11 Theory Practice Physic (front) Surgery (rear) Nosology 1 Diseases of Children 5 Retention of meconium 6 Tumour of the head 7 Aphthae or Thrush 7 Red Gum 13 Strophilus candidus 14 Ulcerated mouth 14 Costiveness 16 Infantile Erysipelas 18 Anomalous Eruptions 19 Crusta Lactea 20 Venereal Eruption 22 Sore Ears 23 Diarrhoea 24a Vomiting 28 Hydrocele 29 Volvulus 30 Constipation with fever 32 Worms 36 Convulsions 46 Epilepsy 49 Chorea 51 Dentition 55 Ricketts 58 Cholera Infan. 60 Tinea Capitis 68 Catarrhal epidemic 70 Gangrene of mouth 80 Chillblains 81 Exposure to extreme cold without freezing 81 Mesenteric fever 82 Cutting frenum 85 Burns 86 Tympanitis 87 Neuralgic aff. of the lower limbs 88 Whooping cough 71 1 Theory & Practice of Physic Nosology Dr Rush condemned nosology but afterwards made use of a system of some sort. We must arrange our knowledge. Dr Ives believes the fundamental principles of the common systems are erroneous Disease is a derangement of some or all of the functions of the body. It is the opposite of health or dis-ease. We must compare it with health. Dr Ives condemns the classification into species general orders etc. as if they were entities or beings instead of merely modes of action Diseases change their seat and their form in the course of their progress Nosologists would have done better than they have if they had imitated the natural classification of the botanists. Very great error is committed in attempting to make the divisions mathematically exact. 2 All the present systems suppose definite diseases with specific modes of treatment this leads to an invariable mode of treatment & to the prescribing for the name of a disease. Still it must be confessed that nosology founded on anatomy and physiology are [latelly] acknowledged that diseases are mere modes of action A classification of epidemics formed upon [remote] causes is equally erroneous as the remote causes are disputed, and unknown Dr Ives divides epidemics into two great classes taxic & ataxic in irritation of the division of natural families into classes The term malignant has sometimes been used in the sense in which Dr Ives uses the term ataxic sometimes for rapid fevers, for those which have a gangrenous tendency & for those which more especially affect the vital fun. Ataxic a morbid state, beyond the power of reactions attacking the vital 3 function not putting on the ordinary forms of fever The first & most important indication in taxic fevers is to moderate the violence of reaction in ataxic, is to produce reaction It may be laid down as a principle that all ataxic epidemics resemble each other Ex. gr sometimes in the yellow fever the powers of life are attacked & prostration or exhaustion continues until death closes the scene. What are called the walking cases are of this kind in which the patient walks about until death. This kind is difficult to describe but when once seen is never forgotten eyes glassy countenance anxious etc. So of cholera of India also of pneumonia typhodes especially as it first appeared in this state It had four distinct varieties of which spotted fever 4 was one. No reaction no pain no heat such cases are said to occur in the plague A person who has treated one ataxic fever is able to manage any other All extreme cases may be classed together under this name, as they are in fact under that of malignant Dysentery of 1814 & 15 mild coma [gentle] sleep no apparent pain stools once in two or three hours not striated with blood etc. etc. when the patient was roused from sleep he said in a faint and indifferent tone of voice he was well immediately fell back into sleep. Yet here was dysentery [although] there was no dysenteric symptom for these cases were beyond question, of the same epidemic as others unequivocally dysenteric The indications were to excite reaction by external and internal irritants and to excite the action of the stomach and bowels by calomel ipecacuan etc. In this epidemic the stomach & duodenum appeared to be principally affected. 5 Diseases of Children Great attention has been paid to this subject within the last 30 or 40 years It was formerly almost entirely neglected owing to the exclusion of the faculty from the practice of midwifery to the prejudices of mothers and nurses & to the indifference of the family themselves Young physicians are more frequently called to the diseases of infants hence the importance of this subject to medical students. In Europe have the physicians been most negligent of this subject The French & Germans less so than the English The European practice differs from ours less so at present than formerly because our constitutions are coming to resemble theirs. Their practice is more mild In general chronic diseases require a milder treatment. Great difficulties result from infants being unable to tell of their complaints yet the 6 other symptoms are more easily understood They practice no disguise or concealment They are not made worse by mental aff. Many prejudices exist e.g. that the child is born with a morbid appetite inherited from the mother which appetite must be gratified This they infer from the natural crying of the child The mother sets herself to recollecting some former longing of her own. Story of a child fed upon this principle with mince pie It had to be physicked severely to save its life The mucous membrane of the al. can. is oftenest affected sometimes spasmodically Be on the watch with regard to the liver. The nervous system is more easily excited from irritation than in adults The vascular system less so. Fevers are generally more irritative than otherwise As a general rule preventive medicine should not be given. Evacuants may be given 7 with great safety Witness the long diarrhoeas & the salivations of dentition which they bear without emaciation The milder purgatives should be used. The drastic are irritative calomel is one of the best. 1st Retention of meconium & its consequent diseases. The meconium is a dark green matter resembling tar Its evacuation should be effected not by medicine but by the first milk of the mother. The act of crying also contributes to this effect. Instead of suffering the nurse to feed the child during the first two or three days the breast should soon be present If the child feeds, it is in danger o f losing the instinct to suck Evacuants are 1 gr. of carbonate soda to a teaspoonful of water until 10 gr. are given is a good cathartic Molasses & water may be used likewise The gall of animals 8 in a good cathartic as a substitute for the childs own bile. It may be given in catnip tea, milk etc. We may use also Decoction of the flowers of the dandelion and of the mullein. The best however is generally castor oil teaspoonfull at a time until evacuation is produce Senna likewise, in conjunction with some aromatic herbs & seeds 1 dr. of these to 4 of senna The operation of cathartics must be assisted by emollient injection & also by fomentations of the bowels & the warm bath. The blue pill may be used. Also 1 gr. calomel & 4 or 5 of chalk repeated once in 2 or 3 hours assisted by bitter & aromatic herbs in the way of injection These last thus will frequently answer by themselves. Blue pill & chalk & calomel rarely offend the stomach These measures must be pushed vigorously & used in conjunction also especially the warm & tepid baths 9 in cases of convulsions from retention of the meconium. Dr Ives has not known salivation produced in infants by mercury. This may be explained by the large quantity of mucous which defends the surface of the intestines and enabling infants to bear large doses of calomel. The abundance of meconium contributes also. Antispasmodics e.g. aqua amm. 3 or 4 drops also 3 or 4 gr. carb. amm. also asafoetida a teaspoonful of the tincture injected in milk & water into the rectum. These may be used Young children are often troubled with hiccups & irritation caused by acidity, which must be corrected by alkalies. Sometimes this must be corrected by regulating the diet of the nurse. If as is occasionally the fact the mothers milk disagrees, as is shown by the [illegible] stools & the obstinate crying of the child, then cows milk diluted with one third or one half water or with arrowroot mixed first 10 a table spoonful of cold & then of hot water in order to make a homogeneous mixture. Children fed on cows milk are more apt to be costive. To prevent this give a little magnesia, decoct. of dandelions etc. Peach tree blossoms are much used as a cathartic, but are too violent. Children are sometimes born with a tumour of the head occasioned by difficult labour This may be distinguished from a tumour occasioned by a defect in the bones of the cranium by a uniform hardness Aphthae or thrush Sometimes accompanied with a typhoid fever Sometimes idiopathic. It is a disease of debility, caused by disorder in the primal viae. In some families all the children are affected with it Among the poor bad air & among the rich too great warmth & confinement are the predisposing causes It is a vulgar but mistaken opinion that all children 11 must have this disorder at some period or other Symptoms 1st languor, then white specks or flocculi in the mouth, which finally affect the aesophagus, the rectum (for the orifices of the tabes are more sensitive) & perhaps also the whole alimentary canal though this is disputed. The white spots are succeeded by others of a darker colour. It is thought to be prevented by giving a teaspoonful of cold water soon after birth & subsequently repeating the remedy [illegible] [illegible] heat good Castor oil is objectionable because it does not affect the secretions & does soften & relax the mucous coat of the intestines 10 gr. to 1 dr. of magnesia chalk cal. Dissolve 4 or 5 gr. ipecac in 6 teasp. water & give one teasp. at a time If it does not evacuate the bowels calomel or rhubarb may be administered. If the ipecac moves 12 the bowels too freely given on a sixth or eighth of a drop of laudanum In case of acidity white decoction consisting of chalk ½ oz carb. pot 1 scruple 1 [illegible] or [illegible] [Comus] [cir] [sericia] & asking [illegible] Lime water & milk may be given for acidity 6 gr. chalk 1 gr. cal. with a little ginger for watery stools or a small quantity of rhubarb instead of the calomel No violen local application should be used It was formerly thought that the disease might be removed by rubbing off the aphthae by a swab of cloth Inflammation of the mouth was caused. A little borax and sugar equal quantities a drachm in a gill of 5 or 6 of [illegible] in [powder] put into the mouth water Or mucilages, of violets (v. pedata) decoc. of sassafras [illegible], or comfrey A small quantity of sugar lead in the mouth may be [illegible] In children more advanced thrush is sometimes a critical termination of diseased action & then frequently a favorable 13 symptom e.g. hydrocephalus Ipecacuanha in small quantities as an alterative is particularly to be recommended Strophilus intertinctus of William red gum papulae Nurses consider it the same disease with thrush Red gum comes from red gown made of [stom] on calicoe The vesicles rarely contain lymph terminating by scales & not attended with constitutional irritation It arises from heat bad air confinement & irritation of primae viae. When repelled followed by bowel complaint & convulsions The patient should be kept clean and daily washed with tepid water. The tepid bath may be continually used & is the most efficient remedy when the eruption is repelled from the skin 14 food Strophilus candidus Papulae with non inflamed base appearing like very small pearls under the skin about half the size of a millet seed continuing sometime Prof. I. has seen it following cholera infantum A close examination is necessary for its detection Reference made to Willan Ulceration of the mouth called canker Sometimes very troublesome called food is a cause Commences with an inflamed point in the mouth The edges of the ulcer inflamed & elevated Child drules much febricula torpor of intestines 1st excite al. can by magnesia or blue pill or calomel. Then use Moseley’s tonic solution. Compound tinct of vitrine (sulph cop. in alc. water of crystals 