of opening the abscess. Mr. Abernethy consider making a puncture into it is advantageous to let the matter out gradually - as this diminishes the constitutional irritation pass a Lancet at the part where the abscess feels rather thick introduce it from the side and make an oblige incision as you have a larger fur pure of the escape of the matter which is generally mixd with clots which must be removed by a probe, then lay a puic of lint over the wound. and over that Empl adhesivim - as the Matter accumulates you must repeat the Operation not suffering much matter to collect - Scrophulous Ophthalmia. This produces very quickly opacity of the cornea even in a few days, give Hydrarg Muriat with the Decoct. Cinchona & Tinct. Cinchona, if the Eye is irritable apply. Rx Hydrang Muriat gÿ Aq: Calcis ℥vi Tinct: Opii ʒÿ Aq Pura ℥i M or Rx Aq: Litharg acet 30 gtt Zinic Vitriol giv Aq: Pura ℥iv this forms the acetate of Lime 15 and congestion takes place in any weak part as before mentiond, - The division of Blood Vessels is the most frequent cause of inflammation. the division of an artery stops its circulation and the neighbouring arteries throw more Blood on the part to keep up a due circulation:- Laceration contusions &c are the existing cause of inflammation: extraneous bodies Gunshot Wounds and ligatures occasion more or less inflammation according to the irritability of the system. Proximate causes the state of the part which produces the symptoms, it has been supposd, that the Blood when in an inflamd, state, was thicker and would not pass through the smaller branches of the arteries, which made the arteries push with great force to get it through, this is now found to be a false idea, the Blood when inflamd. is much thinner, Dr. Cullen thought that inflammations was occasiond, by spasms of the arteries, the contraction of which obstructed the passage of the blood, that the neighbouring arteries pushed with more force to obtain one if the Blood was thus returnd. it would 178 which is to be introduced between the Eye lids: give Calomel. In scrophulous testis give. Calomel to affect the Mouth and Mercurial poultices must be applied It generally occurs in people from 20 to 22 years of Age. It is not attended with much pain and one Testicle is affected which soon extends to the other On Gunshot Wounds Any wound produced by a substance entering the body with great Velocity is of the same consequence as Gunshot wounds The Gunshot Wounds differ from common wounds in their being much more intense extraneous substance most frequently loose and having a sinous tendency during cure. They are divided into two kinds 1st When the Ball is passed through part of the Body: 2nd when they continue to lodge. they require different mode of treatment, the former much the simplest, the surface of the wound is covered by a thick slough as if 179 caustic had been used in consequence of the velocity with which the Ball has passed in the wound where the Ball has passed through there is always less haemorrhage than from incised wound: for the first four days the Patient complains of great pain a Glutinous substance issuing out of the wound. untill the sixth day there is no appearance of suppuration and when it begins it is in consequence of separation of eschar not completed till the tenth day or a fortnight; when the eschar has separated it forms a sinus, unless the Ball has struck a bone no pain is produced but if it has then it communicates a shock to the Body if there is no sinus formed it then goes on as any other common wound Treatment. Bleeding is highly essential in Gunshot Wounds at first to prevent inflammation and afterwards when it is come on the Bowels are to be kept regular, but in these there is the same objections as in Fractures: doses of opium with saline medicines every four hours to keep the patient comatose state to alley the irritability of mind and prevent 180 the locked Jaw, regimen to be the same in moderation. Poultices not only upon the wounded part but upon the whole Limb if there is not much Haemorrhage. but if there is use cold spirituous Lotions with Vinegar. the poultice to be used till suppuration happens, as slough often came away during the cure. the best method of separating them is by the injection of warm waters into the sinuses not using any force. scarify the edges of the wound at the time of inflammation if you have not the opportunity of applying leeches, and do this occasionally as you find inflammation coming on sometimes the inflammation is so great as to produce mortification. there is no discharge from the wound. Apply leeches about the part scarify so as in some degree to dilate the wound with fomentations, & vinegar poultice. The sinus has sometimes been very difficult to heal, make an incision between the two orifices and divide the sinus then it will probably heal. if it does not then pass 181 a Bougie with stimulated ointment on 2nd. Gunshot Wounds, with the Ball lodged. when the Ball and extraneous bodies remain lodged in the parts. Pass a probe or a long bougie into the wound and search for the Ball and if you can feel it attempt its extraction, or if it has passed nearly thro so that you can feel it under the skin you mat cut so as to take it out, but not otherwise, for it is not proper to make extensive incisions to follow them as it is well known that Balls sometimes remain for years in the Body without any disagreeable effect being produced - and from their curious course it is often impossible to find them, and as they pass a long way to make a large incision will be very dangerous for they have been known to enter the middle of the forearm and pass out at the neck, also to enter at the scorbiculus cordis and pass out at the back part by the spinous process of the Vertebrae going round the out sides of the ribs. if the Ball is left and does not form cyst it generally produces inflammation which will ovation the expulsion of it in time 182 therefore it is much better not to cut to far for it- Gunshot Wounds of Arteries Arteries when divided by a Ball Bleed much less than if incised because it leaves a fringe of cellular membrane. and the tone is lost. but still there is considerable danger, even if it has passed near an artery as it will cause the coats to slough & the Patient will die from Haemorrhage when passed near an Artery apply a tourniquet, for if it does not Bleed at first. still it will Bleed, In tying an Artery from a Gunshot Wound it should be done high up from the divided or contused parts as they will soon separate or mortify - the Patient if there is a wound near the Artery should be directed how to manage the tourniquet in case of haemorrhage - Gunshot Wounds of the Abdomen If a Ball passed directly through the abdomen it is fatal in a few hours as it must pass through many folds of the intestines - Bleeding & remedies 183 against inflammations must be used. Opium freely: when shot through the stomach in general die in 30 hours and when through the intestines in 24 hours - an intestine may be wounded and the patient may recover. Gunshot wounds of the Liver spleen or Kidneys Mr. C has not seen Gunshot wounds through the Chest into the Lungs are not so dangerous as incised many instances are occurring, when recovery has been affected when there has been considerable injury, these require only simple mode of treatment. Perfect rest, bleeding very freely, - more danger ensues frequently from bits of cloth & being carried in with the Ball than from the Ball itself causing so much irritation, but it is never necessary to make incisions to take them out for the wound will heal from where the Balls enters and will Ulcerate externally towards the extraneous body. thus closing at the part furthest from the Ball and gradually opening to it silk clothing is safer in this respect as it is not so soon separated and carried in - 184 Gunshot Wound of the Heart are instantly fatal. wounds of the Brain are fatal, yet when only the skull is depressed the Patient may do well after trepanning; the Ball has been known to enter and do through the Othmoidal & Sphenoidal sinus and have not proved fatal nor done any injury to the Brain Compound Fractures occasioned by Gunshot wounds are much worse accidents then when happening from other causes : and consequently more difficult in their treatment as the Bones become much more splintered in these it is necessary to dilate all the wounds, to extract all loose portions of bone for if they remain the Patient will die of the consequent discharge, but if removed tho the limb will be shortened, he will commonly do as well as in other compound Fractures and perhaps render the operation of amputation unnecessary - If the Ball passes near or through a Joint so as to splinter the Joint as in the Ancle, Knee, or Elbow, it is very dangerous much more so than Compound Fractures from other causes, it is necessary to amputate, but it is much better to wait and see whether the wound is of such a nature as to Create symptomatic Fever, and the to consider 185 whether the Patient will be able to bear that Fever if you think the latter it is much better to wait till that has subsided before you begin to Operate. Dr. Babington was Surgeon sometime ago on board a ship, after an engagement 24 were amputated in consequence of [a] Gunshot wounds 21 died soon after and three lived to go to a Hospital where one of the three died after so that two only lived when probably if their limbs had not been amputated till the symptomatic fever had subsided some (if not many) of their lives might have been saved - Burns and Scalds The effects of Burns and scalds are of three different kinds. 1st Vesications of the Cuticle 2nd separation of the Cuticle so as to expose the cutis to a great extent and 3rd Destruction of the cuticle and cutis so as to occasion sloughing these three states require different mode of treatment - in the 1st state when the cuticle is detached in the form of a Blister though extensive it is not dangerous. if the cuticle is over it such burns will always do well under this kind of treatment Rx Aq Litharg: acetat. g xxxÿ Zinc Vitriole gr iv Aq Pura ℥iv M Spt. Vini: Camph is a good 186 application. but the following is the best Lotion to prevent the separation of the Cuticle Rx Spt. Vini Rut. Acet communis part equalis ᵯ - In the second stage. It is most dangerous with the cuticle separated and without the life of the cutis being destroyed. The patient soon dies (though the sore in some cases may be extremely small) let you follow what plan you will: for the extremities of the nerves are exposed and occasions such a Violent degree of constitutional invitation that in a few hours it terminates fatally. sometimes the Diaphragma becomes affected breathing Laborious with spams & in this state a solution of opium will moderate the pain, but as it produces costiveness it out to be guarded against Lime Water and Linseed Oil is a good application to allay the pain and heat at first, but it produces a great discharge from the part, and may also produce pectis symptoms, therefore to not continue its use long - in Consequence of what has been written about spirits of Turpentine in this state of burns M. C had been induced to give it a fair trial. It produces excessive pain and very often extensive sores In a Case now in Guy’s Hospital A Man’s Legs were both equally burnt. to one Leg he applied 187 the Aq Litharg : acetat &c and to the other spirit Terebinth. The Leg which was dressd with the Aq: Lith. &c is completely well and then is on the other a very extensive sore- the danger in this second state is not all over when the immediate symptoms cease for a very profuse discharge will sometimes follow if the surface is large. but this may be restraind. by applying the Lotion of the Aq: Lith: acet &c as before recommended on Lint over the surface it also quickens the formation of cuticle - In the 3rd state when the true skin's life is destroyed it is not so quickly fatal as when the cutis is sensible, the constitution does not become affected for several days, but probably will when it begins to slough: If you do not Judge it proper to amputate you must use fomentation & poultices. When large surfaces have lost their cuticle it is a long time before granulation forms but if you use the Linn Vitriolate & Aq Lith Lotion, granulation will form in a few hours - Sprains. A Laceration of a Ligament, the best mode is to apply the following lotion Rx ammon: muriat ʒi Aq: Ammon Acet. ℥vi M Lotion. if there is 16 Change color; the redness of inflammation proves it does not, it likewise proves that vessels are not lessend, which must be the case if Dr. Cullen's hypothesis was true; The Blood Vessels are distended on the inflamd. part but their actions is not increasd. the arteries near the inflamd. part have a stronger pulsation, but are not distended, the distention is occasiond, beyond particles being pressed into the small vessels, that before only containd. white ones, thus it may be stated that there is always distention without increasd, action of the inflam part increased action without distention on the surrounding parts - to ascertain this Mr. Cooper put a young Frog (as their circulation may be easily seen) with a microscope he applied a stimulus to a part, and in a few minutes saw a red particle forced into the artery on that part it passed into the veins and at every pulsation of the Heart, fresh red particles were forced in till the vessels were filled with them 188 inflammation apply Leeches: put on a bandage as soon as the inflammation will allow: the Patient must be kept quiet four days or the Ligament will be torn through again by walking - a light Bandage should be used if he lay by a month or six weeks it will be difficult to walk a little exercise about the third or fourth day is necessary - Fractures Fractures are divided into simple & Compound called simple when the extremities of the bone are not exposed: there may be wound tho we may call it simple the exposure of the ends make the destruction 189 bone in the Body requires different spaces of time, depending on their size, as the Radius and Ulna will unite in three weeks The tibia never under 5 weeks and in very old people never under 7 or 8 weeks the large Bones in general, as the os femur and Humeri require 5 or 6 weeks before a firm union takes place. Simple Fractures are seldom dangerous to life except under certain circumstance. as a great depression of mind in very old age - Simple Fracture of the Tibia is ascertained by feeling along the skin. or by holding the foot in one hand and rotating it gently, passing the other hand along the bone untill you discover the crepitus when ascertained a slight extension is necessary to replace the bone in contact. but if the muscles oppose much by spasm you must not attempt replacement by force, but foment and poultices a day or two till it is subsided, when it may be readily replaced. You mush then apply the many tailed bandaged over the whole limb: this bandage is better than a long roller, for as the limb will afterwards swell the bandage 190 may be entirely loosed without disturbing the position of the Limb. if there is not excoriation of the skin or much swelling you had better put a rag dipped in aq: Ammon Acet under the Bandage. If excoriation has been produced then the aq. Lith: comp is preferable; over the bandage the whale bone splints are the best, as one set can be adapted to either Limb, and are known in the shops by the name of Martins splints - The posture. The Leg to be laid on the outside, knee a little bent the foot a little raised and supported by or pillow - The Fibula when broken is not commonly about three inches above the ankle and cannot be felt exept by rotating the Limb the other hand gradually feeling up the outside of the Leg untill you discover the crepitus, it is generally connected with a sprain of the ancle and is often mistakes for it rendering the Patient always lame 191 of the Leg with one hand, and rotating it: at the same time feeling along the Os Femoris carefully. when you arrive at the Fracture you will distinguish the crepitus: or by placing one hand on Trochanter Major & rotating the Leg with the other. If there is any Fracture the motion of the Leg will not be obeyed by the Trochanter. Treatment. Apply the many tailed bandage over the Limb, then three splints lined with wool, one before and one on each side. the Position of the Limb should be the Leg resting on the heel rolling a pillow up and laying it under the Ham so as to raise up and bend the knee - Fracture of the Clavicle may be known by tracing the bone with a finger from the sternum towards the scapula, you will find the bone sunk down at the fracture: Treatment. assistant must put the shoulders as much back as possible to bring the fractured ends in a line. then raise the arm so as to keep the clavicle in its place, then apply the stillate bandage (along roller) pass under both 192 axilla &c. not press on the broken extremity of the Clavicle for it would render the Fracture Compound. apply Emplast sapon under it. The shoulder is to be elevated in a sling, during the Cure no use of the Arm is to be allowed. The best mode of elevating the shoulder is to carry it close to the side and bind it down by a lon roller. the just support the arm in a sling - Fracture of the Os Humeri is distinguished easily by feeling the bone. A long roller should be applied round the arm then two splints one before & one behind will answer equally well when made of thick pasteboard, these are to be confined by another roller passed round the Limb in the opposite direction to the first ie. one from without inwards the other from within outwards which prevend. an appearance of twist of the Bone after. The position of the Arm should be hanging by the side supported by a sling on a pillow If in a very plethoric person he should be confined to bed for little while as very great swelling of the arm & forearm is likely to ensue 193 Fracture of the Radius & Ulna requires the same treatment as fracture of the Os Humeri- Fracture of the Radius only generally happens from falls in running - about two inches above the wrist known rotating the hand and applying the other hand along the Radius the fractured end of the bone generally protrudes among the tendons of the fingers so as to impede their motion - Treatment. the same as fracture of the Radius and Ulna to be suspended in a sling on a pillow - Fracture of the Ribs are ascertained by applying the finger to the part where the pain is and when the Patient Coughs a kind of grating sensation is perceived from the ends of the bones rubbing attended with pain Treatment it is necessary to hinder any motion of the ribs, therefore they must be bound very tight with a double headed flannel roller so that respiration is to go on by the Diaphragma - If the Lungs are wounded it is known by the Emphysima the bandage must be applied as before and a number of punctures made above and below it to let the Air escape. this 194 Accident generally gets well in about three weeks or a month unless in very old people - Fracture of the Sternum is a very similar accident to the former and is easily ascertained the lowest end of the bone generally lays under the upper, therefore the union is often irregular - Treatment the same as in Fractured Ribs. in both Bleeding is necessary - Fracture of the Lower Jaw, this happens generally at the symphysis from blows on the angle. The best bandage is leather sling with four heads. The sling being put under the lower Jaw the four ends carried over the head & brought down again and carried under the chin. Liquid food only must be allowed during the Cure - Another method of curing this Fracture is by passing a wire between the Teeth (2 on each side) twisting the ends firmly together this method must only be employed when the Teeth are firm Fractures of the Flat Bones unite exactly in the same way as cylindrical ones ie. by cartilage gradually becoming ossified thus in the skull where if 195 the bones could be brought together would unite gradually and equally as well as others but in these bones where a piece of any size is removed the place is not again filled up except by ligamentous substance - Fractures of the Patella happens generally from falls. the different portions of the bones become divided the upper one being drawn up the Thigh from three to six inches by the muscles inserted into it. the person becomes instantly lame if the pieces are not brought in contact the union is by Ligament but if brought in contact the Union is by bone. Treatment. you must bring down the upper portion in contact with the Lower by extending the Leg and pushing down the piece gradually from day to day as it cannot be done at once but will be done generally in about a week. If the bones is not brought in contact the Ligamentous union will be four or five months and the Patient is always to falls as that Limb is much weaker than the the other from the length of Ligament the patient should begin to move the limb gently after 1 month 196 Fracture of the Olecranon, is generally broke of about an Inch from the upper part and the portion of bone becomes drawn up about 2 inches high, the union as in the patella is either by Ligament or bone, Ligament when the Bones are not brought in contact. but bone when they are; to bring then in contact you must gradually and daily press the upper portion down till they come together. the arm must then be kept extended and a small square cushion laid just above the process which is to bound down by a roller. After the third week the arm must be gently moved every day to prevent anchylosis. - Fracture of the Os Calcis or other bones where large tendons are inserted unite them in the same manner as Fractures of the olecranon Fractures will sometimes not unite at all this happens from some peculiarity of constitution. there are no particular symptoms by which you can foretell it if appears to arise from a languor of constitution so that there is not sufficient inflammation produce to unite the separated parts 197 only Ligamentous substance without ossification. It has been recommended to cut off the two extremities of the bones and keeping the external wound open for some time this but rarely succeeds - If the muscles are affected with at a fracture give large doses of opium Tinct: Opii 30 gtt mane et Meridie et 4x nota hora somni with wine and a free use of spirits. Compound Fractures A Compound Fracture is when a bone is broken and there is at the same time an external wound communicating with the Fracture the wound is generally occasioned by the end of the bone. sometimes there is a haemorrhage. in twelve hours after the fracture there is a discharge of bloody serum much tension and great symptomatic Fever which continues from four to six days when the discharge becomes purulent and granulation arise from the sides and soon after from all the cavity which fills it up and the wound heals The greater degree of danger in compound than simple fracture arises from the greater degree 17 in the same manner great number of vessels were filled that could not be seen before their distention was produced. - the action of the vessels were not increased in this part but in the surrounding parts. The pulsation was much increasd, - Mortification takes place when a part is amputated in an inflamd, state, the living powers are to weak to support it - distention is not confind. to the part at first inflamd. it gradually increases and the whole brachial artery will become enlargd. in consequence of an inflamd. hand: if inflammation extends to a very great degree, the Heart will become enlargd. in which case the pulse will be scarcely perceptible, in case of very extensive inflammation constitutional treatment is necessary, particularly bleeding, this Mr. Cooper thinks is too much laid aside, but there is no occasion to bleed if the constitution is not affected - Blood should be removed quickly, if some degree of faintness is producd, it will be more effectual. 198 of inflammation and suppuration produced. and requires twelve or thirteen weeks to Cure when a simple one require only four or five - Treatment. Extension must be made at both end of the Limbs to bring the parts in opposition not using much force as it is not very material to have it done directly. if there is any haemorrhage apply dry Lint no Ligatures should be used if you can possibly avoid: if there should be tension apply poultice for the first few days. but if not attempt Union by the first intension with a linen rag (thin) in the Blood which comes from the wound. over it apply the many tailed bandage and over which put the splints. (Martins)- If the Fracture happens to the leg it must be laid on the most favorable position for dressing the Wound. if in the Thigh the same bandage is necessary as in the Simple fracture and the same position. the same application in the Upper extremity as in the simple fracture. the only difference is to wrap up the Limb in the rag with with the Blood from the wound. Get 199 the external wound to unite of possible by the first intention, always attempt it as it relieves the patient from great danger. unless there are very great Bruises then you must poultice - Much inflammation often comes on about the fourth day with great pain. loss of sleep stoppage of the discharge the parts about very much swelled. Air coming from the part when pressed the wound appearing dark pulse quick and small, with delirium. Blisters arising on the part with mortification killing in 24 hour - Treatment apply six or eight leeches to the part, general Bleeding im proper. poultice of beer grounds over the wound. Opium freely- Bark 1 dram 2ly poris and let the patient take freely of wine. Porter or Brandy according to the Habit he has been accustomed to live. The less medium the better internally so as to relax the Bowels. these means when employed early will generally prevent the Mortification - Mortification sometimes comes on in old people without any previous pain cheaply in old drunken people: this soon extends a great way and often proves fatal 200 In the reduction or replacement of the bone. when it cannot be done by extension. the most preferable mode is of the bone is not much denuded of its periosteum is to enlarge the wound. but if it is you should saw off the end which is denuded, but this is rarely necessary. if this happens to the Tibia, and the Fibula not broken it must not be sawn off on any amount as the ends of the bone will then be so far distant that no union well ever be effected When a large Artery happens to be divided which occurs oftenest in the Leg the Anterior tibial artery, and the Arteries of the Arms, you should not amputate hastily but cut down on the divided portions and take them up, then treat the fracture as before. A want of union will sometimes arises from a bad constitution and from exfoliating pieces of bone being enclosed. when a Compound Fracture extends unto a Joint it renders it a much more dangerous accident as the suppuration extends into it. Locked jaw coming on &c - Cases that require Amputation 1st when a bone is fractured in numerous pieces and the removal of which will cause such deficiency as will render the Limb 201 useless afterwards - 2ndly The division of a large Artery when it cannot be easily secured, as the posterior tibial Artery and when they are taken up high the Patient generally dies of mortification, but in the Branchial Artery as it is easily got at take it up and try to cure the fracture likewise in the fore arm - 3rdly when a large Joint is opened as the Knee or Ankle, but at the Elbow it should not be done hastily as the use has been sometimes recovered 4ly when the lacerations are very extensive though the fracture be not but should not be amputated hastily as great recoveries are founded to happen - 5ly It has been recommended where locked Jaw has come on - but the removal of the part is useless as it does not appear to relieve the disease at all - Young people often do well under accidents of this kind, when old ones dies - if the patient, Constitution is very irritable Amputation must be performed sooner than in one that is cool and patiently suffering. for in these delirium always follows quickly 202 the upper extremity may be amputated earlier than the lower. Mr. Cooper thinks that amputation in general succeeds better when performed after the patient has recovered from the symptomatic Fever than early if his constitution appears likely to sustain the first symptoms of irritation. - Wounds of Veins - These wounds are but of little importance with regard to the haemorrhage as they can be easily stopped. a wound in the Axillary Vein can be easily stopped with a dossel of Lint. so also the femoral Vein. the greatest danger of them arises from the inflammation of their internal coats the symptoms of which are a stiffness in the limb and part where the wound is and when occasioned from bleeding in the arm a difficulty of extending it. a swelling from the wounded part up the skin the size of a quil of a red colour: an abcess forms nigh the part with Violent shiverings and the matter with great difficulty gets to the skin, before are abscess breaks another forms higher up and often a third above that, when it breaks into the vein 203 then it proves fatal soon. these effects have by different authors been thought to arise from a wound of a Nerve, Tendon or Fascia. Treatment to be pursued is when the inflammation appears to apply leeches to the part & poultice - If these should not abate the inflammation quickly they best mode is to cut through the inflamed part down on the Vein and cut it across it may be done with a Lancet and afterwards compress the Bleeding Vein Wounds of the Nerves - On the division of a nerve the part to which it is distributed becomes senseless, yet the involuntary actions will go on in it as before, a Blister will rise in the usual time on it, and an Ulcer will granulate through not quite so quickly. for a few days after the division, the heat of the part will be greater than where the nerve is entire. as 78 in the entire part and 86 in the senseless part but after a few weeks it becomes much colder. a small branch is sometimes divided in Bleeding. it only causes a sharp pain at the time and a numbness at the fore part of the arm 204 for a month, but it is of no consequence further than that sometimes divided by the ends of fractured bones causing a numbness of the Limb below. When nerves have been divided after sometime they reunite by forming a sort of ganglion or knot at the divided part, and the powers of the part becomes gradually restored, this is also found where the ends of the nerves have been purposely separated. if the divided branch is very small the sense will begin again in three weeks if large from 4 to 8 months or if very large as the sciatic nerve at the Hip two years - Electricity quickens the restoration of sensation and motion: when a nerve is tied and remains undivided it generally kills the patient if large by producing violent pain and irritation & quickness of the pulse. If a nerve that has been cut through has been included in a Ligature as in a stump. the effects produced are according to the patient, constitution in some no ill consequence ensue, in others Violent and Universal spasms Treatment. when exposed lay the extremities in contact only and they will unite. 205 Wounds of Tendons The Tendo Achillis is often accidentally divided or cut across after which the Heel falls down and the upper portion of the divided tendon is drawn up within its thicken an Inch Treatment. Elevate the heel as much as possible by a high heel shoe with a strap extending up the Leg from the back part [of the] which is to be bound in with roller and applied round the calf of the Leg to hinder the spams of the gastrocnemii muscle: no pressure should be made at the divided portion as it will cause an adhesion of the Tendon to the bones and lameness ever after - The dressings are to be lint spread with carat simplex just laid on, if this plan is pursued the Tendon will readily unite and the patient walk with the shoe in ten days, no suture must be used. This tendon is often lacerated by great exertions in walking & ramming. the treatment is exactly the same. The patient may be allowed to walk as soon as the inflammation has a little subsided. it becomes completely united in 3 weeks and height of the shoe heel must be 206 gradually diminished. Partial laceration of the fibres of the tendo Achillis or of the Gastrocnemii: muscle is words accident than either of the former. It happens generally by a false step. the sensation at the time is as if the part was struck by a stone. Where the fibers are ruptured a depression can be felt and an Ecchymosis follows. This injury causes Lameness for years or for ever, if the person walks much on it for sometime after [a] high heeld shoe should be used for sometime with a bandage on the Gastrocnemii muscle for the reason before mentioned and in this manner the part will frequently recover itself in about three weeks or a months time - Wounds of the Abdomen These are of two kinds. Those where the Viscera are wounded. and those where they are not . If no Viscera is wounded, the wound is no otherwise dangerous than from its extent, or the protrution of the intestines which becomes strangulated by pressure 207 When the stomach is wounded the countenance collapses this person becomes insensible, the pulse cannot be felt. blood is vomited up mixd. with the contents of the Stomach, and liquids when swallowed come out at the wound, when this has happened no food should be taken either Liquid or Solid for a week or ten days, the Patient should be nourished by Clysters of Broth in which 120 drops of Tinct: Opii should be put three times a day to retain them after which a small quantity of Jelly may be taken for the space of a week and then solid food Wounds in the small Intestines are accompanied by the same symptoms as Wounds of the Stomach except that the Vomiting is without blood the same Treatment is necessary, but if it protrudes at the external wound, if partially wounded longitudinally and the intestines is seen externally it is right to pass the interrupted suture in it, the stiches only half an inch as under, then return the Intestines just within the Cavity leaving the ends of the Ligatures hanging out 18 There is but one objection to a large orifice it is apt to inflame. Venesection maybe used not only when the pulse is full and hard, but even when there is a weak thready pulse, as that will frequently rise after bleeding, of this we have frequent instances after amputation where the Patient is sinking very fast. if the stump bleeds the pulse rises and he gets better. the same effect take place in the bleeding of a compound fracture: it has been the custom to give bark & wine in these cases of slowness, but it is injudicious as they irritate too much in cases of incipient inflammation; taking [place] away blood in small quantities, will frequently stop its progress and not weaken so much as taking a large quantity at once, which should never be done but, in very extensive inflammation: when there is a very irritable jerking pulse, but if arising from a slight cause we should not bleed as it will only weaken. purgatives relieve by evacuation 208 then unite the Eternal wound by sutures which should not pierce the Peritoneum in eight days gentle efforts are to be made to bring away the ligatures of the Intestines - Wounds of the large Intestines may be known by the escape of the true foeces from the wound which should be treated the same as the former except that the nourishment must be given by milk only by the mouth instead of Clysters, as it will not make so much foeces. When any wound is made into the Cavity of the Abdomen and there is much haemorrhage the wound should not be closed till the haemorrhage ceases, for if Blood is extravasated into the Cavity of the Abdomen it is certainly fatal and not any great degree of inflammation is excited by leaving the wound open as long as twelve hours Wound of the Liver. This is not a fatal accident unless the wound is large a quantity of venous blood is discharged mixd. with bilious matter If the external wound is closed directly a quantity of this matter is extravasated in the abdomen; it should therefore be kept 209 open – lacerations without external wounds are fatal and it is not an uncommon accident. the abdomen swells to an enormous size and the Patient dies in a few hours Wounds of the Gall Bladder. Fatal in about 40 hours known by a discharge of bile Wounds of the Spleen. Although this is a viscus that may be removed from the Body without injury yet the most trifling wound of it is fatal, as great haemorrhage into the Cavity of the Abdomen follows. attended with such an inflammation as destroys the Patient indeed Blood when in any way extravasated in the abdomen proves fatal Wounds of the Chest. These are of two kinds. those which injure , and those which do not injure the contained Viscera: when only a wound is through the parts which contain the Viscera it may be known by the Lungs protruding when the patient expires and in the rushing in of Air at the aperture when he inspires. the wound must be united by sutures & covered with adhesive Plaisters to exclude the air and over them the applications of a roller. the opening closes inside by adhesion of the Lungs 210 Wounds of the Lungs. In these the breathing becomes difficult. coughing and vomiting of blood florid and frothy. with much haemorrhage externally and Emphysema. If the haemorrhage is not stopped you must bleed the patient till it does in general to 20 oz and when it is stopped you must close the external wound as before and the plaister applied, also the roller if the difficulty of Breathing does not prevent it. The Patient should have 20 drops of Tinct: Opii every three hours after. speaking should be avoided. these means will prevent immediate danger, but inflammations comes on sometimes on the fourth or fifth day after the accident which renders it necessary to take away large and repeated quantities of blood. Another danger is haemorrhage happening many days after the accident. when the external wound is healed it is shown by difficulty of breathing coming on without pain: the wound must then be opened again: when the Emphysema is very great small punctures may be made round the Wound not further than 6 inches off. Wound of the Heart & Pericardium are universally fatal as they have no opportunity of healing or uniting because of the Perpetual Motion of the Heart - 211 Of the Tix Doloreux This is the most painful disease the human Body is liable to it produces no disorganization of part. The pain during the fit is compared to a flash of lightning darting through the part with a vibrating or undulating feel in the part. an effect may be brought on from the most trivial causes: the nerves subject to this painful affection are the suborbitary: the ophthalmic branch of the 5th pair. The dental, the pes anserinus of the 7th pair. The nerves distributed to the Tongue & tonsil gland, sometimes the par vagum. the radial and the Anterior tibial nerve ... To Perform the Operation when the suborbitary nerve is affected (which is oftener affected than any other) make an incision with a Phymosis knife 1/2 an inch below the edge of the orbit and divide the nerve near the suborbitary foramen: the incision is to be made about 3/4 of an inch passing the cheek over the knife with the fingers which divides the nerve and the Patient feels a numbness in the upper Lip: the suborbitary artery being also divided. it is necessary to make a pressure on it with the finger for 5 minutes The complaint is very liable to recur in a few months after the operation from the reunion of the nerve. Lord Carlile & Capt Elliot in the navy have undergone this Operation with complete success - 212 As palliative remedies in affections of this nerve. salt held in the mouth and cicuta given internally have proved useful though never wholly effectual - In affection of the Anterior Tibial nerve apply a Caustic upon the part to produce an eschar, this is to be kept open by the introduction of a pea On Gonorrhoea The symptoms of this disease are an Itching sensation near the fraenum generally about the fifth day after impure Coition and on Examining the lips of the Urethra. they appear of a florid colour. on pressare a drop of mucus appears, in a few hours some pain is felt in making water. as the inflammation increases the discharge becomes yellowish, and when it is at its height it is of a greenish yellow colour mixd with blood erections are frequent, proceeding from irritation and is attended with considerable pain. after the pressure appears oedematous producing Phymosis and the dorsum penis when pressed on by ye Fingers feels knotted ie, the absorbents. then the glands of the Groin become enlarged. these symptoms decline if the constitution is very irritable. the will complain of a weighty sensations in - Posines - 213 near the membranous part of the Urethra. frequent inclination to make water, at this time the Testicle frequently enlarges, more especially if he is exposed to cold: the Urine passes in two or more streams as in stricture of the Urethra. If the discharge is of a white colour the inflammation is inconsiderable if it is yellow it is more extensive and if mixd with blood and the lip of the Urethra are excoriated inflammation run very high the appearance of this disease is uncertain sometimes in 24 hours and in others as long as 3 weeks - when the disease is protracted as it generally is in scrophulous habits the cure is more difficult. sometime there will be every Symptom of Gonorrhea present without any discharge The seat. of this disease in a lacuna Just an inch from the lips of the Urethra opposite the fraenum this lacuna is inflamed and in a virulent Gonorrhea the inflammation will extend to the neck of the Bladder and streaks of coagulable Lymph are discharged with urine It has been supposed that an Ulcer exists in the Urethra. but this very scarcely the case, and then only when the lacuna suppurates and bursts. The Progress of Gonorrhea is arrested by an attack of Fever when to all appearance it entirely ceases but as soon as the fever is subdued it returns with unbated violence 214 Treatment. Mercury given to effect the mouth does much mischief by its irritating effect, but mercurial purges may prove serviceable. If a patient has had several Gonorrhoea he is much easier cured than if it is was the first time. In a first Gonorrhoea the inflammation gradually extends for the first ten days, and if at this time you use astringent injections. you will in all probability produce hernia humoralis, or a stricture. If the Urethra will be the consequence. In order to lessen the inflammation give the following - Rx magnes Vitriol ʒÿ Nitri Puri ℈i P.G Arab: ʒ1/2 ᵯ pulv bis vel ter die ex Aq sumed As a purgative in some habits Calomel with Ext. Cath: proves useful. When the ardor Urina is very considerable give the following Rx Aq: Kali: purae gr xv ad xx Ext. Cicuta g iv Mist e: Camph ʒÿ M Haustus. the warm bath is a good remedy soda water is useful after taking the the powder or the following. Rx Kali: Carbonat ʒ1/2 Aqua H1/2 this should be drank mixd with milk it is of a diuretic nature. Local remedies: Rx ol: olii: opt ℥i Pul. Opii ʒ1/2 m. Tinct: Opii ʒÿ Aq: Purae ʒiv ᵯ the Penis should be shaked in warm water frequently for ten minutes. when the inflammation from very high apply a leech or two to the lips of the urethra 215 and the Patient should drink freely of then Gruel or Barley water. When the inflammation has a little subsided use the following injection Rx Aud: Vitriol gr i Aq: Rose ℥i or gr iÿ to ℥ÿ or Aq Vitrol: Albi gr i Aq: Rose ℥i sometimes gr iv to ℥ÿ may be used when the inflammation is nearly abated direct the use of Rx Zinci: Vitr gr iv Aq: Lith Acet 30 gutte Aq: Rose ℥iv M [if] injectio. in this injection a decomposition take place forming an acetate of Zinc, or the following is equally useful. Rx Zinci Acetat gr vi Aq. ℥iv aceti ʒi M - This preparation Mr. C objects to as by its astringent power it is liable to produce strictures - The following is a slow but a sure remedy- Rx Calomel ppr. ʒi Aq Calcis ʒiv M Inject. - The strength of the injection may be determind. by the constitution of the Patient and it ought to be changed every two or three days, they should four or five times in the day and in the night of awake in injecting he is to press under the symphisis pubis so that the injection may not pass further than two or three inches within the passage It should be thrown up with a little force the Elastic bottle syringe is the most convenient for this purpose - In some habits a Gleet will take place after the Inflammatory Symptoms have subsided for which give the following Rx Bals: Cobail ʒi (VO) q's aud Vitriol 4 gtt aqua cinnam ℥ÿ M g Haustus or Rx Bals: Cobail ℥i (VO) [illegible] 216 Aud: Vitriol 20 gtt Aq: Cininam ℥iv M Caps cochl amp tres vel quater in die, when there remains a discharge like the white of Eggs. use the Injection with the acet of Zinc. The Bals Cobail is apt to throw out an eruption on the skin like nettle and which take place in some people after eating Mussels but this disappears by the use of purgatives - the face swells with a troublesome Itching - Consequences of Gonorrhea. Strictures of the Urethra divided into two kinds. permanent and Spasmodic, there is likewise a stricture of mix'd kind, the symptoms of the most common kind are increase of inflammation on discharge of Urine when in Bed frequent inclination to make water a question necessary to ask- this precedes an alteration of size and appearance of the stream which is diminished, and instead of coming out in a round, stream it is broad and sometimes spiral- The most common effect is two or more streams, and when the complaint has been for sometime it will almost stop, and at length either from cold or something very triffling a retention of Urine is occasioned. There is a glary fluid discharge from the Urethra which stains like white of Egg: if guilty of Excess of yellow colour in consequence of inflammation but no Ulcer - The Bladder is affected and thickened with a weight above the Pubis, it’s contracting causes a 217 painful sensation at the upper part of the Pubis. pain of the Loins extending down the Thighs from perineum. Venumd sensation in direction of the crural nerves are the symptoms of the common state. it will produce Fistula in Perineo- The manner it is produced there is an enlargement of the Urethra between the stricture and the Bladder. The occasions a corresponding enlargement of the lacunae. The lacunae in consequence of the collection of Urine and being distended at length bursts. and the urine becomes extravasated between the cellular membrane: every time he makes water there is a great collection and after matter is produced - it depends much on the part where the strictures is formed. Bladder becomes thickened in consequence of stricture where it is existed for considerable time. the Urine becomes like whey being mixd. with Coagulable lymph, the irritations which it occasions the Constitution is mistaken for an intermittent sometimes with rigors & hot pungent skin relieved by sweating and so indeed do the symptoms give away to the use of Bark Kidneys become affected. An enlargement of the Pelvis and infundibule, and wasting of its substance when it continues long a suppuration of the Pelvis of the kidneys takes place so that the whole of the Urinary organ becomes diseased in Consequence - Seat of Stricture it is 7 inches within 19 and lesson the irritation of the Bowels by carrying off any foreign matter that may remain therein Calomel & Extl Cathl. produces this effect the most efficacious- saline purges tho' they occasion plentifull evacutions have not so good an effect - The 3rd mode of stopping inflammation is to excite perspiration - the warm bath relieves inflammation especially of the chronic kind, warm water applied to the feet in bottles or Bladders, are to be used to excite perspiration and hot diluent drink open the pores as soon as they are received into the stomach: in weak irritable inflammations, the Hydrarg. Muriat. in the dose of 16th part of a Grain given three times a day with Decoct sarsaparilla comp: in Decoct Cinchona is of great service. A Girl at Guy's Hospital had lost the use of one Eye by inflamation and the Cornea of the other opacity, many remedies had been tried without effect. it was supposd. a lost case by the use of Hydrarg. Muriat. The inflammation was stoppd. and the opacity of the corner 218 the Urethra. the length of the Urethra is 9 Inches, 2 Inches from the Bladder where Cowper Glands terminates. Which part is always a little naturally contracted. sometimes there are two strictures one an Inch behind the other they differ in length being from 1/8 to half an Inch. There are likewise many in the same Person. and some very near the orifice of the Urethra: description of stricture there are three kinds met with on dissection the first and most common is as if a cord was tied round the part: the 2nd kind is of a considerable length as if there was a broad round ribbon. difficult to cure. requires the use of bougies several times. The 3rd is a membranous band forming a cross the Urethra and sometimes several at the membranous part of the Urethra. There is also a species of are elastic kind in which if you pass a very small Bougie it will resist. but will not a large one. it will not sometimes yield to the passage of Urine. it is dangerous in this kind to make use of Caustic bougie. The cause is from an inflammation of the Urethra from whatever cause that may arise. Mr. Hunter says it does not arise from Gonorrhoea because he has found it in Boys, but the frequency 219 that it follows Gonorrhoea shows this disease is brought on in Consequence of it, but it is more the more of treating it than the Complaint itself that produces. the use of Astringent injection in the highly inflammatory state of Gonorrhoea extending it down the Urethra to where the stricture is situated. riding on Horseback & hard drinking - Method of Treating - The first thing a surgeon is to take a Bougie of the size of the passage. tho Patient Sensation may lead him to suppose it is opposite the frenum. when you have got a Bougie to the size keep increasing the size as the Patient can bear it - If not able to introduce a small bougie, bend it and give it the form of the Urethra. it may be softend by the fire. When there is discharge like common mucus stricture is to be suspected. The Elastic Bougies do not answer so well as the common ones. but Mr. Smith Covent Garden flexible bougies are usefull. Catgut Bougies are seldom used. the have one advantage that of swelling after they have been in a short time and thus dilating the stricture. if there is suppuration of Urine instead of the Catgut use the flexible bougie but this is not so certain a the common Catheter 220 A Catheter of the Natural size will generally where a bougie of a smaller size will not. It is not to be depended on for a Cure but only as a relief to draw off the water - On Caustic Bougie. when a common bougie cannot be passed through the stricture and when a small one does not enlarge the diameter of the stricture and give relief. then it is necessary to have recourse to the Caustic Bougie. Dr. Hunter revised this Practice and instead of a Bougie he conveyed a Caustic up the Urethra in a silver Cannula pushing it forwards untill it arrived at the stricture, but the Bougie is more convenient when the Caustic is inserted at the end of it. a soft Bougie larger than that containing the caustic should be passed first in order to dilate the Urethra as far as the stricture If the Urethra is not distended by this means the caustic will touch it and cause a contraction and will also bring on an haemorrhage. the caustic should not be suffered to project beyond the end of the Bougie. at first application it should only touch the stricture and be immediately withdrawn, after it may be suffered to remain in the Urethra against the stricture for ½ a minute but never longer. the surgeon should proceed cautiously that he may know what degree of irritability the Patient can bear. If 221 the Caustic Bougie remains in the part too long it will inflame and cause a suppuration of Urine Use it twice or three times a week. the slough occasioned by it seldom separates in less than 3 days. if applied oftener the Caustic acts upon the Slough produced. the day before. the Bougie should be of the size of the staff used in the operation of Lithotomy. The Caustic Bougie in strictures have been used with very good effect. and no doubt many lives saved. In a case of stricture under Mr. Coopers care that had continued two years and caused a fistula in perineo. the application of the caustic only 8 times destroyed the stricture and cured the fistula - In general the application must be repeated in proportion to the length of time the compliant has been standing In another case Mr. C. applied the Caustic 104 times. but this stricture had continued 14 years and at length cured by the application. The time it will take to cure is so uncertain that it is wrong to promise any time. The Patient always experiences instant relief but not a certain permanent cure. and if a common bougie or Catheter is not passed from time to time it will return in two or three months Though it has a general good effect. it is liable to inconvenience but in those most 222 Likely to happen when injudiciously used, one is Haemorrhage form the Urethra. Mr. Cooper was called to a Case where after the application of Caustic bougie Blood was discharged and a small pulsatory tumor was found in the Urethra. pressure did not stop the Bleeding and it appeared that the Artery of bulb was divided the tumor was opened, the blood collected in it was discharged. and a compress of Lint introduced into the incision stopd the bleeding for several days. The Gentn was at this time very weak - as soon as he recoverd his strength a little the haemorrhage returned and distended the Scrotum: the blood was again discharged and the hamorrhaege stoped by a compress of Lint: as it returned again Mr. C only supposed the artery of the bulb only half divided and found it in this state divided at quite with a Lancet, this stopt the haemorrhage but the Patient was so weak that he died in a short time after - Another inconvenience is the formation of a false passage. when a Caustic bougie has been used without relieving the Patient. it may be supposed that the Caustic has acted upon a neighboring part instead of the stricture. in this case a large bougie must be used whose end will not enter the false 223 passage but it is a far better way to pass a a piece of caustic in a catheter with the end cut off: this at first will go into the false passage, but if it is then drawn back and passed straight forward it will go to the stricture (it may be easily felt when in the false passage). When drawn back the point of the Catheter should be elevatd before it is passed forward - The Edges of the Catheter round the caustic should be defended by a thin coat of wax to prevent injury to the Urethra - Another inconvenience is the bursting of the Urethra, this will sometimes happen after caustic has been used and the symptoms of stricture very much relieved by: When the Urethra bursts the urine will insinuate itself into the perineum & scrotum and must be discharged by incision If the patient has not a very good constitution it generally proves Fatal - If a Caustic Bougie is kept in for more than a minute it will bring on suppression of Urine on the Treatment of Fistula in Perineo brought on in consequence of stricture. This abcess will take place even as far as opposite the Fraenum it then requires the same Treatment as in perineo, and when it has 224 extended into the scrotum it is particularly necessary as soon as you have found out the complaint to make an opening into it the earlier the better. The urine accumulates in the Cellular Membrane the skin becomes diseased. and so much so in perineo that unless it is opened it gives much pain. The Caustic Bougie must be used for that purpose. there are some whose Urethra is so irritable that the Caustic Bougie will bring on such irritation that it is dangerous to use it. In these Cases use the Catheter. it is to be kept in constantly. only to take it out for 10 minutes twice a week to clean. The Patient should always make water through the Catheter and not suffered to come the natural way if it does it will keep increasing the extravasation. by attending to these rules the aperture soon closes and in about 3 weeks a complete cure is affected. Mr. C has invented a screw to screw on the other. that is should not run down the Thigh. and to prevent the Catheter from [running down] slipping into the Bladder. there is a stop to the top If there is extravasation in the scrotum it is particularly necessary to attend to these rules. Sudden bursting of the Urethra behind the stricture the Urine becomes 225 extravasated in the scrotum and perineum at the time of being at stool or from other causes make an incision into the part by pushing a Lancet to where the Urethra has busted and let the Urine run out at the orifice. as soon as you have cut down upon the rupturd. part, pass in your fingers. let the inflammation be ever so great provided there is not a very great extravasation in the scrotum it will generally give way to this operation. This Rupture of the Urethra arises sometimes from accident it is to be treated in the same manner - Spasmodic Stricture. A sudden suppression of Urine so as not to be able to discharge a single drop of Urine. This sometimes accompanies the permanent stricture after it has existed some years it is an inflammation of the muscular fibres which surround the membranous part of the Urethra. Cause extended inflammation in walking there appears to be a collection of water there with Spasms upon the muscular fibres, extreme pain which is generally relieved by passing a Bougie but it is very difficulty to do it. for when it is passed. the part by the stricture resists it and force is of no use. let the Bougie rest gently against the stricture for several minutes accustom the Urethra to its use and in a little time, it will slip suddenly into the Bladder. 