15 marsh rosemary geranium [rac.] tinct kino internal app [illegible] [illegible] sulph. cop prescription Nitrate silver corrosive sublimate Prof. I’s own case corr. sub. & op [illegible] astringent [illegible] rhus cornus Rx sulph. cupri 10 gr. carb. Peru a dr. given at 1 dr. Hon & dr water 2 touch the part with a pencil violets allied to ipecac So also asclepias particularly A [decumbens] 16 Costiveness in infants A physician is frequently called when the infant is perfectly well with the exception of costiveness. This will produce a variety of complaints e.g. watchfulness, starting, hiccup, & convulsions. Frequently the child is not observed to be unwell until the convulsions come on The remedy is injection. For we can only operate on the al. can. the lower part, & the skin the mouth being closed We must be careful to make our prescriptions for an enema, very definite. Case of a mason’s man hands & knees about 3 ft. off shooting fright, murder Simple warm wat. or milk & water or about a table spoonful of salt or thoroughwort catnip etc. or finally castor & other oils. Sometimes in extreme cases fill the rectum with lard. Sometimes as a nervine a teaspoonful of camphor in a gill of milk. If these do not 17 answer, used the tepid bath. The water should be heating, while the enema is administered. the water should be about blood warm. Be careful not to sprinkle or scatter water in the patient, instead of bathing. Time 5, 10, 15, or 20 minutes As soon as the patient can swallow, or while it is in the bath give calomel For a child 6 months old 6 or 8 even 10 gr. If improper food is the cause 20 gr. are not dangerous for infants will beat full doses of cathartics, but very small of narcotics Various articles of food are used to obviate costiveness. Oatmeal gruel rye-meal gruel, rye bran gruel Castor oil is the best cathartic a teaspoonful or tablespoonful Magnesia is good and may be given in milk Elixir salutis is one of the most common family medicines. Castile soap is a good cathartic but ½ oz or oz is required. The bile of other animals is a good remedy. Blue pill various vig. ext. e.g. fl. of [mullein], peach, dandelion etc. 18 It is better to cure by food than by medicine Mechanical means called suppositories e.g. candy introduced into the rectum] are common among families Infantile erysipelas Its classification is doubtful It answers tolerably well to the [illegible] of Good No species in Bateman & [Willan] like it Red patches A severe & dangerous disease apparently the same with the dangerous roseola or [illegible] of the West Indies. Elevation of the skin is not so great as in erysipelas Generally commencing on the legs and thighs, & extending like erysipelas. Attended with constipation tumefaction of the bowels, hiccup & severe fever & terminates fatally with come Give calomel 8 or 10 gr In two hours repeat the dose. Then evacuate with 19 senna mixed with aromatic seeds or if this is not sufficient, with castor oil senna or scammony Then keep the bowels open with blue pill External applications the best is flour or arrowroot. Prof. I has sometimes blistered in imitation of Dr Physic Probably every case would be fatal if treated with bad water and did not evacuate the bowels. If diarrhoea is produced give compd powder of chalk of the shops & other sim. articles In erysipelas of the head we may use the common discutients in conjunction with evacuants. Children are subject to various anomalous eruptions, in consequence of improper articles of food. This is frequently the case with adults e.g. fish & pokeweed An excessive quant. of food may cause them Always pat attention to the diet. This will 20 if persisted in, cure most eruptive diseases Avoid oily food such as nuts crusta lactea (milk [illegible]) Porrigo larvata of Bateman On the lips forehead scalp. First pustules yielding pus until a scab extends over the whole face. It never leaves a scar. We must be cautious of checking it especially when of considerable continuance. Sometimes it degenerates into a phagadenic ulcer, In such cases Prof. I. has used charcoal externally poultices, a variety, & has seen much advantage derived from roasted flour, it absorbs and excludes the air. It is proper to give a dose of calomel. The buckthorn is thought to be particularly serviceable in cut. aff. In case of great irritability chalk may be combined with 2 or 3 gr. of cal Diluted muriatic ether in doses of 5 or 10 drops in water 2 or three times a day, has been much used, and may be [recommended] It may ½ dr [illegible] 1 oz alcohol Ext. 2 dr cal 1 oz sim. cer. Oxygenated oint Nit. ac. & lard Nit. ac poured on warm lard Citron oint more efficacious When the [illegible] does not answer [illegible] [illegible] [illegible] app e.g. sulphuret of potash 2 dr. [illegible] in a pint of water smells like bilge water This may be [illegible] in doses of a table spoonful. prob. [illegible] to sulph [illegible] Others prefer sulphuret of soda. Sulph. of [illegible] is equally effic. fever ensues If the eruptions dry up suddenly give antimony & calomel [illegible] children have a [illegible] rash [illegible] 22 Teething in children is frequently attended with an eruption, resembling a fine rash This should not be interfered with lest it be translated to an internal part. It is an effort of the system to relieve itself An eruption resembling porrigo frequently comes on in summer consisting of watery pustules resembling the itch. It is not cured by dock root. It may be cured by diet & the warm bath. Eruptions translate action from the viscera especially the liver, as in gutta rosea of rum drinkers. Venereal eruptions Some think it may be inherited from ancestry instead of parents. Smooth hard circumscribed like of half a pea increase slowly for 2 or 3 wks. then become filled with a watery fluid, & become a ragged ulcer 23 Treatment. Change the nurse if derived from her 1/30 or 1/40 gr. corr. sub. in water blue pill in moderate quantities tepid bath sometimes tonics of iron mur. fer. tartrite fer. alk. solution of iron Sometimes patients resist the mercurial prep & the rem. for scrof. In this case send the patient into the country for air & try simple vegetable articles e.g. exp. juice of plantain, ext. & internally It is a popular remedy for poison & is apparently valuable. It has cured such infants, when conjoined with the country air Its virtue is owing to its bland & mucilaginous quality Sore ears Nature has chosen the back part of the ear to eliminate morbid secretions. It relieves affections of the brain Frequently there is a miliary eruption, followed by excoriation In most cases so mild as merely to require 24 washing If the discharge stops suddenly it is liable to be followed with torpid bowels fullness of fontanelles full tense pulse cold extremities. When infants are suddenly attacked with disease inquire if they have had sore ears which have suddenly dried up in this case apply a blister behind the ears, without this nothing will cure perhaps. This is true of old sore [leg]. The theory is not the necessity of the evacuation but of the habitual action in the system Sometimes troublesome ulcers, yielding an excoriating discharge; followed by gangrene & death Poultices & ac. plumb. are good Powdered gypsum is one of the best applications (alabaster is the finest kind) Case in which alabaster cured without red precipitate The oxygenated ointment is the mildest & best where ointments are proper for sometimes they disagree Bowels be kept 24a open with calomel. Frequently it is necessary to change the diet of the nurse & to confine her to a simple diet. A discharge from the nose or ear may frequently be cured by keeping up a discharge behind the ear by blisters A teaspoonful of myrrh to 1 gill of water is one of the mildest ext app. Sometimes use nit. sil. Diarrhoea Sometimes affects children for months & even years, in some families. Sometimes it arises from a bad constitution Caused also by want of cleanliness, bad food & want of cleanliness, bad food & want of air & exercise. Young animal (also vegetables e.g. fruit trees after a season without wind) need exercise Children need mental stimulants, from external objects. This is the principal secret of change of air. If the child 24b Bad air probably causes diarrhoea merely by its depressing influence is teething we must palliate not stop the diarrhoea. For this is an effort of the const. similar to tears from an irritated eye & mucous from the lung IN the commencement of diar. mentha vulgaris pounded the juice expressed, boiled, skinned & mixed with white sugar, will frequently cure. Ipecac will freq. cure. We must generally begin with a cathartic sometimes adding chalk to qualify calomel, when we give it for its deobstruent operat. Use blue pill for feeble & delicate children,. Prof. I could for many years take no other cathartic without griping. Often we must enquire particularly about the diet. Arrow root with a little spice, or a little laudanum, or wine. Sago tapioca, is a hydrate of flour moistened & dried by heat (probably) Roasted or baked flour & flour tied up tight & boiled, then grated, made into porridge is better than flour unaltered Rice in gruel, or thoroughly cooked by boiling 25 The worst cases have dry skin & feeble pulse. Use tep. bath & keep up an action of the skin by flannel In chronic stages absorbents will be needed chalk [illegible] oz cin zii [illegible] 4 oz carb pot zss. wat 1 pint Powerful means of counter irritation e.g. mustard horse radish, monarda punct. sp. turpent. about the precordia when the danger is very great, In case of something like cholera coming on By this means we can make articles stay upon the stomach [illegible] etc. will be grateful & stimulating As a tonic moselys 3 dr 1 al. pt. boil water cathartic [illegible] in [large] [illegible] 4 to 20 drops [somet.] [illegible][absor] Opium is often necessary, generally it is better, when qualified & rendered more diffusible in its action by ipecac. Invaluable in chronic cases of great irritability 26 Charcoal in fine powder, will correct the fetor of the stools & often cure. Particular attention should be paid to the stools for much may be known by them. Acid is formed in the whole al. can. Hence sour & curdled stools This will indicate lime water absorbents & aromatics. The acid may arise either from fomentation or (probably) from secretion. In case of clay coloured stools give opium to allay irritation ipecac. to equalize excitement & determine to the surface mercurials as deobstruents Give also mucilaginous or alkaline or laudanum (in starch) or (in case of griping) camomile injections. Often soap is useful also compd tinct. senna After the long continuance of the disease support the bowels by bandages, & apply a plaster of lead and soap. After great emaciation & when [illegible] [illegible] water softeness 27 tonics astringents (at least 50 ast) e.g. currant raspb. bark in milk oak bark chocolate of acorns Peculiarly adapted are spir. [illegible] & cornus [illegible] or [seria] (decoc in milk) [illegible] It equalizes excitement more white pine bark in milk watery urine In case of great craving as for salt provision etc. in extreme cases gratified Of mucilages are a variety for they will be worn out [typh??] latifolia sassafras bran flaxseed etc. etc. Great aversion & nausea & vomiting attending the administering of remedies will make them operate like tartar emetic, and debilitate. In such uses the gratification of the appetite will prove a stimulus especially to the mind & therefore the more powerful This is true of adults also. Case related of a patient who could retain no medicines & recovered upon bread and cheese. 28 In the latter stages acetate of lead may be given internally. The bowels are too much relaxed to admit of colic. A troublesome symptom is prolapsus ani The intestines should be immediately replaced Take the neck of a bladder or the crop of a fowl, filled with water, as the softest & best irritating thing to apply. A [illegible] cloth will irritate the sphincter & make it contract. Afterwards apply astringent washes e.g. white oak bark or the bark of any of our forest trees Cal mag ½ dr rhub 8 gr gum ar. 1 dr. wat. 1 oz pepper ol. [any] 6 drops [or] tablespoonful Vomiting It is very common in healthy children in consequence of over distention of the stomach. The child should not be allowed to nurse so long at a time Children & old people vomit with more 29 facility than the middle aged Vomiting from irritability of stomach is important feeble pulse, cold extremities must horse rad. 2 z chalk 1 z card. seeds ½ z carb pot or [illegible] [illegible] [illegible] 1 pt water tablespoon Prof Ives thinks the alkali creates an excitability. Frequently the irritation of the lower part of the bowels by an injection of salt & water, or a large bulk of warm water, or a calomel cathartic. The tepid bath & nervines are useful also Young physicians are often called on to prescribe for hydrocele in children Apply opium camphorated applications etc. In the morning apply cold water & spt. of nitre. Prof. I. has had to operate in but one case. 30 Volvulus or introsusception. Not commonly a primary disease. Prof. I. was at first very much perplexed with it, finding no satisfaction from the books. The upper is received into the lower portion Sometimes one involution is doubled in upon another 1st Involution of the small 2nd of the large intestines. It occurs in particular families of delicate constitution. Undoubtedly the bowels sometimes disengage themselves from slight degree of this involution The symptoms of the first kind are constant tendency to vomit, frequently attended with a sympathetic action of the rectum Throwing of the hands & feet paleness of countenance rolling of the head & other symptoms of extreme irritation like strong her. specks only of blood In the large intestines when a cathartic is given it passes down as far as the involution & is then thrown up 31 this act may frequently be heard Drastic cath. often are the causes hence where there is a liability to this disease do not give them In case of the small intestines being affected depend upon opium mixed with aromatics and depend upon this until the bowels restore themselves which however will be doubtful. In the second kind give all remedies by injection, apply the warm bath. By very copious injections, attempt the restoration mechanically. Case related of a young man cured by inserting a bougie of a spermaceti candle with opium at the extremity, & keep it up some time Another case cured in the same manner Sometimes the disease arises from a natural stricture of the bowels incurable 32 It may be caused by worms. Case of a worm involved in the fold of the intestine Case of a delicate school girl. Pulse low weak and small vomiting restlessness, throwing of the hands & feet. Great irritation about the urinary passage & fundament. Tongue not much affected. Deficiency of action in the liver & two or three volvula were discovered on post mort. exam. Ascaris tricocephalus was found to be the cause Cholera constipation of the bowels with fever bilious remittent fever, marasmus etc. etc. It is a common bilious fever, produced by causes affecting the bowels Symptoms pulse full, frequent, tongue furred skin hot. Bowels full and hard, urine small in quantity & high coloured, costiveness breathing laborious face flushed sometimes cough Evacuate the stomach & bowels by emesis & catharsis produced by 5, 10, or 15 gr. 33 of cal., in order to produce a strong impression upon the whole digestive canal & hance upon the system at large In enteric cases & vigorous habits a little tart. emet. may be added Repeat the cal. in 5 gr. doses every 3 or 4 hours leaves senna ½ oz manna 1 oz [pint] give senega blood root etc. if the lungs [illegible] z [seneca] [illegible] [root] may be [illegible] or 2 z [illegible] Give enemas or injections to assist the operation of the cathartics after giving the cath. time to operate The stools frequently contain flocculent portions of membrane. If the stools continue vary cath or [illegible] mag. sol. tartar phosphate of soda neutral salts to In the latter stages of the disease give blue pill instead of calomel 34 Sometimes Prof. I. has added acid to quicken the action of the mercury The fever abates in 48 hours It may continue f or weeks sometimes. The termination may be in volvulus in hydrocephalus If the disease continues for 2 or 3 month a regular remittent, the best remedy is Fowler’s solution in 2 or 3 drop doses If this produces edema & dropsical affec then give bark or Moseley’s tonic sol. beginning with about 4 drops After the inflammatory action has gone off give opium alone or combined with ipecac or antimony Blisters are useful in ass stages. They translate action to parts less essential to life & in the latter stages keep up the action of the system Use any of the irritants. If the lungs are affected apply a blister to the chest. The warm bath is useful. 35 If the head is affected apply a blister to or behind the ears Sometimes the mind is so affected that no medicine will be taken without great force. Then use tepid bath A large blister of aloes & ginger will move the bowels Frequently the derangement & revengeful disposition (according to Dr. Bush an affection of the moral faculty) that we must wait even for 24 hours or more without administering anything Great skill is in this case required to satisfy the parents If cathartics which first produce emesis are used we may be sure that the whole al. canal will be operated on We often also need a remedy more powerful than the disease just as in croup Case of a child 2 yrs. old. Pulse full & frequent tongue furred skin hot etc. After the paroxysms the opposite symptoms come on violently. The system was roused 36 by mustard to the feet & arches followed by blisters on the same parts blister on the chest ammonia in the mouth caustic ammonia in the nostrils to excite infl. Worms. This subject naturally follows that of intestinal diseases. Worms are not contained in the bowels of children under 2 mo. generally not while they suck if they are, they probably are introduced in water Worms in the int. can. are not so common as formerly. Said to be common among the aborigines owing to their crude diet. Derangement of the stomach & intestines produces all the symptoms of worms. It is undoubtedly the fact that healthy children have worms which produce no injury until the system is affected with disease. Case of a healthy child who fell from a great height coma a dose of calomel brought away 20 or 30 large worms 37 They may be injurious from their number consuming too much food 1st Tape worm (taenia) armed & unarmed. 2nd Tricocephalus (hair headed) these are the most irritating 3d Ascaris (round worm) lumbricoides, & vulgaris 4th Gordius rarely found in the human stomach Prof. I has known them coughed up from the lungs they probably came from an abscess in the liver. The gordius is sometimes found in the earth in great numbers they turn black on exposure to the air, and resemble a horse hair, hence called horsehair worm. All eruptive & even all contagious diseases have been attributed to insects. Even miasma has been explained by an Italian writer as consisting of insects vide N.Y. Rep. about the year 1815. Cancer & tooth ache have received this explanation 38 The symptoms of worms are very equivocal and coincide in general with the symp. of irrita Count. pale, flushed bloated sallow eyes dilated grinding of teeth in sleep, starting in sleep palp. of heart, pain in stomach when empty, relieved by food, urine pale coloured, or milky increased or diminished nausea, vomiting, irregular appetite, loss of appetite, costiveness Irritation about the neck of the bladder in the case of ascaris. Severe pain about small intestines & umbilicus, indicates tape worm Irritation at the rectum, indicates ascarides as do also irr. of urethra & increase of urine & milky urine Tape worm oftener affects adults than children. Sometimes it exists without the symptoms of worms. 2 quarts in a day have been brought away in a day, & yet they would return in a few days! They increase with wonderful rapidity. Case of a woman who kept passing them for months in great quantities finally diet was tried instead of medicine 39 All food was roasted or boiled even the water used for drink was boiled Cured Healthy bile or gastric fluid will destroy them. Hence an important indication. Spts of turpentine are an old remedy among the people Case of an old man who made himself drunk with half a gill or more of it. Fowler’s solutions 2 to 4 drops 3 or four times a day has cured. This is prescribed for the taenia or flukeworm [illegible] has been considered a specific Osmanda cinnam. has been given by us for this article. It is bitter astring. & sweet. Polyp. vulg. is a tonic & deob. Other forms may be used Ether, particularly in injection is good mad. [illegible] for [illegible] panada pound & half & 2 or three ounces of fresh butter if costive 1 pint of water salt & [illegible] olive oil or an injection in order to fill up the al. can. 8 or 9 hours after 3 oz [f.] m. in [illegible] 40 in water or decoc. of f.m. or [illegible] cal. & car. 12 gr. each [gamb.] 5 gr in a bolus. Oil is used to fill the respiratory holes of the tapeworm Ether had been added by French & Ger. Rue has been used. Pearl flowers. [illegible] power Amalgam of tin & mercury has been detained in the bowels. These mechanical remedies are not now used. Formerly crude mercury to the amount of a pound was frequently given as a cathartic Astringents have been used bark of milia azedarach of prunus virg. The former is given in decoction to the young negroes at the south who are much subject to worms It has much of its virtue when dry Symptoms of tape worm sense of weight (where the worm is in great quantities) irr. stom. nausea loss of app. irr. app. weak chylop. viscera bloated countenance 41 etc. All which however may arise from mere irritation of the stomach The irritation of the tricephalus amounts to derangement throwing of the hands etc. Prof. I. would prefer narcotics for this worm but cannot speak from his own experience he recommends an injection of a teaspoon or tablespoonful of ether in a gill of water or mucilage. Ether will undoubtedly pass the valves, when injected. Prof. Ives has thought that fern given in pieces operated mechanically especially [assmunda] Ascarides are said to in habit the rectum this is a mistake. They multiply abundantly & lodge in the rectum about the sphincter, as they daily pass off. Besides the irritation of the rectum they produce in the small intestines severe griping pain about the small intestines. Very troublesome to cure the best remedy 42 is injections always effectual for the time being. Relief for the time being by washing them out with injections of warm water. Aloes added will be better. The best however is camphor, as a nervine and narcotic & a poison to the worm Calomel is useful, not in destroying this worm but in restoring healthy secretions for worms will not live in healthy gastric liquor. All indigestible articles such as raw fruit, acids, cold water etc. will be injurious. Alcoholic tinctures aloes, elix. propr. or sol. tincture of hickory buds or bark in teaspoonful doses is one of the best things. To prevent the return of the worms use condiments pepper ginger etc. all warming & bitter things. In extreme cases avoid every thing which has not passed the fire. The eggs are exceedingly minute & yet each consists of numerous others probably they 43 are absorbed by the lymphatics carried into the circulation & deposited in various parts of the body especially upon the muc. memb. of the al. can. only upon the mucous parts. Dry & stimulant diet is better than cold & liquid. Some remedies act upon the worms themselves e.g. narcotics Some narcotics operate on some animals & not upon others e.g. sheep eat stramonium which poisons swine. Mechanical remedies are filings of iron & tin cut hair, & perhaps the prickly cowhage Other remedies are powerful cathartics merely others again tonics & deobstruents Ascaris lumbricoides requires no peculiar treatment Use spigelia, calomel etc. Spigelia is a narcotic it kills the worms & it may also be prescribed for the same set of symptoms where no worms are present. 