226 Sometimes the bougie will not succeed then you should have recourse to the Catheter which will always succeed: the common are of a large size. In the introduction of it it may be necessary to change the posture of the Patient. slight causes has been relieved by the warm bath. sitting in a common tub of warm water is the best way - Medicines does not give relief. Opium does not relieve the stricture. prefer a small dose of Antim Tart. to create a nausea, If Opium is given join it with Calomel. If an uneasy irritation of the neck of the Bladder and the patient has a constant desire to void his Urine, give the Hydrarg Muriat cum Decoct: Cinchona. If accompanied with a high degree of inflammation extending into the adjoining muscles. take 14 ounces of Blood from the Arm and apply Leeches to the part. apply a poultice composd of 1/3 mustard 2/3 Flower this will bring on a redness and give relief, this is to be preferred to Blisters as they will prevent the Patient from walking for sometime after. give a Pill composed of Ext Cicuta and Camphor, after Bleeding inject an Anodyne Enema. which will answer a good purpose as it will act on the muscles - Irritability extending to the Bladder occasions constant desire to make water. Open the Bowels, when evacuants have failed, and indeed has every other Medicine. The following remedy which was discoverd lately has never been known to fail 227 and always gives instant relief: make a small Pill from 1/4 to 2 grains of Ext. of Opium. this to be introduced by the Urethra (with the help of bougie or Catheter) into the Bladder where it becomes readily dissolved - It is wrong to use Bals Cobail if there is much inflammation — If a Discharge of [Urine] Blood with the urine. use the following Rx Opii 1 1/2 gr Cicuta gr iÿ Camphor gr ÿ M f Pilul. Calom may be added to prevent caustiveness Inflammation & Enlargement of the Prostrate Glands- The Prostrate Glands is of diseased by a simple inflammation in Gonorrhoea. more frequently so in old People who have indulged very free in Venereal Actions. it begins with a sensation of weight in the perineum occasioned by its enlargement. This also accasions it to press on the rectum and obstruct the Passage of the foeces- a frequent inclination to make water. and is not able to pass it without they kneel and their Legs wide assunder They generally void their foeces at the time of making water- a pain is felt at the end of the Urethra like that occasioned by a stone. The Urine is sometimes of a Whey colour and when suppressd is of a chocolate colour very offensive looking as if it came from a mortified surface- When thus enlarged the prostrate may be distinctly felt by the Rectum 20 diminished: irritability should be lessoned by medicines which act on the nerves as Opium Cicutæ &c, of the local treatment where inflammation is superficial we may apply cold lotions which diminishes it by restraining the vessels that are distended Lead is one of the best as it has a particular effect on the nerves. the application of Spirits by the cold they produce in evaporation constringes the vessels; other may be applied till the parts are frozen - if these application should not relieve the inflammation Leeches may be applied and the bleeding kept up as long as possible, and the cold applications returnd. to after the bleeding. Fomentations and poultices if not applied very hot will not promote suppuration but when the matter is formd. will bring it forward more speedily when inflamation is very deeply seated, it is servicable external inflammation by means of stimulating Plasters 228 On Dissection it is found to be divided into three tumours. one on each side and one behind between it and the Bladder. The valvular projection of the Prostrate pressing one of the tumours upon the Urethra and occasions the stoppage of the water - If the Prostrate is inflamed on passing your finger up the rectum it will cause much pain which goes on sometimes to be production of matter. the Urethra is three times its natural size that in passing the Catheter a surgeon is often deceiv'd thinking he has got into the Bladder as it may be turned to either side without resistance its length from 1 1/2 to inches more than common - this state of the Prostrate is the effects of growth in old men, or of simple inflammation from Gonorrhoea. in this last case it often suppurates or bursts of itself or is burst in passing a Catheter. This at once relieves the suppression - Treatment Take a large Catheter ½ or 2 Inches longer than the common size which is bent towards the end suddenly. When passed as far as the Gland it must be lifted over the tumour by depressing the handle between the Thighs elevate the point over the Prostrate and pass it into the Bladder. if pushed strait on. it would Rupture the Patient. the Catheter is 229 to be left in the Bladder. The French elastic Catheter is best as it does not soften and become rough like the English Elastic Catheter in three or four days it should be withdrawn to try of the passage is restored if not it must be introduced again - the Bladder is sometime so irritable as it will not bear the Catheter to be left in under this state the Patient generally dies - During the Use of the Catheter the Hydrarg Muriat may be given in Decoct. Cynchonae Soda Water has also a good effect in taking off the irritability of the Bladder or Rx [Sali] Carbonat: ʒ1/2 Pulv. Uva Ursi ℈i Ag Pura ℥iÿ Capt Cochl / major sepi et lactes - most dependence on Hydrarg: Murriat for Permanent relief . Bleeding from the Urethra in Consequence of Gonorrhea - this take place when the inflammation runs high and generally offords some degree of relief but is rather alarming to the Patient. tho it serves to lessen the inflammation. but sometimes a large Vessel is ruptured. and much Blood is discharged and in a very short time ye Blood will run back into the Bladder and be discharged from it in the same manner as the Urine The hemorrhaege generally takes place in the Membranous part of the Urethra. it is wrong to use Bougies - Treatment to find its situation pressure should be made along the Course of the Urethra it is best to begin at the Anus and pass along the 230 perineum to the Scrotum. when its situation is found pressure with the finger for 10 or 15 minutes will stop the hemorrhage. In irritable Habits it is sometimes very troublesome and will not stop by pressure with the finger contined pressure is required and it is best made by binding a Roller up with a [illustration] bandage on the perineum Chordee is a very troublsome symptom caused by imperfect erection making the Penis to be crooked to one side. pain very Violent it feels sometimes as if cord was passed along the under part of the Penis. it usually comes on when warm in Bed. it is caused by inflammation attendant on Gonorrhoea which throws out an effusion of coagulable lymph into the corpus spongiosum and cavernosum. and adhesion is produced in some of the cells which are in consequence glued together and prevents complete erection. a knot is generally felt where the obstruction is. there is sometimes another sort where the erection will be complete. we may call a cordee of two kinds. Viz Simple inflammatory or inflammatory with effusion. The pain is so very Violent that he is obliged to get out of bed and lie down with the part on some cold place. As the best Palliative remedy the Patient may apply a bottle of cold water between the Thighs. Treatment in the first place. 231 purgatives to reduce the inflammation give the following Rx Calomel 2 gr Opii gr i1/2 Cicuta gr iÿ Camphor gr ii M Piled hora somni sumendus this will take off the irritation and prevent the imperfect erection in the day time to take the aq. Kali: pine & Soda Water deaden the irritation of the parts. Local Applins. soak the Penis in warm water and apply a poultice during the night if the inflammation is considerable apply Leeches on each side of the Glans Penis - When the Cordee is gone off the knot may still remain. but may be dispersed by the Camphoratic Merc. Ointment - Hernia Humoralis is an inflammation of the Epididymus more than the body of the Testicles this begins with an uneasy sensation in perineo with inflammation appearing to extend to the neck of the Bladder, pain is then felt in the Spermatic cord. and the Heat extends to the Epididymus which at first appears swelled and afterwards to a considerable degree. when the Testicle becomes affected, the scotum is always much so by a remarkable florid redness, its Vessel, distended on pressure great pain. The spinous process of the ilium & the loins are also affected with pain - causes. This is not as has been thought a sympathetic affection. It is an inflammation beginning at the 232 opening of the seminal ducts in the Urethra and extending along the spermatic cord to the Epididymus. The most common cases is the use of injections in the inflammatory state of Gonorrhoea at that time even when the inflammatory state is subsidded. yet if there is pain in perines. Injections should not be used for they will cause inflammation to spread up the Urethra and produce this effect This inflammation is often brought on by the passing of a Bougie. to prevent such effects the parts should be suspended, during its use and so they ought during the Cure of Gonorrhoea cold water injected for a Gleet has occasioned a hernia hummoralis - Treatment the testis are to be well suspended by a Trap (the common bag Trap is very improper) Calomel purges if it is a slight affection this will be sometimes sufficient. If you find the inflammation continue use fomentations but first apply Leeches. Aq. Ammon: Acet as a Lotion. to be kept in a recumbent posture for this blood is sitting in those parts on account of its Vascularity V.S. in Brachio is sometimes necessary more than once. Sal. Amn and Acetum will sometimes relieve the inflammation but if it will not speedily do it it will excoriate the scrotum. poultices and fomentation are to be preferd 233 after the Leeches - If connected with pain in perineo Bleeding is necessary. Emollients in preference to astringents The Testicle will sometimes enlarge & suppurate in consequence of Hernia Hummoralis fomentations are necessary - make a free opening into the part. give the Bark and in general the patient will recover rather speedily but often when suppuration takes place it arises from a scrophulous Constitution. there is but little pain a long time before it points. and a Curdy substance is discharged a quantity of semen is [discharge] emitted from its Orifice. Inject into the sinus the following with an intention of causing a slight inflammation and promote union of the parts rx Zinic: Vitriol gr iv. Aq: Rosae ℥iv M vel Rx Acid: Vitriol gr ÿ Aq: Rosae ℥ÿ ℥ÿ M f Inject there is a fungus projecting from its orifice like Cauliflower of the size of half a Crown it is unnecessary to remove the Testicle sprinkle powderd. blue Vitriol over the Fungus or take it off with a knife and Join the edges of the skin with sutures, draw it over the sinus and it will heal. After the inflammation has subsided there will probably remain an uneasy hardness of the Epididymus. the best 234 external application is a piece of old silk over the scrotum it causes a copious perspiration and in consequence lessons the hardness and enlargement. this has a greater effect than the Ungn. Hydrarg fort Calomel ppr. externally - Emetics are not improper this enlargd, and hardend. state of the Epydidimus is often the source of much uneasiness to the Patient as he is apt to suppose it will lessen the virile power. but it has not such effect Sympathetic Bubo occurs during the inflammatory state of Gonorrhoea: when you find more than one Gland in the Groin enlarged never use Mercury as you are to believe it sympathetic. many of the Glands in the groin are affected. Simply by the application of Aq: Ammon acet and purges they will give way- they never suppurate unless by the use of mercurials which will occasion an increase of inflammation. Apply emplast: sulfur to the part affected - Impotency is in consequence of Gonorrhoea in some cases - Loss of Testicle. This was formerly considered a loss of Virile power. but it is not the case sometimes in consequence of disease. The testicle will become completely absorbed. if you see the other Testes begin in the same way. though the advice is by no means moral, his only resource is to have frequent connection with women 235 Mr. Cooper mentions a remarkable case of a man Castrated 22nd March 99 in June 22. 1802 having frequent emisions afterwards but at length they subsided, but he had erections. at command - [If the Tes] If both Testes are taken away the beard does no grow - Impotence is produced by loss of the retentive power of the semen. tho Vesicular seminatis loose their power of retention: the semen is dischargd. while he is at stool without erection. this brings on great degree of debility and the parts are incapable afterwards of doing their office. this particularly happens if the Body is in a Costive state. The following form has been found very useful. Rx Gum Oliban ℈i Myrrh ℈ii Ferri [pro?ef]: ℈1/2 Bals:Canud qt M Pilul 20 Capti 3 ter quotidie. at the same time the Bark should be given and the cold bath used. - The next cause of impotence is an irritability of the Vesicula seminalis. causing a discharge of semen by whatever excited Venereal ideas as the sight of a fine Woman. or touching the Penis. as soon as the Patient is warm in bed he has imperfect erections and emissions. which bring on great debility and even impair the mental faculties. Tonics only increase the irritability sedatives are the only remedies to be depended on the Path composed of Opium: Cicuta and camphor succeed the best - 236 Emissions during the night alarm some men but provided they do not occur oftener than once in a week or 10 days he not be under any apprehension as it can only then be called natural. If it occurs frequently a Yoke should be put on the Penis (Composd. Of elastic Gum) is the best. this gives a painful sensation when an imperfect erection comes on, Wakes the patient and thus ye discharge is prevented - Treatment- Cold Both and Pilulce Cicuta- Impressions on the Mind- when a person think himself incapable of coition, supposing a wasting of one Testicle from hernia humoralis &c will impede his power: his fears in this case will render him incapable. but if he can overcome his fears he will find that he has sufficient however - Dr. Hunter advised a person in this state to lie by the side of a very fine woman seven nights and to attempt to have any connection with her untill the end of that period. When he promisd, him that he would have power. this he bound himself to observe that after the 4th or 5th night his were passions were so much excited that he acted with effect and got cured - Stricture in the Urethra will occasion impotence in a case under Mr. Cooper, are the powers had gradually abated during two years, at first pain and difficulty was felt in the emission of the semen, at last it 237 it was totally obstructed passing backwards into the Bladder, and no erection from these circumstance and by a slight Gleet. Mr. Cooper was led to suspect a stricture, this he destroyd. by a Caustic bougie and the Virile powers soon returned. Gleet is a discharge continuing after the affection of Gonorrhoea has ceased Glary in general like white of egg; by irritation produced either by walking dancing riding it becomes yellow and sanous will influence the Urethra so much that a cordee will be produced and very difficult to distinguish from Gonorrhoea. the seat of a Gleet is in the same place as Gonorrhoea, but the lacuna magna is more particularly affected. generally accompanied with a stricture it is difficult to determine when Gonorrhoea ceases and gleets begins. The longest period Mr. C ever knew it infectious was after 5 month and 3 days - Treatment by the use of injections and bougies- Rx Hydrarg Muriat gr i Spt Vini Ten: ℥i Aq: Rosae ℥xÿ M Inject: their strength should seldom be exceeded. If stronger it will inflame the Urethra and cause hernia humoralis. Rx Liqur Cupri: Ammon: grx Aq: Rosae ℥i M [illegible] is particularly recommended. Combine the use of injections with bougie, which you are to introduce three times a week. injections 21 as good an application as any for this purpose is an ointment composd. of ʒÿ antimon Tartar and ℈i of Hogs Lard, which rubd. on the skin produces considerable vesication. Ungm. Hellebore Ungm. Sabrina are used with same intent a Vinegar poultice is frequently of use in inflammation of the Joints when irritation fails poultices will sometimes relieve, soap plaisters by keeping up perspiration are usefull in deep seated inflamations of the Joints, if the parts are in an indolent state, stimulation is necessary, and where inflammation is removed a Tonic plan externally and internally should be used On Wounds Wounds are Violent separations of the skin, and sometimes connected with the Parts beneath, if the parts beneath are divided, and the skin is not. it is not to be considerd. as a wound, - wounds are divided into four kinds 1st. the simple incised 2nd the lacerated 3rd, the puncturd. which is the most dangerous. 4th the contusd., - when the parts are disorganisd. 238 produce stricture. Bougie create a discharge the Injections diminish the discharge and Bougies the stricture. Rx Bals: Cobail ℥i spt. Aether: Nitrosi ℥i M Caht M 40 Cochl; parva ter quotidie - when there is Gleet with stricture use the Bougie oftener & Rx Pulv: Cynchone ℥i Bals: Cobail: gr1/2 Elactn. Caht Cochl 1 parva bis quotidie Mercury does no good in Gonorrhoea but Mr. C knew of one exception in a Gleet & stricture A gentlemen had a Gonorrohea after several months of Gleet and stricture and trying all other remedies, it gave way to the following Rx Hydrarg: nitrat gr i spt. Aether Nitrosi ℥i M Capt Cochl 1 Min vis die - An obstinate Gleet is often brought on by an abscess in one of the Lacunae alternately collecting and bursting: it may be felt on the outside of the Urethra. the Caustic bougie should be used to destroy it. An abscess in the lacunae has been known to bring an hectic symptoms and destroy life - External Gonorrhoea takes place at the External part, only at the Glands, from the Glandula ordoriferia near the fraenum frequently attended with Phymosis. An injection with Rx Calomel prop ʒi Aq: Calies ℥iv M Injection [gr] Rx Aq: Litharg : Acet: 30 gutte Tinc: Opii ʒi Aq Rosae ℥iv M Inject. as Phymosis almost always attends : apply spt. Vini : Camph & Aq Pinae to the Penis 239 Gonorrhea in Women. is a disease which affects the nymphae. and extends to the Glands of the Os externum of the Vagina. when it effects the Meatus Urinarius and occasions a great discharge from the lacunae like that from the Urethra in Men. on account of the shortness of the Meatus Urinarius the external coat of the Bladder is affected. this causes an incontinence of Urine. the Bladder contracts as soon as a very small quantity of water is collected - Pain is more excruciating in the Females than in men. the Glands of the Groin very generally become inflamed forming the sympathetic Bubo. Treatment – at first fomentations should be used: at the same time it will be proper to give purgatives. When the inflammn is subsided use the following Injection Rx Alum: 1 dram Decoct: Cynchona 2 H M It is a good way to keep a sponge with this Injection in the Orifice. All the other Injections mentiond. for the Male are proper - Gleet in Females in very common: it is difficult to say when it has commenced. the discharge may be like the White of Egg. yet it may infect - It will appear that a woman may give the Infection & not know of it herself 240 Treatment, the same as in Gonorrhoea sympathetic Bubo is not Venereal tho it sometimes suppurates: Mercury is very improper these Buboes seldom suppurates when Mercury is not given. If usd. they always do - when irritation is the cause several Glands enlarge. but when a Bubo is occasioned by Gl absorption of Venereal poison. Seldom more then one is enlarged - Treatment- The application of Leeches to the part using the Aq: Ammon: acet as a lotion. and purgatives. when inconvenient to the patient to use Lotions a soap Plaister will prevent suppuration - Chancre. milder form. This is an Ulcer occasioned by the application of Veneral poison to the Cuticle. on its first appearance there is an Itching in the part arising from a small pimple which breaks & discharges, leaves a deep Cavity. edges ragged and very [deep] thick with efflorescence & redness round with tumour. it is a point of importance to distinguish Chancre from simple excoriation. attend to the following circumstance. on taking it up between the Finger & Thumb a hardness is perceived like half a Pea. and excoriation is more superficial & no hardness to be felt 241 Chancre in its progress has much the appearance of a pustule in the small poxs - the time of its appearance after coition is uncertain. being as early as 24 hours and as late as 6 weeks. It attacks different parts, most commonly the Glans & prepuce. it caus Phymosis by thickening the skin. it also attacks the fraenum and commonly destroys it. this is the worst species as it very soon makes a hole through. even if the Patient washes immediately after connection the Poison lodges in the hollow of the fraenum and remain there. on the margin of the prepuce chancre is certain to form Phymosis. they sometimes form in the orifice of the Urethra and produce stricture when on the skin of the penis they have the appearance of wart. and also on the Scrotum occasioned by hanging down of the Penis after impure coitions - no Gonorrhoea accompanies chancre and when both are receivd. together chancre appears after Gonorrhoea has gone off - Treatment. It is to be supposed that Caustic will destroy the whole. if small it may do, this is desirable if the chancre attacks the fraenum. but although the sore will heal it does not necessary follow that it will prevent the symptoms. Give Mercury so as to affect the mouth: [O use] the following Rx 242 Rx Calomel prop ʒi Aq: Calcis ℥iv M : the time necessary to cure is about 3 weeks. give Morning for ten days after disappearance of the Cancre. Unctuos applications are very improper and have a tendency to inflame Calomel sprinkled on the sore is sometimes of service but will in general inflame and cause a deep slough. Red precipitate is a good application when the part is very focal and looks black it may be sprinkled or mix’d with Conser Rosae vel Cynosbat - sometimes after mercury has been use for sometime the Chancre appears stationary apply the following Rx argent Nitrat 1 dram Aq Rosae 1 ounce M once a day use this & constantly wash it with the Aq: Calcis & Calomel solution or if you find it indolent you may apply the Argent Nitrat every 24 hours it will cause a dry scab to form over it, under this a skin will be produced and heal it over. in the most lenient kind of [Mercury] canires it is absolutely necessary to give mercury to prevent the Venereal Virus from again breaking out and probably attack the Throat - Phymosis occasioned most frequently by Chancre on the external margin and sometimes in the Corona Glands. if taking mercury immediately desist from its use. it shews a weakly constitution with irritability. the best plan 243 is to order the lotion with Aq: Calcis & Calomel ℥iv if the pain is severe add Tinit: Opii ʒiÿ this will bring on a healthy state of the sore when the inflammation is subsided. then return to the mercury. suspend the penis towards the abdomen with rags round it will with the Lotion. this plan will sooner reduce the inflammation than any other. sometimes Phymosis will not go off when inflammation has subsided. then use fomentations. for they will absorb it and reduce it. the Mercurial Oint will produce the same effect. if these will not succeed then perform the operation which is very simple - make an incision upon the upper part of the penis. pass a director between the Glans & prepuce make a division with the Phymosis Knife midway between the extremity and the Corona Glands. the prepuce drawn back as much as possible before the operation is performed. make a small incision of the inner parts afterwards. this produces no deformity the Bleeding is very slight apply dry Lint. in healing it keep the skin back behind the Corona Glandis & apply poultices - when the skin is drawn behind the Corona Glandis it is called Paraphymosis. both the prepuce & Glans become swelled and inflamed - an 244 effusion of coagulable lymph into them is taking place, in order to reduce the swelling as much as you can. apply at first a cold Lotion with Aq: Litharg: Acet Comp with Spt Vini the evaporation of the spirits producing a greater degree of cold. but it is much better to proceed at once to the reduction it is wrong to perform even any operation. Take the Glans penis with in the palm of the Hand squeeze it so that it will become quite flacid. by the pressure it forces the blood back. but your fingers over and under the penis bring the integuments forward. and pressing the Glans backwards. so as to push it within the prepuce. A poultice is to be put on the part. It is alarming if attended with Chancre and is not quickly reduced. for it will cause Mortification & sloughing Chancre in an irritable constitution instead of mercury having a good effect. it will make it worse, and the Lotion recommended will be hurtful and Penis lost in consequence. A Chancre itself does not destroy the penis but by inflammation with succeeding sloughing together with high constitutional irritation pulse from 120 to 130 Symptoms are the Patient cannot sleep the part swelled the edges look discolord a sign of approaching Mortification 245 this sloughing extends more along the skin than the body of the penis. it will in general soon cause the whole sloughing of the penis untill it reaches the pubis; If you donot arrest the progress at the beginning it will be of no use - abstain from the use of Mercury if you see any considerable degree of inflammation, and attend to the constitution - do not fear the Penis being destroyed - In this sloughing state of the Penis it has been a custom to use fomentations and Poultices, but it will go on worse if any poultice is used. the following is the best A Tablespoonful of Yeast mixd up with Linseed meal - use also the following Rx Calomel: prop: ʒi1/2 Aq: Calcis ℥iv M there is in this a precipitation taking and which is the oxid of mercury. shake the bottle and tun the mouth upon the tip of your finger, the powder will be deposited on it. apply it on the surface of the sloughing sore- Rx acid: Nitros 30 gtt Aq: Fontan 2 H: M p Lotio. this may be injected under the prepuce even with Phymosis. this is as strong as the Penis is able to bear. check the irritability of the constitution with opium. Bark & sarsaparilla 246 give porter & wine. but in this you must be carefull, and regulate it by the heat of the skin - to put a stop to the bleeding sores dip Lint in ol: Tereb. press it for 4 or 5 minutes but where the Vessel is very large use a needle and Ligature. it is surprising with what good effect this may be used. no degree of irritation will be occasioned by it and the sore will heal in the same manner as if not there - The Urethra bursts from sloughing sometimes with a hole opposite the fraenum if a very small part treat is as a hare lip pare the edges and introduce a hollow bougie to prevent the urine from coming through then pass a suture through the hole. If 1/3 of the Urethra is burst it will be of no use. when a chancre sloughs at the Lips of the Urethra it will close its orifice. when the urine is discharg’d there will perhaps be only a small stream or sometimes a total stoppage. the Urethra is considerably enlarged behind the place where it has stopp’d Take a very narrow bladed Lancet push it into the swell’d part of the Urethra. take then a Trocar and Canula, and leave the Canula in the Urethra and direct him to make water through it - 247 When a chancre is seated in the lips of the Urethra Structure of the Orifice is occasioned. a piece of bougie 2 inches long should be worn constantly for a month or more the passing of a bougie or the use of a caustic bougie is of no use in this Case Mercury is not to be given after the sloughing is cleansed. heal it up as a common sore. If you use Mercury as the constitution is supposed to be very irritable it will produce again the same appearance wait untill you find the Venereal Virus has affected another part. if it should then use the proper steps 22 The appearance of the first kind, is separation of skin with hemorrhage, the indication or cure are to stop the hemorrhage remove the coagulated blood from the surface tiring the edges, to bring them together and unite them by the first intention, pressure will in general stop the hemorrhage. if the divided artery is not very large, union by the first intention is effected in the following manner, a small portion of crasamentum adhering to the cellular membrane glews the edges together in a few hours a slight inflammation comes on which causes the vessels to elongate; their ends project into the interposd. blood which this becomes Vascular, in about 10 days the union is effected - the part produced is similar to that destroyed if the skin is divided it becomes skin if Tendon tendon is produced (instanced in a preparation of the tendon of a dog’s leg which is injected and is in the parts produced 248 If this does not succeed use the following powder. Rx Pulvis Sabinae: Cupri acet. (Verdigris) partis equalis M f Pulvis - apply it on the Warts. A saturated solution of sublimate in spirits gives pain afterwards but not at the time. Mercurial Ointment has removed a number not destroying them by its Mercurial power but by its irritating effect The yellow wash of the Hospital (Aq: Calcis and Hydrarg Muriat) the black wash (Aq Calcis & Calomel) - Treatment of the hard kind, Arsenic in powder upon the part of the Lotion : Rx Arsenic: pulv grii Aq Rosae ʒviÿ M f Lotio - the powder applied to surface only is best. the Lotion being applied to a greater surface is apt to effect the system: the whole of the wart separates in two days put a piece of Lint over it or it will cause the same sloughing from the foreskin a liniment is also used . Rx arenic ʒi Ungn. albi ℥i M. this is not so good as the powder as it runs about upon the Glans Sometimes by cutting them off a cure is effected - Chancres in Women. Its most common seat is in the inner side of the external Labiae. sometimes on the nymphae or externum Vaginae and Rectum. Treatment 249 use the Aq. Calcis and Calomel. give Mercury internally. sometimes sloughing as in the Male and from the same causes When it takes place in the Female it does not stop at the Pubis as in the Male but extends up the abdomen the region of the Pubis, and destroying such a surface as they die of irritation. Use Mercurial Ointment with Opium. the Nitrous aud Lotion page. to sloughing sores which would not yield to any thing else the following Liniment has made a Cure Rx Aq: Lithrarg: acetat : pulv Opii. Mil: Rosar os in ʒii Conserv: Rosar ℥i M p Linn. when they once begin to slough they very seldom stop till Death closes the scene. - Means to prevent the Venereal Disease Ablution with soap and water will prevent a chancre but not Gonorrhoea. the the following Lotion may be also used Rx Aq: Kali: purae 20 gtt Aq: Purae ℥i M p Lotio. If not used directly will answer no purpose — Bubo. Venereal Bubo generally tho' not always appear on that side of the Groin on which the Chancre is situated on the penis. generally single in each groin 50 If other Glands are a little enlargd. they do not increase in a good Constitution. when more than one Gland suppurates it shows a scrophulous [constitution] Habit - Symptoms are like those of a common Abscess except more nocturnal pain. Treatment 1st Cathartics to reduce the inflammation. then the Mercurial pill. apply the Emplast: sapon to the part. the Mercurial Ointment to be rubbd in. it is indifferent in which side it is used. Continue the Mercury untill the Gland is nearly of its natural size. When the Bubo does not yield to this treatment and the pain increases leave off the Mercury for three or four days otherwise the Bubo will suppurate. in these intervals give purgatives and Apply Leeches to the parts also the following Lotion. Rx Ammon muriat ʒi aquae ℥iv M. However a Bubo will suppurate. this known by its size and pain being increased and by the redness of the skin. Here use no Mercury but apply Empl Luth. Comp the Patient must live well and take the Bark. when the Bubo is opened use Mercury again - opening of a Bubo. As soon as fluctuation is perceived the Bubo should be opened If not large open it with a common Lancet 251 on the inferior and anterior part then poultice, and in three days again give Mercury. If the collection is large make an opining at each extremity of the Bubo — Bubo sometimes become very red. of a great size and hard. here abstain from Mercury for the constitution is irritable in this case. foment and poultice in order to bring on a suppuration as soon as there is the least fluctuation open and the swelling becomes absorbd. very soon. If the collection of matter is allowed to be great dreadful consequence will ensure - sometimes a bubo after opeining forms a sinus especially if the Bubo is large. when it is opened apply a Blistter to irritate the skin and inject into the sinus Rx Acid: Vitriol 2 gtt Aq:Rosae ℥i M p Ing also Tinct: Canth - also Hydrarg Mur grii Aq: ℥i M by these means inflammation is brought on and the sides of the sinus are glued together and the enlargement is dissipated - Indolent Bubo. sometimes after the suppuration and also after being opened. If after suppuration do 252 not open it but give Mercury for the absorption of the Matter. If after being opened this does not yield to large exhibition of Mercury and use of Caustic, lay aside all dressings &c and expose the part to the air In three or four days it becomes scabbd, and under which cicatrization will go on Sometimes a considerable number of Glands are enlarged from pouparts Ligament down to the second order, two, or three inches below this is Veneral but scrophula and Mercury does harm Give Tonics Sloughing Bubo this resembles sloughing chancre and occurs in the same irritable constitution and is follow? nearly by the same effects is opened- sloughing with much pain comes on but by the cessasion of the use of Mercury. inflammation abates. separation takes place. and the sore heals but from some triffling cause in a little time sloughing again comes on. In this manner the case goes on till by the repeated sloughing the Femoral Artery or Vein is opened and the Patient dies from haemorrhage - Local Applications. the black wash and if it disagrees vary its 253 proportions, should not this at last suceed apply the following Rx Unguent: Hyd: Nit ℥i pulv Opii ʒ1/2 M p Ungn or Rx Mil: Rosae Tinit: Opii : Aq: Lith Acet [illegible] ʒii Conr rosar ℥i M or Acid nitrosi 20 gtt Aqui 1 H M apply this warm and do not exceed the above strength. yeast poultice composed of a Tablespoonful of yeast & a pint of water. Also the carrot poultice one of the above applications will agree with one constitution and another with another. Give Bark with Acid : Vitriol Opium and Wine. If the wine increases the pules which is often from 120 to 130 in a minute. substitute Ale or porter. In a sloughing Bubo do not give Mercury till it has healed except Venereal symptoms in the constitution endanger life After the constitution is improv’d again is evaluated from the Bubo the Gland will project out and lie [like the Bubo] over the skin. Mercury here produces sloughing. give Tonics. applications Rx Argent: Nitrol ʒ1/2 - ʒi Aq : Rosae ℥i M p solutio vis die applicand - apply the blends 254 Wash after each time. with these applications the Bubo is brought level with the Skin and heals – Venereal Ulcers in the Throat . the Venereal poison is absorbed in the groin carried [carried] into the Blood and produces its first effects on the Throat. there are three parts so affected. the Throat, skin, and the bones; and in this order the Testicle is sometimes affected. In the Throat the Tonsil Glands are generally affected. This is the most favorable for only dryness of the mouth follows their destruction, Symptoms. a dry husky feel especially towards evening no pain except the parts are excoriated by swallowing Acids. Another part affected is the soft palate this sometimes takes place from a small Ulcer in the palate itself most frequently in an extension from the tonsils - Symptoms Liquids in swallowing run trough the Nose. when it reaches the bony palate there is a considerable exfoliation and the Uvula is destroyed - Another part is the Fauces at the back part of the Pharynx. Symptoms. the same as in the soft palate - Another part is the inside of the Pharynx. symptoms. no visible venereal symptoms Horseness so that you can scarcely hear the Patient speak. from irritation 255 of the Epyglottis. Coughing and expectoration of of Matter mixd with blood. no pain in the chest but in the Throat. There is great constitutional irritation and wasting of the Body from which the disease is frequently mistaken for Phthisis Pulmonalis. Treatment when in the Tonsils or Fauces the same kind of Treatment is proper. Rub in Mercury & give Hydrarg Muriat internally and use the following Gargles Rx Hydrarg: Muriat 2 gr Aq: font ℥i M dip a probe with Lint wound round it into this Gargle and apply it to the part- sometimes enlargements of the Tonsils are accompanied with scrophula dip the probe as above in the following Gargle Rx Acid Nitrosi 25 gtt Aquae 1 H M give also Mercury. If not Venereal give the Murialic Acid & Bark- should this not succeed puncture the tonsils 1/2 a dozen times and if scrophula use the Acid wash the enlargement soon disappears. if sloughing comes on leave off Mercury and apply p Boracae over the whole sloughing surface likewise mill: eruginis & Nit: Acid Gargle the constitutional treatment must be the same as in sloughing of the Penis & groin- Treatment in the soft palate the same as in the Tonsils. 256 Treatment in the Bony palate apply the following to the edges of the sore. Rx Acid Muriat 25 gtt Aq: fontan 1/2 H M this acts chemically on the bone and removes it without exfoliation - If in the Larynx give sublimate early and fumigate twice a Day Apply a Blister externally to abate the inflammation Venereal Eruptions are distinguished from other cutaneous eruption by their copper colour a brown crust over their surface and under this crust a sanious pus or serum. This eruption first appears on the Breast 2nd on the Face and very often crust and eruptions hang on the Hare and the head is sore. after other parts of the Body becomes affected. they are as large as half a Crown other times not larger than a flea bite. yet all possess the same copper colour and are attended with little pain except an itching sensation in the evening - the pain is great when the eruptions are large and have ulcerated Treatment. In addition to Mercurial frictions give sublimate internally. Local treatment is unnecessary except the eruption has ulcerated the crust of the eruption is the best covering taking this crust off disposes it to Ulcerate. If Ulceration has taken place with pain (and not unless that pain is very great) 257 apply sublimate and lime water. Rx Pulv: Opii 1 dram Ungn. Hydrarg: Mit ℥i M These eruptions sometimes became Phagadonic Ulcers most commonly situated in the Groin after Bubo they are so called from eating away the parts as they advance. Character A deep sore with the edges of the skin hanging over. the surrounding skin is of a copper colour inclining to a purple. Treatment Rx Argent: Nitral ʒi ad ʒÿ Aq: Pura ℥i M p Lotio wash the sore and surrounding edges with it till they become white every morning - also the Calomel & Aq: Calcis. to use the oxid of Mercury which settles at the bottoms by these means the worst kind of sores are cured. give the following Rx Pulv: Cinchonae . sarsaparilla aci ʒ1/2 M p Pulvis ter qutidce ex Vino Rub Allow the usual beverage of Wine & Spirits After the skin the bones become affected 1st the Bones of the nose: small chancres form upon the membrane of the nose, soreness across the bridge of the nose and pain upon pressure blowing the nose forces out scabs. after there is a discharge of blood & matter. the Breadth is offensive sometimes a considerable portions of bone separate at the vomer and os nasi: the osa nasi will sometimes come down the nostrils 23 produced as vascular as in the other parts) to this rule there are to exceptions, muscles if divided are not united by muscular but by tendinous substance; Glands when divided are united by an intervening substance which never becomes Glandular: in old persons the cartilage of the ribs if divided is united by bone, but in young person it is united by cartilage - union by the first intention will take place between other substances, for if the scalp is torn and replaced it will unite to the scull - the periosteum of the bone will do the same, skin will never unite to cartilage; it will grow together over it, and like a joint is furnishd. with synovia, how much so ever parts may be divided, they should never be separated for they will or may unite- It was the custom of old surgeons when a part had been much separated to cut it away this very much prohibited the cure, and when the bone was exposed as in injuries of the scalp, it produced very troublesome exfoliation - The following care prove 258 and at other times make an opening through the bridge and fall away. Timely attention prevents the latter. Treatment Rx acid : Muriat 1 gtt Aq: fontan 1 H M p Lothi The patient to pour a little of this on the Palm of the hand and sniff up his nose this cleans the sore and quickens exfoliation at the same time use the Mercurial plan To prevent external exfoliation which causes deformity, as soon as the skin becomes inflamed pass the forceps up the nostrils and bring away the loose os nasi: the nose sinks a little - Venereal Diseases in the Bones. Symptoms. Dull pain in the bone especially towards evening and increasing when warm in Bed. these nocturnal pains distinguish it from Rheumatism. soon after a prominence small and painful to the touch appears If the node is left to itself it goes on to suppuration, a glary fluid is formed, in it which by a long inflammation becomes purulent Existence of fluid is known by the redness of the skin. Matter forms in the Bone and not between the bone and periosteum Nodes are situated chiefly in the center of the Cylindrical bones. particularly those that are subject to Vississitudes of weather as the Tibia sometimes the clavicle and sternum. 259 Treatment. Besides the Mercurial plan local means are frequently necessary. soap plaisters to the part lessens the pain &c When there is much inflammation apply a Blister to the part before you give Mercury - nocturnal pains are lessened by wearing fleecy hosiery and woollen stockings during day - If a Node contains fluid do not be hasty to open it for exfoliation will ensue and the cure take up many months. if there is not inflammation the Glary fluid is absorbed by the use of Mercury and the periosteum again adheres to the bones - If suppuration has taken place leave it to Burst of its own accord. These effects in nodes are more frequent in the cranium than any other part: where tumours containing fluid form upon the cranium excite mercurial action quickly and if the skin is not red the fluid will be absorbed - Symptoms of Venereal Disease Universal pains in the Bones distinguished from Rheumatism by being more nocturnal not affecting the Joints like Rheumatism but the Bones: no nodes attend this pain Venereal Pains require a longer course of 260 Mercury than nodes. small moveable venereal tumours are found sometimes in the cellular membranes. in Various parts as large as small marble. They appear like Glands but are quite distant from their situation. there are nocturnal pains which are very difficult of cure. taking 9 weeks under mercury Another situation in the Testicles this is quite different to hernia humoralis in Gonorrhoea, it is an enlargement of one of Testicles- cure Mercury – sometimes in Venereal diseases there occurs after a clap a red line extending from the lips of the urethra along the rapha to the Anus, and has the appearance of Erysipelatous inflammation. Care by mercury Another spasms of the abductor muscles of the Eye drawing the Pupil to one side quite within the socket. Cure mercury – The Venereal disease may be contracted without the contact of the organs of Generation Venereal Matter to the scratch on the Finger produces a Chancre on the part with very Violent inflamation. the absorbents are inflamed to the Axilla. where a Gland becomes enlarged with constitutional irritation so as to endanger life the sore puts on a sloughing appearance 261 Treatment. Apply Aq: Calcis & Calomel. Subdue the inflammation by the antiphlogistic plan. and then give mercury - General remarks on the disease & on the effects of Mercury upon the Body. the Venereal disease only effects a few parts of the body viz the Urethra. the surface of the Glans penis. the first Gland in the Groin The Throat. the skin, and Bones. the Brain the different Viscera - and all the principal Vital organs are not [illegible] effected - Venereal symptoms are divided into primary and secondary. the Three primary are 1st. Gonorrhoea 2nd. Chancre. and 3rd Bubo - The Three secondary are 1st. Throat 2nd skin. and 3rd Bones. however Bubo is not always primary but where there has been no chancre. It is possible for a Bubo to be Venereal altho there has no disease upon the penis - Mr. Hunter has considered the Venereal complaint to be merely a local disease. that is unattended with Fever Mr. Cooper denies it and advances the following arguments. viz that there is a regular exacerbation every evening and that the pulse are quicker &c 2ndly that before 262 the appearance of the Venereal disease and even after he feels unwell having a feverish paroxysm every Evening - Mr. Hunter also says that a child at the Breast of a Woman having the Venereal disease cannot catch the infection, To this Mr. Cooper is Certain to the Contrary. some persons have not susceptibility to receive the Venereal disease altho they may have frequent connections with foul Women. some persons are susceptible only of the affection of gonorrhoea and no other form, as Chancre or Bubo. Persons who have been much on the Town escape the infection when at the same time a person from the country having connexion with some woman will catch the disease. In healthy constitution the Venereal disease is unattended with inflammation or very little: when there is much inflammation mercury disagrees and the disease is more difficult of cure. Mr. Cooper says that Gonorrhoea is not truly Venereal: chancre cannot produce Gonorrhoea nor Gonorrhoea chancres The Venereal Disease in the Throat often takes place without chancre or Bubo. the Poison frequently gets into the Blood and affect the Throat without affecting the 263 the Urethra or Groin- Matter taken from the Throat and inoculated, does not produce the Disease. the Matter by passing the absorbents becomes changed in its nature Matter from Bubo, will not produce Bubo - Effects of Mercury- Mercury effects a Fever in the constitution throughout. which action overpowers and at length destroys the Venereal action in the particular parts. Rule of Cure. The cure of Venereal Disease does not depend on the quantity of Mercury used nor upon the action it excites in a given time but upon the Action being supported for a length of time To Cure a Chancre the Mercurial Action should be kept up for three weeks. To Cure a Bubo from three to four weeks, none of the secondary symptoms are cured under 5 weeks. some of a peculiar habit require 11 or 12 weeks. The Patient should rub in from 12 or 14 times for a Bubo. 2 night, and missing one and sometimes every other night. chancre may be cured by nine times 2 nights and missing one - some persons require much more Mercury to affect the constitution than others some are 264 not affected at all. such persons are of an indolent and scrophulous habit in such cases when afflicted with scrophulous symptoms give the Patient Mercury. keep him warm and let him live upon a cow diet as Liquid Aliment &c. putting the feet in warm water will quicken the circulation - In summer Mercurial Action is sooner excited than it Winter - Also during friction it is a good plan for the Patient to immerse his Legs up to the knees in Water as hot as he can bear it. the warm bath quickens the Mercurial action - A Woman that gives suck cannot be salivated let the amount of Mercury be ever so great-. on the contrary some persons are very soon affected especially those of irritable habits and quick pulse Calomel :3 gr scammon 5 gr has been know to excite salivation, In stout and strong constitutions a 1 dram of Ungn. Hydrarg : fort rubbd in for two or three nights will excite mercurial action while those who seem thin and weak are not at all affected - those having a quick and small pulse are most easily affected, desist. from the use of Mercury when it 265 excites much Fever. there is always a slight chill down the back when it begins to act. if the pulse is quickened and there is a slight fever leave off its use likewise if there is much sweating for if it does it never affects the system. passes off and injures the health. Give Bark and Vitriolic Acid till the sweating ceases. some persons are very quickly salivated without effect on the constitution is they have no soreness of the gums nor swelling of the cheeks Country Air is proper for such persons. In London and in all large Towns there is frequently sloughings of the Venereal Sores which hinders The Cure - here leave of Mercury & give equal parts of Bark & Sarsaparilla, and a considerable quantity of opium. Country Air is the best. after you may give Mercury when the debility of the constitution is gone off - Forms of Mercury. the best is Mercurial friction. begin with Ungn. Merc fort as before directed till the Mouth is affected 266 and as soon as it is affected 1 dram every other night increasing on diminishing it according to the effect it produces on the constitution carry it on progressively untill it produces considerable effect towards the end. you may let the patient walk about for the first three weeks of the course, then let him lay by for a fortnight by this means you will obtain a permanent Cure Next the Blue Pill composed of iÿ grains of Quicksilver and 1/4 gr. of Opium this taken every night and morning Increase the dose if necessary : Opium prevents it from purging. Calomel & Hydrarg Muriate should not be given as they run off by the bowels &c- Calomel is only required when the Mouth is difficult to be effected. This form of Mercury agrees well with some and not with others - next Rx Hydrarg: Muriat grÿ vel 4 Sp. Aether Nit ℥ÿ M Capt. corhl i paru bis terve die. this produces a slow effect upon the system and at the same time improves the health - when the effects of Mercury continue and the salvation does not stop. Rx Argent: Nitrat gr ÿ Aq: Purae ℥iv M the mouth to be Gargled with a Tablespoonful of it. three times a Day its Astringency Braces the relaxd parts 267 The infusion of Roses cum Acid Nitrosi is also useful. at the same time give wine and expose the Body to cold air. the Patient should be careful of catching cold. Mercury has been said to pervade the system in such a quantity. that even the sweat. the saliva. the Urine and Blood contain’d it Mr. Cooper was very anxious to have these experiments tried and it is found by the most accurate chemical tests that it is not true. he took from the arm of a Person in a state of salivation 6g of Blood not the 560 part of a Grain was found in it- A quart of saliva was then tried in which there was not the smallest quantity found: also he took a quart of Urine and there was none there – the effect produced on the Gold in the Pocket is in consequence of the Mercury hanging upon the Patients hands, we may therefore conclude that its nature is altered from pervading the system- Exema Mercuriale This Disease has in some instances proved fatal- Symptoms. Eruption upon the Belly and Thighs. The Eye Lid sometimes inflamed when it affects the Bowels the Patient falls a Victim to the Diarrhoea sometimes 24 the practicability of uniting parts when they have been quite separated- A Gentn. well known by Mr. Cooper. was when a boy playing with a mastiff. the dog flew at him and caught hold of the lower part of his nose and tore it so that it only hung by the skin of the lower part, it was immediately replaced by straps of sticking Plaster being secured and supported, it united so well that the cicatrix is not to be easily perceivd A lady had the lower part of her nose nearly separated by her head being thrust through the widow of her carriage in which she was overturned, it was united by the adhesive plaster and as perfectly as the above case- parts quite separated will if put together will not only unite but grow after their union- Mr. Hunter made a whimsical experiment, he wishd. to try if inserting the Testes of a Cock in the body of a hen would produce any sexual alteration. he did so, and although they did not produce any 268 the whole body is covered. Debility is extreme These eruptions are covered with a crust giving out and odour. When the Patient stands up the crust falls upon the floor and appears as if bran had been scattered sometimes it only Partial upon the Thighs If you scrape off the crust there will be an extreme discharge from the sore. the scrotum is also affected - Treatment. Sulphur internally. Tonics warm Bath. Aq: Lith: Acet. comp has failed. The best mode is country Air Tonics. and the following Lotion Rx Hydrarg: Muriat gr ÿ Aq: Calcis ℥ÿ M fs Lotio this is the yellow wash on the Aqua Phagedonica. the Patient should be wash’d with it from head to foot. it Produces no Mercurial effect - Introductory Lecture Surgery consists in proper Remedies to external disorders, and in performance of Various Operation. It is divided into principles and Practicals - In simple Fractures the Surgeon ought to keep the parts in Opposition. and in Compound Fractures the extremities of the bones are exposed with a bruise, and sometimes splinters which must be carefully removed. It is necessary to bring the two edges together: but If you do not succeed you then promote discharge by warm applications: Granulations follow and the cavity fills up when parts are bruised a sloughing takes place. which requires particular attention. In these cases nature herself will do a great deal - Index Page On Accidents - 1 On the Progress of Inflammation - 8 On specific Inflammation - 13 On Wounds - 21 On Lacerated wounds - 29 On Mortification - 37 On Injuries of the Head - 43 On the effects of compression of the Brain - 49 On Trepanning - 53 On Cataract - 59 On Couching - 68 On Fistula Lachrymalis - 72 Wounds of the Throat - 76 Wounded Arteries - 78 Dtt. - Joints - 79 On Hydrocele - 81 On the Operation for Hydrocele - 86 On Dislocation of the Vertebrae - 91 Page Dislocation of the Clavicle - 92 Ditto of the shoulder - 93 Ditto of the Elbow - 95 Ditto of Wrist - 97 Ditto of the Hip Joint - 98 Ditto of the Patella - 101 Ditto of the knee Joint - 103 Ditto of the Ankle - 105 Incysted Tumours - 107 On diseases of the Testicle - 108 On Aneurism - 112 On Fistula in Ano - 121 On Amputation - 123 Ditto of the Metatarsal - 124 Ditto of the Leg - 125 Ditto of Thigh - 127 Ditto of the Wrist - 127 Ditto of the fore Arm - 128 Ditto of the shoulder Joint - 129 On Diseases of the Female Breasts - 130 On Hydatid Tumours in the Female Breast - 133 Page The Operation for Schirrus Breasts - 133 The Method of Introducing the Female Catheter - 134 The Method of Introducing the Male Catheter - 135 On Opening the Temporal Artery - 135 On Lithotomy - 136 Method of performing the Operation in Male - 138 Ditto in Female - 142 On Suspend Animation - 143 On submersion under Water - 143 Suspension - 143 Introduction of Noxious Air - 144 of Extraneous bodies - 145 Means of recovery - 146 Bronchotomy - 147 Operation for Suppression of Urine - 148 Of Calculi in the Urethra - 149 Cancer of the Penis - 153 Amputation of Dtt - 153 On the Hare Lip - 154 Page Operation for Hare Lip - 155 Of Nasal Polypi - 156 Operation for Dtt - 157 On Dropsy & the Method of Operating - 159 On Scrophula Character of Scrophulous Persons - Treatment - Tabes Mesenterica Scrophulous affections of the Joint - Treatment - Scrophulous Hip Joint Ulceration of ye Vertebrae Scrophulous Ophthalmia Testicle On Gunshot wounds Treatment Burns & Scalds Sprains - Fractures - Compound Fractures Wounds of Veins Page Wounds of nerves Wounds of Tendons - Wounds of the Abdomen Wounds of the small Intestines - Dtt. of the large Intestines Dtt. of the Liver Dtt. of the Gall Bladder Dtt. of the Spleen Dtt. of the Chest. Dtt. of the Lungs - Dtt. of the Heart. Tix. Doloreux - On Gonorrhoea The seat of Gonorrhoea Treatment - Stricture the seat of Stricture Treatment for Stricture Use of Caustic Bougie Spasmodic stricture Irritability extending to the Bladder - Bloody Urine Inflammation & enlargement of the Prostate Gland Treatment - Bleeding from the Urethra Chordee - Hernia Humoralis - Sympathetic Bubo - Impotence - Loss of testicle - Emissions & Impressions &c Gleet - Seat of Gleet - External: Gonorrhoea - Ophthalmia occasioned by Dtt. Gonorrhoea in Females Gleet in Females - Chancres Sympathetic Bubo Phymosis - Paraphymosis - On sloughing - Warts - Page Chancres in Women - Opening a Bubo - Indolent Bubo - Sloughing Bubo - Venerea Ulcers in the Throat - Page Venereal Eruptions. Dtt. Diseases in the Bones Symptoms of the Venereal Disease General remarks on Dtt - Exema Mercuriale - 25 change of that kind, yet they grew and were filled by an injection thrown into the surrounding part- the spur of a young cock being inserted into the comb will grow to the same size as on the Leg- A preparation was handed round the theatre in which a human tooth had been inserted into the comb of a cock and the periosteum of the Tooth was so firmly united that it may be forcibly pulled without any fear of the separation - A Tobacconist in the Borrough had the first joint of his finger cutt off, it was replaced by Mr. Lucas and the soft part united, the nail grew, but the Phalanx exfoliated at the Joint of the finger- soft parts will readily unite on account of their admitting the elongation of the vessels, but hard parts will not - Mr. L. Bell in his fist addition of his system of surgery ridiculed the idea of uniting separated parts, but being in London and seeing the instances above mentiond. he was convinced of the probability of uniting them and in the subsequent 26 editions of his surgery ingeniously confessed his error - A curious operation lately common among the natives of India proves how parts that have been divided may be united. It was the custom of Hydor Ally and his son Tippoo said to cut of the noses of their prisoners to remedy this defect a piece of wax nicely moulded to the shape of the nose is applied to the part and a piece of skin the size and shape sufficient to cover it is cut from from the forehead and is turnd. down over the wax nose, the upper side of the skin is placd. outwards, it is united to the forehead by a small slip left undivided and the edges are inserted into each of the artificial nose, the whole is firmly united in a short time, the strap on the forehead is divided and no one could distinguish the artificial nose from the natural one; the turban hiding the cicatrix on the forehead, the union by the first intention takes place sooner on the upper extremities than 27 in the lower, as the circulation is stronger in those parts, for the same reason it is more difficult in old persons where the circulation is weak the Vessels do not elongate - the impediments to the union by the first intention are irritability of constitution where suppuration takes place, introduction of extraneous bodies ligatures the division of many absorbents, as in transverse wounds of the groin where extravasated lymph prevents union of the parts by the first intention, to promote this union we should not open the parts after the first dressing for ten days or a Fortnight if they are not painfull. if they are exposed too soon inflammation comes on and the cure is protracted - of the importance of union by the first intention as soon as that is effected the danger is over, its quickness [illegible] takes place in as many days as the same wound be weeks in healing by the other means- in the old method of amputating when the Limb was cut 28 off strait, lint and flower applied to the stump the discharge was very great, suppuration frequently took place and the patients frequently died the present method of applying adhesive plaisters soon produces an union and it is very seldom that any bad effects follow amputation, the method of applying the adhesive plaister may be used whenever the Bone supports the parts as in the scalp, neck, longitudinal wounds of the limbs &c &c Wounds of the face if the muscles are divided require sutures as do wounds of the throat, triangular wounds of the extremities, deep transverse wounds of the muscles all require sutures are described in old books of surgery but only two are admitted in the present practice the interrupted and the pulled the first for the wound, above mention'd, and the last for long wounds of the abdomen we should always be carefull to introduce as few sutures as posible - 29 On Lacerated Wounds Lacerated wounds are very little different from the incised, they bleed less, extraneous bodies are frequently introducd., it is difficult to remove them, but necessary if parts are healed by the first intention without removeing them abcesses will ensue, A man had lacerated his scalp by a fall from a scaffold the part was laid over the scull and union took place, matter afterwards form,d in several places, and many small pebbles workd. out - Lacerations are most dangerous in the tendinous parts and frequently occasions lockd. jaws, attempt to produce union by the first intention but if inflamation comes on change your plan to poultices & - contusd. wounds are dangerous they disorganize the parts and hinder the circulation, blood is extravasated in the cellular membrane, inflamation & mortification 30 ensue, these wound are not to be united by the first intention - poultices should be applied to the wounds, and if sloughing comes on hot fomentation should also be applied, as they generally expedite the process of the sloughing, if the inflammation goes on Leeches should be applied, and the swelld. part of the limb should be bathed with St. brine; Camph, as the process of sloughing is attended with irritation, Bark &c should not be given. Opium given in saline draughts will give great relief when the inflamation has subsided, then Bark wine and strengthening remedies should be administerd, - We ought to observe where the process of sloughing is the effect of constitution and not accident, Bark may be given, as in this case it is not attended with irritation which accompanies it when from accident - Punctured wounds are the most dangerous, their effects arise from, two causes, the operation of the nerves and absorbents, but the most 31 common effects is inflamation of the absorbent vessels, the symptoms of this is great pain in the part, red lines extend up the limbs the auxilla enlarges, pulse becomes quick and hard the knees swell and become stiff, delirium comes on and the patient dies; - A young man a Pupil in the Hospital had opened the Body of a man, and in sewing it up he prickd. the tip of his finger, in the evening he complain,d of pain and applied a poultice during the night be became delirious the next day he was calmer, but ye following morning the symptoms returnd, and he died about two o Clock, - A man who had puncturd, his finger had suppuration come on in the axilla the discharge from which was so great that it killed him the effects are produced. by the inflammation spreading through a great number of the absorbents, as these cases have occurred frequently in the practice of dissection, it has been a common opinion that putridity 32 was absorbed, but it does not seem to arise from this but more from the sort of wound and constitution of the person puncturd. - this was the case with the person before mentiond, as the Body was opened before putrefaction came on, and we frequently find that the same symptoms occur from accident where absorption of any kind is impossible Mr. Lucas Surgeon at Guy's had all the symptoms and was very near loosing his life by pricking his finger with the point of a buckle, it was in consequence of putrid matter only, the absorbent vessels that receivd. it would be affected in this case a sharp instrument is thrust into the cellular membrane, where the mouths of many absorbents are lodged, it wounds some and the inflammation spreads along their internal surface, these effects takes place in the constitutions naturally irritable. in those who are intemperate, or those who by long confinement to the close and bad air 33 of the dissecting room have acquired a considerable degree of irritability- Putrid matter has been injected into the cellular membrane of animals, which only produces a swelling that is absorbd. in three days & that without any ill effect to the animal The treatment necessary for punctured wounds of this kind, is to dilate the wound apply a poultice to the part, a frequent application of Leeches- Mr. Cooper applied 31 at different times to the arm of patient the limb should be fomented after the application of Leeches, saline medicine should be given, Calomel & [E?t] Cath should be used and if there is a tendency to delirium opium should be given, many persons has been destroyed by stimulating medicines given in these cases. on supposition of putrid matter being absorbd. - Dr. Watts having mett with an accident of this kind, when the symptoms came on took wine very freely and died in 9 hours - Mr. Cooper when a young man dissecting a body at surgeon's hall punctured his thumb, the symptoms came on 34 and he at first pursued a lowering plan by the advice of a Physician who was an advocate for the stimulating plan, he took a few glasses of wine and on finding the symptoms increase he desisted had a very painfull Night, and the next morning found one of his knees swelld. and stiff, he applied a blister and before that relieved him stiffness and swelling came on in the other knee, had he taken a few glasses more wine it would have killd him - A Gentleman fond of dissecting, punctured his hand, on opening the body and being fearful of venereal infection, rubbd in a large quantity of mercurial ointment and died in a few hours- The nerves are most frequently injured by punctures of the slighter kind the punctures happen generally on the feet and hands, and one ever so slight as to be healed before the symptoms come on may produce a lockd. Jaw. Dr. Ludlow lately died of Lockd. Jaw 35 in consequence of running a thorn into one of his fingers, the first symptoms of Lockd. Jaw is a stiffness of the Mastoid muscles, the Jaw becomes lockd, and is generally more firmly so in the beginning of the disorder ; tinitus aurium and chilliness attends, the Joints are affected and cannot be freely bent, violent spasms of the back come on and the body is bent backwards, it affects the muscles of the abdomen, which are hard and do not yield to the touch, the cheeks and corner of the mouth are drawn upwards and the face is much wrinkled, the body becomes stiff, the muscles of respiration are lastly affected and the patient dies, but most frequently he is attackd. with convulsion fits, the intervals of which becomes shorter & shorter till they carry off the patient in lockd. Jaws there is little disposition to sleep, if he does sleep the Jaw relaxes but shuts closely on waking there is frequently a profuse cold perspiration 36 the body is costive little urine is made and the pulse is from 90 to 160, we have not a sufficient number of cases that have terminated successfully to point out in certain mode to proceed on, the warm bath does no good in this disorder, it may in warm climates, but will not in this, opium will not relieve the spasms. A man at Guys Hospital took the first night of his admission 360 drops in three doses the next morning be took 310, at several doses in the evening he took an ounce at one dose at eight o Clock and at 11 in the same evening he took half an ounce at one dose he died the same night the opiate produced no effect on the spams, Brandy and stimulants faild., the removal of the punctured parts has no effect after the symptoms are commenced Tobacco Glysters give temporary relief but weeken to much for repetition Digitalis was unsuccessfull two cases have been lately successfully treated in the Hospital. A man run a nail into his foot, a week after the symptoms came on and he was admitted into 37 the Hospital, the cold bath only was tried he was allowd. a small quantity of wine, when the spasms came on he went into the bath which constantly relievd him the spasms were thus kept down and he recovered – in the second case Tinct ferri:muriat having been successful in some spasmodic affections, it was determined to make a trial of it in lockd. Jaw- it was given in this case in such a quantity as to keep a constant nausea 60 drops was given every ten minutes, but on this making the mouth very sore it was discontinued, and took 5 grains of ferri Vitriol in its stead this kept up the nausea the spasms were restraind, and he recoverd, he went into the cold bath once but it increasd, the symptoms On Mortification Mortification or Gangrene are synonymous terms signifying the death of a part the rest of the body being sound spacetus 38 signifies the act of separation of the dead part from the living, the first symptoms are those of violent inflammations, great swelling skin florid red, violent pain with quick pulse, loss of rest, and delirium, after which the part suddenly becomes easy, small vesications appearing on its surface containing a sanious dark colour fluid, the skin under these vesications is dark purple and insensible, hiccup comes on partial flushing of the cheeks, and if the part is small the Patient may live, if large dies- When mortification is producd in consequence of exposure to cold only the symptoms are, the parts becomes benumd. feels swelld. when pressed, the inflamation arise when the part is warmed, there is very little pain or constitutional affection, the inflammation abates and returns three or four times before the mortification commences, but in colder countries, such 39 as Russia, the parts become at once perfectly white and sloughing off without any previous inflamation, Thus when the mortification has happened the next process is the separation of the dead part from the living or spacitation which begins first by the appearance of white prominent line between the dead and living part which is the rising of the cuticle under which is a small furrow containing a quantity of serous matter, this is the first sign of the cessation of mortification, the Groove is formed by the absorption of the living part, this gradually extends deeper through the cellular membrane and muscle, until the whole dead part is removed, granulations are thrown out from the living part of the groove, by which the dead parts becomes thrown off: the largest arteries in the Body under these circumstances become separated without any hemorrhage for it is prevented by the formation of coagulum 40 very high up in the sound artery – the separation is the same in all cases, from whatever cause the mortification arises: the predisposing cause is debility: by whatever means it is induced; as by continued fever a mortification is producd. of the Hips when laying in bed the same time with Compound Fracture if the constitution is good no such effects follow it is soon producd. in old people as the circulation is most languid - more common in the extremities than the trunk. they being so much further from the Heart. Tentons are more liable to it than muscles as their living power is much less, loss of blood when great especially of stumps when the limb has been previously removed on out of mortification The occasional causes of Mortification are inflammations violent bruises destroying the texture of the part, and a disease of the Heart as Hydros pectoris. means of prevention when it arises from high inflamation, leeches should be applied to the part. cathartics must 41 be administered, apply the poppy fomentation, and stale beer poultice, or wine Lees, or sps. of wine mix'd in the poultice. when the inflamation is a little abated, give Tinct of Opii & the Bark freely every two hours, which however must not be dependd. upon, if the pain becomes less and the pulse not full, wine may be allowed, but better not while there is much inflammation, unless the person has lived very free before, when the mortification has happend. you must give wine freely - opii gr ij every two hours, cinchonæ and confect: aromat or the Bolus with cayenne pepper, fomentations and stimulating poultices, untill the part is separated, which should not be used to long and should afterwards use Turpentine dressings as soon as you can, Amputation ought never to be performd, while mortification is going on nor till the patient has in some degree recoverd, the irritating effects of it on the constitution and never as soon as the mortification has ceased unless from the inconvenient length of the stumps. it is not at all necessary as the parts 42 will separate of themselves - the Bone shortest the muscles longer than it, and the skin the longest of all so as to form every good stump which will readily heal, - In the mortification which arises from cold - sps. wine and Camph should be applied in such a manner that evaporation can take place and the stimulus created by it, be moderated by the cold produced if this does not succeed moderately, warm poultices an fomentation must be used and in cold countries rub the part with snow which produces a certain warmth moderated by the melting of the snow, mortification of the Feet in old people who have lived very high, begins with pain in his ancle and along the top of the Foot, and a Toe or toes appear black, the upper part of the foot florid, red, and then turning black, extending sometimes up to the calf of the leg, it mostly confines itself to the toes, and then the patient generally does well, occurs chiefly in tall people 43 sometimes also from ossification of the arteries this generally arises in people who having livd. very freely are suddenly deprivd. of their nutriment in this state opium is the best remedy combind. with wine and Brandy and fomentations of milk and water- Injuries of the Head First symptoms of injuries happening to the Brain are nausea vomiting, loss of sense and voluntary motion, fœces pass off involuntary and so does the urine in the same manner as when injury is done to the spine - Bleeding from the nose and Ears, and sometimes vomiting of Blood, as it gets from the back of the fauces into the stomach - A labouring slow irregular intermitting pulse, pupil in some cases dilated, in others not, it is sometimes contracted, but then there generally is spicule of bone, driven in and irritating the brain, respiration is sometimes affected with apoplectic 44 terror convulsions sometimes takes place if light, but if there is injury receivd on one side of the Head there is hemoplegic . - strabismus is the consequence of it and deafness: These symptoms generally arise from two causes only 1st, concussion of the brain 2nd pressure on that organ causing inflammation on concussion of the brain - The first circumstance to be attended to is to distinguish concussion from compression in concussion the breathing is not at first affected, nor is the pulse, sleep is easy the effects of concussion have been thought to arise from the motion being so violent at to interrupt the circulation here, but it appears to arise from laceration of the fibres of the brain as appears by dissection, the part about being of a red colour, and a worm eaten appearance, in slight concussions an altered action of the circulation is produced preventing 45 Ideas being formed - Treatment. In slight cases of concussion sickness is of service we are to consider whether Emetics are to be used when other means have failed, the first thing that must be done is to bleed very copiously, and if the pulse are full bleed as long, and as often as twice a day for several days if necessary, so as to bring it to the natural standard, it is much better to take blood from the jugular or from the Temporal artery as it relieves more speedy than from any other part- in slight cases of concussion Leeches may be applied to the Temple, in concussion of the brain it is wonderfull what quantity of blood will be lost before the pulse is brought to its natural standard or the symptoms relieved - A man was admitted into St. Ths. Hospital May 12th 1803 for concussion of the brain he was bled on that day four different times 8 oz. 16 oz 16 oz - 10 oz - the 13th - 10 oz- 14th 12 oz 10th 12 oz 46 in consequence of intemperance he got worse on the 26th and was bled again twice 32 oz. on the 28th - 10oz - 30th 16 oz. June 1st 10 oz. and in the end perfectly recoverd. losing in the whole 152 oz of blood, this was done under Mr. Cooper, directions, and the blood was drawn by his apprentice - drastic purges should be given freely, antimonials to keep up a diaphoresis, Calomel & Pulv Antim ought to be given in preference to Pulv Ipecac:Comp, a blister to be applied to the whole scalp its use depends on withdrawing the blood from the brain, if incission has been made to search for [the] a Fracture we ought to apply a poultice to it, and procure a discharge then heal it directly, mix Ol. Terebinth in the poultice it has the same effect as a blister. no cordials as wine &c should be allowd, on any account. Trepaning here is totally useless and very dangerous, The opening of the 47 Jugular vein will often put a stop to it when it will fail from the arm, particularly in children, the opening of the Temporal Artery is very usefull, and in extremely young children Leeches are very useful, Partial symptoms occurring from the accident are very difficult of cure, so much so, as the most violent ones such as loss of recollection or Epileptic fits afterwards, these symptoms are also caused by slighter injures to the Head, but these may sometimes be moderated and relieved by a seton in the neck, a partial loss of hearing or sight is sometimes the consequence, and which have been cured by Electricity if applied early - loss of memory is almost always the consequence of it - A man was admitted into the Hospital for concussion of the brain and when he began to get better, spoke different language. in short he perfectly lost the English language, so that there was no person in the Hospital that could understand him 48 A woman who sold milk accidentally coming into the ward and on hearing him talk answerd. him, and it it was discoverd, that he had been talking Welsh, & it was a considerable time before he got his English again, this case tho' remarkable as to be scarcely creditd. all the surgeon in the Hospital well remember - A Gentn recievd. a blow on the forehead and was stunned, in consequence he when home and vomitted and felt relievd. by it, the next day he complaind. of pain in the Head the vomitting came on, and for many weeks continued vomitting once a day and was relieved. it at last got to twice and three times a day and continued - the Trephine was applied to examine the dura mater & was found perfectly sound and in a good state; he lost his reason and died soon after in consequence of this slight blow on the Head- This shews that it was wrong to perform the operation 49 On the effects of compression of the Brain Pressure may arise from three causes. 1st from extravasation of blood within the cranium 2dly. depression of bone in consequence of a Fracture 3rdly. the formation of matter in the brain. - 1st Extravasation of blood within the cranium. The symptoms do not come on directly but will in an hour or two, (in concussion the symptoms come on immediately)- the breathing is laborious, pulse full slow & irregular, Extravasation is always accompanied by a fracture: a simple fracture of the scull without any depression or symptoms of injury does not require trepanning or any thing but the antiphlogistic treatment but when there is depression the symptom, of pressure come on and in violence proportionate to the degree of pressure produced. A great depression may sometimes be felt in some of these accidents 50 Without any symptoms of pressure ensuing, but in this cases the depression is only of the external table, and therefore you should not trepan without symptoms of depression - . a great depression will also take place in young children without any fracture or harm as their bones are very soft. - If symptoms of injury to the brain come on or if with the depression there is an external wound then you should trepan for if in this case you do not inflamation of the dura mater will come on with delirium and will kill the patient, but if there is no external wound neither trepan no make an incission nor if a patient has a depression and external opening so that a portion of brain equal to the diminished space is removd. you need not trepan - A person who has once 51 had a concussion or compression is liable to have some of these symptoms come at a future period. he should therefore if possible keep himself quiet and loose from time to time small quantities of blood. Extravasation between the dura mater and Pia Mater or between the dura mater and bone requires trepanning to be performd., the quantity extravasated sometimes is very small and sometimes large but the dura mater is not to be opend. for it will yield when the bony support is taken away inflammation on the Brain from accident, generally comes on about the 10th day after the accident sometimes as soon as the seventh and even as late as the 21st it begins by pain in the Head on the injured side generally it pulsates if there is a wound the slough becomes brown and there is no discharge. the scalp about the injurd. part pits, it is an odematous swelling. the Patient is siezd. with frequent rigors followd by heat the Eye inflamd., cheeks flushed, pulse 52 quick and irregular, body costive, feet cold, and when matter is collecting on the dura mater or Brain, respiration becomes laborious as soon as these symptoms appear the patient ought to be trepanned, when the scalp is cut through, the Pericranium will be found to be detatched and on perforating you will find the matter between the dura Mater and the bone gush out as soon as you make an opening. be careful in puncturing the dura mater when you wish to see whether is matter is lodged between the membranes, it ought to be carefully obliquely. but even here the surgeon has often failed for it is situated sometimes at the basis of the scull and the case is renderd. irretrievable - Mr. C. never knew a case succeed where the dura Mater had been puncturd. for this purpose before you operate bleed freely. if compression accompanies fracture many hours ought not to elapse before the operation use purgative & VS - the object here is to take away the extravasated blood under the bone - 53 On Trepanning There are parts of the Head where Trepanning ought not to be performed as on the middle of the os frontis over its spine except in young subjects where there is none. above the Eye brows where the frontal sinusses are placed, nor over the coronal sagital suture, or lambdoidal sutures on account of the firm adhesion between the Dura mater and the suture, however it may be done here if absolutely necessary, the sagital suture has been objected to on account of wounding the longitudinal sinus. but that is of no consequence as a pledget of lint will most commonly stop the Haemorrhage, and the immediate discharge of blood from the part is often advantageous, the anterior & inferior angle of the os parietale one inch before the Ear has also been objected to as the Dura matrel artery passes throug a foramen in this angle of the bone and if cut was supposed to be dangerous, however the 54 Hemorrhage may be stoppd with a dossil of lint and it does not prove troublesome This angle of the bone is situated just above the zyogomatic arch — To be certain where the situation of the fracture is you ought to make a crucial incission over the suspected part and turn up the edges of the scalp and examine the bone beneath: if you find a fracture you must trace it by making a longitudinal incision slowly and carefully along its course. if a great separation has taken place take care your knife does not slip and injure the membranes - when the operation of trepanning is inevitable and determind, on, the instruments necessary are the scalpel, Rougine, perforator, Trephine, or instead of perforator, a Trephine with a central moveable pin to act as a perforator. and afterwards to fix the crown of the instrument to work steady, the elevator and Lenticular which is a very bad instrument as it separates so much 55 dura mater from the scull as to cause exfoliation, lastly a pair of forceps which are of no use till the bone is sawd. completely round and is loose, but as this is a very dangerous practice it is rarely employd. - After you have made your crucial incision you are to remove the pericranium which should not be separated further than it is necessary to admit the Trephine, for if you do separate more pericranium than you want an exfoliation will ensue, when you use the old instruments you must make a small hole in the cranium with the perforator into which the central pin in the crown of the trephine is to be applied and continued till you have made a grove sufficiently deep to make the saw work steadily & then to be removed otherwise will protrude beyond the teeth of the saw and perforate the membrane, now when the instruments are used you make the perforation and all with the central pin till you have 56 formed a sufficient grove to work the saw steadily; the screw the central pin up and the instrument will work as before. when the perforator is removed and grove deepens, you must frequently and carefully examine with the end of an eyed probe, in the operation you ought by no means to be hasty or you may slip thro, and if a surgeon has once done so he ought never to be suffered to operate again as it may so easily be prevented by attending to the following rules, after have been sometime sawing and when you are you ought frequently to change hands, to prevent the instrument from hitching you will find a small portion of blood come up by the sides of the Teeth of the saw which tells you that you have entered the diploe which is generally about two thirds through 57 the thickness of the bone, you must then proceed with still greater caution and examine the grove every turn or two of the as it is often extremely thin, as soon as you find the bone completely perforated at any one part then introduce the point of the Elevator under it and the circular portion as far as you can and raise it up gently- by using the elevator at this time you prevent any injury being done to the dura mater which will be avoided for the Teeth of the saw will not come in contact with it, and if at this time the bone will not yield, make another carefull turning or two of the circular saw not pressing so much on that part which is perforated- on raising up the piece of bone there will be roughness left on the scull which may be removd. by the elevator as easily as the Lenticular which ought never to be used, but if [they] it does remain it is not of the least importance. If when you have raisd the bone you find an extravasation which appears in 58 large quantity, another piece of bone ought to be taken out in its course so as to expose it rather than pass a probe or scoop under it- there is never any danger in Trepanning when you find extravasated matter under the bone as you will find the dura mater a great way separated from the bone- and when you have removd, the matter apply a poultice over it- In trepanning for depression of the scull the Instrument should be applied on two thirds of the sound bone and one third of the depressd. then pass the elevator under the depressd. portion and raise it up into its natural place resting on the opposite sound portion If any portion of the depressd bone lies under the sound piece that has been removd. it must be sawd. off or two pieces be removd. before you can raise the bone If there is any wound on the Brain endeavor to unite the external wound as soon as posible 59 by which you may probably cause an adhesion between the dura mater and scalp When in consequence of Fracture you find extravasation, and on operating you ought to leave the integuments open by introducing a dossil of Lint and apply poultices to facilitate the discharge of the extravasation- when Trepanning has been performd. for Fracture with depression & the the depressd portion has been elevated bring the edges of the integuments together and unite as much as possible by the first intention by which means you will prevent exfoliation - On Cataract It is an opacity of the crystaline lens or the capsule in which the humours is containd. both producing the same appearance and symptoms, the first symptoms to be noticd. are sparks appearing to the patient moving in the Eye and one of these spots 60 seem situated in the same place, 2nd dimness of sight 3rd. that the patient see’s better in the evening than in the day time, and which is a principal criterion you may Judge this disease by, and further on looking into the Eye you will perceive a pearly appearance, the whiteness does not always come at once sometimes by a speck, sometimes in many parts over the lens - in a strong light the pupil becomes so much contracted that all the rays are thrown on the opaque spot and in a weak light the pupil becomes so much dilated that the rays do not fall on the diseasd, spot which accts for the person seeing better in a weak light than a strong one - the Eye looks sometimes yellow like matter behind the pupil. A patient with a cataract never becomes perfectly blind so that he can always be able to 61 distinguish a small portion of light. The colour is generally uniform and sometimes streakd. which denotes the cataract to be soft or fluid, sometimes it is of a reddish brown or red and then it is difficult to determine whether it is a cataract or not - they vary in their consistence, sometimes quite solid and different degrees of firmness even the entire fluidity which is a rare circumstance The crystalline humour is met with in three states 1st solid and sometimes contain earth 2dly quite fluid and from that called milky cataract 3rdly. a part of each; it can be distinguishd. if solid you will see it streakd. & in cracks, in all children born with cataracts it is fluid or soon after born it is so. in all these cases it is only necessary to puncture it and let it out into the Eye - There is in families a disposition to form catararts so that this disease may in some degree be calld. hereditary - this is a most remarkable circumstance - [illegible] 62 A Gentleman under his knowledge had a cataract and his two Aunts, Father. Grandfather and Grandfather, Brother. had Cataract, many such cases came under his and Mr. Cline’s knowledge of the same kind - Cataract is sometimes loose and in general attachd. to the Vitrous humour when it arises from thickening of the capsule of the lens it may be judged of by the lens appearing much closer to the opening of the pupil, and like a membranous bag streakd, across the iris - the cause of it appears to be a slow continued inflamation in the capsule or the lens itself its structure has also been found completely alter'd and becoming ossified, medicine has generally faild. but you may try the Hydrarg Muriat & Electricity in slight cases - the removal of the cataract has been found the only sure cure when the crystaline humour becomes opaque it prevents the light passing to the optik nerve - there are two operations 63 1st Extraction. the other by putting needle into it and so open it to let the rays of light pass to the optic nerve - on Extraction the instrument used in this operation is a cornea knife which is shapd like a wedge and exactly like spear pointed lancet, the knife must gradually thicken from the point so as to completely fill the incision as it is made; to prevent the escape of the aquaues humour till the incision is made one edge of the knife must cut through its whole extent the other [over] about half an inch, the speculum formerly in use for fixing the Eye is now laid aside as it is to be fixd by the fingers pressing on the globe. 2d a small hook is used to scratch the capsule of the cristalizd. lens, or by a small instrument made like a very small Gum Lancet for infants 3rdly. a small silver scoop is also useful to remove any broken part of a cataract 4th a small pair of forceps to remove the capsule of the crystalizd. lens opaque - To prepare the patient for 64 this operation you ought to give him Calomel purges for some days previous as it will cause inflamation afterwards, convey a probe for some days under the Eye lid to ensure it to inflamation gradually, if the Patient is of a Plethoric habit Bleed, - The Patient should be placd. on a low chair. & the Surgeons Chair should be six inches higher. - Mr. Cooper thinks laying on a table till you have completed the section of the cornea, as soon as you have done this as the posture is unfavorable for the escape of the lens, the Patient should be directly raisd, up, the light of the room should fall obliquely on the Patient's eye for if strong the Iris contracts so much so that it is liable to be torn in the extraction and there is danger of forcing out the vitreous humour by the force you employ to force out the christalline - Mr. Ware is very particular in that respect and it 65 is owing to that he is so successful, the chair to have a back with a pillow behind and the patient being seated the Surgeon sitting opposite resting his elbow on his knee, The assistant is now to place himself and he is to draw back the edge of the eyelid with an handkerchief. to be careful in not pressing the Eye, but upon the bone, if he does he will prevent the operation from succeeding, the Surgeon with two fingers of the left hand is to hold down the under lid and with the other finger press the Globe of the Eye nigh the inner canthus into the transparent cornea a hair, a breadth before the opaque cornea just so far forwards to prevent wounding the iris - the point of the knife is the to be carried a little backwards to prevent its passing between the laminæ of the cornea, you are then to pass the knife quickly across the Eye and push it through the opposite part of the cornea which 66 should complete the section without drawing the knife back, as that would endanger the iris and loss of the aqueous humour as soon as this done the Eye should be directly closd,, and if there are two catarracts you should proceed with the same steps when the capsule of the Christaline [lenses] is found diseased after the extraction of the lens every portion of it should be immediately removd, by a very small pair of forceps it has been known to have been absorbed but that has happened very rarely - The difficulties in the operation are 1st some Eyes are so unsteady that it is almost imposible to confine them particularly those that are born so, 2nd. is when the knife is sometimes pressed between the laminae not the cornea, and therefore a sufficient opening is not made, you may think sometimes that the pupil does not move which will cause failure as afterwards the pupil will become considerably contracted & loose eye sight 67 before you perform the Operation look at the pupil to see whether it has the power of contraction, or whether it has what is called Gutta serena which you may easily perceive by holding a candle before the Eye and then he cannot see it. When the opacity before mentiond, takes place in the Christalized lens there is in this respect a different in opinion whether it is to be taken away or it will be absorbed by scratching. 99 out of 100 will remain opaque if the operation is not performed, and if it takes up 1/2 an hour or longer every capsule that is opaque ought to be extracted by a pair of forceps- the vitreous humour escapes frequently in consequence of irritation during the operation- supposing a quantity of milky fluid escapes you are not to suppose the operation is complete before you examine whether there is any opacity After the operation apply a linen rag over the eye dipped in equal parts of Brandy and Water - 68 the patient should be placed in a sitting posture in bed so that the Blood may not influence the part- to be kept extremely quiet, no light. & very low the Eye is not to be looked at –if very painful apply leeches, purgatives &c but if there is no pain no remedies is requird, - let the linen rag wett with Brandy and Water remain on three days then let the rag hang loose before the Eye and remain for some time taking care the light does not cause inflammation - On Couching Couching is called depression and carried to the inferior lateral part of the Eye with a needle. The patient is to be placd, in the same manner as in the Cataract the needle is to be put in the Centre of the pupil, the patient is to be in a chair and his head to be held 69 by an assistant the Eyelid to be held in the same way as in Cataract. The surgeon is to stand before the Patient with his hand resting on the temple, his Head to be a little inclind. so as not to prevent the light, the under Eyelid to be drawn by one finger and the Eye fixed by another, the operation consists as follows a needle (that was invented by Mr. Hays is best) is to be introduced first 16th of an inch behind where the transparent cornea joins with the opake and having done so instead of passing it transversely so as to cross the Eye, pass it into the center of the Eye, then the point is to be brought forward so as to see it behind the transparent cornea. that you have it upon the cataract let your instrument rest on the cataract - bring the Handle forwards & the point being by that means depressd, you will find the cataract passed from side to side - There are many objections that have been made against 70 Couching amongst the principal are that the Cataract is very apt to rise to its former place, and until Mr. Hay’s treatise upon the subject couching had almost ceased; yet this objection is not a real one as the operation may be performed several times and at last ultimately succeed. Mr. Hay’s perform it several times in one subject Another objection to this operation has been brought forward, that the needle would hurt the cornea retina &c, but this objection will not particularly hold good - when the capsule of the christaline lens is opake perform the operation of Extraction instead of couching – If the cataract is opake and is united to the iris couching ought not to be performd, The advantages of couching are 1st the ease and safety it is performed as you may see the step when the needle passes into the Eye, 2ndly. when it is 71 a fluid Cataract. this is one that there is great advantage over extraction as the humour will escape, in this case you are to pass the needle into the cristaline lens and tear a little - When children are born with cataracts, or have it soon after, the humour is always fluid the extreme mobility in the Eyes of Children prevents extraction from succeeding and therefore couching is preferred - it is necessary in young Children to use a Speculum under the upper Eyelid - A young Practitioner ought to begin with couching in preference to extraction – Mr. Cooper says that he has seen the Operation of Extraction performed may times but never successfully but once and that was by Mr. Ware 3 weeks ago- the Operation of Extraction ought to be performed only by those who have frequent opportunities - but those practitioners who have only an opportunity 3 or 4 in their life ought always to Couch 72 though extraction is certainly in another point of view to be preferrd. - On Fistula Lacrymalia This disease is divided in three stages 1st. It begins with a small tumor occurring at the corner of the Eye just below the tendon of the orbiculus muscle. As the Patient meets the wind the tears run over the cheek which side it happens. If you press the tumor you will perceive streams of mucus comming out of the Puncta Lachrymalia and dropping on the cheek, in this stage there is no pain felt and may remain for several years - in the 2nd stage it becomes red & inflamd in its first it is called uninflamd. in the 2nd it is called inflamd, and it its 3rd state ulcerated - If the Surgeon does noting it ulcerates & then tears getting into the cellular membrane it extends considerably down the rose. The 73 cause is generally from the venereal disease sometimes from scrophula. It has risen but that very rarely from cold small pox pustule in the part scarlatina anginosa - Treatment of the 1st stage When there is only a simple enlargement press on the tumor and empty it entirely, then inject white vitriol water into it by the puncture lachrymator first turning the Eyelid down introduce a briscle into the puncture as soon as you have done this introduce the syringe into the puncture by this means you throw it into the ductus adnasum, and by throwing it in the wash being admitted into the structurd. part and brace it - Sir Wm. Blizard recommend quicksilver to be sent into the sac- if the obstruction is not quite perfect it will do but if it is it will pass down the cheek Another method is to introduce a probe from the ductus adnasum into the lachrymal sac, but this requires in general more 74 resolution than the patient can exert In the 2nd stage it is necessary to open the sac as it is inflammatory. Feel for the margin of the orbit cut about half an inch below the tendon of orbicularis and 1/8 of an inch behind that ridge the cut into the Lachrymal sac The direction you are to cut by is the fibres of the tendon orbicularis, as soon as you have cut the lachrymal sac pass the probe into the ductus ad nasum if you find the obstruction is very strong order a poultice for 24 hours then try the probe and continue in the same manner from day to day as it may be a week or more before the stricture may give way- If after trying a fortnight without success a caustic bougie may be used- after you have succeeded in making a communication pass an instrument which is called stile into the ductus ad nasum to prevent it from closing and you are to leave it there 75 during the highly inflammatory state of the ductus ad nasum, do not leave it in but only pass a probe continually till the inflammation is gone off, as the stile will irritate and therefore order a poultice , if that does not decrease it then withdraw the stile for 24 hours. but it is necessary to continue the use of for 3 months at least- the 3rd an ulcerative state requires for its treatment somewhat of the same mode as the 2nd, when it is ulcerated it is much diminishd in size so that it is difficult unless you have a good anatomical knowledge to open it after cutting open the sac pass a trochar through the lachrymal sac on the os unguis break it down and thus pass it into the nose, this opening is very apt to close unless a bougie is worn for some months, to prevent which Mr. Cooper invented a cannula with the trocar which he leaves in, but so far as he 76 has seen the operation performed in this manner it has very rarely succeeded On Wounds of the Throat Wounds of the Throat have been frequently misunderstood and are in many books of surgery erroneously described on account of the complex Anatomical structure of the part not being attended to from the chin to the sternum is about nine inches, and may be divided into three equal parts, from the chin to the beginning of the larynx is about 3 inches The Tongue & its muscles fills up the front part of this space, the Pharynx the back part- wounds here pass through the tongue and its muscles into the pharynx - the next there inches reaches the whole length of the Larynx, here the Trachea is in front and esophagus behind it, the lobes of the Thyroid gland are united over it. the 77 carotid rtery lies on each side. The most common wound of the throat is in the first divition when the Tongue or its muscles are divided along with the Pharynx, the Breadth passes through the wound yet the air tube is not wounded. Air and Frothy blood passes from the wound. [of] food solid and liquid passes through the wound which proves the air tube is not injured if it was the food would be rejected with violent coughing. Bring the chin forwards, make five or six sutures and completely close the wound, adhesive plaisters is of no use, the sutures must not be passed deeper than the skin. solid food is easier swallowed than liquid. The Epiglottis not performing its office Liquids get into the Larynx and occasion Violent irritation. The patient should have a handkerchief dipt in Lemonade to keep in his mouth to prevent thirst - wounds of this kind 78 are not mortal but as they are generally made by persons who wish to try destroy themselves. They frequently irritate them and bring on bad effects - Wounds of the Arteries Wounds of the arteries requires much attention the symptoms of a wounded artery are blood of a florid red issuing per saltem corresponding with the action of the Heart. Fainting comes on immediately on receiving the wound; during the Fainting the Hamorrhage stops but as soon as the patient revives a little the Hamorrhage returns. They alternately faint and bleed till death ensues. if the artery is small the fainting effectually stops the Bleeding. The artery when wounded retracts and draws itself an inch or an inch & half above the wound. blood is extravasated into the cellular membrane which coagulates 79 presses on the mouth of the artery and stops it, the divided artery contracts as high as the first anastomosis branch. When an artery is thus stopt by pressure on the outside the Blood forms a coagulum within adheres to the coats of the artery and in time becomes vascular, the contraction of the Artery alone would not be adequate to stop the Hemorrhage without the pressure of the coagulum. When even a large artery is stopt if the constitution is good the circulation will be sufficently free not only to prevent mortification but to preserve a perfect use of the parts - On Wound Joints Wounds of the joint even when small are dangerous as a small one lays open an extensive surface the joint having a [se???ing] surface does not easily heal, the cartilage cannot through off matter but must be absorbed and granulation formed instead if Union by the first intention cannot be effected. The Synovia escaping from the wound will often hinder the union by the first intention. If 80 this does not take place in three or four days a violent and dangerous inflammation comes on. The constitutional symptoms runs high. Matter forms at the Joint in different parts, the abcess form and break one after another, protracts the cure and generally render the joint anchylose. In delicate constitutions Wounds of the Joints frequently terminate fatal. - In the treatment of these wounds the first object should be to unite them as soon as possible sutures must be applied in this but particular care must be taken that they pass no deeper than the skin. If deeper they are productive of much irritation likewise the edges must be still further united with the straps of adhesive plaister laid over the sutures afterwards a roller and the wound should not be opened as long as possible perfect use is necessary to the joints, that of the knee and frequently obliged to be opened to take out loose pieces of cartilage formed there - To perform this operation we must keep the cartilages steady by pressure 81 the skin should be drawn back a small incission made into the joint and the cartilage that is loose taken out by a tenaculum afterwards the skin should be drawn each way over the wound that the joint may be as little exposed as possible a suture should be made through the skin to secure it and the wound treated as above - On Hydrocele - By the term Hydrocele is meant an accumulation of water within the Tunica Vaginalis Testes which tunic is loosely reflected over the Testicle in the same manner as the pericardium is over the heart. This disease begins with a Tumour at the inferior part of the Testicle gradually extending round it, as the water accumulates it produces a tumor of pyramidal shape at which time it extends along the spermatic cord until it reaches the abdominal ring - It is seldom a painful disease till it becomes greatly distended the scrotum seldom appears red but generally transparent. In oder to discover its transparency grasp the Tumour at its posterior part 82 Place the patient in a dark room, a candle being placed opposite will discover its transparency. Another mark to distinguish this disease from any other is its fluctuation and the comparative lightness of the tumour Sometimes two tumours are formed one situated at the abdominal ring. The other in the scrotum which frequently deceives the surgeon who supposes it to be a Hernia The fluid contained within the tunic puts on a Variety of appearances it is generally of a nature similar to the serum of the blood sometimes purulent at other times mixed with the red particles of the blood When the Tunica Vaginalis is thick its transparency is destroyed and which generally takes place in tumours of long standing The tunic becomes ossified and which variety of appearances may mislead the most experienced Surgeon. There is often within the Tunic one or more cysts formed as large as a Chestnut the Testicle is commonly placed behind the tumour in Hydrocele if it were otherwise situated it would probably be wounded in 83 performing the Operation, therefore you should be at all times certain that it is so situated before you attempt to operate - In order to distinguish this disease from Hernia desire the patient to cough if it is a Hernia a distention of the tumour takes place but in hydrocele no such distention takes place but, it must be observd should the tumour extend to the abdominal ring some little distention will necessarily be produced from coughing by the action of the abdominal muscles. another mark is this. if it be Hernia and you attempt to raise the scrotum you will find that you can’t readily do it. but in hydroceles no such difficulty appears - Hydrocele may be distinguished from diseasd. Testicle by its weight. Figure and inflamed or red appearance. This disease is sometimes unfounded with hematocele this is an accumulation of blood within the Tunica Vaginalis, it is generally occasioned by a severe blow on the testicle and may be known by the former marks - The cause of this disease is an increased action of the vessels of the Tunica Vaginalis and not a disease of the 84 absorbents as was formerly supposed but these vessels are generally found enlarged hydrocele is said to be treated in a Palliative and radial way. if in the Palliative, all that is required is to draw off the water from time to time which may be done by a lancet or a small Trocar direct the instrument obliquely upwards at about two thirds the length of the tumour after the operation lay a small piece of adhesive plaister over the wound, It is frequently necessary to perform the operation three or four times a year the Trocar should be preferred, in performing this operation a small incision being first made through the integuments with a lancet & give tonics internally combined with mercury a strong solution of crude sal Ammon dissolved in Vinegar and applied to the part is often of service. It has been found that taking a considerable deal of exercise directly after the operation 85 has produced a Radical cure by bringing on a Violent inflammation by which a quantity of coagulated lymph was thrown out and produced an adhession of the tunics - Of the Radical method of cure this may be affected by the process of granulation or adhesion, the latter is to be preferred. - Of the mode of cure by the Seton recommend by Mr. Pott, this is also liable to objections as it occasions frequent but partial adhesion of the Tunic - in the Hydrocele of young children do not be in haste to operate before you have given every remedy a fair trial The operation by caustic is sometimes employed but this like the method adopted by Mr. Pott is liable to objections - The method of applying it is. take a piece of kali purum rub it round the surface to be cauterizd for the space of 10 minutes which will produce an eschar and the operation is finished. This method of operating has been known to fail even in the most experienced hands. in old people it should never be performed on acct. of 86 the inflammation which succeeds being often very Violent producing high symptoms of irritation and sometimes even Death - It is Mr. Cooper opinion that this method of operating should be entirely done away with - The best method of operating in Children is by taking a common needle the same as is used after amputation arm it with a few threads of silk, pass it through the Tunica Vaginalis in a longitudinal direction and at the same time obliquely draw the threads out at the opposite opening and leave them these by acting as an extraneous Body will produce inflammation and in consequence a Radical Cure will be obtained - On the