44 When given to intoxicate the worms give from 2 z to ½ oz in decoction in the course of the night, accompany it with rhubarb, or follow it with calomel or any cathartic to drive the worms off while in a state of intoxication. Veratrum sabadilla is used as a narcotic Of tonics all the astringents & barks the min. acids sulp. zinc & iron etc. Cathartics the best is calomel also use the drastic, as scammony gall is good ether, asafoet. petroleum, seneca oil, barbadoes tar etc. as antispasmodics Chenopodium anthelminticum & ambrosioides are called worm seeds An essential oil is extracted from them. C. botrys or jerus. oak are useful as nervines & for the cough, but probably do little good as anthelmintics. The garlics are used (nerv.) They have considerable effect upon the intest. canal Artimisia santonica from Africa the tops of flowers, this is called wormseed It is a bitter 45 The asclepiades most of the common species as syriaca, pulchra, or [illegible] this latter is often used & has seemed to do good so A. incarnata & A. decumb. Podophyllum pelt. is used as a cathartic probably not better than others The best form is that of tincture The number of worm cases & colica is much less than formerly owing to the change in our mode of living Butternut bark decoction in tablespoonful doses is a popular remedy. It is intensely bitter The geraniums are used all the aromatics and bitters indeed which are found spontaneous Ether is used both by the mouth and by enema Butternut bark is cathartic & said to be narcotic 46 Convulsions Two kinds sympt. & idiop. Children are more subject than adults Causes all the causes of irritation Sudden suppression of evacuation. Teething irritation of excessive or indigestible food upon the nerves of the intestines. Acetous fermentation of food in the prima viae The predisp. said to be sometimes heredit. Said to be produced by change in the milk Also by agitation in the mind of the mother affecting the milk. The countenance also of the mother affects infants very much much more than is commonly supposed. So of the bystanders Treatment depends principally upon removing the exciting causes & then upon obviating effects If the cause is in the prim. viae give it first 5 or 6 of sulph. zinc or as much of ipecac. If the substance has passed into the duodenum give a cathartic, assisted 47 frequently by injection. OR use calomel as emetic & cathartic both. Enquire particularly about diet for a general answer may be false Frequently several large doses of cathartics are needed to overcome the torpor caused by excessive quantity of food Also the food diminishes the cathartic operation. Hence the French dinner pill calomel 5 to 10 jalap 1 to 3 scammony senna manna castor oil & neutral salts are the cathartics If the convulsions continue used [illegible] Calomel sometimes by irritation produces convulsions spasmodics one of the most efficient is the tepid bath. If the patient is much agitated by being put into water cover the tub with a blanket & lower the patient gradually: there is then no difficulty Potash, carb. pot. or aromatic herbs may be put in the water. Continue in from 5 min to ½ hour if exhausted to be taken out Wrap in a blanket & put in a bed keeping 48 up a uniform temperature Oil of amber was Dr Rush’s sheet anchor musk internally Articles applied the whole length of the spine as mustard, ol. origanum etc. etc. Empyreumatic oils hence soot tea is very useful It contains carbon amm. & pyrol. ac. Oil of valerian is a nervine Mineral oils as british oil petroleum etc. Ammonia is one of the best 2 to 6 drops in 1 oz water Applied also to nose & mouth & rectum Dippels an. oil owed its virt. to ammonia. It is very fetid & distilled from berries 10 to 20 drops tinct. asafoetida; or by enem. 2 z caustic potash, or the impure carbonate by injection is very valuable. So all the caustic alkalies Opium is a powerful antisp. may always be given unless contraindicated by other symptoms The frequent recurrence of spasms may be broken up by continual doses 49 of opium. IF they recur once in a few weeks give cathartics to prevent them. When called 1st inject. 2nd tepid bath with alkali in the water. 3d apply irritants as must. horserad. garlic, ginger etc. giving, even in the commencement ammonia by the nostrils. When the patient can swallow give calomel. When the stomach is overloaded, the child cannot swallow, & we wish to give an emetic, we can often succeed by irritating the throat with a feather laying the infant upon the hand & in this way supporting the abdominal muscles. Epilepsy a regular or irregular return of paroxysms of convulsions attacking suddenly falling twitching etc. followed by coma Causes in children generally diseased state of al. can. kept up by habit which last is frequently very difficult to break up 50 caused also by malformations tumors of brain malformation of brain etc. derangement of system produced before birth by syphilis from the same causes as rickets more rarely from mere irritation without some offending cause as suppressed evacuations Treatment generally the cathartic giving calomel 3 or 4 times a week If the canal is loaded with mucus conjoin 1 or 2 gr. gamboge 5 gr. scammony & 5 of jalap which yet will operate kindly though [illegible] The best evacuants are those which change the secretions If there is a deficiency of mucus an abrasion as it were give blue pill also cojoin chalk. Most cases are curable by careful management both of the physician & of the nurse Regulate the diet with great care. Generally however there is a morbid appetite & a sub derangement about eating & also about climbing & such things 51 They will be so active & artful as to be managed with great difficulty Catalepsy called still convulsions It is a tonic spasm Insensible & apparently asleep scarcely breathes sometimes a little motion of the eyes continues from a few minutes to several hours Treatment the same as in other convulsions It follows other convulsions & sometimes follows drastic cathartics. Whatever position the patient is in in that will he remain Prof. I. has had several cases Chorea Sancti Viti rarely fatal not difficult to cure under the age of puberty If it commences before & continues after that period seldom cured. The muscles are partly subject to the will. They also have involuntary motions. Caused in children often from irr. in prim. viae from 52 morbid irritability arising both from diminished & from increased action Said also to arise from infl. of the brain Indications narcotics & cathartics if arising from disease of al. can. tonics as iron, mineral acids & electricity if debility is the cause. Prof. I thinks the disease frequently runs its course & then the cure is attributed to the last used remedy. The cathartic treatment has not succeeded very well in his practice. It occurs oftenest in females of relaxed const. about the age of puberty especially if they have grown rapidly or been much confined to the needle or to study Ammonuret of copper 1 to 4 gr. was Cullens favorite remedy Case female treated with epispastics & narcotics took arnica 2 z to 1 pt boil. water doses increased till the head was affected (It is tonic & narcotic) Without benefit Next cathartics Next metallic antispasmodics 53 Next epispastics Finally recovered under bark in substance 1 oz a day. Sometimes arises from affection of the mind The presence of strangers is injurious the sensibility of the patients being very great When caused by epilepsy treat as for that disease Sometimes comes on very gradually & is not suspected causing apparently bad habits in walking etc. Case which had been coming on in this manner was brought to a high degree by dysentery & went so far as to present the peculiar symptoms of hydropohobia horror of water etc. Conium [illegible] & iron sulph. zinc sulph. copper & other metallic tonics have been principally used by Prof. I. Use various narcotics as nux vomica Use the antispasmodics as palliatives e.g. valerian asaf. musk Case in which the disease was broken up by elaterium 1/8 of a grain at a dose combined 54 with chalk. This is the only case which Prof. I. has broken up Case of a young man who had been confined as a clerk in N. York thrown into derangement & convulsions by a sight of distress on board of a packet Elaterium was given to prostrate the system & break up the habit successful. This led to its employment in chorea This disease may affect the mind causing it to run upon particular subjects especially numbers. Case of a book pedler with these odd motions & also this facility of calculation equal to Zerah Colburn. he was overtaken by Prof. I. in travelling. Zerah Colburn, though sent to Europe never improved agreeably to the predictions of Prof. I. who has seen several cases Their countenance & articulation are peculiar [memory] & judgment deficient 55 Nux vomica as a narcotic may be given in doses 1 to 2 gr. [illegible] in pill or 15 to 20 drops of alcoholic tincture Setons, issues tartar emetic ointment along the spine are used. The latter is not to be used where there is excessive irritation doing injury. Tepid bathing is seldom proper Cold bathing sometimes succeeds. Prof. I has known little success attend the employment of electricity. If the disease is not translatable it is made worse by counterirritants. Dentition of the highest importance always more or less affecting the bowels & the nervous system It affects also the glands the cell. memb. the brain the ears [illegible] in them the lungs etc. Adults are also affected Case of a young woman cutting 4 wisdom teeth who was thought to be consumptive. The period of cutting commences from the 4th to the 6th month. Some persons 56 never had but 2 incisions Children are occasionally born with teeth but the teeth sit loose in the gum without [fangs] & should be removed to prevent their being troublesome Some families are said to have no teeth their teeth being even with the gums such are very serviceable & are not subject to decay. Case of a family of this kind from Charleston Symptoms fretfulness biting slavering starting in sleep flushings of face fever hot head & cold feet diarrhoea sometimes costiveness green stools increased urine (sometimes diminished) bloating of hands feet & face contracted pupils eruptions on the skin all the symptoms of irritation the children are particularly subject o phlegomonous inflammations. Case of a child who was thought to have an aff. of brain. A tumor was found under the arm Treatment diarrhoea relieves the irritation Indications 1st divide the gums the operation 57 is not usually painful They will even bite the lancet It may be done in sleep without waking them The difficulty is to confine the child & avoid cutting its tongue. [Gum] lancets may be made with a guard. Make two incisions for the double teeth & sometimes it is necessary to divide a ligamentous band in the middle. It is an objection to cutting the teeth too early, that the scar formed by healing will be more difficult to be cut through by the teeth. This not true a scar has less vitality & is more easily broken through 2 or 3 cuttings may be necessary the symptoms continuing to return. For infl. use the antiphlogistic treatment sometimes bleed in the arm better generally to apply leeches behind the ear. Cathartics as magnesia & rhubarb conjoining aromatics & chalk where there is acidity. Equalise excitement by ipecac & antimony with or without opium 58 If a diarrhoea suddenly stops apply counterirritants to the pit of the stomach the warm bath. Avoid currents of air etc. Blisters behind the ear will be often serviceable & prevent hydrocephalus. They are sometimes applied to the arm. Use antispasmodics with or without ipec. etc. Rickets Caused by confinement too much clothing too much saccharine food etc. Generally there is an earlier mental development They do not make abler men however Hence the impression that precocious children # symptoms soft flesh paleness of countenance hectic fever, tumefact. of bowels muscles & cell subst. less joints larger head large fontanelles open veins of the head large & blue app. & dig. bad tendency to acidity The teeth are cut later Appears at about 6 months Nearly allied to scrofula in affecting the lymphatics & osseous system # will die early. They are in fact generally diseased 59 This is a disease of weak morbid action Indication strengthen the vital powers by stimulating & dry diet especially by cold bathing taking the patient out of the bed in the morning bathing & returning occasionally cal. & ipecac. general friction exercise open air mental stimulus of the open air vegetation etc. etc. This affects the secretions powerfully. Different tonics are given e.g. Fowler’s sol. sulph ferri bark (bark waist coat) Astringents & absorbents for there is frequently an acid smell Burnt bones phosphoric acid alkalies (pearlash) etc. Pearl ash is applied externally Of late iodine has been very serviceable 2 to to 4 drops alkoh. tinct. given in mucilage of gum arabic etc. The worst cases are the syphilitic these require mercurials. The deficiency of the phosphate of lime is an effect & not the cause. Hence burnt bones must have been useful as an absorbent & perhaps 60 as a tonic not as supplying the matter of bone The chylopoietic viscera are probably first affected & then the mesenteric glands & lymphatics. Avoid featherbeds etc. Sweet fern beds are very popular. They are hard & the odour corrects the acid smell of the disease. Muriate of lime & of barytis were formerly much used. Cholera infantum Appears in months of July Aug. & Sept. Sometimes in June & Oct. Approaches in various manners e.g. with a gradually increasing diarrhoea with vomiting & purging the stools being green, brown, slimy, watery, or with the smell of putrid meat a high fever may exist also great restlessness in bad cases cries of pain once in 1 or 2 hours pulse quick and weak fever remittent sometimes terminating in hydrocephalus or volvulus Eyes often languid & hollow half closed in sleep often in the latter stage preternaturally 61 There is sometimes a great degree of mental excitement bright (their eyes are half closed in various complaints) The vomiting may cease soon may alternate with the diarrhoea The disease sometimes ceases soon at others runs on for months This summer epidemic varies according to the season according to the changes in the air or the weather which affect children more than adults. The patient is carried off in convulsions or is worn out by emaciation and dies with aphthae or dies with hydroceph. volvulus & other diseases Causes bad atmosphere malaria (a general tern for miasma & [illegible]) Dentition is an exciting cause not the primary cause as some suppose. Children weaned in the spring are very apt to have cholera infantum in the summer. Children at the breast bear the disease better Hence let them be weaned in the fall 62 A disease it is of debility & has for predisposing causes bad food etc. both as remote & exciting causes It is a fever translated like dysentery from the surface to the viscera commencing at the skin & breaking up the balance of the system then attacking the mucous memb. of the intestines Indications 1st evacuate prim. viae 2nd translate action to surface & so equalize excitement 3d excite healthy secretory actions & [illegible] peristalt. action. 4 avoid causes of irritation & remove them where they exist 5 restore the tone of the system particularly of the stomach & bowels 1st Aromatics ess. peppermint counter irr. to stom. & bowels as must. horseradish injections of starch & laudanum & tepid bath must be used in case of vomiting, or attack like cholera of adults When there is a diarrhoea at the attack evacuate with deobstruent cathartics & ipecac. Give calomel & ipecac first giving 6 gr. cal. 63 Small doses of calomel will not answer instead of full doses & ipecac about an hour afterwards ipecac The southern physicians do not use cathartics so much depending upon stimulating injections e.g. of salt and water They give smaller doses of calomel This practice does not answer so well here # In case of small watery stools we have often reason to suspect that the bowels are constricted & confine a large quantity of fecal matter in this case give opium & then follow with cathartics which will often bring away a large quantity of faeces 2d by emetics & by small doses of ipecac with opium repeated also small doses of mercurials cal. qualified with chalk or blue pill (antimonials where there is much arterial action) by fomentations sinapisms blisters to the bowels burdock leaves etc. warm bath which used at night frequently gives a quiet night’s rest this is not to be used however in case of great exhaustion # The French expectant treatment adopted in Philadelphia will frequently be entirely inefficient 64 3d by small doses of mercurials & ipecac with opium Ipecac deserves the name of a specific if any remedy ever deserves this appellation. Still a man very successful with one remedy only may be compared to one very skillful & successful with a penknife About 4 gr. ipecac 4 drops tinct. opii 12 teasp. wat. about every 4th or 5th hour for a child 4 months old keeping the bowels open with mercurials blue pill producing an evacuation once or twice in 24 hours. Double the quantity for a child a year old in the same quantity of water. The quantity of opium must be greater when the child has been [illegible] the habit of taking it. Injections of laudanum & starch 1 tablespoonfuls of flour & 5 10, 15 or 20 drops of laudanum to stop diarrhoea at the same time applying to the abdomen 65 cloths dipped in brandy An eruption of strophilus [albidus] sometimes makes its appearance about the chest particularly in the latter stages 4th indication by dividing the gums if necessary regulating the diet the milk of a nurse is best the operation of sucking is soothing and gratifying operating as a nervine give arrowroot with a little brandy or wine as a condiment or tapioca roasted flour etc. If in the last stages the child craves any particular food, as salt fish or salt meat, it should be gratified Disgust exciting nausea will debilitate. Frequently we can succeed by a different mode of administering medicine the sight of a spoon for instance exciting nausea. A tumbler of wine whey with a teaspoonful of aquae ammonia will often be beneficial to fill the stomach & dilute its contents 66 Correct fetor in stools with charcoal Injections of carbonic acid are used with the same intention. Effervescing mixture may be drunk they are often very grateful Injections of soap suds are recommended to allay irritation. Dr Dewees recommends an injection of 3 teaspoonfuls of salt to a gill of water & also magnesia & rhubarb. 5. In the latter stages give tonics and astringents Prof. I prefers cornus circum. Use also spir. toment. in decoction or extract also geran. mac. which may be given in wine & then we have red wine Often it wil be advisable to support the abdomen with a bandage also with plasters e.g. one of soap & opium A most powerful remedy is change of air It is continually recommended by the Philadelphia & New York physician. Case of a child in articulo mortis apparently 67 brightened up upon being carried in a hack to the top of ah ill where it had a view of the sound etc. It had got beyond the reach of medicine & food While upon the hill it too food returned & recovered The case seems to be the direct opposite of nostalgia there being a sickness of home a despondency caused by the sight of the same domestic objects Erigeron can. is used it is pungent acrid bitter & stimulating & hence affects the kidneys as a diuretic. It seems to do goo in the latter stages of diarrhoea & dysentery It is called strangury weed. It has been long used Vide Barton N.Y. Physico Med. Trans. etc. The other species are also used give it in decoction White vitriol & alum are used as tonics and in doses of 6 to 8 drops as an anti emetic The various species of viburnum are 68 All the [???t? tillas] are astr. so [illegible] [illegible] root etc. used in this disease, as astringents Statica limonium is not so agreeable but frequently more efficacious boiled, sweetened & a little wine or brandy added. It has a taste of salt mud. It is used also as a wash in case of aphthae In the latter stages of the diarrhoea give mucilages made of any of the various articles in use The white pine bark will furnish a valuable mucilage from its being combined with a terebinthinate principle. Post mortem examinations show the seat of the disease to be the muc. mem. of the intestines. The liver is enlarged Scald head or porrigo or tinea capiti A local disease, yet affected by diet. Sometimes commences with scaly eruptions. I have the head & apply a bladder to exclude the air is about 69 the best treatment. Wash clean at all events tar oint. 4 oz. tar. ½ oz. was 1 oz sulph 1 oz sulphur melt & mix Sulphuret of potash has removed the disease in a few days Yeast poultice is efficacious let the head be first shaved. Different dock roots all the species have about the same properties. Apply externally & give internally it is acrid etc. Syrup of buckthorn is recommended as a cathartic. The practice is quite empirical in this complaint. Sulph. pot. is given internally also its solution resembles mineral spring water Mercurials should be used & pay particular attention to diet Asclepius tuberosa expect. diaph. & laxative is a valuable substitute for ipec. to equalize excitement etc. When the tepid bath is used keep a supply of hot & of cold water by in order to keep up a proper temperature 70 Catarrhal epidemic severe hoarse cough differing from coup in the quantity of mucus thrown off extremities cold head hot much febrile action By vomiting great quantities of mucus are thrown up & yet the patient will seem to be suffocating Confined to the lungs, & aesophagus No disease affects the bowels less than this. The stools are healthy Indications Cure the patient immediately by powerful remedies unless the system is too much affected to bear them. This is a general principle, viz. that of breaking up a disease before it has thoroughly attacked the system by means of a strong orgasm Tartar emetic at the commencement to break up after the violence of the disease has been overcome apply a blister to the chest to translate to the surface. Evacuate the bowels also & palliate & relieve the disease by small doses of tart. em. or with camphor & opium to create perspiration or by the 71 tepid bath keeping the patient in ½ an hour or covering patient & nurse both with a blanket, to keep in the steam & cause it to be respired also Sometimes vomiting must be excited by mechanical means. Do not depend upon palliating symptoms merely Hooping cough said to be contagious rarely attacks the second time, but sometimes does. Pres. Dwight had it a second time at 60 yrs of age It appears as an epidemic thought to arise form specific contagious 10 vol. Med. Trans. an account of its breaking out in Block Island without previous intercourse with the main land. Commences with precisely the same symptoms as ordinary catarrh. The peculiar symp. 3 or 4 week Several frequent expirations are made which exhaust the lungs then a 72 stricture takes place which causes a hoarse shrill wheezing during inspiration. The same sound is heard in croup during expiration A spasmodic stricture sometimes takes place in adults which produces the same sound Such patients should not try to breathe. These fits of coughing continue until mucus is thrown up But the mucus is not the cause of the coughing, which arises from irritated action. Continues from 1 to 6 months. During a paroxysm, haemorrage from mouth & nose may come on or convulsions & apoplexy may ensue Case in which an emetic caused convulsions which carried off the child. Most troublesome during the night Duration of paroxysms depends upon the facility with which the mucus is thrown off. Sometimes respiration 73 is laborious between the paroxysms Rarely fatal after 2 yrs. It may terminate in hectic or in marasmus in infl. of the lungs in visceral obstructions of liver, lymphatics etc. It produces a determination to the head Treat the fever, if any, according to diathesis Treatment In vigorous const. & when mild little need be done When there is considerable infl. give ant. & nitre keeping the bow. open in worse cases bleed cup & scarify Sometimes mercurial cath. sometimes cast. ol. etc. It is better however to accomplish this end by diet. Respiration may be promoted by blisters on the sternum Instead of [blist] [illegible] may use 1 oz mild tinct canth. 