operation for Hydrocele The method of Operating by Injection is in a more general use than any other. this operation is of old date, Sir J Earl improvd on this mode of operating - The instruments required for it is 1st a large and small Trocar for the child and adults, 2nd an elastic 87 Bottle with a turn cock, 3rd a Mixture of Red Wine (1 part water & 2 parts wine) but as Wine is liable to vary in strength the Vitrolated water is now used in the following preparations - Rx Vitriol albi ʒi aq:distillate 1 H ᵯ - with this solution the Elastic bottle is to be filled - make a small incision with a Lancet through the skin at the anterior part of the tumour, the introduce the trocar and cannula - inject a quantity of fluid sufficient only to be applied to the whole surface of the tunica vaginalis testes - this should be allowed to remain as long as the patient can bear. about 4 minutes on an average - When the patient complains of a little pain during the operation the greater will be the succeeding inflammation - and Vice Versa - a small quantity of fluid about 2 drams should be allowed to reaming in - the patient ought not to go to bed until he is obligd. to do so from the violence of the pain in the part and also in the loins - If several hours should elapse & little or no inflammation comes on Mr. Cline directs Wine to be given and taking the scrotum 88 in the hand and rubbing it. In 48 hours the swelling is generally as large as when the operation was performed, it feels solid and pitts on pressure with the finger the skin appears in ridges, you then know that the inflammation exists in a sufficient degree - In the course of a week the tumour begins to subside and in three weeks the patient is generally cured - If the testicle is slightly enlarged you are not to be deterrd from operating for by exciting a counter inflammation the swelling will probably subside - If the Tunica Vaginalsis is inflamed you will know by a bloody appearance of the water when drawn off. you must then use the Injection only half the strength before directed that is in proportion to ʒ1/2 to Hj - Mr. Cooper observes it is very wrong practice to inject a quantity of fluid equal to that which is drawn off, but recommend. if ℥vi or ℥viii of water is drawn off to inject not more than ℥iii or ℥iv of the solution - There is some danger attending this operation for if great care is not 89 used in introducing the cannula with in the tunica vaginalis the injection becomes extravasated into the surrounding cellular substance. the consequence is that the whole surface of the scrotum becomes black sloughs and in 8 or 10 days the patient dies from high constitutional irritation -In a child from 6 to 10 years of age this method of operating may be employed if the tumour is large but in those that are younger it should not be employed - Incision with the introduction of Flower or the seton should be had recourse to in these cases - of Incision - this may be considered as a dangerous operation and in which the symptoms in general run high, but its advantages are that it shows you readily the situation of the Testicle, it also shows you if any cysts are formed on the surface of the testicle - This operation should always be performed when any adhesion are found - if the testicle is found anteriorly the incision must be made on the natural part of the tumour. - 90 The advantages of injection are that when it is properly performed it is comparatively a mild operation. it may fail in the fist instance but if repeated will certainly succeed. and with the Vitriolic injection Mr. C has never known it to fail - but treated with the wine & water it has been known to return at the end of two years An Hydrocele of the spermatic cord may be known by a tumour forming at the abdominal ring - it may be easily mistaken for a Hernia as before observed by its projecting when the Patient cough but in this there is a want of transparency in the Tumour. in this the operation is to be preferred in doing this operate as for Hernia which must be done with great caution as the spermatic artery and veins sometimes run on the fore part of the tumour and the vas deferens behind - should any portion of testines adhere you are to desist as it would be useless to operate, this species of Hydrocele is sometimes contained 91 within an hernial sac in which case the operation by incision is to be preferrd. On Dislocation The vertebrae are so connected that no dislocation can take place without a fracture the consequence of which is the compression or division of the spinal marrow the total loss of sensation and use of the parts below where the accident has happened - in these cases the urine is evacuated by the catheter otherwise it will be liable to bust from the patient, being incapable of expelling the urine - the – the foeces pass of involuntary and when dissolution is about to take place the urine runs off in the same manner - If the fracture happens in the Lumbar Vertebrae the patient may live from 17 days to 3 weeks with some little exception - If in the Dorsal about a fortnight – If about the 6 or 7 cervical not more than a week : if in the 2 or 3 cervical not more than 40 hours. if in 92 Atlas or Dentaba the patient generally expires instantly - . The Clavicula is liable to be dislocated at both extremities the sternal end is sometimes thrown before the sternum in its fore and upper part. when the shoulders are drawn back it returns into its place - Treatment - The shoulders are to be drawn and kept back as much as possible by the stellate bandage which ought to be kept on for about 5 weeks The scapular extremities are sometimes dislocated from the processus acromion it the forms a considerable projection on the spin of the scapula. The shoulder on that side falls to the breast therefore from the sternum to that shoulder is less than from the sternum to the other - Treatment. The shoulders are to be drawn back as in the former at the same time the shoulder is to be raised by a sling. In these cases the pain that it produces by keeping the shoulders 93 sufficiently back is more than Patients will generally admit to and when told that it produces no inconvenience by being left to nature (except that of the incapability of the arm being stretched out so far as the other) they prefer rather to be subject to that little inconvenience than suffer the pain that is necessary for the proper Union of the ends of the bones, which is the reason that it seldom or ever cured - The shoulder. is liable to be dislocated in three different direction 1st downwards or into the axilla-the marks of this is the dislocated side is flatter than the other the arm cannot be raised to the Head and the lower edge of the pectoral muscle is raised above that of the opposite, by putting the finger into the axilla at the same time raising the arm the head of the bone may be plainly felt - Treatment if recently done apply a round towel obliquely from the arm pit of the dislocated side to the top of the opposite shoulder it is to be carried over and then to be fastened by a bandage 94 This extension is to be made above the level of the shoulder, upon the dislocated arm the extension is to be made gradually and kept up for a long time - about 5 or 10 minutes the arm will commonly be reduced - If the arm has been out a long time Poultices should be applied; making two or three attempts to reduce it one after another Another mode of reducing recent dislocation of this joint. Place the patient upon his back then put the heel of your foot into the axilla at the same time having hold of the arm make a strong pressure by the foot and gently turn the arm inwards In this way the arm will commonly slip in - The 2nd dislocation is forwards the Head of the bone being placed under the Pectoral muscle just below the clavicle. The patient is incapable of raising his arm to his head. When the head of the bone may be perceived moving under the pectoral muscle on the arm being rotated the dislocated side is flat - Treatment - 95 To be reduced either by pullies or by the Bandages as in the former - Pullies are best as a greater extension is required The 3rd. dislocation is when the Head is thrown backwards or into the scapula when a considerable Tumour appears on the spine of the scapula if the arm is rotated it can be felt - The same treatment as the first - this seldom happens - Dislocations of the Elbow Joint backwards when the Radius and Ulna are placed behind the Os humeri the coronoid process is placed in a hollow above the Articular surface of the Os humeri the Arm is a little bent - Treatment - Take the Arm in one hand and the forearm in the other. having the knee or some fixed part at the inner of the Joint the forearm being pulled downwards the bones will immediately slip in– 2ndly where the extremities of the bones are thrown [in] laterally, either internally or externally, the same Treatment is to be made use of here, but at the same time the Extension is made by an Assistant press the bones towards the Joint - 96 The Ulna is sometimes dislocated without the Radius, in the case the projection is not so great at the Elbow as when both are dislocated. The Reduction is the same sometime the coronary process is broken off by the irregular action of the muscles. the ulna loosing its support is dislocated backwards and appear in a projection at the back part of the Os humeri - The coronoid process is drawn up by the muscles on the forepart of the Os humeri. This is easily reduced but when the extension is taken off it resumes its place - sometimes the head of the Radius is separated from the Ulna and thrown into the hollow above the external condyle of the Os humeri here the arm is incapable of being either bent or strengthened but still returns supination and pronation - Treatment the best way of Reducing this is first to produce fainting by the warm Bath or Tobacco Glysters. the confining the Ulna by placing the foot to it at the same time forcibly and suddenly extend 97 the arm it is however very rarely reduced The wrist is liable to be dislocated in two different ways, backwards and forwards, it is easily reduced by making an extension of the Hand one way and the forearm the other - There is often a tumour appearing like a dislocation of the wrist which is occasioned by an accumulation of coaguable lymph from inflammation produced by a strain of the Tendons - Apply prepare and Mercurial Plaister to reduce the swelling and afterwards electrify it - There are small tumours frequently appearing at the wrist which is a collection of synovia in saculi Mucosi, these are called Glanglions. They commonly move with the Tendons but are sometimes perfectly fixd. and adhere to the ligaments - These ought never to be opened but are to be dispersed by breaking them which is done by bending the wrist and then they become tense when if struck hard will burst and disappear  Professor Fox. M.B. 1 Mr,, Cooper's Lectures on Surgery On the effects of accidents, and diseases on the constitution, and sympathy of diseases on it. Sympathy of diseases are those where one part feels pain in consequence of an injury inflicted on another; Irritation may be only sensation in a diseases, which may affect the action of parts.- A pain in the Loins follows an inflammation of the Testes, A stone in the urethra occasions pain in the Testes and high on the side- The knee is painfull when the Hip Joint is diseased, occasioned by the communication of the Sciatic nerve; therefore where the knee is very painfull, and there is no inflammation, we should be particular in our examination of the Hip Joint, as so many practioners have so frequently been mistaken in this case. - A disorder in the liver occasions 2 a pain in the shoulder, outside of the collar bone, also an itching of the nose and rectum takes place when the rectum is irritated; Dr. Hunter called them sympathetic dilutions but they can be dilusive only to the uninformd. - bad affections of the Liver and stone in the urethra produces only local pain - we cannot discriminate with such accuracy as on their sympathetic symptoms, the Testes becomes painfull in consequence of an inflamation of the Urethra: the glands of the groin will swell and inflame in consequence of the passing of a Bougie producing a sympathetic Bubo - an unexpected blow on the stomach the very trifling will sometimes occasion [the] Death: - A man was endeavouring to part two women fighting in the street received a blow from one of them on the stomach and instantly fell, and was supposed at first to have fainted, but was dead; on opening the body no particular appearance 3 of disease was found- A young healthy man received is slight blow by the back of the hand and fell immediately, Mr. Cooper and another of the Faculty tried the usual modes of inflating the lungs, warm bath &c in vain; on opening the body a small discolouration was found in the stomach where the blow had been given occasioned by extravasation between the coats of the stomach: in these cases the blow on the stomach occasioned a cessation of the action of the Diaphragma and stopd. inspiration - Almonds when eaten will with some people produce violent irritation of the Skin; - Sympathy of actions is where one part acts in consequence of Injuries done to another; Thus injuries of the Head, strictures of the Intestines produces vomiting When a stone is passing the Gallbladder vomiting is producd, as is likewise the case when the uterus is inflamed, in the effects of irritation all the functions of the Body are changed by partial injuries Thus in a Compound Fracture in 24 or 36 hours all the functions will be changed 4 in scrophulous habits the change may be rather slower;- we shall find pains in the back, loins, and Head in Fever; the action of the Heart is altered the pulse becoming quick hard and intermittent, the alimentary Canal is affected the Tongue is firrd., white when the degree of irritation is small, brown when it is great, sickness of the stomach takes place and constipation of the Bowels, perspiration is stopd. the nerves become affected sleep interrupted, delirium and subsultus tendinum follow; a profuse sweat will break out and then the symptoms abate, but in a short time they return with greater violence;- The Symptoms should be regulated and checkd,, their Violence depend on the importance of the part Injurd, - a very small wound of the Intestines, will occasion a cessation of the pulse, or make it so faint as scarcely to be perceived - in parts not so essential to the vital functions, the symptom depends on the size of the wound, and on the degree of vital power possessd. by the part. Thus wounds of the Tendons produce more irritation 5. for the tendons being less Vascular require a greater afford of nature to restore Injury - A man was kicked by a Horse on the Intestine there was no pulse felt in the wrist, and yet survivd. 12 hours - The smallest ulcer on the Lungs will produce more considerable effects to the constitution than the largest ulcer on the Legs or any other part - In accidents many things are to be considered. 1st the importance of parts injured. 2ly the extent of the Injury. 3ly. wheather the Vital powers are weak or strong the weaker the better; Symptoms depend greatly on the natural irritability of the constitution A man was brought into the Hospital with a Compound Fracture of the elbow. The bones of which were laid bare. his hand at the same time quite crushd, amputation was thought inevitable but the man refusd. to submit and the arm got well without much pain and without any bad symptoms except a small abcess on the upper part: a much less injury in a person of an irritable habit, would have producd. Mortification and Death - the signs of irritability are great pain, extended inflammation, fear of Death, restless and delirium; 6 Fat persons are generally irritable. intemperate persons have a very considerable degree of irritability; the passions of the mind has a great effect in all operations; and in accidents it is always proper to inspire the patient with hope: the passions that influences the Body are grief, anger and fear- Joy and hope produce stimulating and healthy effects= Grief fear and anger lower the actions of the Vital power, and retart recovery. Grief particularly effects the Liver and produces conjection of bile,. Fear has a more particular effect on the Constitution than the rest. Anger produces a quick hard pulse and influences the irritation of the mind on the Body. - Mr. Cooper attended a gentn. for a Chancre. it had a healthy appearance but suddenly became worse without any apparent cause, it afterwards went on well again & again became worse had frequent lapses of this kind; till at Mr. Cooper accidentally calling found the Gentleman in a Violent fit of Passion and on examining the chancre he found it considerable worse sloughing be 7 on removing him to another place where he was not exposd. to anything which could cause passion the Chancre was soon healed by the same means that had been used before tho the air of the place to which he was removed was not so healthy as where he first resided.- Fear will frequently occasion Death; where there would not have been any danger without - A man with a Simple Fracture of the thigh was brought to S. ThS. Hospital he was prepossesd. he should die, his fears were smiled at, but on the eighth he died there was no inflammation nor was there any union of the bone taken place - a lad 17 years of age died in a similar manner of a simple fracture - Mr. Pott was called to Gentleman of a very timid disposition, who had symptoms of stone, the nature of the complaint his Friends had carefully concealed from him. Mr. Pott made an examination (with the sound) and having found a stone and being ignorant of his timidity told him the case, and that he might be effectually relieved by an operation 98 The Os Femoris is liable to dislocation in four different directions - 1st upwards or into the dorsum of the Illium about two inches above the acetabulum the trocanter Major is turned forwards and the head backwards the foot inwards and the leg on that side is about 2 o 2 ½ inches shorter than the other the limb cannot be moved at the hip Joint being so strongly bound by the muscles - Treatment - Place the Patient on the opposite side to the dislocated one. the Pelvis is then to be fixed by carrying a girt between the scrotum and the Thigh of the dislocated side round to the outer part of the Pelvis and there to be fixd. to a pillar or some steady point. The dislocated Thight is to be brought over to about the middle of the oposide side a bandage then being fixd. above the knee which is to be kept bent. the extension to be made obliquely forwards and downwards. after this has been made for sometime and it does not succeed let 99 a bandage be put round the upper part of the Thigh which is to be so long as to admit the Head of an assistant through it he then is to place his hands upon the Pelvis to prevent its raising than gradually and forcibly raise himself- The head of the bone will be elevated over the brim of the acetabulum and will slip in. this elevation is to be made at the same time as the former extension. or it is sometimes reduced by pressing hard upon the Trocanter major while the extension is made 2nd, dislocation is downward or into the foramen ovale the leg in this is much longer the foot turned inwards. The knee separated at some distance from the other and the patient cannot bring it to the other - Treatment. place the Patient on his back carry a girt round the upper part of the thigh and fix it to a point as the former the limb being bent press upon the knee by the weight of the body inwards. by these means the bone will 100 generally be reduced. 3rd Dislocation into the Ischiatic notch. The leg is very little if any shorter the Toes turned in the knee Lying upon the other, and the heel separated at the distance from the other. Treatt. Place the Patient upon his side and fix the Pelvis bend the Thigh at right angle with the body the extension is then to be made in this direction at the same time bend the knee a little downwards. otherwise in making the extension the head of the thigh bone would be drawn below the acetabulum and pulled into the foramen ovale, therefore to prevent this the knee must be a little bent. the same bandage is to be used here as in the first to raise the head of the bone above the brim of the acetabulum 4th dislocation is forwards as upon the Pelvis. the Foot is turned out. the leg is nearly the same length by rotating the limb the head of the bone is seen moving in the usual situation of a Bubo Just at the middle of Pouparts ligament 101 treatment. Place the Patient upon his side, carry a Girt round the upper part of the Pelvis which is to be confined by a roller from the girt round the thigh a bandage is then to be put round the upper part of the thigh into which a pully is to be fastened. The extension to be made rather obliquely upwards - These Dislocations are to be careful distinguished from Fractures of the cervix of the femoris. this however happens generally in Old People. In these cases the Leg is shorter and the Foot turned out - Dislocations of the Patella 1st outwards when it becomes immoveably fixd, to any common force that is applied Treatment. The leg being already extended (for the Patint cannot bend it) put your hand to the outward edge of the Patella and then press it downwards and at the same time inwards 2nd. Dislocation Inwards when it is situated internally the reduction is the same as the former 102 3rd Dislocation upwards from the Ligament connecting it to the tibia being torn throug: the Patella is then drawn up two or three inches by the rectus muscle about the knee - Treatment A cushion is to be put at the upper part of the Patella and confined by a roller pressing above and below the knee. There is over the Patella between the skin and the Tendon a Bursa Mucosa which often becomes enlarged, and frequently in women who are much accustomed to kneel. The bursa inflames swells and often increases to a considerable size Treatment. the knee is to be bent as much as possible the the tumour will became tense and hard. and if struck two or three hard blows will generally disappear If this does not succeed make an incission the whole length of the tumour and dissect out the sac after which bring the edges of the wound together by plaster and treat as a common wound 103 If inflammation comes on poultice and fomentation are to be applied and also Leeches this operation does not produce such violent symptoms as if it had been left to suppurate Dislocation of the knee joint It is liable to be dislocated in four different directions 1st outwards. the head of the Tibia is thrown on the outer side of the Os Femoris Treatment. An extension is to be made in a straight direction at the same time pressing the bone inwards - 2nd dislocation Inwards which very rarely happens it requires the same treatment as the former 3rd Dislocation Backwards little extension is requisite to reduce this notwithstanding the injures which must happen from these dislocations yet the Joint generally recovers its proper function 4th Dislocation is when one of the cartilages becomes separated from the Tibia and 104 Os femoris and is resting upon the ends of the Tibia instead of the cartilages it produces but little deformity in the Joint. the knee cannot be straightened but allows of flexion. Treatment The limb is not to be attempted to be straightened but bend it back as much as possible towards the nates. This allows the Cartilage to return into its place the Leg may then be straightened and it will resume its proper place when this accident has once happened it is very liable to return the Joint therefore is to be straightened by bandages - There are loose cartilages sometimes forming in the cavity of the knee Joint, and on the outer part which produce great inconveniences, a person when walking is liable to fall down suddenly from the cartilage slipping between the extremities of the bone soon afterwards it will move and the person will be able to walk again. These are 105 to be removed by an operation. the Cartilage is to be pushed if possible to the outside of the Joint an incission is then to be made the whole length of the Cartilage - before the incission is made the integuments are to be drawn very much above the Cartilage. so that the external orifice shall not be even with that communicating with the Joint the incission being made the cartilage is to be extracted. If it does not come out readily it will be right to extract by a tenaculum. the edges of the wound are then to be brought together and confind. By sutures which more effectually prevents subsequent inflammations at the hazard of the Patients life or expose him to extreme pain by the formation of Matter and anchylosis - Dislocations of the Ancle The 1st and most frequent is the Joint being thrown forward on the upper part of the foot the lower end of the fibula remaining in its 106 place and of course must be broke the heel is much lengthened and the distance from the Toes to the end of the metatarsal bones much shortened Treatment. make an extension by putting the Tibia downwards. the Foot likewise extended, after this reduction the Limb should always be laid upon the heel till the parts are recovered otherwise a return of the accident is liable to take place. 2nd Inwards when the end of the Tibia is resting on the inner edges of the astragalus the over extremities of both bones being broke off a large tumour appears on the inner [crossed out] side of the ancle . Treatt. Take hold of the Foot with one hand and with the other hand keep the leg steady a very gentle extension is to be made at the same time let pressure be applied on the projecting bone, when reduced lay the limb on the outside. 3rd when the end, of the bones are thrown on the outside of the Tarsus. the maleolus externus 107 being broken off - Treatment to be the same as the former, and when reduced lay it on the outside - When a compound dislocation happens, the Tibia and Fibula broke appear externally and the Joint laid open, it is a question whether it will be bent to amputate or not. attempts ought to be made to save the limb. for amputation performed so early after the accident is generally productive to the Patient - if advanced in years the operation ought not to be performed as the living power is very weak in those - on the contrary if the Patient is under 40 years a chance ought to be given - On Incysted Tumours These don't require to be removed as they occasion but little inconvenience. if they are large and no considerable vessels near, you may treat them in the same manner as Hydrocele either by Seton or Injection- If small remove them by the knife but if any large vessels are situated near open the tumour with the lancet and inject a little 8 The gentleman replied that the operation would not be necessary, for the idea of having a a stone in the Bladder would kill him - Mr. Pott took his leave but observing a great attention in his countenance sent Dr. Harris to inquire after him the same evening & when he came the person was dead: - A Lady with a scirrous Breast of no great extent was much pressed by her Friends to submit to the operation she refusd. for a long time; but at length she consented: she said she did it in compliance with the wishes of her Friends but was sure she should not survive it. Mr. Cline performed it and nothing could be done in a better manner. The Lady was put in bed; her countenance sunk and she died very soon after; her prepossession was so strong that she ticketed her keys and disposd. of every thing in such manner, that the Family affair might not have any interruption - On the Progress of Inflammation The existence of inflammation is known by redness 108 of the white Vitriol solution - Children are particularly subject to the formation of these incysted tumours On Diseases of the Testicle The diseases rendering its removal necessary are four 1st. Hidated disease this begins in the extremities of the Epydidymus extends into the Body of the Testicle back towards the spermatic cord, it is never attended with much pain, it may therefore be mistaken for Hydrocele; It is not of a cancerous substance; is confined entirely to the Testicle and is of a very considerable size. This diseases generally occurs between the age of 20 and 30 and sometimes later in life - In order to distinguish this Disease from Hydrocele it is to be observed that it differs ins shape, but, is of the form of the Testicle is prominent before and flat on each side, secondly its weight 109 is very considerable, but its want of transparency is the best mark. This Disease is very liable to deceive even the more eminent of Surgeons: Mr. Pott and Mr. Cruckshank have both fallen into this error - If you have any doubt in your mind respecting the disease puncture the Tumour with a lancet, and if there is no water. proceed to treat it as a diseased Testicle. This disease is found to be collection of a number of cysts on the surface of the Testicle filled with a mucilaginous substance, these cysts vary in their size from a pea to a marble, after the Operation for this complaint the Patient in general does remarkable well - The 2nd complaint is the true schirrous Testicle which originates in the body of the Testicle and becomes as it were all at once hard and considerably enlarged, it the proceeds to the Epididymis and spermatic cord- it may be distinguished from all other diseases of the Testicle by its stony hardness, it is likewise attended with considerable pain, but not constant 110 triffling causes produces this disease. it is envisioned by a deposit of coagulable lymph becoming at length cartilaginous runs up the spermatic cord into the abdomen and produces the same disease in the Loins as that originally in the Testicle Before you operate examine if the spermatic cord is diseased for it is of no use to operate if it is, therefore you should operate as early as possible - There is another species of cancer in the Testicle which Mr. Cline calls the Pulpy cancer this is a much more dangerous disease it originates in the same manner as the former, but its effects are much more sooner destructive . In a few weeks this disease extends into the abdomen and renders any operation fruitless and generally in the course of 20 weeks proves fatal, its called the Pulpy cancer because when you feel it it seems like the Hydatid Testicle. great pain attends this disease and if a Lancet is pushed into the Tumour Blood flows out 111 a sallow countenance is another decisive mark of this complaint so that with a little attention this disease may be distinguished from any other. The Operation must be performed as soon as the Cancer is attended with pain. The Tumour formed in the Loins from this disease when allowd. to take its course is much larger than the schirrous amounting in some case to 11 or 12 pounds when it is cut in its early stage it appears like curdly coagulable Lymph, but in the latter stage like Brain broken down by Putrefaction - This disease has been known to extend to the thoracic duct so as to destroy its internal surface - The 3rd is that of suppuration in the testicles. This begins sometimes from venereal causes, leeches are to be applied with a strict Antiphlogistic regimen. Calomel also ought to be given to promote absorption it likewise arises frequently from scrophula. The abscess which is formed in the testicle being of a scrophulous nature - It may arise from a violent blow on the testicle slight febrile attack attend this complaint remitting often 112 for many days, but ultimately the operation will be found necessary. When the Testicle is cut into, a curdly abscess is found in its centre - A fungus on the surface of the Testicle has been supposd to require an Operation for its removal but all that is unnecessary, but make circular inception round the Fungus including a small portion of the surrounding skin - cut it off just as it springs from the Tunica albuginea. bring the edges of the wound together and unite them by sutures On Aneurism By the term Aneurism is meant a Tumour containing blood formed by the yielding of the coats of an Artery, and which tumour has generally a pulsatory motion corresponding to that of the artery of which it is placed These tumours when examined may be divided into 3 stages with regard to their symptoms - 1st, when the tumour is very small its pulsation is remarkable 113 strong and the fluid which it contains, can be made to disappear by pressing on the Artery between it and the Heart, but on the pressure being removed it instantly reappears. in this stage of the disease the Patient suffers but little pain except that he feels slight spasms about the part during the night - 2nd stage If the Tumour is very large you cannot press the blood out of it as before, as the Blood is at this time in a coagulated state and deposited in layers, but the skin remains undiscoloured although the pain is very considerable. in this state the tumour may remain for years especially if it be situated under a Fascia - but with regard to this point every thing depends on its situation. 3rd stage, when the Tumour is about to burst but prior to this taking place, the skin becomes of Brownish red color. after a time it cracks discharging a Bloody Icher it then becomes mortified where it had been red, and sloughs, its edges in separating opens 114 into the sac. The Hemorrhage sometimes destroys the Patient suddenly but this is comparatively a rare circumstance as the progress of its bursting is generally very slow. When the Tumour appears ready to slough Mr. Cline advises it to be bound down with adhesive Plaister which prevents its bursting as soon as it otherwise would - Aneurism is found to take place most frequently in the extending portions of the aorta & its arch which it forms towards the dorsal vertebrae, when it is thus situated it shows itself by forming a Tumor under the sternum or Cartilages of the Ribs When it takes place in the Arteri Innominata a Tumour is seen under the carotid artery in the neck. sometimes an aneurism is formed between the curvature of the Aorta and Diaphragm. then the Death of the Patient is occasioned by the Pressure of the Tumour on the Trachea and osaphagus into which last it generally bursts. When it is situated in the abdomen it produces various symptoms, the Foot 115 being regurgitated generally soon after it is taken into the stomach so that the Patient dies exhausted and in a manner starvd., it generally shows itself by a Tumour situated at the umbilicus - An aneurism is now and then forming in the aorta just when the emulgent arteries are passing off. in this case a Tumour is formed in the side of the spine and which Tumour has no pulsation, these Tumours have been mistaken for Lumber abcesses and opened without detriment to the Patient. but when we do this Mr. Cline advices the puncture to be very small, a difficulty of passing the urine and foeces are sometimes occasioned by these Tumours. On Dissection of Aneurisms you find the artery in general given way only on one side; The aorta has be been known to give entirely, but this is very rarely the case - This disease generally takes place between the age of 35 & 50 Tho sometimes at a more advanced age, one case which Mr. Cline had under his care 116 occurred in a patient only 24 years Pophlitic Aneurism differ from all others from its being liable to be produced by local causes, as Violent exertions &c independent of any constitutional affection and may occur at any period of life. The cause of Aneurism in any other part is that the cuticular or internal coat of the Artery inflames, thickens & destroys its Texture, by which it gives way from the impetus of the Blood passing through it. its external coat remaining unaltered To distinguish this disease from any other you may suppose that its pulsation is a certain criterion, but in this you may be mistaken ..... Tumours sometimes forms, for instance in the neck under the carotid artery which is running over its substance. if you feel this Tumour and find a pulsation you at first suppose that it is an aneurism but if you put your finger on each side the tumour you will find that it does not pulsate, and by this mark you can ascertain whether it is an 117 Aneurism or not, if it is one. by taking the Tumour and lifting it form its bed as much as possible you will find it to pulsate strongly. these therefore are circumstances highly necessary to keep in mind - by attention to diet &c these Patients may be kept alive for a considerable time. Calomel should be taken when any pain is felt in the Tumour and Leeches applied on some part little distance from it - The Operation for Aneurism as it was performed 20 years ago. The first step in the Operation was to secure the artery by Tourniquet. then an incision made the whole length of the Tumour the coagulated Blood became exposed, this being removed and the sac washed out with a sponge dipt in warm water. the mouth of the artery being [removed] laid open then the Tourniquet loosened a little, in order more readily to discover them a Probe is to be passed into the superior extremity of the artery and a ligature made on it about an inch above the Tumour the 9 swelling pain and heat, these are the diagnostic sign’s. Tumors arise from the different causes from distention of the Vessels; where there is much tension, serum is pourd. from the extremity of the cellular membrane, and sometimes coagulated lymph: the nerves are strecthed by expansion of the Vessels, this occasions pain which depends on the degree of inflamation, this may be perceivd in operations which produce sometimes a great degree of pain while others that take a great deal more time before they perform are not so painfull that was increased in inflammation Dr. Hunter doubted from experiments he made on animals he injected corros: sublim into the rectum of a dog and waiting 24 hours when the inflammation was at its height he introduced a thermometer and found that the natural heat was not increased, he tried the same experiment on the vagina of an Ass, in 12 hours when the inflammation was beginning he found the natural heat had fallen one degree, and when the inflammation was at its height the heat was at its natural standard. we may conclude that this circumstance takes place only 118 same was done in the inferior portion of the Artery about an inch below; the edges of the wound were then brought into contract (the ends of the ligature being brought out at the wound) and secured by sutures or adhesive plaisters which finished the operation. but in consequence of the Ligature being thrown off, after the operation frequently, it now entirely laid aside - The present method of performing this operation; make an incision the whole length of the tumour (it is a popliteal aneurism meant) in order to expose the sactorious muscle you are then to dissect it away on its outer edge, pull it on one side and the Fascia is laid bare which encloses the femoral artery vein & nerve which last is to be carefully avoided, the Vein is situated between the artery & bone you are then to cut through for the Fascia to such an extent as to admit an instrument passing freely under it & then pass the director under the artery and in so doing give it a slight lateral 119 motion so as early to tear through the the cellular membrane beneath it: you are then to take an eyed Probe arming it with a double Ligature, having a needle at each end, the Probe is then passed through, along the hollow of the director the director is then to be withdrawn the Ligatures being drawn to an equal length on each side the Probe may be cut away: you then separate the Ligatures about an inch from each other: securing the upper portion of the artery first the same must be done with the inferior portion of the artery; first tearing away away the cellular membrane, this being done, the needles are to be passd through the Coats of the artery and again secured, then bring the edges of the wound in contact with the ends of the Lignature hanging out of the wound and endeavor to heal it if possible by the 1st intention, hemorrhage has been known to ensure when the Ligature came away - In applying the adhesive plaster leave small interstice to allow the escape of matter, but donot apply a roller because by its prepare in the anastomosing branches of 120 of the artery it sometimes produces Hemorrhage. The Patient should be placed on his back with the knee slightly bent and a pillow placed under it The limb being wrapped in flannel as the Patient will complain of cold and unless proper care is taken mortification will ensue, In two or there days after the operation the heat in the affected limb in greater than in the other. If no hemorrhage comes on at first there is no danger till the ligatures come away, which they do sometimes as early as the 4 Day. at other times on the 17 or 23. at this time bring the edges of the wound in contact unless there is considerable suppuration and apply a roller. The consequence of this operation is that the Patient in general complains of a weakness in the Limb with a sense of coldness - In Aneurism of either the Posterior or Anterior Tibial Artery. The Femoral Artery should be secured in the middle of the Thigh in preference to the Ham. as here the Vessel is deeper seated. If the Brachial Artery be wounded in 121 Bleeding cut down on it and secure it above and below and divide it between the Ligatures - never apply a Ligature near an Aneurismal sac. as inflammation may extend to it, produce suppuration and destroy the Patient neither contegious to the Anasomosing branch of an Artery In aneurism of the Carotid, Posterior aural or Brachial Arteries Mr. Cline makes an incision on the sac. securing the Artery above and below as before directed & dissect the Tumour out &c - On Fistula in Ano This Disease in produced by and abscess forming itself in the Cellular substance surrounding the extremity of the Rectum or just by the verge of the anus. The sinus occasioned by this does not always confine itself to a straight direction. but sometimes extends nearly round the Anus - when the Fistula is one formed it seldom or ever heals itself It is because the the Rectum is constantly tearing the sides of the sinus on account of its contractile power, therefore to remedy this 122 The sinus must be entirely laid open This disease frequently attacks Patients after long continued Fevers, or disease of the Bowels or Liver, in this last case Calomel must be given before you attempt to operate. The Piles generally preceeds this Complaint - it is also a frequent attendant in Phthisis Pulmonalis, but it is of no use to Operate in these Patients as no cure will be obtained : Fistula is sometimes depending on local causes as costiveness &c sometimes from long continued exercise on Horseback & from Violent irritation of the Parts - The method of operating. Pass a probe up the sinus with a Finger of the other Hand previously dipt in oil into the Rectum by this you will distinguish if the sinus runs into the gutt then pass Potts Bistary along ye probe untill it meets the extremity of your Finger the lay it open through its whole extent, place a dip of dry lint into the wound after & continue this dressing till a cure is obtaind. - Fistula may sometimes be cured without any operation by Injecting the following 3 or 4 times a Day Rx Aq:Calcis ℥iv Hydrarg Muriate giv M and at the same time give Wards paste Rx Pulv: Enul : Campan Hi semen fenual dule Hip Piper negre H1/2 Pulver bene at adde sacchar et Milles a a Hi M sumat L.N.M vis vel ter in die - 123 On Amputation The first step necessary to be taken in this Operation is to apply the Tourniquet. If The Operation is to be performed below the knee it should be applied a little above the middle of the inner part of the Thigh as there the Artery requires less pressure - If the Operation is to be performed so high up on the Thigh that the Tourniquet cannot be applied pressure must be made on the Artery in the groin as it passes over the pubis by an assistant - When on the Arm apply the Tourniquet on the middle of the inner part of the Arm between the shoulder and Elbow (near the insertion of the Biceps Muscle called the Deltoid) - if very high an assistant must secure the Artery by pressing behind the Clavicle - On Amputation of the Fingers. in amputating the 2 or 3 joints make a circular incission a little above the Joint and then make a Longitudinal incision on each side as far as the Joint in order to leave a double Flap to cover the stump, then 124 pass your knife into the Joint and remove it cover the stump with integuments and apply adhesive plaisters. The first joint is amputated rather different. make an incision between the Fingers on each side which incision should meet on the back of the Hand, divide the Tendons on each side rather short. remove the Finger by cutting into the joint. Cover the stump with integuments and apply ample adhesive On amputation of the Metatarsal Bones In Performing this Operation save as much integuments as is required to cover the stump from the bottom of the Foot, then make a circular incision saw through the Tarsal bones bring the Flap over the stump, pass sutures thro' the integuments and cover them with ample adhesive and light dressings. the parts in general heal readily. In this operation half the Foot is only removed - On amputation below the knee with a flap according to Mr. Hay’s method is as follows. first measure the leg from the knee to the ancle 125 and take half the length as the spot where you are to take off the limb, next take off the circumference of the Leg, one third of which is to be the length of the Flap. The parts should then be markd. With Ink. the catlin is then thrust through the Limb at this place and carried down to 3 or 4 inches in the adult and brought out make a circular incision round the Limb draw up the integuments and cut thro' the muscles to the bone, pass the catlin between the bones to divide the interosseous ligament, and saw off the Bones turning the limb round so as to apply the saw on both bones at once. The Fibula should be sawd. through first. bring the Flap over the stump and pass sutures Mr. Hay makes use of eight in this operation The [am] patients who undergo amputation in these Hospitals suture can rarely be made use of by the advance of Mr. Allamon they are at one time used in the Hospitals but were found to occasion with great constitutional irritation and symptoms of Trismus 126 or lockd, jaw so that in two or three days they were obliged to be removed consequently adhesive Plasters was made use of with a compress of Lint, a cross cloth with the Roller, and the stump kept cool - The Present method. The distance below the knee where the incision is to be made is a hands breadth in the adult, in children about 3 Fingers below the joint of the Patella, or Rotula, make the first incision about 2 inches below the part at which the bone is to be sawn off, in order to save integuments to cover the stump: in Children about 1 ½ Inch divide the Fascia which binds down the muscles on each side of the bone, then draw the Integuments upwards next divide the muscles to the bone. turning the the edge of your knife rather obliquely towards the knee: pass the catlin between the bones and apply the saw as before directed bring the integuments over the stump, having secured the Tibialis anterior arteries and Intercostal artery apply ample adhesive Lint Roller cross cloth and give the Patient an anodyne - 126 Amputation above the knee Begin your circular incision as near as you can above the knee joint. but in case of white swelling be careful not to cut near the diseased part as a cure after the operation will be tedious. make a circular incision through the common integuments divide the Fascia on the Anterior and lateral parts of the Thigh to allow enough to be drawn up then divide the muscles to the bone inclining the knife a little upwards then saw the bone as high up as you can, the Tourniquet being slackend you must secure the Femoral Artery and a branch of the arterial profunda. in securing the this Artery be careful not to include the nerve bring the integuments over the stump and treat as before - Amputation at the wrist – In performing this operation save as much integuments as you require to cover the stump from the Palm of the Hand, feel for the extremity of the Radius and make an incision just at the root of the Thumb to some 10 in the internal parts of the Body, the surface is evidently hot to the touch and the heat occasiond. by the inflammation of blisters has in in a great number of experiments been found to exceed the natural heat from 4 to 7 degrees Inflammations are divided into common and specific common is that which arrives from wounds or spontaneously in a good constitution without any particular change of arterial action producing an effusion different from the common inflammation, it will cause four effects 1st. adhesion or resolution this is by coagulated lymph pourd. from the extremities of the blood vessels- it consolidates the parts a preparation of a Heart shews this in a very distinct manner, it is coverd. With a coat of coagulated lymph which gives the external surface a rough appearance- the 2nd. effect is suppuration, the vessels here pour out matter instead of coagulated lymph - 3rd effect is ulceration which is an absorption of the inflamd. part producd. by a violent action of the absorbents - 4th mortification in 128 depth make an Incision round the wrist so as to meet the Flap whether on the back or inside of the hand, dividing the Tendons completely draw back the integuments and insert the knife into Joint and remove. bring the Flap over the stump and endeavour as much as possible to heal by the first intention, there are two Arteries to be secured the Ulnal and Radial, but this last if in a Gun shot accident rarely requires to be secured Amputation of the Fore Arm This operation is more dangerous in diseased Habits, than the upper Arm as suppuration frequently takes place between the Tendons with high constitutional irritation Lock Jaw and Death - First make a circular incision through the common integuments dividing the Fascia on both sides the Arm, draw back the integuments as much as possible. next divide the muscles to the Bone inclining the edge of the knife obliquely upward, next divide the Interossious Ligament by passing the catlin between the Bones turn the Limb round and apply the saw 129 on both bones at once. when the Limb is removed three arteries must be secured Viz the Radial, Ulnai Intercostal. then proceed as before directed - Amputation of the Shoulder Joint with a flap - The first step necessary to be taken is to secure the Axillary Artery, when this is exposed pass a Director under and carry a needle armed with a ligature along the grove of the director and secure the vessel, next take hold of the Deltoid Muscle between your Finger and Thumb and carry your incision obliquely upwards towards the bone this leaves the Flap which is afterwards to cover the stump, then make a circular incision round the Bone, turn the head of the Humerus out of its socket & cut it away bring the Flap over the wound and endeavour to heal by the first intention. - 130 In Diseases of the Female Breast The first disease we sall speak of is the formation of Hydatis in the breast. similar to those occurring in the Testicle in the Male. in this Disease the Patient at first suffers but, trifling pain. In the early stage, the Breast feels as if small knots were placed under the skin of various sizes, when the disease has continued a long time, one of the Tumours increases in size, ulcerates, and discharges a Glary Fluid, and if more Tumours Ulcerate very troublesome sinusses ensue In the removal of these Tumours there is no danger, and when removd. do not return [or] this disease does not extend by absorption as in cancerous Tumours The next disease to be treated of is that of schirrous The symptoms of which are a discharge of Blood from the nipple. or an uneasy sensation in the Breast when the Arm is thrown back. Pain in the Breast shooting into the axilla, a Tumour formed of a remarkable hardness feeling like a marble under the skin. in an early stage the 131 Tumour is moveable. and the Patient suffers very severe pain at time but not constantly- If the woman is menstruating a Day or two Prior to this the Tumour enlarges and becomes more painful - it goes on gradually until it becomes of a considerable size, the Glands in the Axilla becomes affected, with a slight pricking in the skin forming a kind hollow over some part of the Tumour. when this is the case Dr. Cheston of Gloucester observes that no success will attend the Operation if performed; the skin also appears rather inflamed. one or two Glands under the edge of the Pectoral Muscle first becomes affected and the Glands above the axillary artery and Vein, the disease also extend, into the Chest. Tumours are formed opposite the middle of the Clavicle in this case all you can do is but palliatives - in case of adhesion to the Pectoral muscle only you may operate with advantage as a considerable portion of this muscle may be removed without detriment to the Patient If the Tumour is left to itself it ulcerates and discharges a bloody Ichor. these schirrous Tumours become sometimes entirely cartilaginous 132 Prior to the patient dying of this disease the arm of the affected side swells, becomes oedematous, acute pains are felt shooting from the axilla to the finger ends Patients sometimes die of a Cancer in a very curious manner, they complain of violent and unremitting pain in different parts of the Body. Opium tho given in large doses give but little relief and the Patient lives but a short time Mr. Cline related a case of a woman in Guy's Hospital, who had a cancer in both Breasts extending as low as the navel and not less than 50 small cancerous Tumours in different parts of the Body. the scalp in Particular she was attackd with difficulty of Breathing with violent pains in divers parts, high constitutional Irritation the Womand died. - The true schirrous generally takes place about the time when women cease to menstruate that is between 40 & 50. Old age is rarely subject to this disease - The Fungus Haematodes sometimes though rarely exists in the Breast, it is a disease similar to the pulpy cancer, which sometimes affects the Testicles in the Male and if you take a Lancet and make a puncture into the Tumour a fungus excrescence appears 133 like the Head of a cauliflower. when the Tumour bursts the patient survives but a short time. no advantage is to be [crossed out] gained by an operation as these Tumours will form again shortly – Women from the age of 16 to 24 or 25 are frequently the subject of Tumours in the Breasts which at first sight may be readily mistaken for a schirrus but this Tumour has no sensible limits when felt, appearing gradually to loose itself in the surrounding substance. but in the true schirrous you can readily discover its extent. it is accompanied with pain in the axilla shooting down the arm - It generally attack young women of strong Passions and delicate constitutions also young married women. The treatment in this disease is first to apply leeches to the part when the pain is Violent. apply a soap Plaister and over this apply the skin of some animal as is Hare, to keep up a degree of perspiration. which relieves the Pain and diminish the size of the Tumour give internally Ferri: Ammonia gr.v bis vix ter quotidie Gentle exercise on Horseback should also be recommended - In Performing the Operation for schirrus 134 Cancer makes your fist Incission in a semicircular direction over the upper part of the Tumour you then divide the Arteries which supply the Tumour with Blood, compression being made on these by an assistant, dissect out the Tumour so as to lay the Fibres of the Pectoral muscles. no ligatures are required bring the skin over the wound apply [Empt] adhesive & a Roller - The Method of Introducing ye Female Catheter The Patient lying on her back. feel with the forefinger of the left hand for the extremity of the Clitoris which having found carry your finger in a straight line one inch below, when you meet with the orifice of the meatus urinarius, then with your right hand you are gently to introduce the catheter. in introducing it elevate the point of the Catheter by depressing the Handle. The Cather should be somewhat more curved than usual as it then more readily takes the course of the meatus urinarius - 135 The Method of Introducing the Male Catheter - The Patient being placed on a Table. stand by his left side near the shoulder, introduce the catheter untill it reaches the neck of the bladder, the by depressing the Handle backwards so as to let it sink between the Patients Thigh. it elevates the point & the catheter readily passes into the Bladder - On Opening the Temporal Artery The best place for making an incision into this Artery is just as it emerges from the root of the Hair, make an oblique incision through the integuments in order to lay the artery bare. then make a small puncture in the side of the Artery - when you have taken away a sufficient quantity of Blood introduce the Lancet and divide the artery completely if it is not divided Haemorrhage will be continually recurring - 136 On Lithotomy First of the formation of Calculi in the kidneys their presence may be known by the Patient complaining of Pain in the Loins of a dull kind attended with sickness, and on rubbing the Back an uneasy sensation is produced in the side where the stone is lodged. after much exercise Blood is discharged with the urine. where these Calculi are passing along the Ureters the Patient complains of pain in the Thigh of the affected side, extending a little below the Groins in the course of the anterior Crural nerve and the Testicle is drawn up by the action of the Cremaster Muscle to the abdominal ring: Bloody urine is occasionally discharged Death sometimes takes place from a swelling of the abdomen coming on which fluxtuates, and on dissection is found to be an of the kindneys - The symptoms of stone in the Bladder are a cutting sensation at the extremity of the Penis, and when the Patient is discharging his urine it suddenly 137 stops. when the Bladder is nearly emptied itself there is frequent inclination to make water. with a disposition to go to stool at the same time, and when the symptoms run high the Foeces are often discharged involuntarily in any change of position. the Patient always feels pain, when much exercise has been used, mucus passes off with the urine. - If a stone has existed a long time purulent matter is discharged with urine from a disease in the Bladder - If this is unaccompanied with pain in the Loins you may safely operate: The Patient becomes frequently seizd. with violent shiverings like an intermittent succeeded by heat with profuse sweating, spasms of the abdominal muscles and the contagious parts, but the degree of irritability is not proportioned to the size of the stone, as a large stone frequently produces less irritation than a small one Dr. Franklin the Philosopher in America was the subject of the Disease. The size of calculi are various. there is a stone in Mr. Foriter's Possession surgeon to Guy’s Hospital which weighs ℥xxv and of a remarkable compact Texture there is another in the Library of Trinity College Cambridge which weighs ℥xiv & 11 which the circulation cease and the parts require to be separated from each other or Death must ensue.