1 z tart ant. applied with a cloth until vesication comes on then dress with simple cerate Antimony may be combined with opium Godfrey’s cordial made of molasses & water 74 with a little laudanum & ol. anise this was very popular. Use diluents. If there Is danger of convulsions from vomiting give blood root & other such things. In some constitutions antimony produces peculiar symptoms e.g. severe spasmodic stricture, which if it comes on should be relieved by diluents & small doses of opium. In very young children it is difficult to get down much medicine the stomach becoming irritable In the latter stages use 5 or 6 grains of sulphate zinc with as much of ipecac instead of antimony Where this much viscid secretion an emetic of squills may be used or we may use the [illegible] seneca root bruised & squills each ½ pound water 8 pds boil & evap. to ½ strain & add 4 pts honey & boil again to 6 pts to every oz add 1 gr. tart. ant. dose 8 or 10 drops child 4 mo. old, every 15 m. This is called Hives syrup 75 Dried leaves in 1 gr. doses, in milk, of atropa bell. or 1/6 of a grain of the root has been used in Germany Objection that this disease has a tendency to run its course, is no good reason for not curing it. It has been prescribed for more empirically than any other proof of the difficulty of curing it El. par. 1 oz ant. vix. ½ oz 3 z glyc. ext. powd. g. at. 2 oz wat. 6 oz. triturate & boil dose ½ teaspoonful to a table spoonful This is called the Brown mixture It may be varied by using ipecac etc. 2d Antispasm. & tonics & narcotics are used in the latter stages e.g. sulph. zinc & copper & tinct. canth musk, fetid gum, petroleum etc. belladonna, hyoscyamus, opium artificial musk or oxygenated ol. amber Nitric 76 acid 3 ½ z ol. [illegible] 1 z place in the sun in tinct 1 z to pt. alc. dose 10 dr to a teasp. or 1 z to 1 oz ether dose few (2 or 3) drops upon sugar. It was very celebrated & afterwards was thought to be ill made The truth was the diathesis had changed. Copal gum, oxygenated by distillation, will be the same substance. Copal is probably the same with amber Case of a vein of olibanum or frankincence in S. America Opium should be qualified & determined to the skin by ant. & ipecac. Hyoscyamus is bitter, having no tendency to produce costiveness zi pearl ash with cochineal to colour it to pt. water 8s a popular remedy & useful The whole effect is owing to the pearl ash which is antispasmodic cochineal has no apparent virtues. Pearl ash is not only antacid but produces a peculiar 77 excitement upon the stomach & aesophagus making them susceptible to other articles Conium maculation has been much used A more commanding remedy is stramonium 1/10 gr. to 2 gr. of extract or seed for a dose. It counteracts that irritability which gives a tendency to convulsions Sulph. zinc has been most used as a tonic by Prof. I. either dissolved or in the form of Moseley’s tonic solution Sulph copper possesses about the same properties The compd vitriolic tinct. of sul. cop. & kino 10 to 30 drops is pleasant & has been much used. Flowers of zinc & also bismuth have been used. So also per. bark. Bark, canth. & sul. cop. in combination are recommended by Chalmers of S. Ca. Cantharides are indicated where the 78 system is relaxed & too low for inflammatory action in order to excite a healthy infl. action Something may be done by rubbing the spine with the stim. oils e.g. ol. caps. or orig. etc. or with [illegible] of ammonia to excite the nerves & spinal marrow in the latter stages. Change of scene, of air, riding etc. should be resorted to in bad cases to tranquillize & stimulate the patient. Sometimes the little patients will be in a constant tease & worry; until this is done. In the worst of such cases medicine does little good Even the irritation of administering the medicine may counteract the beneficial effects of the medicine. Prof. I. thinks a relaxation of the ventricles of the heart & of the sinuses of the head takes place owing to the violence of the cough Indicated 79 by resp. high count. bloated lips swollen & by a soft flowering & almost intermitting pulse In such cases give blood root 5 to 10 gr. in water alone or qualified Lead (acetate), also iodine, have been recommended. One year, the hoop. cough prevailed extensively in the spring but was Prussic ac. & arsenic occasionally cut the hoop. cough, short entirely The former is dangerous from want of uniformity of strength Fowler’s sol. is safe but does not answer so well in the first stages. It may leave the patient livid weak with swollen lips etc. which is to be cured by bark & other tonics 80 Gangrene in the mouth 81 Chilblains Exposure to extreme cold without freezing 82 Mesenteric fever tumefaction & pain of the bowels (distress rather than sharp pain) indigestion costiveness, loss of app. or [irreg.] app. Countenance pale except when flushed with fever sometimes a consequence of other fevers oftenest in scrofulous habits most common among the poor. It may become chronic. Indurated lump in the mesenteric glands Indications Act upon the bowels keeping up a peristaltic action evacuating the bow. changing the secretions & removing the obstructions of the lymphatic system. Give blue pill or calomel & chalk. In chronic cases friction once or twice a day will be beneficial Pill 4 parts blue pill 1 part ipecac or ½ part ipecac. Or 1 gr. ipecac in pill with a small quantity of opium Or tinct. rhubarb with aromatics & alkaline salts Burnt sponge is recommended perhaps it would be better to give iodine at once 83 in definite quantities Still the composition of articles existing in burnt sponge may be better [illegible] nodosus & vesiculosus (rockweed) are used Even the neutral salts with tonics have been useful Even as of camomile tea will relieve a paroxysm of pain Articles containing carbonic acid in a free state, sometimes with aromatics as ginger or spice, will be grateful and also useful From tinct muriate of iron martial flowers of iron or alkaline solution are used as tonics but iron is apt to irritate. Cold bath will invigorate the system Injections of mercury have been proposed Tepid bath will cleanse the skin etc. Muriate of lime with small doses of cal. or blue pill may be useful, but 84 is now generally superseded by iodine dissolve carb. lime in muriatic acid & give from 5 to 50 drops in water beginning with small doses, in case it may offend the stomach. Muriate of barytes might be used. Carb. barytes is used dose from 2 to 3 gr it being a powerful article The flesh brush thoroughly applied has a powerful effect A plaster of opium & diachylon or soap plaster, with an equal quantity of opium, applied to the abdomen has been very beneficial where opium did not agree. Or we may use 2 parts opium to 1 plaster. Diet dry toasted bread broiled meat use condiments farinaceous substances & sometimes the broth of lean meat Avoiding raw fruits potatoes corned beef etc. Take care 85 with wine Use farinaceous veg. well boiled not to interrupt digestion by distending the stomach with liquids The terebinthinates will benefit the mucous membrane of the ac. canal. The bests article is decoction of white pine bark which will be much milder than any preparation than any of the turpentine of the shops This disease may terminate in a peculiar hectic sometimes it commences with very considerable fever S. Cutting the fraenum. Very seldom practised now formerly thought to be almost always necessary. Complaints would be made that the child could not nurse on account of its being tongue tied. In such cases it was Dr Munson’s practice to apply the back of the knife, & thereby give very great satisfaction 86 Burns & scalds 87 Tympanitic abdomen a symptom in various diseases 88 Neuralgic affection of the lower limbs 1 Surgery Lecture 1st External injuries 1st Extensive injuries first produce a shock upon the system e.g. contusion upon the abdomen & frequently when a limb is carried off by a cannon ball the haemorrhage is slight & the patient dies of the shock Great difference in patients as to susceptibility of constitution. In the army it has hence been the custom to operate on some immediately and administer cordials & consolation to others State of the mind e.g. wounds after a defeat or after a victory. State of habit porter & gin drinkers in Soudan & debauchers in high life bad subjects The subsequent inflammation however is not in a direct proportion to the shock 2 1st of such injuries as prostrate the system beyond the point of reaction Coldness of surface faintness & prostration immediately follow large gun shot wounds The same effects follow the slight injury of important points e.g. punctures of the joints etc. These effects are through the medium of the nervous system The common people remark that extensive injuries of strike into the stomach This is merely part of the constitutional aff. Case of violent vomiting in a blacksmith whose eye was penetrated by a scale of iron & yet the eye recovered without difficulty Affected distress may be detected by the state of the pulse or respiration the ease with which the attention may be diverted. Sometimes die of the mortal inquietude even without internal haemorrhage Frequently difficult to test with respect to the propriety of amputation A navy 3 surgeon it has been said would probably have amputated Mr. [Huskisson’s] shattered thigh the constitutional irritation will be less after the operation The intellectual functions are suspended blindness sometimes continues for hours The food is not digested & the peristaltic motion suspended. Vomiting frequently favorable as marking a return of vital function. Case of a gentleman in a profound stupor from a fall from a horse no injury could be discovered Complaint of pain generally a favorable symptom particularly if an external part Infants frequently vomit etc. severely with paleness etc. & yet recover after a few hours sleep 1st indication restore warmth to the surface by frictions & the warm bath frictions should be dry, for moist cloths produce evaporation 4 warm blankets & may be applied especially by passing warm substances up & down the back 2nd indication restore the action of the pulse by brandy once an hour peppermint opium etc. [Discontinue] stimulants when reaction comes on as it may be excessive. 3d moderate pain & 4th const. irr. relieve pain by opium except (in Hubbard’s practice in cases of the head) One of the first things to be done is frequently to bleed which will be followed by a rise of the pulse It is a common practice in some places is to send immediately for a bleeder, who however in cases of a great shock is unable to obtain blood until after a surgeon has roused the vital powers Injections may be used. H. prefers among cathartics the mercurial in order to restore the peristaltic action These will answer the 4th indication also 5 We must be careful to examine for local injuries for frequently in cases of extreme prostration they are first mentioned by the patient after the return of consciousness Case of a man who was first unconscious next complained of his head after some hours of his knee & while he was recovering it was discovered that the orbit of the eye had splinters of pine in the flesh. Great caution frequently necessary in removing the sufferer for simple fractures are liable to be made compound. Cold is injurious The viscera are sometimes fractured in falls from great heights e.g. the liver Suppuration of the liver sometimes follows an external injury after a long interval The injury of a fall not necessarily proportioned the height. 8 or 10 drops of laudanum in gruel or starch by injection relied upon in Paris for the cure of traumatic delirium 6 apparently a trifling remedy recommended for trial relied upon implicitly by the French Mr. Travers is the only author who has treated regularly upon the subject of external injuries Inflammation Characterized by heat, pain, redness, tumefaction & soreness. When considerable or affecting important parts, it is [altered] with fever of constitutional irritation. This is different from the local fever which is called symptomatic. The pain usually precedes the heat & tumefaction The causes may be external or such as effect the system primarily. First of such as are caused by external injury or phlegmonous inflammation called also health inflammation This manner in which injury produces inflammation is not well understood 7 Phlegmonous infl. is characterised by a central spot & a circular outline Hunter speaks of healthy infl. considering it as a process set up by nature to accomplish a cure & believed that new vessels are formed An injury is generally followed by pain, which does not arise from inflammation for this has not yet come on, but from the separation of the parts. Great pain is produced by effused fluid as in sprains. After an injury there is pain etc. also there is a sense of distention & the action of the arteries in the neighborhood of the part is increased This extends to the whole arterial system, producing increased frequently fulness and even hardness of the pulse. The pain is caused by the nerves being affected. Mention should have been made of the cold stage which precedes extensive inflammation the cause of which seems to be unknown 8 Professor H. thinks fevers essentially different from inflammations, in opposition to the French physiologists. He thinks that at least at the commencement of infl. there is increased action of the vessels The pulse varies according to the part inflamed (vide below) Local causes of infl. may be heat, cold, mineral acids, acrid substances etc. the various sorts of external injuries Constitutional causes are fevers and various anomalous affections of the const. Prognosis Very violent inflammations are danger so also very extensive ones as burns. Infl. of important parts in the viscera is dangerous. In inf. of the bowels the pulse is quick small & tense & hard of the heart full The terminations are resolution suppuration adhesion & gangrene. Adhesive infl takes place in serous membranes & wounds that heal by the first intention Suppuration takes place when wounds 9 do not heal by the first intentions boils etc. Gangrene follows violent infl. which do not suppurate. It is the death of the part 1st indication is to remove the cause as splinters & in case of dislocation As much should be done by local remedies as possible. Reduce the temperature by cold or tepid lotions (according to the sensations of the patient) sometimes fomentations or poultices give more relief than any other mode of applying warmth especially in pelvic infl. & by the French in thoracic. The warm bath is frequently useful especially to children. In case of fomentations permanent moisture should be kept up. Warm applications may be made to reduce the heat of the part by evaporation if not too warm. The same thing may be accomplished by spirit. Acetate of lead sulphate of zinc vinegar and cold water 10 are used Perhaps the latter is generally as good as any of the patient will be satisfied with it. Narcotics sometimes are used externally but their utility is doubtful. Blisters are used especially in infl. of the joints & deep seated parts in general The first general remedy and the most powerful is bleeding it would seem to be one of the best arguments for it that those of opposites [illegible] recommend it viz. those who believe action to be increased & those who believe it to be diminished Of course not always necessary, as in trifling cases, & delicate habits, No rules can be given as to the extent to which it may be carried. The modes are venesection [arteriotones] leeches & cupping Venesection is the most common and most convenient. In children the veins of the hand or foot or the external jugular may be more convenient than those of the arm It is a good rule to draw blood until pain is relieved or faintness is produced provided the patient is in an erect position 11 There is no doubt of the propriety of taking a large amount of blood at once rather than by several small bleedings. The buffy coat not to be relied on Prof. H. thinks the heat of the extracted blood of more consequence Blood letting has been objected to in case of old persons. Prof. H. has often practised it with advantages. So of delicate constitutions if the patient is kept in a horizontal posture Arteriotomy from the temporal artery has apparently no advantages over venesection Prof. H. sees no advantage in the use of leeches in preference to venesection except in chronic inflammation Cupping seems to combine the advantages of depletion and counterirritation & is highly spoken of. Prof. H. has not used it much Cathartics are used next. also antimonials especially in the Italian way of beginning with small doses frequently repeated until the quantity which may be taken without nausea is very great 12 Narcotics are used for the same purpose Soreness is relieved by quiet etc. Pain may be diminished by elevating the part. Diet should be antiphlogistic, but generally the patient has not much appetite. Great difference is produced by the constitution and habits of the patient e.g. intemperate patients will not bear some things N.B. they do not bear bleeding well Frequently cordials and tonics are useful at the close of the cure. The best work on inflammation is Thompson on inflammation. Erysipelas an inflammation of the skin sometimes extending to the cellular membrane Distinguished by leaving a white spot after pressure by the finger & by being terminated by a definite [line] It has a tendency to spread sometimes leaving one part & spreading to another. Occasionally affecting various parts at the same time 13 When caused by a wound it frequently affects distant instead of adjacent parts colour dark & yellowish little swelling leathery feel. More yellowness towards the decline of the disease. This disease is liable to affect the mucous memb. of the mouth, & is said to affect int. parts It is accompanied with chills fever etc. & in erysip. of the head with delirium Sometimes the fever precedes. The fever is also followed by a bitter taste in the mouth Case of an old woman attacked with feverish symptoms, which, as was expected were soon followed by erysipelas. Various divisions have been made as phlegmonous bilious etc. Prof. H. divides into that affecting the skin & that extending to the cell. mem. 1st of the skin. it terminates by scales & affects the young It however may term. by sup. & also affects all ages The second is attended with more tumefaction & terminates in sloughing suppuration & in gangrene. It sometimes extends to the fascia & tendons so that they will slough. This kind of erysipelas 14 is oftenest met with with in old and intemperate persons as in cases of chronic sore leg Erysipelas is distinguished from phlegmonic infl. by the latter having a central spot its circumference being less defined, & its pus collected into a central cavity The nervous irritation of erysipelas is greater producing delirium etc. The heart & arteries are more irritated producing a sharp and quick pulse which is very weak when the infl. tends to gangrene. The al. can. is generally affected, producing sometimes dysenteric symptoms. The exciting causes are wounds contusions irritations of the skin by acrid substances by alterations of temperature etc. 15 The predisposing cause is in the constitution & is unknown from the yellowness of the skin some have ascribed it to the liver We know not why some wounds should be followed by phlegmonous & some by erysipelatous inflammation except that at the time the patient was not in good health. This may be caused by malaria, the bad air of hospitals etc. Case of Pomfret when the meadows were drained. From its prevailing in hospitals some have thought it contagious This not probable Though depending upon the state of constitution, yet the extent of the constitutional is proportioned that of the local affection. It sometimes seems to alternate with other diseases 16 Prognosis varies according to the age & habits of the patient & the extent of the infl. The most dangerous cases are those of the head which are frequently attended with delirium & coma. Coma is however a common symptom in ole people Indications 1st to promote a resolution 1st by topical 2nd by general remedies Some are opposed to topical application Prof. H. finds no danger in them. The best Is acetate of lead. Cold water, milk & water Also 2 dr. mur. amm. in a gill of water or corros. sublimate 10 or [illegible] sometimes a drachm of opium to a pint of water or of the solution of acetate of lead Mercurial ointments are best in the decline of the disease The lard by itself is good especially when the [branny] scales are abundant. To this is ascribed by come all the benefit of the mercurial ointment. One of the most common applications is dry wheat flour. Yet it is one of the worst 17 2nd General remedies. They should be always used to prevent the affection from being driven in & then returning 1st venesection Strongly urged & strongly opposed Prof. H. approves of it in case of strong constitutional affection but not when there is extensive suppuration & when the pulse is weak & small 2nd purgatives they have been universally used. The indication has by many been drawn from the yellowness etc. The mercurial cathartics are best Calomel may be combined with a little opium in case of great irritation Neutral salts sulphur & magnesia have been recommended Antimonials are much used, especially in the Italian mode of beginning’ with say 1/6 gr. & doubling the dose (of tartar em.) until even 4 gr. are given 3d Tonics their use is strongly urged upon the supposition of erys. being 18 an atonic disease In cases of malaria and gangrenous tendency bark is undoubtedly proper. Opium & Dovers powder are proper in one of great irritation & opium is given by some as a stimulant. The most common preventive remedy among the people is neutral salts. They generally do much injury. Even low diet is generally injurious when practised with this view Infants are frequently affected with this disease. Sometimes their pudenda are badly affected with it Treatment calomel internally acetate of lead externally etc. A new remedy is nitrate of silver externally applied by moistening & touching. Prof. H. has tried this and found it useful but not deserving so very high commendation as it has received Prof. H has found blisters very as have Dr. Rush & others 19 especially in violent cases & in those which affect the cell. mem. An old mode has been lately revived viz that of making long & deep incisions even to the extent of 6 or 9 inches. This is efficacious in violent cases especially when suppuration is suspected. This disease requires great care and attention. Sometimes the disease may without our knowledge attack another part hence the old patients affected with stupor & infants should be examined every day Abscesses When phlegmonous infl. does not terminate by resolution it does by suppuration. So of erysipelatous. The signs of suppuration are diminution of the pain & chills (the patient will say he has caught cold) in external phlegm. infl. a softness will be felt. This will increase & frequently be surrounded by a hard rim sometimes there is a sharp [illegible] or [illegible] pain Pus is discovered by its fluctuation. We must press 20 alternately with the fingers or better with the the thumbs. IN muscular parts we may be deceived by the fluctuation of the muscles under the fascia, if we press transversely. We nay be deceived by fungous tumours Tumours of the viscera are apt to be mistaken for a collection of pus Great mischief is done by opening fungous tumours. In a gland suppuration never takes place until after the skin has adhered to the gland. Prof H. know of no remedies for promoting suppuration but poultices & similar applications. On pus. It is a secretion. A French surgeon maintains that it is secreted by a membrane lining the internal surface of the abscess. (Delbecke) It is of very little consequence of what poultices are made. Fomentations, as by wringing out woollen cloths dipped in hot water & then applying them to the part. Venesection & evacuant remedies are contraindicated. The bowels should