- symptoms of the [state] first state an uniform swelling the skin uninflamd, with a dull equal and constant pain, parts easily pit, in hernia humoralis these symptoms are very perceptible, in the sound state the skin is red however deep the inflammation the most certain criterion is a softness in the middle surrounded by hardness – A man in the Hospital with symptoms of a diseasd. Liver had a Tumor on the side with the appearance of softness surrounded with hardness, it was opend, and a great quantity of matter was dischargd. the abcess was so deep that probe would but part reach the bottom. The pain in this state is variable and darting- the 3rd state has “gnawing pain which marks the action of the absorbents, the skin becomes thin the cuticle loses its color and becomes white it separates, when the matter is dischargd, Ulceration ceases - in the 4th state there is excessive 138 is nearly as large as that weighting ℥xxv The largest stone Mr. Cooper ever saw extract weighd. ℥iv1/2 ounces - In extracting a small stone from the Bladder the flat forceps are preferable - The circumstance necessary to be attended to previous to performing the operation are to observe if the Patient is in good health, for if a pain is felt in the Loins a disease of the Kidneys in all probability exists, give two or three purgatives in the week previous to the operation. and morning before give a purgative Enema. if the Patient is plethoric VS - To Perform this Operation. Place your Patient on a Table of convenient height & having properly secured the Hands and Feet the perineum being shaved, make your incision beginning immediately under the Arch of the Pubis carrying it opposite to the middle of the Anus, this incision lay bare the accelerator urine and bulb of the urethra. this last is divided in making your second incision and sometimes the internal Pudendal Artery (but this is not so likely to happen when the cutting Gorget is used as when you use ye blunt 139 Gorget) In making your second incision you carry it into the Grove of the staff. and keeping your scalpel there to serve as a disector for the Gorgett, and before you withdraw the staff ascertain clearly that it is open throughout its extent having done this remove it, and feel for the stone with your Finger or Forceps having ascertain its situation, pass your Forceps along the Gorget, and having taken firm hold of the stone. remove the Gorget, and in extracting the stone give your Forceps a slight lateral motion which tends greatly to facilitate the extraction of the stone - the staff when you cut into it should be held nearly perpendicular, so that in making your first incision you can’t feel the staff - If the stone is containd. within a sacculus, you are directed to use Potts Bistoury and dilate it. Ricketty children have frequently the Tuberositus of the Ischia so close together, as not to allow the passage of the stone, in this case you must endeavour to break the stone. the case however generally proves fatal. If you succeed in breaking the stone, introduce 140 the flat forceps in preference to the scoop Mr. C observes it is a wron practice to inject any fluid to wash assay the particle of stone- In Norfolk this disease is more frequent than elsewhere. in Norfolk and Norwich Hospitals above 300 stones are collected, and of those Patients operated on, about two fifteen die on an average in these Hospitals according to Mr. C estimate about one in 13 die of this operation Mr. Cline in the first 24 cases he Operated on lost none after that he lost three successively. Mr. Cooper in in the first 24 cases he operated on lost one. which Patient was a very young Child and died of Convulsions. therefore it is more dangerous to Operate in young Children than old people In those Children who labour under Tabes Mesenterica this operation should never be performed, as they stand no chance of recovering, Age makes but little difference in this respect Mr. C Operated on a Gentn. 82 years old who recovered in a short time 141 In order to stop Haemorrhage from the Pudendal Artery. press on for about 10 minutes with your Finger but dont introduce Lint. for in this case the pressure applied is often incomplete and the Blood escapes into the Bladder producing shiverings &c. after the Operation apply superficial dressings - Mr. Cooper thinks there is no occasion for any- If there is a considerable discharge it is a favourable Symptom. If otherwise the abdomen becomes painfull, then you are to apply the Leeches with fomentations of Chamomile Flower & Spts. and when it can be had the warm Bath - In 14 or 20 hours after the Operation a little urine is discharged by the Penis, when you are to bring the Thighs together, and secure them by Ligatures, if the external wounds does not heal in 17 or 20 days pass Bougies up the Urethra - In the Patients who wont submit to this Operation as Palliatives you may employ Alkalies give aq: mephitic for common drink & the following may be taken with advantage twice a Day - Rx carbonate of Potash ʒ1/2 aq 1/2 ♏︎ the PA sapon may be given with advantage - Women are less liable to this disease than men as the meatus urinarius in them 142 is short and a stone of a considerable size will frequently pass of itself, a women who has once been operated on never after requires the Gorget - In Performing this Operation in the Female. Having the necessary preparations Sound the Patient with a small male Catheter in order to discover the calculus, this done introduce another sound with the grove turned downwards the pass the back of the Gorget into the Grove of the staff, and carry it into the Bladder, then withdraw the staff and carry your Finger into the Bladder to fee for the stone, having discovered its situation introduce the Forceps along the Gorget, withdraw the Gorget as before directed, and laying hold of the stone (which is generally found in a hollow immediately over the vagina) extract it using a slight lateral motion in the extraction &c NB Mr. C. observes young women wish to have this operation performed on then for what reason he cannot tell, but believes it to be a species of insanity, these women have generally diseased ovaries - 143 On suspended Animation The causes giving rise to suspended Animation are Submersion, Suspension, Noxious Airs Extraneous Bodies, and Tumours pressing on the Trachea - Submersion Under Water In this case the animal does not die from water getting into the air cells of the Lungs, but from the exclusion of the Air from the Lungs, the blood is rendered incapable of undergoing that change which fits for the purpose of Respiration and Life- It is found from experiment that very little water is found or containd in the Lungs and not more than three or four Ounces generally in the stomach - Mr. Coleman observes that the Blood accumulating in the right side of the Heart is impeded in its passage to the left, but Mr. Cooper differs in Opinion and says that the Blood is not impeded in its Passage but diminished in quantity Suspension It was generally supposed that apoplexy was the effect of suspension, but that is an idea erroneous for if there happens 144 any congestion in the Head it is only within the Vessels themselves which cannot produce this effect. Persons that are hanged die precisely under the same circumstance as in drowning, for if you take an animal and make an aperture into the Trachea below the cord, and a pipe being introduced into it the Animal will live for many hours. It was supposed by some that the Vertebrae suffered and the medulla spinallis became compressed but this like the former opinion is erroneous Vide Coleman on Suspended Animation Introduction of Noxious Air As Hydrogen Gas, Carbonic Acid Gas. these act as Poisons by their effect on the Nervous System & thereby destroy life, a Frog may be kept alive for three hours under water but if Carbonic Acid Gas be employed it will die in 8 or 10 minutes. If Animals are immersed in Hydrogen Gas and taken out just before the functions of Life is [destroyed] cease they will recover for a time but in general die in a few hours with convulsive symptoms. In those who 145 are destroyed by the Mephitic Gas emitted from charcoal or Carbonic Acid Gas - In the Brewers Vatts it is found that the temperature of their of their Bodies is far above the standard and continues so for many hours after Death has taken place - From this fatal exposure scarce any person is ever recovered as it acts as a direct poison when applied to the Lungs, and not as some gasses merely by the exclusion of the respirable part of Atmosphere Air - Extraneous Bodies introduced into the Larynx produces suffocation in this case the Patient dies suddenly generally: sometimes not for many hours, and it has happened where they have lived for 3 weeks, an obstruction is produced in the Larynx by substances in eating dipping under the epiglottis, where it may kill instantly or by the irritation it may cause which when it happens after swallowing a substance great difficulty of Breathing is caused with a Violent Cough – Emetics have been known to eject the substance by their action, which should be used strong The throwing up of a piece of coagulable lymph in Cynanche trachealis is a frequent cause 146 for this complaint, sometimes also from swelling of the Glotis and Epiglotis in Angina Scarlatina, also from an abcess arising on the Cartilages of the Larynx from pressure and irritation Means of Recovery In infants just born, and no symptoms of respiration, bring them to the fire or put them into warm water inflate the Lungs employ friction with hot flannels – If an adult under submersion or suspension warm Bath. Opening the Jugular Veins taking away not more than one or two ounces of Blood, inflate the Lungs by means of a pair of bellows pressing at the same time upon the Chest for the purpose of producing artificial respiration. pour spirits down the Throat probably some of it may pass into the Trachea, and if it excits any emotion it will be the means of recovering him - Electricity is but seldom employd. with advantage as circumstances occur to render it inadmissible. when you have inflate the Lungs, and left side of the Heart begins to Act emply friction with warm flannels, some use salt. in case 147 of suspended animation from the inhalation of Noxious Airs do not take away Blood but heat it as under submersion and suspension When any Extraneous Body is Lodged in the Larynx never use a probeing for its removal but pass your finger under the epiglottis and endeavor to extract it before you attempt any operation If you cannot succeed in that way give a smart Emetic: there has been instances where it has proved effectual. if neither of these succeed set about performing the Operation as follows - Bronchotomy This is the most unsuccessful Operation in Surgery It was once performed by Mr. Andrie with successes and which is the only instance on record Mr. Sharp recommends to make an incision of an Inch in length at the ring of the Trachea half way between the Cricoid Cartilage, and the Sternum, this Incision lays bare the Trachea, you are then to pass the front of your scalpel through the substance of the Trachea between the ring, but this plan of Operating is by no means advisable, as the Thyroidal vein becomes divided and the Blood 12 acute pain, vesications arises containing sanous serum the parts under the vesication is of a brownish red this procedes gradually, delirium takes place when mortification takes place in consequence of accident, singultus comes on, the stomach and Bowels are affected, much air is expeld, constipation takes place, the pulse are in general quick and pain varies according to the importance of the parts affected; when the limbs are the seat of the disorder [it is] they are quick and hard when in the abdomen they are exceeding small sometimes full in the first stage they are slow in inflammations of the Lungs & rises on venesection and becomes more like a natural pulse in inflammation of the Heart the pulse is tense beating work a jerk like a broad wire: in inflammation of the brain the pulse is full and slow: if there is much effusion on the brain, the blood when inflamd, is much thinner and separates into three parts, and takes a longer time to regulate and the red particles are not sustained by the lymph, the Blood becomes cuppd on both 148 gushes into the Treache and suffocates the Patient - Mr. Cooper recommends the incision to be made between the Thyroid & Cricoid cartilages, and a probe to be introduced to push the extraneous body into the Throat in this manner you avoid the Thyroidal Vein and it is an Operation that ought to be performed without fear - Mr. Coleman recommends to make an incision on the Thyroid Cartilage but this Mr. Cooper objects to there not being room left sufficient for the Passage of the Air from the Trachea from the elasticity of this Cartilage and sometimes it being met with in an ossified state On the Operation for Suppression of Urine The best method of performing this is about the Pubis. First make an incision one Inch in length as near the Pubis as possible, feeling for the Symphisis Pubis then pass a Trocar & Canula directly downward towards the Bladder the length of the Trocar & Canula should be 4 inches the Canula should be rather longer than it is generally used as the urine is apt to be extravasated, the coats of the Bladder receding from it as the 149 urine passes off then fix the Cannula by strings to the abdomen- it should not be allowed to remain in more than 2 Days when it should be withdrawn and a shorter one introduced if necessary: even this method of operating is liable to objections as it generally brings on disease of the Bladder from irritation Mr. Cooper recommends an incision to be made into the membranous part of the urethra as it depends chiefly on a stricture in that part : there generally occur about 2 or 3 inches from the Bladder or 7 Inches from the lips of the Urethra - The incision is to be made with a Lancet made straight and this is to be thrust through the Tumour in the perineum into the Bladder - Of Calculi in the Urethra The presence of calculi in the Urethra may be known by the Patients complaining of cutting sensation at the lips of the Urethra a sudden suppression of Urine and if a Catheter is used to surgeon hears it strike against the stone If the stone is lodged two or three inches within the passage make an incision through the Urethra upon the stone keeping 150 it at the same time steady between your Finger and Thumb, and taking care that your external incision is larger than the internal: this done extract the stone with a dissecting hook: the wound will heal by granulation: you must not attempt to heal by the first intention for obvious reasons - When the Calculus is situated directly opposite the Scrotum it is not to be distinctly felt : it is more difficult to extract, and likewise endangers a sloughing of the Penis by the urine extravasating itself within the surrounding cellular [membrane] substance therefore it is recommended to push back the stone in perineo, where it is less difficult to extract. If you intend to operate in its first situation (viz directly opposite the scrotum) make your incision from 1 ½ Inch to 2 Inches through the integuments covering the stone to allow the Urine to escape freely after the Operation and extract the Calculus with the forceps or dissecting hook- In Children this Operation is not so dangerous - 151 apply poultices to the wound, and heal by granulation as before observed - the next situation of Calculus we shall speak of is at the Prostate gland which of itself will sometimes produce Calculi different from those found in the Bladder or Kidneys. before you attempt any operation in this case give the Patient a few hours to wait, for there has been instances of the urine accumulating behind it and forming by his efforts to void his urine from its situation, and it being in consequence expelled with the Urine. but Mr. Cooper advises at the same time Bougie to be introduced as far as the stone, and suffer to remain there as long as the patient can bear it, when it being withdrawn and the Patient desired to void the contents of the Bladder, the stone will in all probability pass off along with it, but if a Fistula in perineo attends this complaint this will not happen but the stone will make its way through the Perineum If after you have tried this plan of treatment and gain no advantage you must proceed to operate as follows 152 First pass a staff along the Urethra untill you distinctly feel it resting on the stone pressing it into the Perineum so as to feel, then cut, make an incision with a scalpel into the point of the staff within its grove pass a probe into it and push it along the Urethra (over the stone) towards the Bladder beyond the stone this done extend the incision with a Phymoses knife untill the extremity of the stone where you may readily extract it with your Finger or a fine pair of forceps. after Treatment as before directed - If a stone is situated at the membranous part of the Urethra with a stricture, it must be removed make an incision through the perineum and extract it with forceps A stone lodged in the Meatus Urinarius of the Female seldom requires any operation for its removal , but it sometimes produces Ulceration, and part of the stone being lodged in the meatus and the other in the Vagina - you must introduce a pair of forceps break off that part in the vagina and afterwards remove the other portion within the meatus urinarius Mr. C. saw this operation performd. on a woman who had previously a 153 very difficult Labour and it was found that one portion of the stone communicated with the other by a narrow neck - On Amputation of the Penis The Penis is subject to two species of cancer First the Watery Cancer so called from its first appearance being similar to that of a Venereal Wart this increases to a considerable size resembling a Cauliflower this Ulcerates and destroys the Penis the Urine is discharged by many orifaces and the Patient suffers excruciating Pain 154 saving of integuments as the corpora Cavernosa recede considerably, and besides that the integuments are more diseased than the Body of the Penis. when the wound begins to granulate you must introduce a bougie, and suffered to remain there, if it induces a discharge from the Urethra it must be only occasionally introduced (viz) two or three times a day if this is not strictly attended to much mischief will ensue- On the Hare Lip Children are frequently born with a deficiency in the formation of the Lips and which forms is its resemblance to a Hares Lip. it has been denominated by surgical writers Labia Leborino this deficiency extend sometimes through the palate to the Uvula. in this case the Operation is more difficult If there is a fissure in the Velum pendulum Palati only it produces a nasal pronunciation of sound. The hare lip exists sometimes on both sides in this case you must succeed with one operation before you attempt the other 155 If this Operation is to be performed in a Child its age is to be first considered Mr. C advises the Operation never to be performed until the Child is two or three years old, there are two reasons for this, in the first place if very early performed it generally prove unsuccessfull, and secondly if delicate Children it proves dangerous. the Lip from the violent irritation it occasions brings on Diarrhea Convulsions &c - Operation Pass the point of a Lancet through the skin of the Lip, extending your incision first upwards towards the fissure and then downwards towards the edge of the Lip so as to make it a recent wound this done on both sides, pass the first suture through the middle of the red part of the Lip and the second half way between the first and the nose exactly; the sutures are then to be tied, you are to bring the cheeks together and apply in a day or two a slip of Empl adhesive across the Lip from the Angle of the Jaw on one side to the opposite angle, this is to remain for 10 days. and if any excoriation is produced by 156 it. first apply a slip of Lint & the empl adhesive over it - If it is a double Hare Lip there is always a projecting portion of bone if in the Adult, this is to be removed by the bone forceps, in young Children it is of no material consequence - In this Operation, the Labial Artery is divided and in order to stop the haemorrhage you are to pass the Lower suture so as to include the Artery if possible and which is not very difficult to accomplish: The Middle Suture must be taken away on the 4th day - and the lower one on the 5th . In Children leave the Ligatures to Ulcerate of themselves, for the inflammation which they produce is trifling, but still keep adhesive plaster over the lip - On Nasal Polypi These Polipi which arise from the Pituitary membrane of the nose, are sometimes found transparent, at other times of an Amber colour, they are found depending by a narrow neck, are easily movable and are contained within a thin Bladder they are not very sensible and but slightly vascular, Patients under 157 this disease complain that when the weather is moist the nose feels stopd up, so that they cannot readily breath, and if they have a a cold the nostrill on the affected side seems stopt up, while the other remains free, they are sometimes found branching and at other times to contain a Hydatid Operation If the Polypus appear at the nose. place the Patient in a clear light and examine with a probe where the neck of the Polypus is attached. it generally to the septum nasi. then introduce a pair of pointed Forceps, take hold of the neck of the Polypus and by a sudden jerk extract it a small portion of bone sometimes is brought with and which is a describable circumstance if not they are very liable to return in a few months Polypi sometimes occur of an Hydatid kind filling up the cavity of the nostril completely and when you attempt to extract them they break under the forceps so that you can’t remove them in this way they contain a small quantity of fluid, they occasion swelling of the 13 sides which is a stronger sign of inflammation than buff, - on Specific Inflamation Specific inflammation is where the arterial action is changed, and the effusion is different from those already described, those in the Gout. the skin is inflamd, but chalky matter is deposited on the Joints instead of lymph - in cancer and schirrous where the disposition is on a peculiar nature. the discharge is very different from pus. small pox erisipelatous fever. Angina scarlatina are specific inflammations. Inflammation is salutary if it does not precede to too great a length; granulation could not be affected without an inflammation of the surface of a wounded part - if matter forms in the interior part it could not get out without a process of ulceration - Bone exposed to accident must always remain so did inflamation produce exfoliation. Inflammation therefore should be suppressd, its symptoms are to be attended to and regulated, weakness is the predisposing cause of spontaneous inflammation 158 cheeks, Ulcerate and destroy the nose producing violent constitutional irritation which puts a period to the Patients sufferings. This Disease is not of a cancerous nature, An Injection of Hydrar: Muriat & aq:Calci is recommended A Cancerous Polypus sometimes occurs between the age of 40 & 80 it’s colour livid & when touched bleed profusely it is attended with a shootin pain thru the Head, sometimes extends through the ductus a nasum and forms a Tumour just opposite to the Lachrymal sac - Treatment - use Injections with Tinct:Opii & give opium muriatae On Dropsy & Method of Operating Dropsy of the abdomen is of two kind. First Ascites which is an accumulation of water within the Cavity of the [abdomen] Peritoneum or Encysted when the water is collected in the Ovaria, or in an Hydatid on its surface - I ascites the water gradually accumulates upwards untill it reaches the navel, when there is but a 159 small quantity of water an undulating motion is felt by the Patient in charge of posture, this Disease produces an accumulation of water in the extremities which there takes the name of Anasarca if it is accompanied with difficulty of Breathing much danger is to be apprehend Ascites is generally the effect of a Diseased Liver, sometimes from the omentum or spleen becoming hard and enlarged, the Tabes Mesenteria is sometimes a cause of this disease, and especially the abuse of spirit Liquors, from it producing a great determination of Blood to the Viscera: whatever hurries the circulation is a frequent cause on Dissecting those who die of this disease the Peritoneum is in general found studded with Patches of coagulable Lymph - Encysted Dropsy caused from an accumulation of serous fluid in the Cavity of the Ovaria. it becomes considerably enlarged before the Patient is aware of the Disease existing forming a large Tumour on one side of the abdomen there is at this time on the Museum 160 of St. Thomas, Hospital, an ovarium which contained 12 Gallons and one Pint of water purchasd. from Dr. Poles collection by Mr. Cooper in General they contain from 20 to 30 Pints The Water is sometimes accumulated in many cysts, therefore it is not advisable to operate early - The fluid which these enlarged ovaries contain, differs much at various times, at first it appears like the serum of the Blood the next time it appears glary & Tenuious as the White of an Egg after which it seems like pus & Hydatis is found in it; the fluctuation in this Disease is not to be distinct as in ascites - water is more & there discharged by the the urethra & vagina Operation Have the Patient in a Chair with a sheet thrown round the abdomen, and confind. there having made an incision with a Lancet one Inch below the navel in the course of the Linia Alba introduce a large Trocar and Canula after the water is evacuated close the wound with Empl adhesive Very Carefully. This operation maybe performed at the navel or an Inch above it if the Tumour is high - If the operation is performed Low down the Bladder should be previously emptied - It requires to be often repeated 161 Scrophula Scrophula is an inflammatory disease accompanied with great debility, all the processes are attempted as in common inflammation but they are slow & imperfect. The adhesive process instead of taking place in a few hours as in common inflammation is sometimes weeks, and there is not that kind of adhesion as in inflammation: the coagulable Lymph is soft and imperfect the Suppuration stage is slow and imperfect. the pus is like a serous fluid mixd with curd like matter Ulceration is also very slow. there is evidence of fluctuation long before the abscess breaks when opened the edges of the skin are curled at the ends and turn inwards, not opposite to one another and considerable scars are produced Scrophulous complaints occur at different periods of life first there is a scrophulous enlargement of mesenteric gland in very young Children called Tabes Mesenterica, at two years of Age the glands of the neck becomes enlarged next from 6 to 12 years there are generally the different white swellings in the Joints about Puberty Phithisis Pulmonatis occurs & generally continues to 35 years of age about the same time lumber abscesses take place upon the spine and also in the Loins and groin. From 20 to 23 the Testicle becomes scrophulous 162 there is no pain, great enlargement & hardness, this extends to the vesicule seminal and Prostrate Gland - Scrophulous Opthalmia occurs at any Period under 35 years, An enlargement of the Prostrate Gland in old age is said to be scrophulous but doubtful, Truly scruphulous complaint are rare after 35 years - Exceptions - Character of Scruphulous Persons Distinguishing mark, Then skin, delicate constitution, light florid complexion light in general, fixed colour in the cheeks you may see the Veins distinctly under the skin usually about the neck and Temples. the hair hangs straight, pliable fine light and sometimes very dark. upper lips much the thickest and projecting over the lower, Scruphulous Children are liable to diseased secretions behind the Ears producing and enlargement of the Glands of the neck - No disease is hereditary Every constitution is liable to scrophula when exposed to particular causes. no Child is born with scrophula but only with that disposition to it like its parents and their disposition must be acted upon by the same existing causes before the disease is produced the Disposition is hereditary but not the disease. Predisposing Causes Weakness generally the effects of some Fever - scrophula frequently occurs after the inoculation of 163 the Variolae prior to the introduction of the inoculation for the small pox into this country scrophula was not so frequent[ly] as it was afterwards, but since the introduction of vaccination scrophula is not frequent as it was. also caused after the Fever produced by Mercury- the most common cause is Angina Scarlatina, the more Violent the Scarlatina the less Violent the scrophula &c close confined situations and scanty nourishment - The treatment consists in restoring the tone of the Arteries and in the formation of better Blood. Begin with enriching the Blood Good Nourishment must be kept up - 3 Glasses of Wine for a Child out of arms per day. Scarcely any Vegetable Food should be given. Meat at breakfast again before dinner & at dinner the Child should never fast long: nutritive food in as small a compass as possible; Exercise with other Children frequently but not to fatigue Good Air. On this plan you must place more dependence than Medical treatment Medicine steel and Gentian combind with Bark. If inflammation is going on give the following Rx Hydrarg Muriat gr 1/8 Tinct. Cinchone 164 Comp 1 dram bis terve die sumendus ex vino rubro. This is particularly beneficial in scrophulous ophthalmia. The above is a dose for a Child, it produces absorption of scrophulous enlargement prior to the formation of abscess - scrophulous Diseases of the Absorbent Glands - In the Glands of the neck an amount of the exposed state of the face and ears inflammation is produced the almonds of the Ears are said to come down inflammation takes place on the mucus membrane of the nose; with these scrophulous enlargement of the Glands of the neck: there is but a slight degree of pain: remain for a long time in a very indolent state, then with no obvious cause on a sudden go to suppuration which is shewn by the redness of the skin afterwards of a purple colour and when the Glands Ulcerates the edges turn in the Granulations or flacid & glassy and take great length of time to heal. sometimes the Tumours produce fatal consequences by pressing on the Larynx obstructing Breathing and from taking sufficient nourishment. likewise pressing on the Jugular vein and occasioning apoplexy - 165 The plan of treatment proper in these cases If you are called in at an early period of the enlargement it is best to apply aq Lith Acet: comp and to give purges of calomel If there is any considerable pain apply Leeches repeatedly and prevent suppuratoin if possible endeavour to keep the inflammation under Medicines Rx Hydrarg Muriat & 1/8 Tint: Cinchone ʒi bis terve die. If the pain & inflammation is great the Tint: Cinchone should be left but, where it does not ammount to suppuration it will promote the action of the Absorbent Vessels- When the Tumour is of a very indolent kind use the soap plaister. If in the early stage the Emph sapon and flannel put over with rest and Calomel purges will cause a cure in a few days. If suppuration takes place after all the means you have tried, as soon as there is any fluctuation open the abscess - If in the Female be a little particular for fear of making a mark - make your incision with a Lancet transversly into the abscess - after it is opened 166 apply the following Lotion Rx Zinci Vitriole gr xÿ Aq: Rose ℥viÿ ᵯ If it checks the discharge too much, mix it up with Bread as a poultice which is the only alteration found necessary- It requires daily attention to prevent it from closing by passing the probe in - The reason scars are so frequent after these abscesses is the skin is suffered to get diseased before the opening is made and the edges of the skin is drawn into puckers Earthy matter is discharged from some of these abscesses sometimes and are more difficult to cure. use the following Rx Ferri Ammon. ʒi Cerat alt ʒi M Ung Rx Ferri Rubigo ʒi Ung & Albi 1 ounce M. or the Martiat Cerate - When granulation is risen near or quite to the skin use white Vitriol or the Vitriolic Acid wash Lime Water or the following Ointment Rx gum: Elemi 2 ounces Milt Commun ℥i or Tercl ℥1/2 Adipis scilla ℥i ᵯ f Ungm to every half ounces of this ointment udde pulv Ammon prop ʒii ᵯ f Ung. The Glands about of the bronchiae are often affected and the Patient cough up a considerable quantity of Earthy matter - they become enlarged & adhere to the bronchiae - 167 Tabes Mesenterica This is a common disease in Children at a very early Period of life attributed by their Parents to worms, but the real cause is an enlargement of the Mesenteric gland these Glands are placed between the Thoracic duct and intestines, by the enlargement of these Glands nutrition is prevented from going into the intestines in a proper manner. the Child makes a chyle as usual but passes it off by stool which is supposed by their ignorant Parents to be worms. The Chyle not getting into the Blood the Wasting of the Body is extreme appetite very irregular. enlargement of the belly: picking of the nose &c Treatment Rx Calomel gr iÿ Pulv e scummon gr v M f Pulv this is to be repeated every five days - In all diseases of Children Mr. C. always recommends the above powder except in those which are considered specific in themselves: such as Hooping Cough: small pox measles &c. as he wishes to produce vomiting and purging – do not depend on Calomel 14 on which account the Legs especially of old persons are most apt to ulcerate, their circulation being slower than that of rest of the Body Intemperance weakens and produces a great disposition to inflammation, for the same reason persons who take too much exercise immediately after they have recoverd. from Fevers are liable to suppurations near the knee Blisters are liable to produce sloughs after Typhus Fever or Measles - The occasional causes of inflammation are those that change the action of the Blood Vessels of a part. thus in Fevers the Blood is pumpd. too fast through the arterial system if it meets with a weak part congestion takes place and an increasd. action of the part is set up to take up the congestion, - the sudden application of cold to parts in a healed state stop these suppurations and a large quantity of blood is impelld to the part to keep up the resistance of these vessels that had been constringed by the cold - violent exercise produces an increasd. circulation 168 alone. if in a very delicate habit use Rhubarb with it at the same time the Vinum Ferri a Teaspoonful in a Tablespoonful of Red Wine three or four times a Day. Nutritive food in small compass and entirely on meat, not vegetable Air and exercise without fatigue. Empl Litharg Comp on Empl fix Burgand on the surface of the abdomen is very usefull - This disease if suffered to go on too long or treated improperly will terminate in Dropsy. and even after the disease itself has been cured it has been necessary to draw off the water. abscesses have been produced and large tumours of earthy matter also - Scrophulous affection of the Joints white swelling called so because the skin remains of its natural colour. symptoms at first, a stiffness is felt with slight pain: then in a few days an enlargement of the Joint begins: this continues for a length of time, & as there 169 is not much pain it does not execute alarm after being sometime in this indolent state a sudden change takes place a general Chilliness, pain and suppuration in the part, the slightest Jar of the Joint causes exquisite pain. when matter has begun to form it goes on increasing in quantity suppuration takes place below the Joint If it is at the Knee it will be 6 inches below and sometimes a little above when the abscess is opened the process of ulceration is very slow - the dishcharg will continue for a length of time for 2 years unless some active means are used to prevent it - Appearance on dissection. under the skin a quantity of Fat is found under which the common capsular Ligament is considerably thickened, the Vascular Ligaments from whence the synovia is secreted are particularly affected: the Cartilages are in part absorbed sometimes wholly so Bones throwing out spicule in several different parts with holes in them- If when it has made any 170 progress and ultimately cured it is anchylosed. Treatment supposing it only stiffness with slight degree of pain Rest. Rx Linim Ammon. Spt Vini camph [an] ℥1/2 Antim Tart 1 dram rub in 1 dram every night and morning on the part affected. in three days there will appear an eruption like the small pox: and if the Linim Camph is omitted the eruption will appear as in Henerial - It is preferable to the use of Blisters & Ungn. Sabina tho the Blister may effect a cure there is always left a greater contraction of the Joint with weakness and Lameness After using the liniment for 3 days apply a common poultice which is to be kept on for 3 days renewing it occasionally at which time the Liniment is to be used again - Another form which is used – Rx Antim Tart ʒiÿ Ungn. Sperm Coli ℥i 1 H f Ungn -this produces a more irritable eruption but the former is far preferable give Hydrary & Tinct Cinchona. If much pain it is usual to apply Leeches but these produce 171 weakness in the part which ought therefore to be avoided if possible - Rx hydrard Muriat combind. with opium to produce nausea answers well - A considerable quantity of opium is sometimes required to be given to prevent pain- the following is the form to give at night Rx Calomel prop gr i Pati: Opii gr 1/2 Ferri Vitriol gr 1/2 M Omni nosta sumendus - The Vinegar poultice is also used. it produces an eruption in about 3 days. it has not so good an effect as the Liniment the Emp Lith the Empl pix Burgand are good applications Emplast Epispast & savn Ointment is in common use - The best means of Restoring the Joint, if you have subdued the inflammation use friction with frequent motion but not too quick nor begin too soon. If suppuration takes place in the Joint no means can prevent it from taking its course. therefore it is best to encourage it, and to bring it on speedily give Tonic Medicines and use warm applications to the part after it has been opened inject the following into the [sinus] Rx Acid Vitriol ʒi aq Purce ℥vi throw this into the joint 172 Put a Blister over the Joint and dress it with savin Ointment, in time the inflammation will be lessened and the discharge but a stop to- Surgeons have several times performed amputation unnecessarily in this disease, It is never necessary unless there are the most powerful hectic symptoms, never suffer it to be amputated though the Patient may be lame the whole of his life - the weakness which the Amputation occasions in that particular constitution will probably prevent the stump from healing and it is a great chance if some other part is not affected - Disease of the Hip Joint. Pain in the knee is the first symptom. If you fix the Thigh bend and extend the knee it will give no pain in the knee, but if you take the Leg and raise it up towards the Body you will cause pain extending to the knee. in walking the Patient turns his Toes out - the Toes can turn in but triffle. The Joint does not feel round but flat - the disease limb appears longer than the sound one, as the Head 173 of the bone is thrust out a little from the Acetabulum by an effusion of coagulable lymph into the acetabulum, the nates of the diseased side is one inch below the opposite - If you turn the Patient on his face there is a fold in the groin by pouparts Ligament while the opposite groin is straight from the lengthening of the Leg at last the limb becomes shorter, so that the head of the Thigh bone becomes diminished greatly and the Acetabulum becomes lengthened upwards: it is one or two inches shorter. If suppuration has taken place they never recover with less than one inch shortening of the limb. Abscesses sometimes break opposite the Trocanter Major, there has been a Case in the Hospital of these Ulcerating the coats of the Femoral Artery and causing Death from Hamorrhage - Treatment. this should be undertaken as early as possible. give the Hydrary Muriat cum Tinct. Cinchona so as to excite nausea this will often diminish the pain in the knee apply Leeches. if very painfull use the following on the Hip Joint Rx Linim: Amon: Camph ℥i Antim Tart ʒÿ M rub in 1 dram nocta manque, and continue untill Pimples are produced. order Rest let the Patient use 174 Crutches and no motion of the limb be employed whatsoever. if you do not succeed in this plan early, make an Issue with Kali purum about the size of a shilling on each side of the Trochanter Major: this is preferable to a Blister with the Ungn Sabina, these Issues should be kept open for six Months or more: untill the pain in the knee has ceased - If abcesses are formed from the Joint let them take their own course. if they are opened the inflammation will extend upwards and the whole of the Joint will become inflamed - should the Patient recover fast he should be in haste to use the limb as he may bring on the disease again. and ought to continue the crutches for some time after. the cavity of the acetabulum becoming absorbed the head of the Thigh bone passes into the pelvis, and by its irritation destroys life or produces abscesses bursting into the Rectum and kills him also. if in a woman the abcess burt into the Vagina and may recover - Ulceration of the vertebrae. This complaint begins with a pain in the affected part soon after there is a projection of one 175 of the spinous processes, which becomes detached and the spine suddenly forms an angle, weakness in the lower extremities so that he often falls down suddenly when sitting he draws his heels under his seat. during the night spasms of the muscles of the lower extremities at length producing a paralytic affection, but the muscles are not relaxed, but spasmodically affected - the Vertebrae press on the spinal marrow and produce irritation: the Bladder [find] looses its retention power as does the Rectum. If the cervical vertebrae are affected, the patient has no use of his Arms or Legs, the Head only being free from disease. in some Case as many as four or five of the Vertebrae has been destroyed and yet recovered, sometimes there is a considerable abcess forming in the fore part of the spine adheres to the Lungs burst, and is discharged by coughing - Treatment setons or Issues by the side of the Vertebrae. Issues are most affectual but setons are most convenient these Issues must be kept open for 12 months or more and sometimes two years. but it depends on the Relief afforded if sufficient irritation irritation is not made dip the pea in unguent cantharid - 176 When a Cure is affected it is with an Anchylosis of the Vertebrae so that the spine never after becomes straight yet the spinel marrow does not become compressd. The constitutional treatment should be the same as before directed as Hydrar Muriat & Tinct Cinchona - Psoas and Lumber Abcesses, these are singular to the last symptoms. Pain in the Loins for months before there is any appearance of disease. a small Tumour in the Groin where Bubo appears, which dilates in Coughing as in Hernia. this Tumour extends downwards and is of a considerable size. this sometimes form two las one on each side the Femoral Artery and Vein, the tumour at length bursts and discharges from H1/2 to Hi of Matter three or four days after: much Fever is excited and hectic symptoms come on, night sweats chilliness succeeded by heat. and the case soon terminates fatally - On Dissection the Origin is found to be from the Spine and the Matter Ulcerates through the Psoas muscle to the Thigh under pouparts Ligament. it destroys the Ligaments of the spine where it is situated and the Psoas Muscle become hollowed 177 Treatment. Excite irritation at the part where the Patient complains of pain. make Issues and keep them open for a month or six weeks before you have any thing to do with the abscess, then you are next to consider the propriety of opening the abscess. Mr. Abernethy consider making a puncture into it is advantageous to let the matter out gradually - as this diminishes the constitutional irritation pass a Lancet at the part where the abscess feels rather thick introduce it from the side and make an oblige incision as you have a larger fur pure of the escape of the matter which is generally mixd with clots which must be removed by a probe, then lay a puic of lint over the wound. and over that Empl adhesivim - as the Matter accumulates you must repeat the Operation not suffering much matter to collect - Scrophulous Ophthalmia. This produces very quickly opacity of the cornea even in a few days, give Hydrarg Muriat with the Decoct. Cinchona & Tinct. Cinchona, if the Eye is irritable apply. Rx Hydrang Muriat gÿ Aq: Calcis ℥vi Tinct: Opii ʒÿ Aq Pura ℥i M or Rx Aq: Litharg acet 30 gtt Zinic Vitriol giv Aq: Pura ℥iv this forms the acetate of Lime 15 and congestion takes place in any weak part as before mentiond, - The division of Blood Vessels is the most frequent cause of inflammation. the division of an artery stops its circulation and the neighbouring arteries throw more Blood on the part to keep up a due circulation:- Laceration contusions &c are the existing cause of inflammation: extraneous bodies Gunshot Wounds and ligatures occasion more or less inflammation according to the irritability of the system. Proximate causes the state of the part which produces the symptoms, it has been supposd, that the Blood when in an inflamd, state, was thicker and would not pass through the smaller branches of the arteries, which made the arteries push with great force to get it through, this is now found to be a false idea, the Blood when inflamd. is much thinner, Dr. Cullen thought that inflammations was occasiond, by spasms of the arteries, the contraction of which obstructed the passage of the blood, that the neighbouring arteries pushed with more force to obtain one if the Blood was thus returnd. it would 178 which is to be introduced between the Eye lids: give Calomel. In scrophulous testis give. Calomel to affect the Mouth and Mercurial poultices must be applied It generally occurs in people from 20 to 22 years of Age. It is not attended with much pain and one Testicle is affected which soon extends to the other On Gunshot Wounds Any wound produced by a substance entering the body with great Velocity is of the same consequence as Gunshot wounds The Gunshot Wounds differ from common wounds in their being much more intense extraneous substance most frequently loose and having a sinous tendency during cure. They are divided into two kinds 1st When the Ball is passed through part of the Body: 2nd when they continue to lodge. they require different mode of treatment, the former much the simplest, the surface of the wound is covered by a thick slough as if 179 caustic had been used in consequence of the velocity with which the Ball has passed in the wound where the Ball has passed through there is always less haemorrhage than from incised wound: for the first four days the Patient complains of great pain a Glutinous substance issuing out of the wound. untill the sixth day there is no appearance of suppuration and when it begins it is in consequence of separation of eschar not completed till the tenth day or a fortnight; when the eschar has separated it forms a sinus, unless the Ball has struck a bone no pain is produced but if it has then it communicates a shock to the Body if there is no sinus formed it then goes on as any other common wound Treatment. Bleeding is highly essential in Gunshot Wounds at first to prevent inflammation and afterwards when it is come on the Bowels are to be kept regular, but in these there is the same objections as in Fractures: doses of opium with saline medicines every four hours to keep the patient comatose state to alley the irritability of mind and prevent 180 the locked Jaw, regimen to be the same in moderation. Poultices not only upon the wounded part but upon the whole Limb if there is not much Haemorrhage. but if there is use cold spirituous Lotions with Vinegar. the poultice to be used till suppuration happens, as slough often came away during the cure. the best method of separating them is by the injection of warm waters into the sinuses not using any force. scarify the edges of the wound at the time of inflammation if you have not the opportunity of applying leeches, and do this occasionally as you find inflammation coming on sometimes the inflammation is so great as to produce mortification. there is no discharge from the wound. Apply leeches about the part scarify so as in some degree to dilate the wound with fomentations, & vinegar poultice. The sinus has sometimes been very difficult to heal, make an incision between the two orifices and divide the sinus then it will probably heal. if it does not then pass 181 a Bougie with stimulated ointment on 2nd. Gunshot Wounds, with the Ball lodged. when the Ball and extraneous bodies remain lodged in the parts. Pass a probe or a long bougie into the wound and search for the Ball and if you can feel it attempt its extraction, or if it has passed nearly thro so that you can feel it under the skin you mat cut so as to take it out, but not otherwise, for it is not proper to make extensive incisions to follow them as it is well known that Balls sometimes remain for years in the Body without any disagreeable effect being produced - and from their curious course it is often impossible to find them, and as they pass a long way to make a large incision will be very dangerous for they have been known to enter the middle of the forearm and pass out at the neck, also to enter at the scorbiculus cordis and pass out at the back part by the spinous process of the Vertebrae going round the out sides of the ribs. if the Ball is left and does not form cyst it generally produces inflammation which will ovation the expulsion of it in time 182 therefore it is much better not to cut to far for it- Gunshot Wounds of Arteries Arteries when divided by a Ball Bleed much less than if incised because it leaves a fringe of cellular membrane. and the tone is lost. but still there is considerable danger, even if it has passed near an artery as it will cause the coats to slough & the Patient will die from Haemorrhage when passed near an Artery apply a tourniquet, for if it does not Bleed at first. still it will Bleed, In tying an Artery from a Gunshot Wound it should be done high up from the divided or contused parts as they will soon separate or mortify - the Patient if there is a wound near the Artery should be directed how to manage the tourniquet in case of haemorrhage - Gunshot Wounds of the Abdomen If a Ball passed directly through the abdomen it is fatal in a few hours as it must pass through many folds of the intestines - Bleeding & remedies 183 against inflammations must be used. Opium freely: when shot through the stomach in general die in 30 hours and when through the intestines in 24 hours - an intestine may be wounded and the patient may recover. Gunshot wounds of the Liver spleen or Kidneys Mr. C has not seen Gunshot wounds through the Chest into the Lungs are not so dangerous as incised many instances are occurring, when recovery has been affected when there has been considerable injury, these require only simple mode of treatment. Perfect rest, bleeding very freely, - more danger ensues frequently from bits of cloth & being carried in with the Ball than from the Ball itself causing so much irritation, but it is never necessary to make incisions to take them out for the wound will heal from where the Balls enters and will Ulcerate externally towards the extraneous body. thus closing at the part furthest from the Ball and gradually opening to it silk clothing is safer in this respect as it is not so soon separated and carried in - 184 Gunshot Wound of the Heart are instantly fatal. wounds of the Brain are fatal, yet when only the skull is depressed the Patient may do well after trepanning; the Ball has been known to enter and do through the Othmoidal & Sphenoidal sinus and have not proved fatal nor done any injury to the Brain Compound Fractures occasioned by Gunshot wounds are much worse accidents then when happening from other causes : and consequently more difficult in their treatment as the Bones become much more splintered in these it is necessary to dilate all the wounds, to extract all loose portions of bone for if they remain the Patient will die of the consequent discharge, but if removed tho the limb will be shortened, he will commonly do as well as in other compound Fractures and perhaps render the operation of amputation unnecessary - If the Ball passes near or through a Joint so as to splinter the Joint as in the Ancle, Knee, or Elbow, it is very dangerous much more so than Compound Fractures from other causes, it is necessary to amputate, but it is much better to wait and see whether the wound is of such a nature as to Create symptomatic Fever, and the to consider 185 whether the Patient will be able to bear that Fever if you think the latter it is much better to wait till that has subsided before you begin to Operate. Dr. Babington was Surgeon sometime ago on board a ship, after an engagement 24 were amputated in consequence of [a] Gunshot wounds 21 died soon after and three lived to go to a Hospital where one of the three died after so that two only lived when probably if their limbs had not been amputated till the symptomatic fever had subsided some (if not many) of their lives might have been saved - Burns and Scalds The effects of Burns and scalds are of three different kinds. 1st Vesications of the Cuticle 2nd separation of the Cuticle so as to expose the cutis to a great extent and 3rd Destruction of the cuticle and cutis so as to occasion sloughing these three states require different mode of treatment - in the 1st state when the cuticle is detached in the form of a Blister though extensive it is not dangerous. if the cuticle is over it such burns will always do well under this kind of treatment Rx Aq Litharg: acetat. g xxxÿ Zinc Vitriole gr iv Aq Pura ℥iv M Spt. Vini: Camph is a good 186 application. but the following is the best Lotion to prevent the separation of the Cuticle Rx Spt. Vini Rut. Acet communis part equalis ᵯ - In the second stage. It is most dangerous with the cuticle separated and without the life of the cutis being destroyed. The patient soon dies (though the sore in some cases may be extremely small) let you follow what plan you will: for the extremities of the nerves are exposed and occasions such a Violent degree of constitutional invitation that in a few hours it terminates fatally. sometimes the Diaphragma becomes affected breathing Laborious with spams & in this state a solution of opium will moderate the pain, but as it produces costiveness it out to be guarded against Lime Water and Linseed Oil is a good application to allay the pain and heat at first, but it produces a great discharge from the part, and may also produce pectis symptoms, therefore to not continue its use long - in Consequence of what has been written about spirits of Turpentine in this state of burns M. C had been induced to give it a fair trial. It produces excessive pain and very often extensive sores In a Case now in Guy’s Hospital A Man’s Legs were both equally burnt. to one Leg he applied 187 the Aq Litharg : acetat &c and to the other spirit Terebinth. The Leg which was dressd with the Aq: Lith. &c is completely well and then is on the other a very extensive sore- the danger in this second state is not all over when the immediate symptoms cease for a very profuse discharge will sometimes follow if the surface is large. but this may be restraind. by applying the Lotion of the Aq: Lith: acet &c as before recommended on Lint over the surface it also quickens the formation of cuticle - In the 3rd state when the true skin's life is destroyed it is not so quickly fatal as when the cutis is sensible, the constitution does not become affected for several days, but probably will when it begins to slough: If you do not Judge it proper to amputate you must use fomentation & poultices. When large surfaces have lost their cuticle it is a long time before granulation forms but if you use the Linn Vitriolate & Aq Lith Lotion, granulation will form in a few hours - Sprains. A Laceration of a Ligament, the best mode is to apply the following lotion Rx ammon: muriat ʒi Aq: Ammon Acet. ℥vi M Lotion. if there is 16 Change color; the redness of inflammation proves it does not, it likewise proves that vessels are not lessend, which must be the case if Dr. Cullen's hypothesis was true; The Blood Vessels are distended on the inflamd. part but their actions is not increasd. the arteries near the inflamd. part have a stronger pulsation, but are not distended, the distention is occasiond, beyond particles being pressed into the small vessels, that before only containd. white ones, thus it may be stated that there is always distention without increasd, action of the inflam part increased action without distention on the surrounding parts - to ascertain this Mr. Cooper put a young Frog (as their circulation may be easily seen) with a microscope he applied a stimulus to a part, and in a few minutes saw a red particle forced into the artery on that part it passed into the veins and at every pulsation of the Heart, fresh red particles were forced in till the vessels were filled with them 188 inflammation apply Leeches: put on a bandage as soon as the inflammation will allow: the Patient must be kept quiet four days or the Ligament will be torn through again by walking - a light Bandage should be used if he lay by a month or six weeks it will be difficult to walk a little exercise about the third or fourth day is necessary - Fractures Fractures are divided into simple & Compound called simple when the extremities of the bone are not exposed: there may be wound tho we may call it simple the exposure of the ends make the destruction 189 bone in the Body requires different spaces of time, depending on their size, as the Radius and Ulna will unite in three weeks The tibia never under 5 weeks and in very old people never under 7 or 8 weeks the large Bones in general, as the os femur and Humeri require 5 or 6 weeks before a firm union takes place. Simple Fractures are seldom dangerous to life except under certain circumstance. as a great depression of mind in very old age - Simple Fracture of the Tibia is ascertained by feeling along the skin. or by holding the foot in one hand and rotating it gently, passing the other hand along the bone untill you discover the crepitus when ascertained a slight extension is necessary to replace the bone in contact. but if the muscles oppose much by spasm you must not attempt replacement by force, but foment and poultices a day or two till it is subsided, when it may be readily replaced. You mush then apply the many tailed bandaged over the whole limb: this bandage is better than a long roller, for as the limb will afterwards swell the bandage 190 may be entirely loosed without disturbing the position of the Limb. if there is not excoriation of the skin or much swelling you had better put a rag dipped in aq: Ammon Acet under the Bandage. If excoriation has been produced then the aq. Lith: comp is preferable; over the bandage the whale bone splints are the best, as one set can be adapted to either Limb, and are known in the shops by the name of Martins splints - The posture. The Leg to be laid on the outside, knee a little bent the foot a little raised and supported by or pillow - The Fibula when broken is not commonly about three inches above the ankle and cannot be felt exept by rotating the Limb the other hand gradually feeling up the outside of the Leg untill you discover the crepitus, it is generally connected with a sprain of the ancle and is often mistakes for it rendering the Patient always lame 191 of the Leg with one hand, and rotating it: at the same time feeling along the Os Femoris carefully. when you arrive at the Fracture you will distinguish the crepitus: or by placing one hand on Trochanter Major & rotating the Leg with the other. If there is any Fracture the motion of the Leg will not be obeyed by the Trochanter. Treatment. Apply the many tailed bandage over the Limb, then three splints lined with wool, one before and one on each side. the Position of the Limb should be the Leg resting on the heel rolling a pillow up and laying it under the Ham so as to raise up and bend the knee - Fracture of the Clavicle may be known by tracing the bone with a finger from the sternum towards the scapula, you will find the bone sunk down at the fracture: Treatment. assistant must put the shoulders as much back as possible to bring the fractured ends in a line. then raise the arm so as to keep the clavicle in its place, then apply the stillate bandage (along roller) pass under both 192 axilla &c. not press on the broken extremity of the Clavicle for it would render the Fracture Compound. apply Emplast sapon under it. The shoulder is to be elevated in a sling, during the Cure no use of the Arm is to be allowed. The best mode of elevating the shoulder is to carry it close to the side and bind it down by a lon roller. the just support the arm in a sling - Fracture of the Os Humeri is distinguished easily by feeling the bone. A long roller should be applied round the arm then two splints one before & one behind will answer equally well when made of thick pasteboard, these are to be confined by another roller passed round the Limb in the opposite direction to the first ie. one from without inwards the other from within outwards which prevend. an appearance of twist of the Bone after. The position of the Arm should be hanging by the side supported by a sling on a pillow If in a very plethoric person he should be confined to bed for little while as very great swelling of the arm & forearm is likely to ensue 193 Fracture of the Radius & Ulna requires the same treatment as fracture of the Os Humeri- Fracture of the Radius only generally happens from falls in running - about two inches above the wrist known rotating the hand and applying the other hand along the Radius the fractured end of the bone generally protrudes among the tendons of the fingers so as to impede their motion - Treatment. the same as fracture of the Radius and Ulna to be suspended in a sling on a pillow - Fracture of the Ribs are ascertained by applying the finger to the part where the pain is and when the Patient Coughs a kind of grating sensation is perceived from the ends of the bones rubbing attended with pain Treatment it is necessary to hinder any motion of the ribs, therefore they must be bound very tight with a double headed flannel roller so that respiration is to go on by the Diaphragma - If the Lungs are wounded it is known by the Emphysima the bandage must be applied as before and a number of punctures made above and below it to let the Air escape. this 194 Accident generally gets well in about three weeks or a month unless in very old people - Fracture of the Sternum is a very similar accident to the former and is easily ascertained the lowest end of the bone generally lays under the upper, therefore the union is often irregular - Treatment the same as in Fractured Ribs. in both Bleeding is necessary - Fracture of the Lower Jaw, this happens generally at the symphysis from blows on the angle. The best bandage is leather sling with four heads. The sling being put under the lower Jaw the four ends carried over the head & brought down again and carried under the chin. Liquid food only must be allowed during the Cure - Another method of curing this Fracture is by passing a wire between the Teeth (2 on each side) twisting the ends firmly together this method must only be employed when the Teeth are firm Fractures of the Flat Bones unite exactly in the same way as cylindrical ones ie. by cartilage gradually becoming ossified thus in the skull where if 195 the bones could be brought together would unite gradually and equally as well as others but in these bones where a piece of any size is removed the place is not again filled up except by ligamentous substance - Fractures of the Patella happens generally from falls. the different portions of the bones become divided the upper one being drawn up the Thigh from three to six inches by the muscles inserted into it. the person becomes instantly lame if the pieces are not brought in contact the union is by Ligament but if brought in contact the Union is by bone. Treatment. you must bring down the upper portion in contact with the Lower by extending the Leg and pushing down the piece gradually from day to day as it cannot be done at once but will be done generally in about a week. If the bones is not brought in contact the Ligamentous union will be four or five months and the Patient is always to falls as that Limb is much weaker than the the other from the length of Ligament the patient should begin to move the limb gently after 1 month 196 Fracture of the Olecranon, is generally broke of about an Inch from the upper part and the portion of bone becomes drawn up about 2 inches high, the union as in the patella is either by Ligament or bone, Ligament when the Bones are not brought in contact. but bone when they are; to bring then in contact you must gradually and daily press the upper portion down till they come together. the arm must then be kept extended and a small square cushion laid just above the process which is to bound down by a roller. After the third week the arm must be gently moved every day to prevent anchylosis. - Fracture of the Os Calcis or other bones where large tendons are inserted unite them in the same manner as Fractures of the olecranon Fractures will sometimes not unite at all this happens from some peculiarity of constitution. there are no particular symptoms by which you can foretell it if appears to arise from a languor of constitution so that there is not sufficient inflammation produce to unite the separated parts 197 only Ligamentous substance without ossification. It has been recommended to cut off the two extremities of the bones and keeping the external wound open for some time this but rarely succeeds - If the muscles are affected with at a fracture give large doses of opium Tinct: Opii 30 gtt mane et Meridie et 4x nota hora somni with wine and a free use of spirits. Compound Fractures A Compound Fracture is when a bone is broken and there is at the same time an external wound communicating with the Fracture the wound is generally occasioned by the end of the bone. sometimes there is a haemorrhage. in twelve hours after the fracture there is a discharge of bloody serum much tension and great symptomatic Fever which continues from four to six days when the discharge becomes purulent and granulation arise from the sides and soon after from all the cavity which fills it up and the wound heals The greater degree of danger in compound than simple fracture arises from the greater degree 17 in the same manner great number of vessels were filled that could not be seen before their distention was produced. - the action of the vessels were not increased in this part but in the surrounding parts. The pulsation was much increasd, - Mortification takes place when a part is amputated in an inflamd, state, the living powers are to weak to support it - distention is not confind. to the part at first inflamd. it gradually increases and the whole brachial artery will become enlargd. in consequence of an inflamd. hand: if inflammation extends to a very great degree, the Heart will become enlargd. in which case the pulse will be scarcely perceptible, in case of very extensive inflammation constitutional treatment is necessary, particularly bleeding, this Mr. Cooper thinks is too much laid aside, but there is no occasion to bleed if the constitution is not affected - Blood should be removed quickly, if some degree of faintness is producd, it will be more effectual. 198 of inflammation and suppuration produced. and requires twelve or thirteen weeks to Cure when a simple one require only four or five - Treatment. Extension must be made at both end of the Limbs to bring the parts in opposition not using much force as it is not very material to have it done directly. if there is any haemorrhage apply dry Lint no Ligatures should be used if you can possibly avoid: if there should be tension apply poultice for the first few days. but if not attempt Union by the first intension with a linen rag (thin) in the Blood which comes from the wound. over it apply the many tailed bandage and over which put the splints. (Martins)- If the Fracture happens to the leg it must be laid on the most favorable position for dressing the Wound. if in the Thigh the same bandage is necessary as in the Simple fracture and the same position. the same application in the Upper extremity as in the simple fracture. the only difference is to wrap up the Limb in the rag with with the Blood from the wound. Get 199 the external wound to unite of possible by the first intention, always attempt it as it relieves the patient from great danger. unless there are very great Bruises then you must poultice - Much inflammation often comes on about the fourth day with great pain. loss of sleep stoppage of the discharge the parts about very much swelled. Air coming from the part when pressed the wound appearing dark pulse quick and small, with delirium. Blisters arising on the part with mortification killing in 24 hour - Treatment apply six or eight leeches to the part, general Bleeding im proper. poultice of beer grounds over the wound. Opium freely- Bark 1 dram 2ly poris and let the patient take freely of wine. Porter or Brandy according to the Habit he has been accustomed to live. The less medium the better internally so as to relax the Bowels. these means when employed early will generally prevent the Mortification - Mortification sometimes comes on in old people without any previous pain cheaply in old drunken people: this soon extends a great way and often proves fatal 200 In the reduction or replacement of the bone. when it cannot be done by extension. the most preferable mode is of the bone is not much denuded of its periosteum is to enlarge the wound. but if it is you should saw off the end which is denuded, but this is rarely necessary. if this happens to the Tibia, and the Fibula not broken it must not be sawn off on any amount as the ends of the bone will then be so far distant that no union well ever be effected When a large Artery happens to be divided which occurs oftenest in the Leg the Anterior tibial artery, and the Arteries of the Arms, you should not amputate hastily but cut down on the divided portions and take them up, then treat the fracture as before. A want of union will sometimes arises from a bad constitution and from exfoliating pieces of bone being enclosed. when a Compound Fracture extends unto a Joint it renders it a much more dangerous accident as the suppuration extends into it. Locked jaw coming on &c - Cases that require Amputation 1st when a bone is fractured in numerous pieces and the removal of which will cause such deficiency as will render the Limb 201 useless afterwards - 2ndly The division of a large Artery when it cannot be easily secured, as the posterior tibial Artery and when they are taken up high the Patient generally dies of mortification, but in the Branchial Artery as it is easily got at take it up and try to cure the fracture likewise in the fore arm - 3rdly when a large Joint is opened as the Knee or Ankle, but at the Elbow it should not be done hastily as the use has been sometimes recovered 4ly when the lacerations are very extensive though the fracture be not but should not be amputated hastily as great recoveries are founded to happen - 5ly It has been recommended where locked Jaw has come on - but the removal of the part is useless as it does not appear to relieve the disease at all - Young people often do well under accidents of this kind, when old ones dies - if the patient, Constitution is very irritable Amputation must be performed sooner than in one that is cool and patiently suffering. for in these delirium always follows quickly 202 the upper extremity may be amputated earlier than the lower. Mr. Cooper thinks that amputation in general succeeds better when performed after the patient has recovered from the symptomatic Fever than early if his constitution appears likely to sustain the first symptoms of irritation. - Wounds of Veins - These wounds are but of little importance with regard to the haemorrhage as they can be easily stopped. a wound in the Axillary Vein can be easily stopped with a dossel of Lint. so also the femoral Vein. the greatest danger of them arises from the inflammation of their internal coats the symptoms of which are a stiffness in the limb and part where the wound is and when occasioned from bleeding in the arm a difficulty of extending it. a swelling from the wounded part up the skin the size of a quil of a red colour: an abcess forms nigh the part with Violent shiverings and the matter with great difficulty gets to the skin, before are abscess breaks another forms higher up and often a third above that, when it breaks into the vein 203 then it proves fatal soon. these effects have by different authors been thought to arise from a wound of a Nerve, Tendon or Fascia. Treatment to be pursued is when the inflammation appears to apply leeches to the part & poultice - If these should not abate the inflammation quickly they best mode is to cut through the inflamed part down on the Vein and cut it across it may be done with a Lancet and afterwards compress the Bleeding Vein Wounds of the Nerves - On the division of a nerve the part to which it is distributed becomes senseless, yet the involuntary actions will go on in it as before, a Blister will rise in the usual time on it, and an Ulcer will granulate through not quite so quickly. for a few days after the division, the heat of the part will be greater than where the nerve is entire. as 78 in the entire part and 86 in the senseless part but after a few weeks it becomes much colder. a small branch is sometimes divided in Bleeding. it only causes a sharp pain at the time and a numbness at the fore part of the arm 204 for a month, but it is of no consequence further than that sometimes divided by the ends of fractured bones causing a numbness of the Limb below. When nerves have been divided after sometime they reunite by forming a sort of ganglion or knot at the divided part, and the powers of the part becomes gradually restored, this is also found where the ends of the nerves have been purposely separated. if the divided branch is very small the sense will begin again in three weeks if large from 4 to 8 months or if very large as the sciatic nerve at the Hip two years - Electricity quickens the restoration of sensation and motion: when a nerve is tied and remains undivided it generally kills the patient if large by producing violent pain and irritation & quickness of the pulse. If a nerve that has been cut through has been included in a Ligature as in a stump. the effects produced are according to the patient, constitution in some no ill consequence ensue, in others Violent and Universal spasms Treatment. when exposed lay the extremities in contact only and they will unite. 205 Wounds of Tendons The Tendo Achillis is often accidentally divided or cut across after which the Heel falls down and the upper portion of the divided tendon is drawn up within its thicken an Inch Treatment. Elevate the heel as much as possible by a high heel shoe with a strap extending up the Leg from the back part [of the] which is to be bound in with roller and applied round the calf of the Leg to hinder the spams of the gastrocnemii muscle: no pressure should be made at the divided portion as it will cause an adhesion of the Tendon to the bones and lameness ever after - The dressings are to be lint spread with carat simplex just laid on, if this plan is pursued the Tendon will readily unite and the patient walk with the shoe in ten days, no suture must be used. This tendon is often lacerated by great exertions in walking & ramming. the treatment is exactly the same. The patient may be allowed to walk as soon as the inflammation has a little subsided. it becomes completely united in 3 weeks and height of the shoe heel must be 206 gradually diminished. Partial laceration of the fibres of the tendo Achillis or of the Gastrocnemii: muscle is words accident than either of the former. It happens generally by a false step. the sensation at the time is as if the part was struck by a stone. Where the fibers are ruptured a depression can be felt and an Ecchymosis follows. This injury causes Lameness for years or for ever, if the person walks much on it for sometime after [a] high heeld shoe should be used for sometime with a bandage on the Gastrocnemii muscle for the reason before mentioned and in this manner the part will frequently recover itself in about three weeks or a months time - Wounds of the Abdomen These are of two kinds. Those where the Viscera are wounded. and those where they are not . If no Viscera is wounded, the wound is no otherwise dangerous than from its extent, or the protrution of the intestines which becomes strangulated by pressure 207 When the stomach is wounded the countenance collapses this person becomes insensible, the pulse cannot be felt. blood is vomited up mixd. with the contents of the Stomach, and liquids when swallowed come out at the wound, when this has happened no food should be taken either Liquid or Solid for a week or ten days, the Patient should be nourished by Clysters of Broth in which 120 drops of Tinct: Opii should be put three times a day to retain them after which a small quantity of Jelly may be taken for the space of a week and then solid food Wounds in the small Intestines are accompanied by the same symptoms as Wounds of the Stomach except that the Vomiting is without blood the same Treatment is necessary, but if it protrudes at the external wound, if partially wounded longitudinally and the intestines is seen externally it is right to pass the interrupted suture in it, the stiches only half an inch as under, then return the Intestines just within the Cavity leaving the ends of the Ligatures hanging out 18 There is but one objection to a large orifice it is apt to inflame. Venesection maybe used not only when the pulse is full and hard, but even when there is a weak thready pulse, as that will frequently rise after bleeding, of this we have frequent instances after amputation where the Patient is sinking very fast. if the stump bleeds the pulse rises and he gets better. the same effect take place in the bleeding of a compound fracture: it has been the custom to give bark & wine in these cases of slowness, but it is injudicious as they irritate too much in cases of incipient inflammation; taking [place] away blood in small quantities, will frequently stop its progress and not weaken so much as taking a large quantity at once, which should never be done but, in very extensive inflammation: when there is a very irritable jerking pulse, but if arising from a slight cause we should not bleed as it will only weaken. purgatives relieve by evacuation 208 then unite the Eternal wound by sutures which should not pierce the Peritoneum in eight days gentle efforts are to be made to bring away the ligatures of the Intestines - Wounds of the large Intestines may be known by the escape of the true foeces from the wound which should be treated the same as the former except that the nourishment must be given by milk only by the mouth instead of Clysters, as it will not make so much foeces. When any wound is made into the Cavity of the Abdomen and there is much haemorrhage the wound should not be closed till the haemorrhage ceases, for if Blood is extravasated into the Cavity of the Abdomen it is certainly fatal and not any great degree of inflammation is excited by leaving the wound open as long as twelve hours Wound of the Liver. This is not a fatal accident unless the wound is large a quantity of venous blood is discharged mixd. with bilious matter If the external wound is closed directly a quantity of this matter is extravasated in the abdomen; it should therefore be kept 209 open – lacerations without external wounds are fatal and it is not an uncommon accident. the abdomen swells to an enormous size and the Patient dies in a few hours Wounds of the Gall Bladder. Fatal in about 40 hours known by a discharge of bile Wounds of the Spleen. Although this is a viscus that may be removed from the Body without injury yet the most trifling wound of it is fatal, as great haemorrhage into the Cavity of the Abdomen follows. attended with such an inflammation as destroys the Patient indeed Blood when in any way extravasated in the abdomen proves fatal Wounds of the Chest. These are of two kinds. those which injure , and those which do not injure the contained Viscera: when only a wound is through the parts which contain the Viscera it may be known by the Lungs protruding when the patient expires and in the rushing in of Air at the aperture when he inspires. the wound must be united by sutures & covered with adhesive Plaisters to exclude the air and over them the applications of a roller. the opening closes inside by adhesion of the Lungs 210 Wounds of the Lungs. In these the breathing becomes difficult. coughing and vomiting of blood florid and frothy. with much haemorrhage externally and Emphysema. If the haemorrhage is not stopped you must bleed the patient till it does in general to 20 oz and when it is stopped you must close the external wound as before and the plaister applied, also the roller if the difficulty of Breathing does not prevent it. The Patient should have 20 drops of Tinct: Opii every three hours after. speaking should be avoided. these means will prevent immediate danger, but inflammations comes on sometimes on the fourth or fifth day after the accident which renders it necessary to take away large and repeated quantities of blood. Another danger is haemorrhage happening many days after the accident. when the external wound is healed it is shown by difficulty of breathing coming on without pain: the wound must then be opened again: when the Emphysema is very great small punctures may be made round the Wound not further than 6 inches off. Wound of the Heart & Pericardium are universally fatal as they have no opportunity of healing or uniting because of the Perpetual Motion of the Heart - 211 Of the Tix Doloreux This is the most painful disease the human Body is liable to it produces no disorganization of part. The pain during the fit is compared to a flash of lightning darting through the part with a vibrating or undulating feel in the part. an effect may be brought on from the most trivial causes: the nerves subject to this painful affection are the suborbitary: the ophthalmic branch of the 5th pair. The dental, the pes anserinus of the 7th pair. The nerves distributed to the Tongue & tonsil gland, sometimes the par vagum. the radial and the Anterior tibial nerve ... To Perform the Operation when the suborbitary nerve is affected (which is oftener affected than any other) make an incision with a Phymosis knife 1/2 an inch below the edge of the orbit and divide the nerve near the suborbitary foramen: the incision is to be made about 3/4 of an inch passing the cheek over the knife with the fingers which divides the nerve and the Patient feels a numbness in the upper Lip: the suborbitary artery being also divided. it is necessary to make a pressure on it with the finger for 5 minutes The complaint is very liable to recur in a few months after the operation from the reunion of the nerve. Lord Carlile & Capt Elliot in the navy have undergone this Operation with complete success - 212 As palliative remedies in affections of this nerve. salt held in the mouth and cicuta given internally have proved useful though never wholly effectual - In affection of the Anterior Tibial nerve apply a Caustic upon the part to produce an eschar, this is to be kept open by the introduction of a pea On Gonorrhoea The symptoms of this disease are an Itching sensation near the fraenum generally about the fifth day after impure Coition and on Examining the lips of the Urethra. they appear of a florid colour. on pressare a drop of mucus appears, in a few hours some pain is felt in making water. as the inflammation increases the discharge becomes yellowish, and when it is at its height it is of a greenish yellow colour mixd with blood erections are frequent, proceeding from irritation and is attended with considerable pain. after the pressure appears oedematous producing Phymosis and the dorsum penis when pressed on by ye Fingers feels knotted ie, the absorbents. then the glands of the Groin become enlarged. these symptoms decline if the constitution is very irritable. the will complain of a weighty sensations in - Posines - 213 near the membranous part of the Urethra. frequent inclination to make water, at this time the Testicle frequently enlarges, more especially if he is exposed to cold: the Urine passes in two or more streams as in stricture of the Urethra. If the discharge is of a white colour the inflammation is inconsiderable if it is yellow it is more extensive and if mixd with blood and the lip of the Urethra are excoriated inflammation run very high the appearance of this disease is uncertain sometimes in 24 hours and in others as long as 3 weeks - when the disease is protracted as it generally is in scrophulous habits the cure is more difficult. sometime there will be every Symptom of Gonorrhea present without any discharge The seat. of this disease in a lacuna Just an inch from the lips of the Urethra opposite the fraenum this lacuna is inflamed and in a virulent Gonorrhea the inflammation will extend to the neck of the Bladder and streaks of coagulable Lymph are discharged with urine It has been supposed that an Ulcer exists in the Urethra. but this very scarcely the case, and then only when the lacuna suppurates and bursts. The Progress of Gonorrhea is arrested by an attack of Fever when to all appearance it entirely ceases but as soon as the fever is subdued it returns with unbated violence 214 Treatment. Mercury given to effect the mouth does much mischief by its irritating effect, but mercurial purges may prove serviceable. If a patient has had several Gonorrhoea he is much easier cured than if it is was the first time. In a first Gonorrhoea the inflammation gradually extends for the first ten days, and if at this time you use astringent injections. you will in all probability produce hernia humoralis, or a stricture. If the Urethra will be the consequence. In order to lessen the inflammation give the following - Rx magnes Vitriol ʒÿ Nitri Puri ℈i P.G Arab: ʒ1/2 ᵯ pulv bis vel ter die ex Aq sumed As a purgative in some habits Calomel with Ext. Cath: proves useful. When the ardor Urina is very considerable give the following Rx Aq: Kali: purae gr xv ad xx Ext. Cicuta g iv Mist e: Camph ʒÿ M Haustus. the warm bath is a good remedy soda water is useful after taking the the powder or the following. Rx Kali: Carbonat ʒ1/2 Aqua H1/2 this should be drank mixd with milk it is of a diuretic nature. Local remedies: Rx ol: olii: opt ℥i Pul. Opii ʒ1/2 m. Tinct: Opii ʒÿ Aq: Purae ʒiv ᵯ the Penis should be shaked in warm water frequently for ten minutes. when the inflammation from very high apply a leech or two to the lips of the urethra 215 and the Patient should drink freely of then Gruel or Barley water. When the inflammation has a little subsided use the following injection Rx Aud: Vitriol gr i Aq: Rose ℥i or gr iÿ to ℥ÿ or Aq Vitrol: Albi gr i Aq: Rose ℥i sometimes gr iv to ℥ÿ may be used when the inflammation is nearly abated direct the use of Rx Zinci: Vitr gr iv Aq: Lith Acet 30 gutte Aq: Rose ℥iv M [if] injectio. in this injection a decomposition take place forming an acetate of Zinc, or the following is equally useful. Rx Zinci Acetat gr vi Aq. ℥iv aceti ʒi M - This preparation Mr. C objects to as by its astringent power it is liable to produce strictures - The following is a slow but a sure remedy- Rx Calomel ppr. ʒi Aq Calcis ʒiv M Inject. - The strength of the injection may be determind. by the constitution of the Patient and it ought to be changed every two or three days, they should four or five times in the day and in the night of awake in injecting he is to press under the symphisis pubis so that the injection may not pass further than two or three inches within the passage It should be thrown up with a little force the Elastic bottle syringe is the most convenient for this purpose - In some habits a Gleet will take place after the Inflammatory Symptoms have subsided for which give the following Rx Bals: Cobail ʒi (VO) q's aud Vitriol 4 gtt aqua cinnam ℥ÿ M g Haustus or Rx Bals: Cobail ℥i (VO) [illegible] 216 Aud: Vitriol 20 gtt Aq: Cininam ℥iv M Caps cochl amp tres vel quater in die, when there remains a discharge like the white of Eggs. use the Injection with the acet of Zinc. The Bals Cobail is apt to throw out an eruption on the skin like nettle and which take place in some people after eating Mussels but this disappears by the use of purgatives - the face swells with a troublesome Itching - Consequences of Gonorrhea. Strictures of the Urethra divided into two kinds. permanent and Spasmodic, there is likewise a stricture of mix'd kind, the symptoms of the most common kind are increase of inflammation on discharge of Urine when in Bed frequent inclination to make water a question necessary to ask- this precedes an alteration of size and appearance of the stream which is diminished, and instead of coming out in a round, stream it is broad and sometimes spiral- The most common effect is two or more streams, and when the complaint has been for sometime it will almost stop, and at length either from cold or something very triffling a retention of Urine is occasioned. There is a glary fluid discharge from the Urethra which stains like white of Egg: if guilty of Excess of yellow colour in consequence of inflammation but no Ulcer - The Bladder is affected and thickened with a weight above the Pubis, it’s contracting causes a 217 painful sensation at the upper part of the Pubis. pain of the Loins extending down the Thighs from perineum. Venumd sensation in direction of the crural nerves are the symptoms of the common state. it will produce Fistula in Perineo- The manner it is produced there is an enlargement of the Urethra between the stricture and the Bladder. The occasions a corresponding enlargement of the lacunae. The lacunae in consequence of the collection of Urine and being distended at length bursts. and the urine becomes extravasated between the cellular membrane: every time he makes water there is a great collection and after matter is produced - it depends much on the part where the strictures is formed. Bladder becomes thickened in consequence of stricture where it is existed for considerable time. the Urine becomes like whey being mixd. with Coagulable lymph, the irritations which it occasions the Constitution is mistaken for an intermittent sometimes with rigors & hot pungent skin relieved by sweating and so indeed do the symptoms give away to the use of Bark Kidneys become affected. An enlargement of the Pelvis and infundibule, and wasting of its substance when it continues long a suppuration of the Pelvis of the kidneys takes place so that the whole of the Urinary organ becomes diseased in Consequence - Seat of Stricture it is 7 inches within 19 and lesson the irritation of the Bowels by carrying off any foreign matter that may remain therein Calomel & Extl Cathl. produces this effect the most efficacious- saline purges tho' they occasion plentifull evacutions have not so good an effect - The 3rd mode of stopping inflammation is to excite perspiration - the warm bath relieves inflammation especially of the chronic kind, warm water applied to the feet in bottles or Bladders, are to be used to excite perspiration and hot diluent drink open the pores as soon as they are received into the stomach: in weak irritable inflammations, the Hydrarg. Muriat. in the dose of 16th part of a Grain given three times a day with Decoct sarsaparilla comp: in Decoct Cinchona is of great service. A Girl at Guy's Hospital had lost the use of one Eye by inflamation and the Cornea of the other opacity, many remedies had been tried without effect. it was supposd. a lost case by the use of Hydrarg. Muriat. The inflammation was stoppd. and the opacity of the corner 218 the Urethra. the length of the Urethra is 9 Inches, 2 Inches from the Bladder where Cowper Glands terminates. Which part is always a little naturally contracted. sometimes there are two strictures one an Inch behind the other they differ in length being from 1/8 to half an Inch. There are likewise many in the same Person. and some very near the orifice of the Urethra: description of stricture there are three kinds met with on dissection the first and most common is as if a cord was tied round the part: the 2nd kind is of a considerable length as if there was a broad round ribbon. difficult to cure. requires the use of bougies several times. The 3rd is a membranous band forming a cross the Urethra and sometimes several at the membranous part of the Urethra. There is also a species of are elastic kind in which if you pass a very small Bougie it will resist. but will not a large one. it will not sometimes yield to the passage of Urine. it is dangerous in this kind to make use of Caustic bougie. The cause is from an inflammation of the Urethra from whatever cause that may arise. Mr. Hunter says it does not arise from Gonorrhoea because he has found it in Boys, but the frequency 219 that it follows Gonorrhoea shows this disease is brought on in Consequence of it, but it is more the more of treating it than the Complaint itself that produces. the use of Astringent injection in the highly inflammatory state of Gonorrhoea extending it down the Urethra to where the stricture is situated. riding on Horseback & hard drinking - Method of Treating - The first thing a surgeon is to take a Bougie of the size of the passage. tho Patient Sensation may lead him to suppose it is opposite the frenum. when you have got a Bougie to the size keep increasing the size as the Patient can bear it - If not able to introduce a small bougie, bend it and give it the form of the Urethra. it may be softend by the fire. When there is discharge like common mucus stricture is to be suspected. The Elastic Bougies do not answer so well as the common ones. but Mr. Smith Covent Garden flexible bougies are usefull. Catgut Bougies are seldom used. the have one advantage that of swelling after they have been in a short time and thus dilating the stricture. if there is suppuration of Urine instead of the Catgut use the flexible bougie but this is not so certain a the common Catheter 220 A Catheter of the Natural size will generally where a bougie of a smaller size will not. It is not to be depended on for a Cure but only as a relief to draw off the water - On Caustic Bougie. when a common bougie cannot be passed through the stricture and when a small one does not enlarge the diameter of the stricture and give relief. then it is necessary to have recourse to the Caustic Bougie. Dr. Hunter revised this Practice and instead of a Bougie he conveyed a Caustic up the Urethra in a silver Cannula pushing it forwards untill it arrived at the stricture, but the Bougie is more convenient when the Caustic is inserted at the end of it. a soft Bougie larger than that containing the caustic should be passed first in order to dilate the Urethra as far as the stricture If the Urethra is not distended by this means the caustic will touch it and cause a contraction and will also bring on an haemorrhage. the caustic should not be suffered to project beyond the end of the Bougie. at first application it should only touch the stricture and be immediately withdrawn, after it may be suffered to remain in the Urethra against the stricture for ½ a minute but never longer. the surgeon should proceed cautiously that he may know what degree of irritability the Patient can bear. If 221 the Caustic Bougie remains in the part too long it will inflame and cause a suppuration of Urine Use it twice or three times a week. the slough occasioned by it seldom separates in less than 3 days. if applied oftener the Caustic acts upon the Slough produced. the day before. the Bougie should be of the size of the staff used in the operation of Lithotomy. The Caustic Bougie in strictures have been used with very good effect. and no doubt many lives saved. In a case of stricture under Mr. Coopers care that had continued two years and caused a fistula in perineo. the application of the caustic only 8 times destroyed the stricture and cured the fistula - In general the application must be repeated in proportion to the length of time the compliant has been standing In another case Mr. C. applied the Caustic 104 times. but this stricture had continued 14 years and at length cured by the application. The time it will take to cure is so uncertain that it is wrong to promise any time. The Patient always experiences instant relief but not a certain permanent cure. and if a common bougie or Catheter is not passed from time to time it will return in two or three months Though it has a general good effect. it is liable to inconvenience but in those most 222 Likely to happen when injudiciously used, one is Haemorrhage form the Urethra. Mr. Cooper was called to a Case where after the application of Caustic bougie Blood was discharged and a small pulsatory tumor was found in the Urethra. pressure did not stop the Bleeding and it appeared that the Artery of bulb was divided the tumor was opened, the blood collected in it was discharged. and a compress of Lint introduced into the incision stopd the bleeding for several days. The Gentn was at this time very weak - as soon as he recoverd his strength a little the haemorrhage returned and distended the Scrotum: the blood was again discharged and the hamorrhaege stoped by a compress of Lint: as it returned again Mr. C only supposed the artery of the bulb only half divided and found it in this state divided at quite with a Lancet, this stopt the haemorrhage but the Patient was so weak that he died in a short time after - Another inconvenience is the formation of a false passage. when a Caustic bougie has been used without relieving the Patient. it may be supposed that the Caustic has acted upon a neighboring part instead of the stricture. in this case a large bougie must be used whose end will not enter the false 223 passage but it is a far better way to pass a a piece of caustic in a catheter with the end cut off: this at first will go into the false passage, but if it is then drawn back and passed straight forward it will go to the stricture (it may be easily felt when in the false passage). When drawn back the point of the Catheter should be elevatd before it is passed forward - The Edges of the Catheter round the caustic should be defended by a thin coat of wax to prevent injury to the Urethra - Another inconvenience is the bursting of the Urethra, this will sometimes happen after caustic has been used and the symptoms of stricture very much relieved by: When the Urethra bursts the urine will insinuate itself into the perineum & scrotum and must be discharged by incision If the patient has not a very good constitution it generally proves Fatal - If a Caustic Bougie is kept in for more than a minute it will bring on suppression of Urine on the Treatment of Fistula in Perineo brought on in consequence of stricture. This abcess will take place even as far as opposite the Fraenum it then requires the same Treatment as in perineo, and when it has 224 extended into the scrotum it is particularly necessary as soon as you have found out the complaint to make an opening into it the earlier the better. The urine accumulates in the Cellular Membrane the skin becomes diseased. and so much so in perineo that unless it is opened it gives much pain. The Caustic Bougie must be used for that purpose. there are some whose Urethra is so irritable that the Caustic Bougie will bring on such irritation that it is dangerous to use it. In these Cases use the Catheter. it is to be kept in constantly. only to take it out for 10 minutes twice a week to clean. The Patient should always make water through the Catheter and not suffered to come the natural way if it does it will keep increasing the extravasation. by attending to these rules the aperture soon closes and in about 3 weeks a complete cure is affected. Mr. C has invented a screw to screw on the other. that is should not run down the Thigh. and to prevent the Catheter from [running down] slipping into the Bladder. there is a stop to the top If there is extravasation in the scrotum it is particularly necessary to attend to these rules. Sudden bursting of the Urethra behind the stricture the Urine becomes 225 extravasated in the scrotum and perineum at the time of being at stool or from other causes make an incision into the part by pushing a Lancet to where the Urethra has busted and let the Urine run out at the orifice. as soon as you have cut down upon the rupturd. part, pass in your fingers. let the inflammation be ever so great provided there is not a very great extravasation in the scrotum it will generally give way to this operation. This Rupture of the Urethra arises sometimes from accident it is to be treated in the same manner - Spasmodic Stricture. A sudden suppression of Urine so as not to be able to discharge a single drop of Urine. This sometimes accompanies the permanent stricture after it has existed some years it is an inflammation of the muscular fibres which surround the membranous part of the Urethra. Cause extended inflammation in walking there appears to be a collection of water there with Spasms upon the muscular fibres, extreme pain which is generally relieved by passing a Bougie but it is very difficulty to do it. for when it is passed. the part by the stricture resists it and force is of no use. let the Bougie rest gently against the stricture for several minutes accustom the Urethra to its use and in a little time, it will slip suddenly into the Bladder. 226 Sometimes the bougie will not succeed then you should have recourse to the Catheter which will always succeed: the common are of a large size. In the introduction of it it may be necessary to change the posture of the Patient. slight causes has been relieved by the warm bath. sitting in a common tub of warm water is the best way - Medicines does not give relief. Opium does not relieve the stricture. prefer a small dose of Antim Tart. to create a nausea, If Opium is given join it with Calomel. If an uneasy irritation of the neck of the Bladder and the patient has a constant desire to void his Urine, give the Hydrarg Muriat cum Decoct: Cinchona. If accompanied with a high degree of inflammation extending into the adjoining muscles. take 14 ounces of Blood from the Arm and apply Leeches to the part. apply a poultice composd of 1/3 mustard 2/3 Flower this will bring on a redness and give relief, this is to be preferred to Blisters as they will prevent the Patient from walking for sometime after. give a Pill composed of Ext Cicuta and Camphor, after Bleeding inject an Anodyne Enema. which will answer a good purpose as it will act on the muscles - Irritability extending to the Bladder occasions constant desire to make water. Open the Bowels, when evacuants have failed, and indeed has every other Medicine. The following remedy which was discoverd lately has never been known to fail 227 and always gives instant relief: make a small Pill from 1/4 to 2 grains of Ext. of Opium. this to be introduced by the Urethra (with the help of bougie or Catheter) into the Bladder where it becomes readily dissolved - It is wrong to use Bals Cobail if there is much inflammation — If a Discharge of [Urine] Blood with the urine. use the following Rx Opii 1 1/2 gr Cicuta gr iÿ Camphor gr ÿ M f Pilul. Calom may be added to prevent caustiveness Inflammation & Enlargement of the Prostrate Glands- The Prostrate Glands is of diseased by a simple inflammation in Gonorrhoea. more frequently so in old People who have indulged very free in Venereal Actions. it begins with a sensation of weight in the perineum occasioned by its enlargement. This also accasions it to press on the rectum and obstruct the Passage of the foeces- a frequent inclination to make water. and is not able to pass it without they kneel and their Legs wide assunder They generally void their foeces at the time of making water- a pain is felt at the end of the Urethra like that occasioned by a stone. The Urine is sometimes of a Whey colour and when suppressd is of a chocolate colour very offensive looking as if it came from a mortified surface- When thus enlarged the prostrate may be distinctly felt by the Rectum 20 diminished: irritability should be lessoned by medicines which act on the nerves as Opium Cicutæ &c, of the local treatment where inflammation is superficial we may apply cold lotions which diminishes it by restraining the vessels that are distended Lead is one of the best as it has a particular effect on the nerves. the application of Spirits by the cold they produce in evaporation constringes the vessels; other may be applied till the parts are frozen - if these application should not relieve the inflammation Leeches may be applied and the bleeding kept up as long as possible, and the cold applications returnd. to after the bleeding. Fomentations and poultices if not applied very hot will not promote suppuration but when the matter is formd. will bring it forward more speedily when inflamation is very deeply seated, it is servicable external inflammation by means of stimulating Plasters 228 On Dissection it is found to be divided into three tumours. one on each side and one behind between it and the Bladder. The valvular projection of the Prostrate pressing one of the tumours upon the Urethra and occasions the stoppage of the water - If the Prostrate is inflamed on passing your finger up the rectum it will cause much pain which goes on sometimes to be production of matter. the Urethra is three times its natural size that in passing the Catheter a surgeon is often deceiv'd thinking he has got into the Bladder as it may be turned to either side without resistance its length from 1 1/2 to inches more than common - this state of the Prostrate is the effects of growth in old men, or of simple inflammation from Gonorrhoea. in this last case it often suppurates or bursts of itself or is burst in passing a Catheter. This at once relieves the suppression - Treatment Take a large Catheter ½ or 2 Inches longer than the common size which is bent towards the end suddenly. When passed as far as the Gland it must be lifted over the tumour by depressing the handle between the Thighs elevate the point over the Prostrate and pass it into the Bladder. if pushed strait on. it would Rupture the Patient. the Catheter is 229 to be left in the Bladder. The French elastic Catheter is best as it does not soften and become rough like the English Elastic Catheter in three or four days it should be withdrawn to try of the passage is restored if not it must be introduced again - the Bladder is sometime so irritable as it will not bear the Catheter to be left in under this state the Patient generally dies - During the Use of the Catheter the Hydrarg Muriat may be given in Decoct. Cynchonae Soda Water has also a good effect in taking off the irritability of the Bladder or Rx [Sali] Carbonat: ʒ1/2 Pulv. Uva Ursi ℈i Ag Pura ℥iÿ Capt Cochl / major sepi et lactes - most dependence on Hydrarg: Murriat for Permanent relief . Bleeding from the Urethra in Consequence of Gonorrhea - this take place when the inflammation runs high and generally offords some degree of relief but is rather alarming to the Patient. tho it serves to lessen the inflammation. but sometimes a large Vessel is ruptured. and much Blood is discharged and in a very short time ye Blood will run back into the Bladder and be discharged from it in the same manner as the Urine The hemorrhaege generally takes place in the Membranous part of the Urethra. it is wrong to use Bougies - Treatment to find its situation pressure should be made along the Course of the Urethra it is best to begin at the Anus and pass along the 230 perineum to the Scrotum. when its situation is found pressure with the finger for 10 or 15 minutes will stop the hemorrhage. In irritable Habits it is sometimes very troublesome and will not stop by pressure with the finger contined pressure is required and it is best made by binding a Roller up with a [illustration] bandage on the perineum Chordee is a very troublsome symptom caused by imperfect erection making the Penis to be crooked to one side. pain very Violent it feels sometimes as if cord was passed along the under part of the Penis. it usually comes on when warm in Bed. it is caused by inflammation attendant on Gonorrhoea which throws out an effusion of coagulable lymph into the corpus spongiosum and cavernosum. and adhesion is produced in some of the cells which are in consequence glued together and prevents complete erection. a knot is generally felt where the obstruction is. there is sometimes another sort where the erection will be complete. we may call a cordee of two kinds. Viz Simple inflammatory or inflammatory with effusion. The pain is so very Violent that he is obliged to get out of bed and lie down with the part on some cold place. As the best Palliative remedy the Patient may apply a bottle of cold water between the Thighs. Treatment in the first place. 231 purgatives to reduce the inflammation give the following Rx Calomel 2 gr Opii gr i1/2 Cicuta gr iÿ Camphor gr ii M Piled hora somni sumendus this will take off the irritation and prevent the imperfect erection in the day time to take the aq. Kali: pine & Soda Water deaden the irritation of the parts. Local Applins. soak the Penis in warm water and apply a poultice during the night if the inflammation is considerable apply Leeches on each side of the Glans Penis - When the Cordee is gone off the knot may still remain. but may be dispersed by the Camphoratic Merc. Ointment - Hernia Humoralis is an inflammation of the Epididymus more than the body of the Testicles this begins with an uneasy sensation in perineo with inflammation appearing to extend to the neck of the Bladder, pain is then felt in the Spermatic cord. and the Heat extends to the Epididymus which at first appears swelled and afterwards to a considerable degree. when the Testicle becomes affected, the scotum is always much so by a remarkable florid redness, its Vessel, distended on pressure great pain. The spinous process of the ilium & the loins are also affected with pain - causes. This is not as has been thought a sympathetic affection. It is an inflammation beginning at the 232 opening of the seminal ducts in the Urethra and extending along the spermatic cord to the Epididymus. The most common cases is the use of injections in the inflammatory state of Gonorrhoea at that time even when the inflammatory state is subsidded. yet if there is pain in perines. Injections should not be used for they will cause inflammation to spread up the Urethra and produce this effect This inflammation is often brought on by the passing of a Bougie. to prevent such effects the parts should be suspended, during its use and so they ought during the Cure of Gonorrhoea cold water injected for a Gleet has occasioned a hernia hummoralis - Treatment the testis are to be well suspended by a Trap (the common bag Trap is very improper) Calomel purges if it is a slight affection this will be sometimes sufficient. If you find the inflammation continue use fomentations but first apply Leeches. Aq. Ammon: Acet as a Lotion. to be kept in a recumbent posture for this blood is sitting in those parts on account of its Vascularity V.S. in Brachio is sometimes necessary more than once. Sal. Amn and Acetum will sometimes relieve the inflammation but if it will not speedily do it it will excoriate the scrotum. poultices and fomentation are to be preferd 233 after the Leeches - If connected with pain in perineo Bleeding is necessary. Emollients in preference to astringents The Testicle will sometimes enlarge & suppurate in consequence of Hernia Hummoralis fomentations are necessary - make a free opening into the part. give the Bark and in general the patient will recover rather speedily but often when suppuration takes place it arises from a scrophulous Constitution. there is but little pain a long time before it points. and a Curdy substance is discharged a quantity of semen is [discharge] emitted from its Orifice. Inject into the sinus the following with an intention of causing a slight inflammation and promote union of the parts rx Zinic: Vitriol gr iv. Aq: Rosae ℥iv M vel Rx Acid: Vitriol gr ÿ Aq: Rosae ℥ÿ ℥ÿ M f Inject there is a fungus projecting from its orifice like Cauliflower of the size of half a Crown it is unnecessary to remove the Testicle sprinkle powderd. blue Vitriol over the Fungus or take it off with a knife and Join the edges of the skin with sutures, draw it over the sinus and it will heal. After the inflammation has subsided there will probably remain an uneasy hardness of the Epididymus. the best 234 external application is a piece of old silk over the scrotum it causes a copious perspiration and in consequence lessons the hardness and enlargement. this has a greater effect than the Ungn. Hydrarg fort Calomel ppr. externally - Emetics are not improper this enlargd, and hardend. state of the Epydidimus is often the source of much uneasiness to the Patient as he is apt to suppose it will lessen the virile power. but it has not such effect Sympathetic Bubo occurs during the inflammatory state of Gonorrhoea: when you find more than one Gland in the Groin enlarged never use Mercury as you are to believe it sympathetic. many of the Glands in the groin are affected. Simply by the application of Aq: Ammon acet and purges they will give way- they never suppurate unless by the use of mercurials which will occasion an increase of inflammation. Apply emplast: sulfur to the part affected - Impotency is in consequence of Gonorrhoea in some cases - Loss of Testicle. This was formerly considered a loss of Virile power. but it is not the case sometimes in consequence of disease. The testicle will become completely absorbed. if you see the other Testes begin in the same way. though the advice is by no means moral, his only resource is to have frequent connection with women 235 Mr. Cooper mentions a remarkable case of a man Castrated 22nd March 99 in June 22. 1802 having frequent emisions afterwards but at length they subsided, but he had erections. at command - [If the Tes] If both Testes are taken away the beard does no grow - Impotence is produced by loss of the retentive power of the semen. tho Vesicular seminatis loose their power of retention: the semen is dischargd. while he is at stool without erection. this brings on great degree of debility and the parts are incapable afterwards of doing their office. this particularly happens if the Body is in a Costive state. The following form has been found very useful. Rx Gum Oliban ℈i Myrrh ℈ii Ferri [pro?ef]: ℈1/2 Bals:Canud qt M Pilul 20 Capti 3 ter quotidie. at the same time the Bark should be given and the cold bath used. - The next cause of impotence is an irritability of the Vesicula seminalis. causing a discharge of semen by whatever excited Venereal ideas as the sight of a fine Woman. or touching the Penis. as soon as the Patient is warm in bed he has imperfect erections and emissions. which bring on great debility and even impair the mental faculties. Tonics only increase the irritability sedatives are the only remedies to be depended on the Path composed of Opium: Cicuta and camphor succeed the best - 236 Emissions during the night alarm some men but provided they do not occur oftener than once in a week or 10 days he not be under any apprehension as it can only then be called natural. If it occurs frequently a Yoke should be put on the Penis (Composd. Of elastic Gum) is the best. this gives a painful sensation when an imperfect erection comes on, Wakes the patient and thus ye discharge is prevented - Treatment- Cold Both and Pilulce Cicuta- Impressions on the Mind- when a person think himself incapable of coition, supposing a wasting of one Testicle from hernia humoralis &c will impede his power: his fears in this case will render him incapable. but if he can overcome his fears he will find that he has sufficient however - Dr. Hunter advised a person in this state to lie by the side of a very fine woman seven nights and to attempt to have any connection with her untill the end of that period. When he promisd, him that he would have power. this he bound himself to observe that after the 4th or 5th night his were passions were so much excited that he acted with effect and got cured - Stricture in the Urethra will occasion impotence in a case under Mr. Cooper, are the powers had gradually abated during two years, at first pain and difficulty was felt in the emission of the semen, at last it 237 it was totally obstructed passing backwards into the Bladder, and no erection from these circumstance and by a slight Gleet. Mr. Cooper was led to suspect a stricture, this he destroyd. by a Caustic bougie and the Virile powers soon returned. Gleet is a discharge continuing after the affection of Gonorrhoea has ceased Glary in general like white of egg; by irritation produced either by walking dancing riding it becomes yellow and sanous will influence the Urethra so much that a cordee will be produced and very difficult to distinguish from Gonorrhoea. the seat of a Gleet is in the same place as Gonorrhoea, but the lacuna magna is more particularly affected. generally accompanied with a stricture it is difficult to determine when Gonorrhoea ceases and gleets begins. The longest period Mr. C ever knew it infectious was after 5 month and 3 days - Treatment by the use of injections and bougies- Rx Hydrarg Muriat gr i Spt Vini Ten: ℥i Aq: Rosae ℥xÿ M Inject: their strength should seldom be exceeded. If stronger it will inflame the Urethra and cause hernia humoralis. Rx Liqur Cupri: Ammon: grx Aq: Rosae ℥i M [illegible] is particularly recommended. Combine the use of injections with bougie, which you are to introduce three times a week. injections 21 as good an application as any for this purpose is an ointment composd. of ʒÿ antimon Tartar and ℈i of Hogs Lard, which rubd. on the skin produces considerable vesication. Ungm. Hellebore Ungm. Sabrina are used with same intent a Vinegar poultice is frequently of use in inflammation of the Joints when irritation fails poultices will sometimes relieve, soap plaisters by keeping up perspiration are usefull in deep seated inflamations of the Joints, if the parts are in an indolent state, stimulation is necessary, and where inflammation is removed a Tonic plan externally and internally should be used On Wounds Wounds are Violent separations of the skin, and sometimes connected with the Parts beneath, if the parts beneath are divided, and the skin is not. it is not to be considerd. as a wound, - wounds are divided into four kinds 1st. the simple incised 2nd the lacerated 3rd, the puncturd. which is the most dangerous. 4th the contusd., - when the parts are disorganisd. 238 produce stricture. Bougie create a discharge the Injections diminish the discharge and Bougies the stricture. Rx Bals: Cobail ℥i spt. Aether: Nitrosi ℥i M Caht M 40 Cochl; parva ter quotidie - when there is Gleet with stricture use the Bougie oftener & Rx Pulv: Cynchone ℥i Bals: Cobail: gr1/2 Elactn. Caht Cochl 1 parva bis quotidie Mercury does no good in Gonorrhoea but Mr. C knew of one exception in a Gleet & stricture A gentlemen had a Gonorrohea after several months of Gleet and stricture and trying all other remedies, it gave way to the following Rx Hydrarg: nitrat gr i spt. Aether Nitrosi ℥i M Capt Cochl 1 Min vis die - An obstinate Gleet is often brought on by an abscess in one of the Lacunae alternately collecting and bursting: it may be felt on the outside of the Urethra. the Caustic bougie should be used to destroy it. An abscess in the lacunae has been known to bring an hectic symptoms and destroy life - External Gonorrhoea takes place at the External part, only at the Glands, from the Glandula ordoriferia near the fraenum frequently attended with Phymosis. An injection with Rx Calomel prop ʒi Aq: Calies ℥iv M Injection [gr] Rx Aq: Litharg : Acet: 30 gutte Tinc: Opii ʒi Aq Rosae ℥iv M Inject. as Phymosis almost always attends : apply spt. Vini : Camph & Aq Pinae to the Penis 239 Gonorrhea in Women. is a disease which affects the nymphae. and extends to the Glands of the Os externum of the Vagina. when it effects the Meatus Urinarius and occasions a great discharge from the lacunae like that from the Urethra in Men. on account of the shortness of the Meatus Urinarius the external coat of the Bladder is affected. this causes an incontinence of Urine. the Bladder contracts as soon as a very small quantity of water is collected - Pain is more excruciating in the Females than in men. the Glands of the Groin very generally become inflamed forming the sympathetic Bubo. Treatment – at first fomentations should be used: at the same time it will be proper to give purgatives. When the inflammn is subsided use the following Injection Rx Alum: 1 dram Decoct: Cynchona 2 H M It is a good way to keep a sponge with this Injection in the Orifice. All the other Injections mentiond. for the Male are proper - Gleet in Females in very common: it is difficult to say when it has commenced. the discharge may be like the White of Egg. yet it may infect - It will appear that a woman may give the Infection & not know of it herself 240 Treatment, the same as in Gonorrhoea sympathetic Bubo is not Venereal tho it sometimes suppurates: Mercury is very improper these Buboes seldom suppurates when Mercury is not given. If usd. they always do - when irritation is the cause several Glands enlarge. but when a Bubo is occasioned by Gl absorption of Venereal poison. Seldom more then one is enlarged - Treatment- The application of Leeches to the part using the Aq: Ammon: acet as a lotion. and purgatives. when inconvenient to the patient to use Lotions a soap Plaister will prevent suppuration - Chancre. milder form. This is an Ulcer occasioned by the application of Veneral poison to the Cuticle. on its first appearance there is an Itching in the part arising from a small pimple which breaks & discharges, leaves a deep Cavity. edges ragged and very [deep] thick with efflorescence & redness round with tumour. it is a point of importance to distinguish Chancre from simple excoriation. attend to the following circumstance. on taking it up between the Finger & Thumb a hardness is perceived like half a Pea. and excoriation is more superficial & no hardness to be felt 241 Chancre in its progress has much the appearance of a pustule in the small poxs - the time of its appearance after coition is uncertain. being as early as 24 hours and as late as 6 weeks. It attacks different parts, most commonly the Glans & prepuce. it caus Phymosis by thickening the skin. it also attacks the fraenum and commonly destroys it. this is the worst species as it very soon makes a hole through. even if the Patient washes immediately after connection the Poison lodges in the hollow of the fraenum and remain there. on the margin of the prepuce chancre is certain to form Phymosis. they sometimes form in the orifice of the Urethra and produce stricture when on the skin of the penis they have the appearance of wart. and also on the Scrotum occasioned by hanging down of the Penis after impure coitions - no Gonorrhoea accompanies chancre and when both are receivd. together chancre appears after Gonorrhoea has gone off - Treatment. It is to be supposed that Caustic will destroy the whole. if small it may do, this is desirable if the chancre attacks the fraenum. but although the sore will heal it does not necessary follow that it will prevent the symptoms. Give Mercury so as to affect the mouth: [O use] the following Rx 242 Rx Calomel prop ʒi Aq: Calcis ℥iv M : the time necessary to cure is about 3 weeks. give Morning for ten days after disappearance of the Cancre. Unctuos applications are very improper and have a tendency to inflame Calomel sprinkled on the sore is sometimes of service but will in general inflame and cause a deep slough. Red precipitate is a good application when the part is very focal and looks black it may be sprinkled or mix’d with Conser Rosae vel Cynosbat - sometimes after mercury has been use for sometime the Chancre appears stationary apply the following Rx argent Nitrat 1 dram Aq Rosae 1 ounce M once a day use this & constantly wash it with the Aq: Calcis & Calomel solution or if you find it indolent you may apply the Argent Nitrat every 24 hours it will cause a dry scab to form over it, under this a skin will be produced and heal it over. in the most lenient kind of [Mercury] canires it is absolutely necessary to give mercury to prevent the Venereal Virus from again breaking out and probably attack the Throat - Phymosis occasioned most frequently by Chancre on the external margin and sometimes in the Corona Glands. if taking mercury immediately desist from its use. it shews a weakly constitution with irritability. the best plan 243 is to order the lotion with Aq: Calcis & Calomel ℥iv if the pain is severe add Tinit: Opii ʒiÿ this will bring on a healthy state of the sore when the inflammation is subsided. then return to the mercury. suspend the penis towards the abdomen with rags round it will with the Lotion. this plan will sooner reduce the inflammation than any other. sometimes Phymosis will not go off when inflammation has subsided. then use fomentations. for they will absorb it and reduce it. the Mercurial Oint will produce the same effect. if these will not succeed then perform the operation which is very simple - make an incision upon the upper part of the penis. pass a director between the Glans & prepuce make a division with the Phymosis Knife midway between the extremity and the Corona Glands. the prepuce drawn back as much as possible before the operation is performed. make a small incision of the inner parts afterwards. this produces no deformity the Bleeding is very slight apply dry Lint. in healing it keep the skin back behind the Corona Glandis & apply poultices - when the skin is drawn behind the Corona Glandis it is called Paraphymosis. both the prepuce & Glans become swelled and inflamed - an 244 effusion of coagulable lymph into them is taking place, in order to reduce the swelling as much as you can. apply at first a cold Lotion with Aq: Litharg: Acet Comp with Spt Vini the evaporation of the spirits producing a greater degree of cold. but it is much better to proceed at once to the reduction it is wrong to perform even any operation. Take the Glans penis with in the palm of the Hand squeeze it so that it will become quite flacid. by the pressure it forces the blood back. but your fingers over and under the penis bring the integuments forward. and pressing the Glans backwards. so as to push it within the prepuce. A poultice is to be put on the part. It is alarming if attended with Chancre and is not quickly reduced. for it will cause Mortification & sloughing Chancre in an irritable constitution instead of mercury having a good effect. it will make it worse, and the Lotion recommended will be hurtful and Penis lost in consequence. A Chancre itself does not destroy the penis but by inflammation with succeeding sloughing together with high constitutional irritation pulse from 120 to 130 Symptoms are the Patient cannot sleep the part swelled the edges look discolord a sign of approaching Mortification 245 this sloughing extends more along the skin than the body of the penis. it will in general soon cause the whole sloughing of the penis untill it reaches the pubis; If you donot arrest the progress at the beginning it will be of no use - abstain from the use of Mercury if you see any considerable degree of inflammation, and attend to the constitution - do not fear the Penis being destroyed - In this sloughing state of the Penis it has been a custom to use fomentations and Poultices, but it will go on worse if any poultice is used. the following is the best A Tablespoonful of Yeast mixd up with Linseed meal - use also the following Rx Calomel: prop: ʒi1/2 Aq: Calcis ℥iv M there is in this a precipitation taking and which is the oxid of mercury. shake the bottle and tun the mouth upon the tip of your finger, the powder will be deposited on it. apply it on the surface of the sloughing sore- Rx acid: Nitros 30 gtt Aq: Fontan 2 H: M p Lotio. this may be injected under the prepuce even with Phymosis. this is as strong as the Penis is able to bear. check the irritability of the constitution with opium. Bark & sarsaparilla 246 give porter & wine. but in this you must be carefull, and regulate it by the heat of the skin - to put a stop to the bleeding sores dip Lint in ol: Tereb. press it for 4 or 5 minutes but where the Vessel is very large use a needle and Ligature. it is surprising with what good effect this may be used. no degree of irritation will be occasioned by it and the sore will heal in the same manner as if not there - The Urethra bursts from sloughing sometimes with a hole opposite the fraenum if a very small part treat is as a hare lip pare the edges and introduce a hollow bougie to prevent the urine from coming through then pass a suture through the hole. If 1/3 of the Urethra is burst it will be of no use. when a chancre sloughs at the Lips of the Urethra it will close its orifice. when the urine is discharg’d there will perhaps be only a small stream or sometimes a total stoppage. the Urethra is considerably enlarged behind the place where it has stopp’d Take a very narrow bladed Lancet push it into the swell’d part of the Urethra. take then a Trocar and Canula, and leave the Canula in the Urethra and direct him to make water through it - 247 When a chancre is seated in the lips of the Urethra Structure of the Orifice is occasioned. a piece of bougie 2 inches long should be worn constantly for a month or more the passing of a bougie or the use of a caustic bougie is of no use in this Case Mercury is not to be given after the sloughing is cleansed. heal it up as a common sore. If you use Mercury as the constitution is supposed to be very irritable it will produce again the same appearance wait untill you find the Venereal Virus has affected another part. if it should then use the proper steps 22 The appearance of the first kind, is separation of skin with hemorrhage, the indication or cure are to stop the hemorrhage remove the coagulated blood from the surface tiring the edges, to bring them together and unite them by the first intention, pressure will in general stop the hemorrhage. if the divided artery is not very large, union by the first intention is effected in the following manner, a small portion of crasamentum adhering to the cellular membrane glews the edges together in a few hours a slight inflammation comes on which causes the vessels to elongate; their ends project into the interposd. blood which this becomes Vascular, in about 10 days the union is effected - the part produced is similar to that destroyed if the skin is divided it becomes skin if Tendon tendon is produced (instanced in a preparation of the tendon of a dog’s leg which is injected and is in the parts produced 248 If this does not succeed use the following powder. Rx Pulvis Sabinae: Cupri acet. (Verdigris) partis equalis M f Pulvis - apply it on the Warts. A saturated solution of sublimate in spirits gives pain afterwards but not at the time. Mercurial Ointment has removed a number not destroying them by its Mercurial power but by its irritating effect The yellow wash of the Hospital (Aq: Calcis and Hydrarg Muriat) the black wash (Aq Calcis & Calomel) - Treatment of the hard kind, Arsenic in powder upon the part of the Lotion : Rx Arsenic: pulv grii Aq Rosae ʒviÿ M f Lotio - the powder applied to surface only is best. the Lotion being applied to a greater surface is apt to effect the system: the whole of the wart separates in two days put a piece of Lint over it or it will cause the same sloughing from the foreskin a liniment is also used . Rx arenic ʒi Ungn. albi ℥i M. this is not so good as the powder as it runs about upon the Glans Sometimes by cutting them off a cure is effected - Chancres in Women. Its most common seat is in the inner side of the external Labiae. sometimes on the nymphae or externum Vaginae and Rectum. Treatment 249 use the Aq. Calcis and Calomel. give Mercury internally. sometimes sloughing as in the Male and from the same causes When it takes place in the Female it does not stop at the Pubis as in the Male but extends up the abdomen the region of the Pubis, and destroying such a surface as they die of irritation. Use Mercurial Ointment with Opium. the Nitrous aud Lotion page. to sloughing sores which would not yield to any thing else the following Liniment has made a Cure Rx Aq: Lithrarg: acetat : pulv Opii. Mil: Rosar os in ʒii Conserv: Rosar ℥i M p Linn. when they once begin to slough they very seldom stop till Death closes the scene. - Means to prevent the Venereal Disease Ablution with soap and water will prevent a chancre but not Gonorrhoea. the the following Lotion may be also used Rx Aq: Kali: purae 20 gtt Aq: Purae ℥i M p Lotio. If not used directly will answer no purpose — Bubo. Venereal Bubo generally tho' not always appear on that side of the Groin on which the Chancre is situated on the penis. generally single in each groin 50 If other Glands are a little enlargd. they do not increase in a good Constitution. when more than one Gland suppurates it shows a scrophulous [constitution] Habit - Symptoms are like those of a common Abscess except more nocturnal pain. Treatment 1st Cathartics to reduce the inflammation. then the Mercurial pill. apply the Emplast: sapon to the part. the Mercurial Ointment to be rubbd in. it is indifferent in which side it is used. Continue the Mercury untill the Gland is nearly of its natural size. When the Bubo does not yield to this treatment and the pain increases leave off the Mercury for three or four days otherwise the Bubo will suppurate. in these intervals give purgatives and Apply Leeches to the parts also the following Lotion. Rx Ammon muriat ʒi aquae ℥iv M. However a Bubo will suppurate. this known by its size and pain being increased and by the redness of the skin. Here use no Mercury but apply Empl Luth. Comp the Patient must live well and take the Bark. when the Bubo is opened use Mercury again - opening of a Bubo. As soon as fluctuation is perceived the Bubo should be opened If not large open it with a common Lancet 251 on the inferior and anterior part then poultice, and in three days again give Mercury. If the collection is large make an opining at each extremity of the Bubo — Bubo sometimes become very red. of a great size and hard. here abstain from Mercury for the constitution is irritable in this case. foment and poultice in order to bring on a suppuration as soon as there is the least fluctuation open and the swelling becomes absorbd. very soon. If the collection of matter is allowed to be great dreadful consequence will ensure - sometimes a bubo after opeining forms a sinus especially if the Bubo is large. when it is opened apply a Blistter to irritate the skin and inject into the sinus Rx Acid: Vitriol 2 gtt Aq:Rosae ℥i M p Ing also Tinct: Canth - also Hydrarg Mur grii Aq: ℥i M by these means inflammation is brought on and the sides of the sinus are glued together and the enlargement is dissipated - Indolent Bubo. sometimes after the suppuration and also after being opened. If after suppuration do 252 not open it but give Mercury for the absorption of the Matter. If after being opened this does not yield to large exhibition of Mercury and use of Caustic, lay aside all dressings &c and expose the part to the air In three or four days it becomes scabbd, and under which cicatrization will go on Sometimes a considerable number of Glands are enlarged from pouparts Ligament down to the second order, two, or three inches below this is Veneral but scrophula and Mercury does harm Give Tonics Sloughing Bubo this resembles sloughing chancre and occurs in the same irritable constitution and is follow? nearly by the same effects is opened- sloughing with much pain comes on but by the cessasion of the use of Mercury. inflammation abates. separation takes place. and the sore heals but from some triffling cause in a little time sloughing again comes on. In this manner the case goes on till by the repeated sloughing the Femoral Artery or Vein is opened and the Patient dies from haemorrhage - Local Applications. the black wash and if it disagrees vary its 253 proportions, should not this at last suceed apply the following Rx Unguent: Hyd: Nit ℥i pulv Opii ʒ1/2 M p Ungn or Rx Mil: Rosae Tinit: Opii : Aq: Lith Acet [illegible] ʒii Conr rosar ℥i M or Acid nitrosi 20 gtt Aqui 1 H M apply this warm and do not exceed the above strength. yeast poultice composed of a Tablespoonful of yeast & a pint of water. Also the carrot poultice one of the above applications will agree with one constitution and another with another. Give Bark with Acid : Vitriol Opium and Wine. If the wine increases the pules which is often from 120 to 130 in a minute. substitute Ale or porter. In a sloughing Bubo do not give Mercury till it has healed except Venereal symptoms in the constitution endanger life After the constitution is improv’d again is evaluated from the Bubo the Gland will project out and lie [like the Bubo] over the skin. Mercury here produces sloughing. give Tonics. applications Rx Argent: Nitrol ʒ1/2 - ʒi Aq : Rosae ℥i M p solutio vis die applicand - apply the blends 254 Wash after each time. with these applications the Bubo is brought level with the Skin and heals – Venereal Ulcers in the Throat . the Venereal poison is absorbed in the groin carried [carried] into the Blood and produces its first effects on the Throat. there are three parts so affected. the Throat, skin, and the bones; and in this order the Testicle is sometimes affected. In the Throat the Tonsil Glands are generally affected. This is the most favorable for only dryness of the mouth follows their destruction, Symptoms. a dry husky feel especially towards evening no pain except the parts are excoriated by swallowing Acids. Another part affected is the soft palate this sometimes takes place from a small Ulcer in the palate itself most frequently in an extension from the tonsils - Symptoms Liquids in swallowing run trough the Nose. when it reaches the bony palate there is a considerable exfoliation and the Uvula is destroyed - Another part is the Fauces at the back part of the Pharynx. Symptoms. the same as in the soft palate - Another part is the inside of the Pharynx. symptoms. no visible venereal symptoms Horseness so that you can scarcely hear the Patient speak. from irritation 255 of the Epyglottis. Coughing and expectoration of of Matter mixd with blood. no pain in the chest but in the Throat. There is great constitutional irritation and wasting of the Body from which the disease is frequently mistaken for Phthisis Pulmonalis. Treatment when in the Tonsils or Fauces the same kind of Treatment is proper. Rub in Mercury & give Hydrarg Muriat internally and use the following Gargles Rx Hydrarg: Muriat 2 gr Aq: font ℥i M dip a probe with Lint wound round it into this Gargle and apply it to the part- sometimes enlargements of the Tonsils are accompanied with scrophula dip the probe as above in the following Gargle Rx Acid Nitrosi 25 gtt Aquae 1 H M give also Mercury. If not Venereal give the Murialic Acid & Bark- should this not succeed puncture the tonsils 1/2 a dozen times and if scrophula use the Acid wash the enlargement soon disappears. if sloughing comes on leave off Mercury and apply p Boracae over the whole sloughing surface likewise mill: eruginis & Nit: Acid Gargle the constitutional treatment must be the same as in sloughing of the Penis & groin- Treatment in the soft palate the same as in the Tonsils. 256 Treatment in the Bony palate apply the following to the edges of the sore. Rx Acid Muriat 25 gtt Aq: fontan 1/2 H M this acts chemically on the bone and removes it without exfoliation - If in the Larynx give sublimate early and fumigate twice a Day Apply a Blister externally to abate the inflammation Venereal Eruptions are distinguished from other cutaneous eruption by their copper colour a brown crust over their surface and under this crust a sanious pus or serum. This eruption first appears on the Breast 2nd on the Face and very often crust and eruptions hang on the Hare and the head is sore. after other parts of the Body becomes affected. they are as large as half a Crown other times not larger than a flea bite. yet all possess the same copper colour and are attended with little pain except an itching sensation in the evening - the pain is great when the eruptions are large and have ulcerated Treatment. In addition to Mercurial frictions give sublimate internally. Local treatment is unnecessary except the eruption has ulcerated the crust of the eruption is the best covering taking this crust off disposes it to Ulcerate. If Ulceration has taken place with pain (and not unless that pain is very great) 257 apply sublimate and lime water. Rx Pulv: Opii 1 dram Ungn. Hydrarg: Mit ℥i M These eruptions sometimes became Phagadonic Ulcers most commonly situated in the Groin after Bubo they are so called from eating away the parts as they advance. Character A deep sore with the edges of the skin hanging over. the surrounding skin is of a copper colour inclining to a purple. Treatment Rx Argent: Nitral ʒi ad ʒÿ Aq: Pura ℥i M p Lotio wash the sore and surrounding edges with it till they become white every morning - also the Calomel & Aq: Calcis. to use the oxid of Mercury which settles at the bottoms by these means the worst kind of sores are cured. give the following Rx Pulv: Cinchonae . sarsaparilla aci ʒ1/2 M p Pulvis ter qutidce ex Vino Rub Allow the usual beverage of Wine & Spirits After the skin the bones become affected 1st the Bones of the nose: small chancres form upon the membrane of the nose, soreness across the bridge of the nose and pain upon pressure blowing the nose forces out scabs. after there is a discharge of blood & matter. the Breadth is offensive sometimes a considerable portions of bone separate at the vomer and os nasi: the osa nasi will sometimes come down the nostrils 23 produced as vascular as in the other parts) to this rule there are to exceptions, muscles if divided are not united by muscular but by tendinous substance; Glands when divided are united by an intervening substance which never becomes Glandular: in old persons the cartilage of the ribs if divided is united by bone, but in young person it is united by cartilage - union by the first intention will take place between other substances, for if the scalp is torn and replaced it will unite to the scull - the periosteum of the bone will do the same, skin will never unite to cartilage; it will grow together over it, and like a joint is furnishd. with synovia, how much so ever parts may be divided, they should never be separated for they will or may unite- It was the custom of old surgeons when a part had been much separated to cut it away this very much prohibited the cure, and when the bone was exposed as in injuries of the scalp, it produced very troublesome exfoliation - The following care prove 258 and at other times make an opening through the bridge and fall away. Timely attention prevents the latter. Treatment Rx acid : Muriat 1 gtt Aq: fontan 1 H M p Lothi The patient to pour a little of this on the Palm of the hand and sniff up his nose this cleans the sore and quickens exfoliation at the same time use the Mercurial plan To prevent external exfoliation which causes deformity, as soon as the skin becomes inflamed pass the forceps up the nostrils and bring away the loose os nasi: the nose sinks a little - Venereal Diseases in the Bones. Symptoms. Dull pain in the bone especially towards evening and increasing when warm in Bed. these nocturnal pains distinguish it from Rheumatism. soon after a prominence small and painful to the touch appears If the node is left to itself it goes on to suppuration, a glary fluid is formed, in it which by a long inflammation becomes purulent Existence of fluid is known by the redness of the skin. Matter forms in the Bone and not between the bone and periosteum Nodes are situated chiefly in the center of the Cylindrical bones. particularly those that are subject to Vississitudes of weather as the Tibia sometimes the clavicle and sternum. 259 Treatment. Besides the Mercurial plan local means are frequently necessary. soap plaisters to the part lessens the pain &c When there is much inflammation apply a Blister to the part before you give Mercury - nocturnal pains are lessened by wearing fleecy hosiery and woollen stockings during day - If a Node contains fluid do not be hasty to open it for exfoliation will ensue and the cure take up many months. if there is not inflammation the Glary fluid is absorbed by the use of Mercury and the periosteum again adheres to the bones - If suppuration has taken place leave it to Burst of its own accord. These effects in nodes are more frequent in the cranium than any other part: where tumours containing fluid form upon the cranium excite mercurial action quickly and if the skin is not red the fluid will be absorbed - Symptoms of Venereal Disease Universal pains in the Bones distinguished from Rheumatism by being more nocturnal not affecting the Joints like Rheumatism but the Bones: no nodes attend this pain Venereal Pains require a longer course of 260 Mercury than nodes. small moveable venereal tumours are found sometimes in the cellular membranes. in Various parts as large as small marble. They appear like Glands but are quite distant from their situation. there are nocturnal pains which are very difficult of cure. taking 9 weeks under mercury Another situation in the Testicles this is quite different to hernia humoralis in Gonorrhoea, it is an enlargement of one of Testicles- cure Mercury – sometimes in Venereal diseases there occurs after a clap a red line extending from the lips of the urethra along the rapha to the Anus, and has the appearance of Erysipelatous inflammation. Care by mercury Another spasms of the abductor muscles of the Eye drawing the Pupil to one side quite within the socket. Cure mercury – The Venereal disease may be contracted without the contact of the organs of Generation Venereal Matter to the scratch on the Finger produces a Chancre on the part with very Violent inflamation. the absorbents are inflamed to the Axilla. where a Gland becomes enlarged with constitutional irritation so as to endanger life the sore puts on a sloughing appearance 261 Treatment. Apply Aq: Calcis & Calomel. Subdue the inflammation by the antiphlogistic plan. and then give mercury - General remarks on the disease & on the effects of Mercury upon the Body. the Venereal disease only effects a few parts of the body viz the Urethra. the surface of the Glans penis. the first Gland in the Groin The Throat. the skin, and Bones. the Brain the different Viscera - and all the principal Vital organs are not [illegible] effected - Venereal symptoms are divided into primary and secondary. the Three primary are 1st. Gonorrhoea 2nd. Chancre. and 3rd Bubo - The Three secondary are 1st. Throat 2nd skin. and 3rd Bones. however Bubo is not always primary but where there has been no chancre. It is possible for a Bubo to be Venereal altho there has no disease upon the penis - Mr. Hunter has considered the Venereal complaint to be merely a local disease. that is unattended with Fever Mr. Cooper denies it and advances the following arguments. viz that there is a regular exacerbation every evening and that the pulse are quicker &c 2ndly that before 262 the appearance of the Venereal disease and even after he feels unwell having a feverish paroxysm every Evening - Mr. Hunter also says that a child at the Breast of a Woman having the Venereal disease cannot catch the infection, To this Mr. Cooper is Certain to the Contrary. some persons have not susceptibility to receive the Venereal disease altho they may have frequent connections with foul Women. some persons are susceptible only of the affection of gonorrhoea and no other form, as Chancre or Bubo. Persons who have been much on the Town escape the infection when at the same time a person from the country having connexion with some woman will catch the disease. In healthy constitution the Venereal disease is unattended with inflammation or very little: when there is much inflammation mercury disagrees and the disease is more difficult of cure. Mr. Cooper says that Gonorrhoea is not truly Venereal: chancre cannot produce Gonorrhoea nor Gonorrhoea chancres The Venereal Disease in the Throat often takes place without chancre or Bubo. the Poison frequently gets into the Blood and affect the Throat without affecting the 263 the Urethra or Groin- Matter taken from the Throat and inoculated, does not produce the Disease. the Matter by passing the absorbents becomes changed in its nature Matter from Bubo, will not produce Bubo - Effects of Mercury- Mercury effects a Fever in the constitution throughout. which action overpowers and at length destroys the Venereal action in the particular parts. Rule of Cure. The cure of Venereal Disease does not depend on the quantity of Mercury used nor upon the action it excites in a given time but upon the Action being supported for a length of time To Cure a Chancre the Mercurial Action should be kept up for three weeks. To Cure a Bubo from three to four weeks, none of the secondary symptoms are cured under 5 weeks. some of a peculiar habit require 11 or 12 weeks. The Patient should rub in from 12 or 14 times for a Bubo. 2 night, and missing one and sometimes every other night. chancre may be cured by nine times 2 nights and missing one - some persons require much more Mercury to affect the constitution than others some are 264 not affected at all. such persons are of an indolent and scrophulous habit in such cases when afflicted with scrophulous symptoms give the Patient Mercury. keep him warm and let him live upon a cow diet as Liquid Aliment &c. putting the feet in warm water will quicken the circulation - In summer Mercurial Action is sooner excited than it Winter - Also during friction it is a good plan for the Patient to immerse his Legs up to the knees in Water as hot as he can bear it. the warm bath quickens the Mercurial action - A Woman that gives suck cannot be salivated let the amount of Mercury be ever so great-. on the contrary some persons are very soon affected especially those of irritable habits and quick pulse Calomel :3 gr scammon 5 gr has been know to excite salivation, In stout and strong constitutions a 1 dram of Ungn. Hydrarg : fort rubbd in for two or three nights will excite mercurial action while those who seem thin and weak are not at all affected - those having a quick and small pulse are most easily affected, desist. from the use of Mercury when it 265 excites much Fever. there is always a slight chill down the back when it begins to act. if the pulse is quickened and there is a slight fever leave off its use likewise if there is much sweating for if it does it never affects the system. passes off and injures the health. Give Bark and Vitriolic Acid till the sweating ceases. some persons are very quickly salivated without effect on the constitution is they have no soreness of the gums nor swelling of the cheeks Country Air is proper for such persons. In London and in all large Towns there is frequently sloughings of the Venereal Sores which hinders The Cure - here leave of Mercury & give equal parts of Bark & Sarsaparilla, and a considerable quantity of opium. Country Air is the best. after you may give Mercury when the debility of the constitution is gone off - Forms of Mercury. the best is Mercurial friction. begin with Ungn. Merc fort as before directed till the Mouth is affected 266 and as soon as it is affected 1 dram every other night increasing on diminishing it according to the effect it produces on the constitution carry it on progressively untill it produces considerable effect towards the end. you may let the patient walk about for the first three weeks of the course, then let him lay by for a fortnight by this means you will obtain a permanent Cure Next the Blue Pill composed of iÿ grains of Quicksilver and 1/4 gr. of Opium this taken every night and morning Increase the dose if necessary : Opium prevents it from purging. Calomel & Hydrarg Muriate should not be given as they run off by the bowels &c- Calomel is only required when the Mouth is difficult to be effected. This form of Mercury agrees well with some and not with others - next Rx Hydrarg: Muriat grÿ vel 4 Sp. Aether Nit ℥ÿ M Capt. corhl i paru bis terve die. this produces a slow effect upon the system and at the same time improves the health - when the effects of Mercury continue and the salvation does not stop. Rx Argent: Nitrat gr ÿ Aq: Purae ℥iv M the mouth to be Gargled with a Tablespoonful of it. three times a Day its Astringency Braces the relaxd parts 267 The infusion of Roses cum Acid Nitrosi is also useful. at the same time give wine and expose the Body to cold air. the Patient should be careful of catching cold. Mercury has been said to pervade the system in such a quantity. that even the sweat. the saliva. the Urine and Blood contain’d it Mr. Cooper was very anxious to have these experiments tried and it is found by the most accurate chemical tests that it is not true. he took from the arm of a Person in a state of salivation 6g of Blood not the 560 part of a Grain was found in it- A quart of saliva was then tried in which there was not the smallest quantity found: also he took a quart of Urine and there was none there – the effect produced on the Gold in the Pocket is in consequence of the Mercury hanging upon the Patients hands, we may therefore conclude that its nature is altered from pervading the system- Exema Mercuriale This Disease has in some instances proved fatal- Symptoms. Eruption upon the Belly and Thighs. The Eye Lid sometimes inflamed when it affects the Bowels the Patient falls a Victim to the Diarrhoea sometimes 24 the practicability of uniting parts when they have been quite separated- A Gentn. well known by Mr. Cooper. was when a boy playing with a mastiff. the dog flew at him and caught hold of the lower part of his nose and tore it so that it only hung by the skin of the lower part, it was immediately replaced by straps of sticking Plaster being secured and supported, it united so well that the cicatrix is not to be easily perceivd A lady had the lower part of her nose nearly separated by her head being thrust through the widow of her carriage in which she was overturned, it was united by the adhesive plaster and as perfectly as the above case- parts quite separated will if put together will not only unite but grow after their union- Mr. Hunter made a whimsical experiment, he wishd. to try if inserting the Testes of a Cock in the body of a hen would produce any sexual alteration. he did so, and although they did not produce any 268 the whole body is covered. Debility is extreme These eruptions are covered with a crust giving out and odour. When the Patient stands up the crust falls upon the floor and appears as if bran had been scattered sometimes it only Partial upon the Thighs If you scrape off the crust there will be an extreme discharge from the sore. the scrotum is also affected - Treatment. Sulphur internally. Tonics warm Bath. Aq: Lith: Acet. comp has failed. The best mode is country Air Tonics. and the following Lotion Rx Hydrarg: Muriat gr ÿ Aq: Calcis ℥ÿ M fs Lotio this is the yellow wash on the Aqua Phagedonica. the Patient should be wash’d with it from head to foot. it Produces no Mercurial effect - Introductory Lecture Surgery consists in proper Remedies to external disorders, and in performance of Various Operation. It is divided into principles and Practicals - In simple Fractures the Surgeon ought to keep the parts in Opposition. and in Compound Fractures the extremities of the bones are exposed with a bruise, and sometimes splinters which must be carefully removed. It is necessary to bring the two edges together: but If you do not succeed you then promote discharge by warm applications: Granulations follow and the cavity fills up when parts are bruised a sloughing takes place. which requires particular attention. In these cases nature herself will do a great deal - Index Page On Accidents - 1 On the Progress of Inflammation - 8 On specific Inflammation - 13 On Wounds - 21 On Lacerated wounds - 29 On Mortification - 37 On Injuries of the Head - 43 On the effects of compression of the Brain - 49 On Trepanning - 53 On Cataract - 59 On Couching - 68 On Fistula Lachrymalis - 72 Wounds of the Throat - 76 Wounded Arteries - 78 Dtt. - Joints - 79 On Hydrocele - 81 On the Operation for Hydrocele - 86 On Dislocation of the Vertebrae - 91 Page Dislocation of the Clavicle - 92 Ditto of the shoulder - 93 Ditto of the Elbow - 95 Ditto of Wrist - 97 Ditto of the Hip Joint - 98 Ditto of the Patella - 101 Ditto of the knee Joint - 103 Ditto of the Ankle - 105 Incysted Tumours - 107 On diseases of the Testicle - 108 On Aneurism - 112 On Fistula in Ano - 121 On Amputation - 123 Ditto of the Metatarsal - 124 Ditto of the Leg - 125 Ditto of Thigh - 127 Ditto of the Wrist - 127 Ditto of the fore Arm - 128 Ditto of the shoulder Joint - 129 On Diseases of the Female Breasts - 130 On Hydatid Tumours in the Female Breast - 133 Page The Operation for Schirrus Breasts - 133 The Method of Introducing the Female Catheter - 134 The Method of Introducing the Male Catheter - 135 On Opening the Temporal Artery - 135 On Lithotomy - 136 Method of performing the Operation in Male - 138 Ditto in Female - 142 On Suspend Animation - 143 On submersion under Water - 143 Suspension - 143 Introduction of Noxious Air - 144 of Extraneous bodies - 145 Means of recovery - 146 Bronchotomy - 147 Operation for Suppression of Urine - 148 Of Calculi in the Urethra - 149 Cancer of the Penis - 153 Amputation of Dtt - 153 On the Hare Lip - 154 Page Operation for Hare Lip - 155 Of Nasal Polypi - 156 Operation for Dtt - 157 On Dropsy & the Method of Operating - 159 On Scrophula Character of Scrophulous Persons - Treatment - Tabes Mesenterica Scrophulous affections of the Joint - Treatment - Scrophulous Hip Joint Ulceration of ye Vertebrae Scrophulous Ophthalmia Testicle On Gunshot wounds Treatment Burns & Scalds Sprains - Fractures - Compound Fractures Wounds of Veins Page Wounds of nerves Wounds of Tendons - Wounds of the Abdomen Wounds of the small Intestines - Dtt. of the large Intestines Dtt. of the Liver Dtt. of the Gall Bladder Dtt. of the Spleen Dtt. of the Chest. Dtt. of the Lungs - Dtt. of the Heart. Tix. Doloreux - On Gonorrhoea The seat of Gonorrhoea Treatment - Stricture the seat of Stricture Treatment for Stricture Use of Caustic Bougie Spasmodic stricture Irritability extending to the Bladder - Bloody Urine Inflammation & enlargement of the Prostate Gland Treatment - Bleeding from the Urethra Chordee - Hernia Humoralis - Sympathetic Bubo - Impotence - Loss of testicle - Emissions & Impressions &c Gleet - Seat of Gleet - External: Gonorrhoea - Ophthalmia occasioned by Dtt. Gonorrhoea in Females Gleet in Females - Chancres Sympathetic Bubo Phymosis - Paraphymosis - On sloughing - Warts - Page Chancres in Women - Opening a Bubo - Indolent Bubo - Sloughing Bubo - Venerea Ulcers in the Throat - Page Venereal Eruptions. Dtt. Diseases in the Bones Symptoms of the Venereal Disease General remarks on Dtt - Exema Mercuriale - 25 change of that kind, yet they grew and were filled by an injection thrown into the surrounding part- the spur of a young cock being inserted into the comb will grow to the same size as on the Leg- A preparation was handed round the theatre in which a human tooth had been inserted into the comb of a cock and the periosteum of the Tooth was so firmly united that it may be forcibly pulled without any fear of the separation - A Tobacconist in the Borrough had the first joint of his finger cutt off, it was replaced by Mr. Lucas and the soft part united, the nail grew, but the Phalanx exfoliated at the Joint of the finger- soft parts will readily unite on account of their admitting the elongation of the vessels, but hard parts will not - Mr. L. Bell in his fist addition of his system of surgery ridiculed the idea of uniting separated parts, but being in London and seeing the instances above mentiond. he was convinced of the probability of uniting them and in the subsequent 26 editions of his surgery ingeniously confessed his error - A curious operation lately common among the natives of India proves how parts that have been divided may be united. It was the custom of Hydor Ally and his son Tippoo said to cut of the noses of their prisoners to remedy this defect a piece of wax nicely moulded to the shape of the nose is applied to the part and a piece of skin the size and shape sufficient to cover it is cut from from the forehead and is turnd. down over the wax nose, the upper side of the skin is placd. outwards, it is united to the forehead by a small slip left undivided and the edges are inserted into each of the artificial nose, the whole is firmly united in a short time, the strap on the forehead is divided and no one could distinguish the artificial nose from the natural one; the turban hiding the cicatrix on the forehead, the union by the first intention takes place sooner on the upper extremities than 27 in the lower, as the circulation is stronger in those parts, for the same reason it is more difficult in old persons where the circulation is weak the Vessels do not elongate - the impediments to the union by the first intention are irritability of constitution where suppuration takes place, introduction of extraneous bodies ligatures the division of many absorbents, as in transverse wounds of the groin where extravasated lymph prevents union of the parts by the first intention, to promote this union we should not open the parts after the first dressing for ten days or a Fortnight if they are not painfull. if they are exposed too soon inflammation comes on and the cure is protracted - of the importance of union by the first intention as soon as that is effected the danger is over, its quickness [illegible] takes place in as many days as the same wound be weeks in healing by the other means- in the old method of amputating when the Limb was cut 28 off strait, lint and flower applied to the stump the discharge was very great, suppuration frequently took place and the patients frequently died the present method of applying adhesive plaisters soon produces an union and it is very seldom that any bad effects follow amputation, the method of applying the adhesive plaister may be used whenever the Bone supports the parts as in the scalp, neck, longitudinal wounds of the limbs &c &c Wounds of the face if the muscles are divided require sutures as do wounds of the throat, triangular wounds of the extremities, deep transverse wounds of the muscles all require sutures are described in old books of surgery but only two are admitted in the present practice the interrupted and the pulled the first for the wound, above mention'd, and the last for long wounds of the abdomen we should always be carefull to introduce as few sutures as posible - 29 On Lacerated Wounds Lacerated wounds are very little different from the incised, they bleed less, extraneous bodies are frequently introducd., it is difficult to remove them, but necessary if parts are healed by the first intention without removeing them abcesses will ensue, A man had lacerated his scalp by a fall from a scaffold the part was laid over the scull and union took place, matter afterwards form,d in several places, and many small pebbles workd. out - Lacerations are most dangerous in the tendinous parts and frequently occasions lockd. jaws, attempt to produce union by the first intention but if inflamation comes on change your plan to poultices & - contusd. wounds are dangerous they disorganize the parts and hinder the circulation, blood is extravasated in the cellular membrane, inflamation & mortification 30 ensue, these wound are not to be united by the first intention - poultices should be applied to the wounds, and if sloughing comes on hot fomentation should also be applied, as they generally expedite the process of the sloughing, if the inflammation goes on Leeches should be applied, and the swelld. part of the limb should be bathed with St. brine; Camph, as the process of sloughing is attended with irritation, Bark &c should not be given. Opium given in saline draughts will give great relief when the inflamation has subsided, then Bark wine and strengthening remedies should be administerd, - We ought to observe where the process of sloughing is the effect of constitution and not accident, Bark may be given, as in this case it is not attended with irritation which accompanies it when from accident - Punctured wounds are the most dangerous, their effects arise from, two causes, the operation of the nerves and absorbents, but the most 31 common effects is inflamation of the absorbent vessels, the symptoms of this is great pain in the part, red lines extend up the limbs the auxilla enlarges, pulse becomes quick and hard the knees swell and become stiff, delirium comes on and the patient dies; - A young man a Pupil in the Hospital had opened the Body of a man, and in sewing it up he prickd. the tip of his finger, in the evening he complain,d of pain and applied a poultice during the night be became delirious the next day he was calmer, but ye following morning the symptoms returnd, and he died about two o Clock, - A man who had puncturd, his finger had suppuration come on in the axilla the discharge from which was so great that it killed him the effects are produced. by the inflammation spreading through a great number of the absorbents, as these cases have occurred frequently in the practice of dissection, it has been a common opinion that putridity 32 was absorbed, but it does not seem to arise from this but more from the sort of wound and constitution of the person puncturd. - this was the case with the person before mentiond, as the Body was opened before putrefaction came on, and we frequently find that the same symptoms occur from accident where absorption of any kind is impossible Mr. Lucas Surgeon at Guy's had all the symptoms and was very near loosing his life by pricking his finger with the point of a buckle, it was in consequence of putrid matter only, the absorbent vessels that receivd. it would be affected in this case a sharp instrument is thrust into the cellular membrane, where the mouths of many absorbents are lodged, it wounds some and the inflammation spreads along their internal surface, these effects takes place in the constitutions naturally irritable. in those who are intemperate, or those who by long confinement to the close and bad air 33 of the dissecting room have acquired a considerable degree of irritability- Putrid matter has been injected into the cellular membrane of animals, which only produces a swelling that is absorbd. in three days & that without any ill effect to the animal The treatment necessary for punctured wounds of this kind, is to dilate the wound apply a poultice to the part, a frequent application of Leeches- Mr. Cooper applied 31 at different times to the arm of patient the limb should be fomented after the application of Leeches, saline medicine should be given, Calomel & [E?t] Cath should be used and if there is a tendency to delirium opium should be given, many persons has been destroyed by stimulating medicines given in these cases. on supposition of putrid matter being absorbd. - Dr. Watts having mett with an accident of this kind, when the symptoms came on took wine very freely and died in 9 hours - Mr. Cooper when a young man dissecting a body at surgeon's hall punctured his thumb, the symptoms came on 34 and he at first pursued a lowering plan by the advice of a Physician who was an advocate for the stimulating plan, he took a few glasses of wine and on finding the symptoms increase he desisted had a very painfull Night, and the next morning found one of his knees swelld. and stiff, he applied a blister and before that relieved him stiffness and swelling came on in the other knee, had he taken a few glasses more wine it would have killd him - A Gentleman fond of dissecting, punctured his hand, on opening the body and being fearful of venereal infection, rubbd in a large quantity of mercurial ointment and died in a few hours- The nerves are most frequently injured by punctures of the slighter kind the punctures happen generally on the feet and hands, and one ever so slight as to be healed before the symptoms come on may produce a lockd. Jaw. Dr. Ludlow lately died of Lockd. Jaw 35 in consequence of running a thorn into one of his fingers, the first symptoms of Lockd. Jaw is a stiffness of the Mastoid muscles, the Jaw becomes lockd, and is generally more firmly so in the beginning of the disorder ; tinitus aurium and chilliness attends, the Joints are affected and cannot be freely bent, violent spasms of the back come on and the body is bent backwards, it affects the muscles of the abdomen, which are hard and do not yield to the touch, the cheeks and corner of the mouth are drawn upwards and the face is much wrinkled, the body becomes stiff, the muscles of respiration are lastly affected and the patient dies, but most frequently he is attackd. with convulsion fits, the intervals of which becomes shorter & shorter till they carry off the patient in lockd. Jaws there is little disposition to sleep, if he does sleep the Jaw relaxes but shuts closely on waking there is frequently a profuse cold perspiration 36 the body is costive little urine is made and the pulse is from 90 to 160, we have not a sufficient number of cases that have terminated successfully to point out in certain mode to proceed on, the warm bath does no good in this disorder, it may in warm climates, but will not in this, opium will not relieve the spasms. A man at Guys Hospital took the first night of his admission 360 drops in three doses the next morning be took 310, at several doses in the evening he took an ounce at one dose at eight o Clock and at 11 in the same evening he took half an ounce at one dose he died the same night the opiate produced no effect on the spams, Brandy and stimulants faild., the removal of the punctured parts has no effect after the symptoms are commenced Tobacco Glysters give temporary relief but weeken to much for repetition Digitalis was unsuccessfull two cases have been lately successfully treated in the Hospital. A man run a nail into his foot, a week after the symptoms came on and he was admitted into 37 the Hospital, the cold bath only was tried he was allowd. a small quantity of wine, when the spasms came on he went into the bath which constantly relievd him the spasms were thus kept down and he recovered – in the second case Tinct ferri:muriat having been successful in some spasmodic affections, it was determined to make a trial of it in lockd. Jaw- it was given in this case in such a quantity as to keep a constant nausea 60 drops was given every ten minutes, but on this making the mouth very sore it was discontinued, and took 5 grains of ferri Vitriol in its stead this kept up the nausea the spasms were restraind, and he recoverd, he went into the cold bath once but it increasd, the symptoms On Mortification Mortification or Gangrene are synonymous terms signifying the death of a part the rest of the body being sound spacetus 38 signifies the act of separation of the dead part from the living, the first symptoms are those of violent inflammations, great swelling skin florid red, violent pain with quick pulse, loss of rest, and delirium, after which the part suddenly becomes easy, small vesications appearing on its surface containing a sanious dark colour fluid, the skin under these vesications is dark purple and insensible, hiccup comes on partial flushing of the cheeks, and if the part is small the Patient may live, if large dies- When mortification is producd in consequence of exposure to cold only the symptoms are, the parts becomes benumd. feels swelld. when pressed, the inflamation arise when the part is warmed, there is very little pain or constitutional affection, the inflammation abates and returns three or four times before the mortification commences, but in colder countries, such 39 as Russia, the parts become at once perfectly white and sloughing off without any previous inflamation, Thus when the mortification has happened the next process is the separation of the dead part from the living or spacitation which begins first by the appearance of white prominent line between the dead and living part which is the rising of the cuticle under which is a small furrow containing a quantity of serous matter, this is the first sign of the cessation of mortification, the Groove is formed by the absorption of the living part, this gradually extends deeper through the cellular membrane and muscle, until the whole dead part is removed, granulations are thrown out from the living part of the groove, by which the dead parts becomes thrown off: the largest arteries in the Body under these circumstances become separated without any hemorrhage for it is prevented by the formation of coagulum 40 very high up in the sound artery – the separation is the same in all cases, from whatever cause the mortification arises: the predisposing cause is debility: by whatever means it is induced; as by continued fever a mortification is producd. of the Hips when laying in bed the same time with Compound Fracture if the constitution is good no such effects follow it is soon producd. in old people as the circulation is most languid - more common in the extremities than the trunk. they being so much further from the Heart. Tentons are more liable to it than muscles as their living power is much less, loss of blood when great especially of stumps when the limb has been previously removed on out of mortification The occasional causes of Mortification are inflammations violent bruises destroying the texture of the part, and a disease of the Heart as Hydros pectoris. means of prevention when it arises from high inflamation, leeches should be applied to the part. cathartics must 41 be administered, apply the poppy fomentation, and stale beer poultice, or wine Lees, or sps. of wine mix'd in the poultice. when the inflamation is a little abated, give Tinct of Opii & the Bark freely every two hours, which however must not be dependd. upon, if the pain becomes less and the pulse not full, wine may be allowed, but better not while there is much inflammation, unless the person has lived very free before, when the mortification has happend. you must give wine freely - opii gr ij every two hours, cinchonæ and confect: aromat or the Bolus with cayenne pepper, fomentations and stimulating poultices, untill the part is separated, which should not be used to long and should afterwards use Turpentine dressings as soon as you can, Amputation ought never to be performd, while mortification is going on nor till the patient has in some degree recoverd, the irritating effects of it on the constitution and never as soon as the mortification has ceased unless from the inconvenient length of the stumps. it is not at all necessary as the parts 42 will separate of themselves - the Bone shortest the muscles longer than it, and the skin the longest of all so as to form every good stump which will readily heal, - In the mortification which arises from cold - sps. wine and Camph should be applied in such a manner that evaporation can take place and the stimulus created by it, be moderated by the cold produced if this does not succeed moderately, warm poultices an fomentation must be used and in cold countries rub the part with snow which produces a certain warmth moderated by the melting of the snow, mortification of the Feet in old people who have lived very high, begins with pain in his ancle and along the top of the Foot, and a Toe or toes appear black, the upper part of the foot florid, red, and then turning black, extending sometimes up to the calf of the leg, it mostly confines itself to the toes, and then the patient generally does well, occurs chiefly in tall people 43 sometimes also from ossification of the arteries this generally arises in people who having livd. very freely are suddenly deprivd. of their nutriment in this state opium is the best remedy combind. with wine and Brandy and fomentations of milk and water- Injuries of the Head First symptoms of injuries happening to the Brain are nausea vomiting, loss of sense and voluntary motion, fœces pass off involuntary and so does the urine in the same manner as when injury is done to the spine - Bleeding from the nose and Ears, and sometimes vomiting of Blood, as it gets from the back of the fauces into the stomach - A labouring slow irregular intermitting pulse, pupil in some cases dilated, in others not, it is sometimes contracted, but then there generally is spicule of bone, driven in and irritating the brain, respiration is sometimes affected with apoplectic 44 terror convulsions sometimes takes place if light, but if there is injury receivd on one side of the Head there is hemoplegic . - strabismus is the consequence of it and deafness: These symptoms generally arise from two causes only 1st, concussion of the brain 2nd pressure on that organ causing inflammation on concussion of the brain - The first circumstance to be attended to is to distinguish concussion from compression in concussion the breathing is not at first affected, nor is the pulse, sleep is easy the effects of concussion have been thought to arise from the motion being so violent at to interrupt the circulation here, but it appears to arise from laceration of the fibres of the brain as appears by dissection, the part about being of a red colour, and a worm eaten appearance, in slight concussions an altered action of the circulation is produced preventing 45 Ideas being formed - Treatment. In slight cases of concussion sickness is of service we are to consider whether Emetics are to be used when other means have failed, the first thing that must be done is to bleed very copiously, and if the pulse are full bleed as long, and as often as twice a day for several days if necessary, so as to bring it to the natural standard, it is much better to take blood from the jugular or from the Temporal artery as it relieves more speedy than from any other part- in slight cases of concussion Leeches may be applied to the Temple, in concussion of the brain it is wonderfull what quantity of blood will be lost before the pulse is brought to its natural standard or the symptoms relieved - A man was admitted into St. Ths. Hospital May 12th 1803 for concussion of the brain he was bled on that day four different times 8 oz. 16 oz 16 oz - 10 oz - the 13th - 10 oz- 14th 12 oz 10th 12 oz 46 in consequence of intemperance he got worse on the 26th and was bled again twice 32 oz. on the 28th - 10oz - 30th 16 oz. June 1st 10 oz. and in the end perfectly recoverd. losing in the whole 152 oz of blood, this was done under Mr. Cooper, directions, and the blood was drawn by his apprentice - drastic purges should be given freely, antimonials to keep up a diaphoresis, Calomel & Pulv Antim ought to be given in preference to Pulv Ipecac:Comp, a blister to be applied to the whole scalp its use depends on withdrawing the blood from the brain, if incission has been made to search for [the] a Fracture we ought to apply a poultice to it, and procure a discharge then heal it directly, mix Ol. Terebinth in the poultice it has the same effect as a blister. no cordials as wine &c should be allowd, on any account. Trepaning here is totally useless and very dangerous, The opening of the 47 Jugular vein will often put a stop to it when it will fail from the arm, particularly in children, the opening of the Temporal Artery is very usefull, and in extremely young children Leeches are very useful, Partial symptoms occurring from the accident are very difficult of cure, so much so, as the most violent ones such as loss of recollection or Epileptic fits afterwards, these symptoms are also caused by slighter injures to the Head, but these may sometimes be moderated and relieved by a seton in the neck, a partial loss of hearing or sight is sometimes the consequence, and which have been cured by Electricity if applied early - loss of memory is almost always the consequence of it - A man was admitted into the Hospital for concussion of the brain and when he began to get better, spoke different language. in short he perfectly lost the English language, so that there was no person in the Hospital that could understand him 48 A woman who sold milk accidentally coming into the ward and on hearing him talk answerd. him, and it it was discoverd, that he had been talking Welsh, & it was a considerable time before he got his English again, this case tho' remarkable as to be scarcely creditd. all the surgeon in the Hospital well remember - A Gentn recievd. a blow on the forehead and was stunned, in consequence he when home and vomitted and felt relievd. by it, the next day he complaind. of pain in the Head the vomitting came on, and for many weeks continued vomitting once a day and was relieved. it at last got to twice and three times a day and continued - the Trephine was applied to examine the dura mater & was found perfectly sound and in a good state; he lost his reason and died soon after in consequence of this slight blow on the Head- This shews that it was wrong to perform the operation 49 On the effects of compression of the Brain Pressure may arise from three causes. 1st from extravasation of blood within the cranium 2dly. depression of bone in consequence of a Fracture 3rdly. the formation of matter in the brain. - 1st Extravasation of blood within the cranium. The symptoms do not come on directly but will in an hour or two, (in concussion the symptoms come on immediately)- the breathing is laborious, pulse full slow & irregular, Extravasation is always accompanied by a fracture: a simple fracture of the scull without any depression or symptoms of injury does not require trepanning or any thing but the antiphlogistic treatment but when there is depression the symptom, of pressure come on and in violence proportionate to the degree of pressure produced. A great depression may sometimes be felt in some of these accidents 50 Without any symptoms of pressure ensuing, but in this cases the depression is only of the external table, and therefore you should not trepan without symptoms of depression - . a great depression will also take place in young children without any fracture or harm as their bones are very soft. - If symptoms of injury to the brain come on or if with the depression there is an external wound then you should trepan for if in this case you do not inflamation of the dura mater will come on with delirium and will kill the patient, but if there is no external wound neither trepan no make an incission nor if a patient has a depression and external opening so that a portion of brain equal to the diminished space is removd. you need not trepan - A person who has once 51 had a concussion or compression is liable to have some of these symptoms come at a future period. he should therefore if possible keep himself quiet and loose from time to time small quantities of blood. Extravasation between the dura mater and Pia Mater or between the dura mater and bone requires trepanning to be performd., the quantity extravasated sometimes is very small and sometimes large but the dura mater is not to be opend. for it will yield when the bony support is taken away inflammation on the Brain from accident, generally comes on about the 10th day after the accident sometimes as soon as the seventh and even as late as the 21st it begins by pain in the Head on the injured side generally it pulsates if there is a wound the slough becomes brown and there is no discharge. the scalp about the injurd. part pits, it is an odematous swelling. the Patient is siezd. with frequent rigors followd by heat the Eye inflamd., cheeks flushed, pulse 52 quick and irregular, body costive, feet cold, and when matter is collecting on the dura mater or Brain, respiration becomes laborious as soon as these symptoms appear the patient ought to be trepanned, when the scalp is cut through, the Pericranium will be found to be detatched and on perforating you will find the matter between the dura Mater and the bone gush out as soon as you make an opening. be careful in puncturing the dura mater when you wish to see whether is matter is lodged between the membranes, it ought to be carefully obliquely. but even here the surgeon has often failed for it is situated sometimes at the basis of the scull and the case is renderd. irretrievable - Mr. C. never knew a case succeed where the dura Mater had been puncturd. for this purpose before you operate bleed freely. if compression accompanies fracture many hours ought not to elapse before the operation use purgative & VS - the object here is to take away the extravasated blood under the bone - 53 On Trepanning There are parts of the Head where Trepanning ought not to be performed as on the middle of the os frontis over its spine except in young subjects where there is none. above the Eye brows where the frontal sinusses are placed, nor over the coronal sagital suture, or lambdoidal sutures on account of the firm adhesion between the Dura mater and the suture, however it may be done here if absolutely necessary, the sagital suture has been objected to on account of wounding the longitudinal sinus. but that is of no consequence as a pledget of lint will most commonly stop the Haemorrhage, and the immediate discharge of blood from the part is often advantageous, the anterior & inferior angle of the os parietale one inch before the Ear has also been objected to as the Dura matrel artery passes throug a foramen in this angle of the bone and if cut was supposed to be dangerous, however the 54 Hemorrhage may be stoppd with a dossil of lint and it does not prove troublesome This angle of the bone is situated just above the zyogomatic arch — To be certain where the situation of the fracture is you ought to make a crucial incission over the suspected part and turn up the edges of the scalp and examine the bone beneath: if you find a fracture you must trace it by making a longitudinal incision slowly and carefully along its course. if a great separation has taken place take care your knife does not slip and injure the membranes - when the operation of trepanning is inevitable and determind, on, the instruments necessary are the scalpel, Rougine, perforator, Trephine, or instead of perforator, a Trephine with a central moveable pin to act as a perforator. and afterwards to fix the crown of the instrument to work steady, the elevator and Lenticular which is a very bad instrument as it separates so much 55 dura mater from the scull as to cause exfoliation, lastly a pair of forceps which are of no use till the bone is sawd. completely round and is loose, but as this is a very dangerous practice it is rarely employd. - After you have made your crucial incision you are to remove the pericranium which should not be separated further than it is necessary to admit the Trephine, for if you do separate more pericranium than you want an exfoliation will ensue, when you use the old instruments you must make a small hole in the cranium with the perforator into which the central pin in the crown of the trephine is to be applied and continued till you have made a grove sufficiently deep to make the saw work steadily & then to be removed otherwise will protrude beyond the teeth of the saw and perforate the membrane, now when the instruments are used you make the perforation and all with the central pin till you have 56 formed a sufficient grove to work the saw steadily; the screw the central pin up and the instrument will work as before. when the perforator is removed and grove deepens, you must frequently and carefully examine with the end of an eyed probe, in the operation you ought by no means to be hasty or you may slip thro, and if a surgeon has once done so he ought never to be suffered to operate again as it may so easily be prevented by attending to the following rules, after have been sometime sawing and when you are you ought frequently to change hands, to prevent the instrument from hitching you will find a small portion of blood come up by the sides of the Teeth of the saw which tells you that you have entered the diploe which is generally about two thirds through 57 the thickness of the bone, you must then proceed with still greater caution and examine the grove every turn or two of the as it is often extremely thin, as soon as you find the bone completely perforated at any one part then introduce the point of the Elevator under it and the circular portion as far as you can and raise it up gently- by using the elevator at this time you prevent any injury being done to the dura mater which will be avoided for the Teeth of the saw will not come in contact with it, and if at this time the bone will not yield, make another carefull turning or two of the circular saw not pressing so much on that part which is perforated- on raising up the piece of bone there will be roughness left on the scull which may be removd. by the elevator as easily as the Lenticular which ought never to be used, but if [they] it does remain it is not of the least importance. If when you have raisd the bone you find an extravasation which appears in 58 large quantity, another piece of bone ought to be taken out in its course so as to expose it rather than pass a probe or scoop under it- there is never any danger in Trepanning when you find extravasated matter under the bone as you will find the dura mater a great way separated from the bone- and when you have removd, the matter apply a poultice over it- In trepanning for depression of the scull the Instrument should be applied on two thirds of the sound bone and one third of the depressd. then pass the elevator under the depressd. portion and raise it up into its natural place resting on the opposite sound portion If any portion of the depressd bone lies under the sound piece that has been removd. it must be sawd. off or two pieces be removd. before you can raise the bone If there is any wound on the Brain endeavor to unite the external wound as soon as posible 59 by which you may probably cause an adhesion between the dura mater and scalp When in consequence of Fracture you find extravasation, and on operating you ought to leave the integuments open by introducing a dossil of Lint and apply poultices to facilitate the discharge of the extravasation- when Trepanning has been performd. for Fracture with depression & the the depressd portion has been elevated bring the edges of the integuments together and unite as much as possible by the first intention by which means you will prevent exfoliation - On Cataract It is an opacity of the crystaline lens or the capsule in which the humours is containd. both producing the same appearance and symptoms, the first symptoms to be noticd. are sparks appearing to the patient moving in the Eye and one of these spots 60 seem situated in the same place, 2nd dimness of sight 3rd. that the patient see’s better in the evening than in the day time, and which is a principal criterion you may Judge this disease by, and further on looking into the Eye you will perceive a pearly appearance, the whiteness does not always come at once sometimes by a speck, sometimes in many parts over the lens - in a strong light the pupil becomes so much contracted that all the rays are thrown on the opaque spot and in a weak light the pupil becomes so much dilated that the rays do not fall on the diseasd, spot which accts for the person seeing better in a weak light than a strong one - the Eye looks sometimes yellow like matter behind the pupil. A patient with a cataract never becomes perfectly blind so that he can always be able to 61 distinguish a small portion of light. The colour is generally uniform and sometimes streakd. which denotes the cataract to be soft or fluid, sometimes it is of a reddish brown or red and then it is difficult to determine whether it is a cataract or not - they vary in their consistence, sometimes quite solid and different degrees of firmness even the entire fluidity which is a rare circumstance The crystalline humour is met with in three states 1st solid and sometimes contain earth 2dly quite fluid and from that called milky cataract 3rdly. a part of each; it can be distinguishd. if solid you will see it streakd. & in cracks, in all children born with cataracts it is fluid or soon after born it is so. in all these cases it is only necessary to puncture it and let it out into the Eye - There is in families a disposition to form catararts so that this disease may in some degree be calld. hereditary - this is a most remarkable circumstance - [illegible] 62 A Gentleman under his knowledge had a cataract and his two Aunts, Father. Grandfather and Grandfather, Brother. had Cataract, many such cases came under his and Mr. Cline’s knowledge of the same kind - Cataract is sometimes loose and in general attachd. to the Vitrous humour when it arises from thickening of the capsule of the lens it may be judged of by the lens appearing much closer to the opening of the pupil, and like a membranous bag streakd, across the iris - the cause of it appears to be a slow continued inflamation in the capsule or the lens itself its structure has also been found completely alter'd and becoming ossified, medicine has generally faild. but you may try the Hydrarg Muriat & Electricity in slight cases - the removal of the cataract has been found the only sure cure when the crystaline humour becomes opaque it prevents the light passing to the optik nerve - there are two operations 63 1st Extraction. the other by putting needle into it and so open it to let the rays of light pass to the optic nerve - on Extraction the instrument used in this operation is a cornea knife which is shapd like a wedge and exactly like spear pointed lancet, the knife must gradually thicken from the point so as to completely fill the incision as it is made; to prevent the escape of the aquaues humour till the incision is made one edge of the knife must cut through its whole extent the other [over] about half an inch, the speculum formerly in use for fixing the Eye is now laid aside as it is to be fixd by the fingers pressing on the globe. 2d a small hook is used to scratch the capsule of the cristalizd. lens, or by a small instrument made like a very small Gum Lancet for infants 3rdly. a small silver scoop is also useful to remove any broken part of a cataract 4th a small pair of forceps to remove the capsule of the crystalizd. lens opaque - To prepare the patient for 64 this operation you ought to give him Calomel purges for some days previous as it will cause inflamation afterwards, convey a probe for some days under the Eye lid to ensure it to inflamation gradually, if the Patient is of a Plethoric habit Bleed, - The Patient should be placd. on a low chair. & the Surgeons Chair should be six inches higher. - Mr. Cooper thinks laying on a table till you have completed the section of the cornea, as soon as you have done this as the posture is unfavorable for the escape of the lens, the Patient should be directly raisd, up, the light of the room should fall obliquely on the Patient's eye for if strong the Iris contracts so much so that it is liable to be torn in the extraction and there is danger of forcing out the vitreous humour by the force you employ to force out the christalline - Mr. Ware is very particular in that respect and it 65 is owing to that he is so successful, the chair to have a back with a pillow behind and the patient being seated the Surgeon sitting opposite resting his elbow on his knee, The assistant is now to place himself and he is to draw back the edge of the eyelid with an handkerchief. to be careful in not pressing the Eye, but upon the bone, if he does he will prevent the operation from succeeding, the Surgeon with two fingers of the left hand is to hold down the under lid and with the other finger press the Globe of the Eye nigh the inner canthus into the transparent cornea a hair, a breadth before the opaque cornea just so far forwards to prevent wounding the iris - the point of the knife is the to be carried a little backwards to prevent its passing between the laminæ of the cornea, you are then to pass the knife quickly across the Eye and push it through the opposite part of the cornea which 66 should complete the section without drawing the knife back, as that would endanger the iris and loss of the aqueous humour as soon as this done the Eye should be directly closd,, and if there are two catarracts you should proceed with the same steps when the capsule of the Christaline [lenses] is found diseased after the extraction of the lens every portion of it should be immediately removd, by a very small pair of forceps it has been known to have been absorbed but that has happened very rarely - The difficulties in the operation are 1st some Eyes are so unsteady that it is almost imposible to confine them particularly those that are born so, 2nd. is when the knife is sometimes pressed between the laminae not the cornea, and therefore a sufficient opening is not made, you may think sometimes that the pupil does not move which will cause failure as afterwards the pupil will become considerably contracted & loose eye sight 67 before you perform the Operation look at the pupil to see whether it has the power of contraction, or whether it has what is called Gutta serena which you may easily perceive by holding a candle before the Eye and then he cannot see it. When the opacity before mentiond, takes place in the Christalized lens there is in this respect a different in opinion whether it is to be taken away or it will be absorbed by scratching. 99 out of 100 will remain opaque if the operation is not performed, and if it takes up 1/2 an hour or longer every capsule that is opaque ought to be extracted by a pair of forceps- the vitreous humour escapes frequently in consequence of irritation during the operation- supposing a quantity of milky fluid escapes you are not to suppose the operation is complete before you examine whether there is any opacity After the operation apply a linen rag over the eye dipped in equal parts of Brandy and Water - 68 the patient should be placed in a sitting posture in bed so that the Blood may not influence the part- to be kept extremely quiet, no light. & very low the Eye is not to be looked at –if very painful apply leeches, purgatives &c but if there is no pain no remedies is requird, - let the linen rag wett with Brandy and Water remain on three days then let the rag hang loose before the Eye and remain for some time taking care the light does not cause inflammation - On Couching Couching is called depression and carried to the inferior lateral part of the Eye with a needle. The patient is to be placd, in the same manner as in the Cataract the needle is to be put in the Centre of the pupil, the patient is to be in a chair and his head to be held 69 by an assistant the Eyelid to be held in the same way as in Cataract. The surgeon is to stand before the Patient with his hand resting on the temple, his Head to be a little inclind. so as not to prevent the light, the under Eyelid to be drawn by one finger and the Eye fixed by another, the operation consists as follows a needle (that was invented by Mr. Hays is best) is to be introduced first 16th of an inch behind where the transparent cornea joins with the opake and having done so instead of passing it transversely so as to cross the Eye, pass it into the center of the Eye, then the point is to be brought forward so as to see it behind the transparent cornea. that you have it upon the cataract let your instrument rest on the cataract - bring the Handle forwards & the point being by that means depressd, you will find the cataract passed from side to side - There are many objections that have been made against 70 Couching amongst the principal are that the Cataract is very apt to rise to its former place, and until Mr. Hay’s treatise upon the subject couching had almost ceased; yet this objection is not a real one as the operation may be performed several times and at last ultimately succeed. Mr. Hay’s perform it several times in one subject Another objection to this operation has been brought forward, that the needle would hurt the cornea retina &c, but this objection will not particularly hold good - when the capsule of the christaline lens is opake perform the operation of Extraction instead of couching – If the cataract is opake and is united to the iris couching ought not to be performd, The advantages of couching are 1st the ease and safety it is performed as you may see the step when the needle passes into the Eye, 2ndly. when it is 71 a fluid Cataract. this is one that there is great advantage over extraction as the humour will escape, in this case you are to pass the needle into the cristaline lens and tear a little - When children are born with cataracts, or have it soon after, the humour is always fluid the extreme mobility in the Eyes of Children prevents extraction from succeeding and therefore couching is preferred - it is necessary in young Children to use a Speculum under the upper Eyelid - A young Practitioner ought to begin with couching in preference to extraction – Mr. Cooper says that he has seen the Operation of Extraction performed may times but never successfully but once and that was by Mr. Ware 3 weeks ago- the Operation of Extraction ought to be performed only by those who have frequent opportunities - but those practitioners who have only an opportunity 3 or 4 in their life ought always to Couch 72 though extraction is certainly in another point of view to be preferrd. - On Fistula Lacrymalia This disease is divided in three stages 1st. It begins with a small tumor occurring at the corner of the Eye just below the tendon of the orbiculus muscle. As the Patient meets the wind the tears run over the cheek which side it happens. If you press the tumor you will perceive streams of mucus comming out of the Puncta Lachrymalia and dropping on the cheek, in this stage there is no pain felt and may remain for several years - in the 2nd stage it becomes red & inflamd in its first it is called uninflamd. in the 2nd it is called inflamd, and it its 3rd state ulcerated - If the Surgeon does noting it ulcerates & then tears getting into the cellular membrane it extends considerably down the rose. The 73 cause is generally from the venereal disease sometimes from scrophula. It has risen but that very rarely from cold small pox pustule in the part scarlatina anginosa - Treatment of the 1st stage When there is only a simple enlargement press on the tumor and empty it entirely, then inject white vitriol water into it by the puncture lachrymator first turning the Eyelid down introduce a briscle into the puncture as soon as you have done this introduce the syringe into the puncture by this means you throw it into the ductus adnasum, and by throwing it in the wash being admitted into the structurd. part and brace it - Sir Wm. Blizard recommend quicksilver to be sent into the sac- if the obstruction is not quite perfect it will do but if it is it will pass down the cheek Another method is to introduce a probe from the ductus adnasum into the lachrymal sac, but this requires in general more 74 resolution than the patient can exert In the 2nd stage it is necessary to open the sac as it is inflammatory. Feel for the margin of the orbit cut about half an inch below the tendon of orbicularis and 1/8 of an inch behind that ridge the cut into the Lachrymal sac The direction you are to cut by is the fibres of the tendon orbicularis, as soon as you have cut the lachrymal sac pass the probe into the ductus ad nasum if you find the obstruction is very strong order a poultice for 24 hours then try the probe and continue in the same manner from day to day as it may be a week or more before the stricture may give way- If after trying a fortnight without success a caustic bougie may be used- after you have succeeded in making a communication pass an instrument which is called stile into the ductus ad nasum to prevent it from closing and you are to leave it there 75 during the highly inflammatory state of the ductus ad nasum, do not leave it in but only pass a probe continually till the inflammation is gone off, as the stile will irritate and therefore order a poultice , if that does not decrease it then withdraw the stile for 24 hours. but it is necessary to continue the use of for 3 months at least- the 3rd an ulcerative state requires for its treatment somewhat of the same mode as the 2nd, when it is ulcerated it is much diminishd in size so that it is difficult unless you have a good anatomical knowledge to open it after cutting open the sac pass a trochar through the lachrymal sac on the os unguis break it down and thus pass it into the nose, this opening is very apt to close unless a bougie is worn for some months, to prevent which Mr. Cooper invented a cannula with the trocar which he leaves in, but so far as he 76 has seen the operation performed in this manner it has very rarely succeeded On Wounds of the Throat Wounds of the Throat have been frequently misunderstood and are in many books of surgery erroneously described on account of the complex Anatomical structure of the part not being attended to from the chin to the sternum is about nine inches, and may be divided into three equal parts, from the chin to the beginning of the larynx is about 3 inches The Tongue & its muscles fills up the front part of this space, the Pharynx the back part- wounds here pass through the tongue and its muscles into the pharynx - the next there inches reaches the whole length of the Larynx, here the Trachea is in front and esophagus behind it, the lobes of the Thyroid gland are united over it. the 77 carotid rtery lies on each side. The most common wound of the throat is in the first divition when the Tongue or its muscles are divided along with the Pharynx, the Breadth passes through the wound yet the air tube is not wounded. Air and Frothy blood passes from the wound. [of] food solid and liquid passes through the wound which proves the air tube is not injured if it was the food would be rejected with violent coughing. Bring the chin forwards, make five or six sutures and completely close the wound, adhesive plaisters is of no use, the sutures must not be passed deeper than the skin. solid food is easier swallowed than liquid. The Epiglottis not performing its office Liquids get into the Larynx and occasion Violent irritation. The patient should have a handkerchief dipt in Lemonade to keep in his mouth to prevent thirst - wounds of this kind 78 are not mortal but as they are generally made by persons who wish to try destroy themselves. They frequently irritate them and bring on bad effects - Wounds of the Arteries Wounds of the arteries requires much attention the symptoms of a wounded artery are blood of a florid red issuing per saltem corresponding with the action of the Heart. Fainting comes on immediately on receiving the wound; during the Fainting the Hamorrhage stops but as soon as the patient revives a little the Hamorrhage returns. They alternately faint and bleed till death ensues. if the artery is small the fainting effectually stops the Bleeding. The artery when wounded retracts and draws itself an inch or an inch & half above the wound. blood is extravasated into the cellular membrane which coagulates 79 presses on the mouth of the artery and stops it, the divided artery contracts as high as the first anastomosis branch. When an artery is thus stopt by pressure on the outside the Blood forms a coagulum within adheres to the coats of the artery and in time becomes vascular, the contraction of the Artery alone would not be adequate to stop the Hemorrhage without the pressure of the coagulum. When even a large artery is stopt if the constitution is good the circulation will be sufficently free not only to prevent mortification but to preserve a perfect use of the parts - On Wound Joints Wounds of the joint even when small are dangerous as a small one lays open an extensive surface the joint having a [se???ing] surface does not easily heal, the cartilage cannot through off matter but must be absorbed and granulation formed instead if Union by the first intention cannot be effected. The Synovia escaping from the wound will often hinder the union by the first intention. If 80 this does not take place in three or four days a violent and dangerous inflammation comes on. The constitutional symptoms runs high. Matter forms at the Joint in different parts, the abcess form and break one after another, protracts the cure and generally render the joint anchylose. In delicate constitutions Wounds of the Joints frequently terminate fatal. - In the treatment of these wounds the first object should be to unite them as soon as possible sutures must be applied in this but particular care must be taken that they pass no deeper than the skin. If deeper they are productive of much irritation likewise the edges must be still further united with the straps of adhesive plaister laid over the sutures afterwards a roller and the wound should not be opened as long as possible perfect use is necessary to the joints, that of the knee and frequently obliged to be opened to take out loose pieces of cartilage formed there - To perform this operation we must keep the cartilages steady by pressure 81 the skin should be drawn back a small incission made into the joint and the cartilage that is loose taken out by a tenaculum afterwards the skin should be drawn each way over the wound that the joint may be as little exposed as possible a suture should be made through the skin to secure it and the wound treated as above - On Hydrocele - By the term Hydrocele is meant an accumulation of water within the Tunica Vaginalis Testes which tunic is loosely reflected over the Testicle in the same manner as the pericardium is over the heart. This disease begins with a Tumour at the inferior part of the Testicle gradually extending round it, as the water accumulates it produces a tumor of pyramidal shape at which time it extends along the spermatic cord until it reaches the abdominal ring - It is seldom a painful disease till it becomes greatly distended the scrotum seldom appears red but generally transparent. In oder to discover its transparency grasp the Tumour at its posterior part 82 Place the patient in a dark room, a candle being placed opposite will discover its transparency. Another mark to distinguish this disease from any other is its fluctuation and the comparative lightness of the tumour Sometimes two tumours are formed one situated at the abdominal ring. The other in the scrotum which frequently deceives the surgeon who supposes it to be a Hernia The fluid contained within the tunic puts on a Variety of appearances it is generally of a nature similar to the serum of the blood sometimes purulent at other times mixed with the red particles of the blood When the Tunica Vaginalis is thick its transparency is destroyed and which generally takes place in tumours of long standing The tunic becomes ossified and which variety of appearances may mislead the most experienced Surgeon. There is often within the Tunic one or more cysts formed as large as a Chestnut the Testicle is commonly placed behind the tumour in Hydrocele if it were otherwise situated it would probably be wounded in 83 performing the Operation, therefore you should be at all times certain that it is so situated before you attempt to operate - In order to distinguish this disease from Hernia desire the patient to cough if it is a Hernia a distention of the tumour takes place but in hydrocele no such distention takes place but, it must be observd should the tumour extend to the abdominal ring some little distention will necessarily be produced from coughing by the action of the abdominal muscles. another mark is this. if it be Hernia and you attempt to raise the scrotum you will find that you can’t readily do it. but in hydroceles no such difficulty appears - Hydrocele may be distinguished from diseasd. Testicle by its weight. Figure and inflamed or red appearance. This disease is sometimes unfounded with hematocele this is an accumulation of blood within the Tunica Vaginalis, it is generally occasioned by a severe blow on the testicle and may be known by the former marks - The cause of this disease is an increased action of the vessels of the Tunica Vaginalis and not a disease of the 84 absorbents as was formerly supposed but these vessels are generally found enlarged hydrocele is said to be treated in a Palliative and radial way. if in the Palliative, all that is required is to draw off the water from time to time which may be done by a lancet or a small Trocar direct the instrument obliquely upwards at about two thirds the length of the tumour after the operation lay a small piece of adhesive plaister over the wound, It is frequently necessary to perform the operation three or four times a year the Trocar should be preferred, in performing this operation a small incision being first made through the integuments with a lancet & give tonics internally combined with mercury a strong solution of crude sal Ammon dissolved in Vinegar and applied to the part is often of service. It has been found that taking a considerable deal of exercise directly after the operation 85 has produced a Radical cure by bringing on a Violent inflammation by which a quantity of coagulated lymph was thrown out and produced an adhession of the tunics - Of the Radical method of cure this may be affected by the process of granulation or adhesion, the latter is to be preferred. - Of the mode of cure by the Seton recommend by Mr. Pott, this is also liable to objections as it occasions frequent but partial adhesion of the Tunic - in the Hydrocele of young children do not be in haste to operate before you have given every remedy a fair trial The operation by caustic is sometimes employed but this like the method adopted by Mr. Pott is liable to objections - The method of applying it is. take a piece of kali purum rub it round the surface to be cauterizd for the space of 10 minutes which will produce an eschar and the operation is finished. This method of operating has been known to fail even in the most experienced hands. in old people it should never be performed on acct. of 86 the inflammation which succeeds being often very Violent producing high symptoms of irritation and sometimes even Death - It is Mr. Cooper opinion that this method of operating should be entirely done away with - The best method of operating in Children is by taking a common needle the same as is used after amputation arm it with a few threads of silk, pass it through the Tunica Vaginalis in a longitudinal direction and at the same time obliquely draw the threads out at the opposite opening and leave them these by acting as an extraneous Body will produce inflammation and in consequence a Radical Cure will be obtained - On the operation for Hydrocele The method of Operating by Injection is in a more general use than any other. this operation is of old date, Sir J Earl improvd on this mode of operating - The instruments required for it is 1st a large and small Trocar for the child and adults, 2nd an elastic 87 Bottle with a turn cock, 3rd a Mixture of Red Wine (1 part water & 2 parts wine) but as Wine is liable to vary in strength the Vitrolated water is now used in the following preparations - Rx Vitriol albi ʒi aq:distillate 1 H ᵯ - with this solution the Elastic bottle is to be filled - make a small incision with a Lancet through the skin at the anterior part of the tumour, the introduce the trocar and cannula - inject a quantity of fluid sufficient only to be applied to the whole surface of the tunica vaginalis testes - this should be allowed to remain as long as the patient can bear. about 4 minutes on an average - When the patient complains of a little pain during the operation the greater will be the succeeding inflammation - and Vice Versa - a small quantity of fluid about 2 drams should be allowed to reaming in - the patient ought not to go to bed until he is obligd. to do so from the violence of the pain in the part and also in the loins - If several hours should elapse & little or no inflammation comes on Mr. Cline directs Wine to be given and taking the scrotum 88 in the hand and rubbing it. In 48 hours the swelling is generally as large as when the operation was performed, it feels solid and pitts on pressure with the finger the skin appears in ridges, you then know that the inflammation exists in a sufficient degree - In the course of a week the tumour begins to subside and in three weeks the patient is generally cured - If the testicle is slightly enlarged you are not to be deterrd from operating for by exciting a counter inflammation the swelling will probably subside - If the Tunica Vaginalsis is inflamed you will know by a bloody appearance of the water when drawn off. you must then use the Injection only half the strength before directed that is in proportion to ʒ1/2 to Hj - Mr. Cooper observes it is very wrong practice to inject a quantity of fluid equal to that which is drawn off, but recommend. if ℥vi or ℥viii of water is drawn off to inject not more than ℥iii or ℥iv of the solution - There is some danger attending this operation for if great care is not 89 used in introducing the cannula with in the tunica vaginalis the injection becomes extravasated into the surrounding cellular substance. the consequence is that the whole surface of the scrotum becomes black sloughs and in 8 or 10 days the patient dies from high constitutional irritation -In a child from 6 to 10 years of age this method of operating may be employed if the tumour is large but in those that are younger it should not be employed - Incision with the introduction of Flower or the seton should be had recourse to in these cases - of Incision - this may be considered as a dangerous operation and in which the symptoms in general run high, but its advantages are that it shows you readily the situation of the Testicle, it also shows you if any cysts are formed on the surface of the testicle - This operation should always be performed when any adhesion are found - if the testicle is found anteriorly the incision must be made on the natural part of the tumour. - 90 The advantages of injection are that when it is properly performed it is comparatively a mild operation. it may fail in the fist instance but if repeated will certainly succeed. and with the Vitriolic injection Mr. C has never known it to fail - but treated with the wine & water it has been known to return at the end of two years An Hydrocele of the spermatic cord may be known by a tumour forming at the abdominal ring - it may be easily mistaken for a Hernia as before observed by its projecting when the Patient cough but in this there is a want of transparency in the Tumour. in this the operation is to be preferred in doing this operate as for Hernia which must be done with great caution as the spermatic artery and veins sometimes run on the fore part of the tumour and the vas deferens behind - should any portion of testines adhere you are to desist as it would be useless to operate, this species of Hydrocele is sometimes contained 91 within an hernial sac in which case the operation by incision is to be preferrd. On Dislocation The vertebrae are so connected that no dislocation can take place without a fracture the consequence of which is the compression or division of the spinal marrow the total loss of sensation and use of the parts below where the accident has happened - in these cases the urine is evacuated by the catheter otherwise it will be liable to bust from the patient, being incapable of expelling the urine - the – the foeces pass of involuntary and when dissolution is about to take place the urine runs off in the same manner - If the fracture happens in the Lumbar Vertebrae the patient may live from 17 days to 3 weeks with some little exception - If in the Dorsal about a fortnight – If about the 6 or 7 cervical not more than a week : if in the 2 or 3 cervical not more than 40 hours. if in 92 Atlas or Dentaba the patient generally expires instantly - . The Clavicula is liable to be dislocated at both extremities the sternal end is sometimes thrown before the sternum in its fore and upper part. when the shoulders are drawn back it returns into its place - Treatment - The shoulders are to be drawn and kept back as much as possible by the stellate bandage which ought to be kept on for about 5 weeks The scapular extremities are sometimes dislocated from the processus acromion it the forms a considerable projection on the spin of the scapula. The shoulder on that side falls to the breast therefore from the sternum to that shoulder is less than from the sternum to the other - Treatment. The shoulders are to be drawn back as in the former at the same time the shoulder is to be raised by a sling. In these cases the pain that it produces by keeping the shoulders 93 sufficiently back is more than Patients will generally admit to and when told that it produces no inconvenience by being left to nature (except that of the incapability of the arm being stretched out so far as the other) they prefer rather to be subject to that little inconvenience than suffer the pain that is necessary for the proper Union of the ends of the bones, which is the reason that it seldom or ever cured - The shoulder. is liable to be dislocated in three different direction 1st downwards or into the axilla-the marks of this is the dislocated side is flatter than the other the arm cannot be raised to the Head and the lower edge of the pectoral muscle is raised above that of the opposite, by putting the finger into the axilla at the same time raising the arm the head of the bone may be plainly felt - Treatment if recently done apply a round towel obliquely from the arm pit of the dislocated side to the top of the opposite shoulder it is to be carried over and then to be fastened by a bandage 94 This extension is to be made above the level of the shoulder, upon the dislocated arm the extension is to be made gradually and kept up for a long time - about 5 or 10 minutes the arm will commonly be reduced - If the arm has been out a long time Poultices should be applied; making two or three attempts to reduce it one after another Another mode of reducing recent dislocation of this joint. Place the patient upon his back then put the heel of your foot into the axilla at the same time having hold of the arm make a strong pressure by the foot and gently turn the arm inwards In this way the arm will commonly slip in - The 2nd dislocation is forwards the Head of the bone being placed under the Pectoral muscle just below the clavicle. The patient is incapable of raising his arm to his head. When the head of the bone may be perceived moving under the pectoral muscle on the arm being rotated the dislocated side is flat - Treatment - 95 To be reduced either by pullies or by the Bandages as in the former - Pullies are best as a greater extension is required The 3rd. dislocation is when the Head is thrown backwards or into the scapula when a considerable Tumour appears on the spine of the scapula if the arm is rotated it can be felt - The same treatment as the first - this seldom happens - Dislocations of the Elbow Joint backwards when the Radius and Ulna are placed behind the Os humeri the coronoid process is placed in a hollow above the Articular surface of the Os humeri the Arm is a little bent - Treatment - Take the Arm in one hand and the forearm in the other. having the knee or some fixed part at the inner of the Joint the forearm being pulled downwards the bones will immediately slip in– 2ndly where the extremities of the bones are thrown [in] laterally, either internally or externally, the same Treatment is to be made use of here, but at the same time the Extension is made by an Assistant press the bones towards the Joint - 96 The Ulna is sometimes dislocated without the Radius, in the case the projection is not so great at the Elbow as when both are dislocated. The Reduction is the same sometime the coronary process is broken off by the irregular action of the muscles. the ulna loosing its support is dislocated backwards and appear in a projection at the back part of the Os humeri - The coronoid process is drawn up by the muscles on the forepart of the Os humeri. This is easily reduced but when the extension is taken off it resumes its place - sometimes the head of the Radius is separated from the Ulna and thrown into the hollow above the external condyle of the Os humeri here the arm is incapable of being either bent or strengthened but still returns supination and pronation - Treatment the best way of Reducing this is first to produce fainting by the warm Bath or Tobacco Glysters. the confining the Ulna by placing the foot to it at the same time forcibly and suddenly extend 97 the arm it is however very rarely reduced The wrist is liable to be dislocated in two different ways, backwards and forwards, it is easily reduced by making an extension of the Hand one way and the forearm the other - There is often a tumour appearing like a dislocation of the wrist which is occasioned by an accumulation of coaguable lymph from inflammation produced by a strain of the Tendons - Apply prepare and Mercurial Plaister to reduce the swelling and afterwards electrify it - There are small tumours frequently appearing at the wrist which is a collection of synovia in saculi Mucosi, these are called Glanglions. They commonly move with the Tendons but are sometimes perfectly fixd. and adhere to the ligaments - These ought never to be opened but are to be dispersed by breaking them which is done by bending the wrist and then they become tense when if struck hard will burst and disappear