be 21 kept free. Tonics are not generally needed Opium may sometimes be used according to circumstances. Prof’s Smith & Hubbard approved of opening abscesses immediately & not waiting for them to burst In erysipelatous infl. the pus is diffused & not in a cavity of a circular form Abscesses tend towards the surface unless prevented by strong fasciae etc. The opening need not be very large but should allow of a free passage to the pus There are inflammations of the cellular membrane where there is no erysipelas of the skin. The inflamed part is hard & is sometimes very extensive The constitutional symptoms are very severe & resemble those of erysipelas The suppuration has a peculiar [illegible] irregular feel. [illegible] this kid very dangerous generally arising in bad habits Indications moderate the const. affect. by calomel opium etc. The best external 22 remedy is blistering extensively afterwards using external lotions etc. This kind of inflammation frequently follows wounds of dissection Case of a man who lay down under a haystack & fell asleep. Infl. in the thigh, leg, shoulder & knees confined to the cellular membrane & yielding quarts & pints of matter when opened finally recovered. Another upon whom numerous similar abscesses were opened on succession finally there was an effusion in the thorax & the man died. The two last kinds of inf. & much more dangerous than phlegmonous. Frequently they arise from a very slight cause as a scratch in the old & intemperate. In the latter, delirium tremens is frequently caused by such inflammations. Prof. H. does not open with caustic He does not call the furunculus a proper phlegmonic inflam. The core of a boil is a dead portion of 23 cell memb. There are no better remedies than poultices etc. After opening an abscess we may use pressure to expel the matter but too great violence must not be used. Then a plug of lint may sometimes be advantageously introduced & finally the sides of the abscess should be brought together by a bandage if possible Frequently by a skilfull application of bandages around the opening, pus may be expelled which could not otherwise be obtained When it is wished to make a second opening into an abscess near the first, instead of lifting up the skin upon a probe & then cutting down to the probe, it is better to close up the first opening & suffer the pus to accumulate so as to cause a protrusion an incision may then be made with ease 24 Anthrax Begins with a small pimple a vesicle filled with lymph. The burning heat and pain very great. The const. irr. very great. The redness is of a darker colour than in the furunculus There is an areola somewhat resembling that of [illegible] pox. This will be surrounded with small pimples, which become small holes filled with a yellow matter The swelling extends & with it the holes Sometimes a considerable portion of skin sloughs off Eventually a considerable portion of cell. memb. sloughs off with a copious discharge of pus & the patient recovers In fatal cases extensive gangrene takes place without suppuration. Sometimes before the cure large portions of cell memb. (rotten) may be extracted with the [illegible]. Const. aff. very great tongue white & eventually yellow 25 When the anthrax is near the head delirium & coma are produced The infl. seems to be more erysipelatous than phlegmonous. Some persons of broken const. are liable to be [illegible] Prognosis depends 1st on the situation & extent of the anthrax Apt to be fatal if on the head face & neck especially if nothing but serum is discharged. If upon the limbs & back with suppuration they are there it is dangerous 2nd the const. sympt. Violent pain severe fever old age & intemperance especially the latter are bad symptoms One of the best local applications is an extensive blister plaster followed by cerate & if there is much heat & inflammation apply over the cerate ac. plumbi or in bad cases, emollient poultices The sooner the pus is formed and discharged the better. It relieves the irrit. 26 Frequently pus may be felt through the sloughing skin. Caustics are used by some but Prof. H. prefers blistering & if the first application does not relieve the pain & irritation apply a second. Frequently a slight incision is necessary to evacuate the pus Const. remedies 1st Venes. in rigorous habits, and early in the disease Mercurial purges are always proper unless there is great exhaustion Opium when there is great irritation and towards the close when the patient is weak give bark. Give dov. powd. at first & afterwards opium alone. Farther remarks on abscesses. Sometimes after opening an abscess lunar caustic or a solution of cor. sub. must be introduced to promote the healing of the sides of the abscess Sometimes the pus is collected in the bursae mucosae, as on the olecranon 27 process. The thumb the knees. The serous membranes of the bursae are liable to inflammation followed by a rapid collection of pus, & violent const. irr. It is especially important to open abscess of this kind, near the joints. Acute inflammation of the joints sometimes occurs, essentially different from chronic infl. It occurs oftenest in the hip Sometimes it is fatal in a few days Caused occasionally by injuries. The mode of cure is to cut boldly into the joint, to save life. The female mammae are especially liable to abscesses. Sore breasts & broken breasts are not all the same disease 1st superficial phlegmonic abscess. There is infl. of the gland The skin adheres. Venesection purging & antimony may be used. Tartar emetic has been lately recommended very strongly The usual external remedies may be used 28 It is decidedly advisable to open these abscesses though there is a prejudice against the practice. Erysipelas of the breasts is common & treated as other erys. infl. Infl. in the bur. muc. which lies between the mammary gland & the pectoral muscles Sometimes the pus makes its way out between the two breasts. We must open with an abscess lancet & then promote the healing by injections of cor. sub. etc. If this fails, introduce a seton of several threads & extract one thread at a time (vide Dorsey) Chronic inflammation. Sometimes a sequel of acute infl. That which follow acute phlegmonous infl. will be circumscribed It will not be of the skin but of the cell memb. Glandular parts are those which generally run into chronic infl. e.g. testis mammary glands the lymphatics (scrofula) These last are frequently subjects of surgical treatment, they are occasionally 29 inflamed from wounds The joints are peculiarly liable to it. The constitutional symptoms are less severe, resembling hectic generally without sweat & chills. The tongue is commonly coated sometimes [illegible] appetite capricious emaciation restlessness Coagulable infl. is effused & causes rigidity & tumefact. Indications, lessen the action of the vessels & promote absorption Bleeding must be practised with caution. Cupping & leeches are most commonly used. Prof. H. has found occasional bleeding serviceable promoting absorption. Cathartics must be used moderately The mercurial most valuable & the stimulant as aloes Narcotics, opium, hyoscyamus conium to allay irritation. Frequently the mineral acids as tonics Iron & arsenic & other mineral tonics seem 30 to cease irritation Iodine is used. Blistering is the best local application Case of its application to infl. mammary Tartar em ointment setons moxa compression is valuable when practicable, especially in infl. of cell. mem. It may be alternated with blisters mur. amm. etc. If the limbs are inflamed, exercise is useful Stimulating liniments, opodeldoc etc. are applied Chronic abscess. One which has either not been preceded by violent symptoms or in which they have [illegible] off. The patients account will often be that at some previous time he had a fever etc. followed by a swelling The fever did not leave him well etc. Sometimes the chronic abscess will be found in a different part [from] that in which the pain was formerly felt. 31 Prof H. has never known a fair case of perfect absorption of pus Though the evacuations may have taken place only after years of continuance. The prognosis is difficult The French open by caustic. Prof H. has not tried it. Lumbar abscess, as an example of chronic abscesses in general. Arises from scrofula, from injury or from no apparent cause The lameness at first often is ascribed to rheumatism The patient bends forward & towards the part affected. A soreness may be felt Finally a collection & a tumour pointing to the top of the thigh or even down the leg The pus is contained in the bur. muc. which protrudes under [illegible] lig. This may be mistaken for hernia & even for aneurism of ext iliac. It sometimes bursts in the groin 32 By proper examination in a standing posture the fluctuation may be discovered. Open by placing the pat. on his side, making pressure & inserting an abscess lancet making the orifice of the cyst as large as that of the skin by a turn of the point of the lancet. The pus discharges better in a [standing] posture of the patient when the tumour points downwards. When the pus is all out apply a compressing bandage & heal the orifice by the first intention. Afterwards open the abscess again & so continue. Keep the bandage on to diminish the secretion of pus After three or four openings, the orifice will generally ulcerate, if the abscess is not healed Sometimes a seton must be used This practice is a great improvement of Abernethy’s. Various remedies were formerly tried to promote the absorption of pus. Prof. H. has never known the cure. Sudden deaths arise from unopened chronic 33 as well as acute abscesses. After great operations, abscesses of the lung frequently come on Hectic fever following the permanent opening of chronic lumbar abscesses Chills, heat feebleness, irritation soreness confinement to the bed nausea vomiting loss of appetite. This is frequently mistaken for a new disease John Hunter was the first to deny the doctrine that hectic fever is produced by the absorption of pus. James Rose’s son 13 or 14 yrs. of age Injured his back by lifting. Became lame, was treated for rheumatism. Became more lame, emaciation & sallowness Prof. H. found a coll. of pus extending half way down the thigh. By Abernethy’s mode, about 3 pts of pus came out. The attending physician did not pursue the same mode but kept the orifice open. Hectic fever confinement to bed 34 died miserably in about a year. Instead of being better, they may find themselves worse immediately after the opening Oxygen has been supposed to be the cause. Cold air likewise has been brought [illegible] 10 gr. corr. sub. to 1 pt. water is the best injection when a lumb. abscess remains open. If no benefit results after a few weeks it must be abandoned. Limewater has been recommended as an injection. Calomel is the best treatment for the symptomatic fever, except when the patient is exhausted Irritation may be relieved by Dov. powder, quietness etc. The cavity should be carefully cleaned out every day Slight ptyalism may follow the corr. sub. Prof. Smith was in the habit of using this injection immediately after opening Prognosis Some have ascribed lumb. abs. to an aff. of vertebrae Very probably this affection of the vertebrae may be an affect instead of a 35 cause Small chronic (as scrofulous) abscesses may be treated like acute abscesses In scrofula the abscesses will not be regular & round like phlegmon They should be opened as soon a pus is formed In abscesses of this kind granulations are frequently found which must be removed by caustic. Sometimes the skin must be cut away to get at them Case related to illustrate the danger of opening [chronic] abscesses by large incisions & keeping the orifice open. Died in a week Quality of the discharge Commonly mild & inodorous thick (sometimes curdy) before the healing, it becomes thin & whey like. Acute abscesses frequently furnish this thin discharge, especially if’ erysipelatous Hectic fever Blood drawn will generally exhibit the buffy coat, before the opening of the abscess. Afterwards 36 we have hectic fever Pulse quick (sometimes not in old persons) generally 2 paroxysms in a day the nightly one attended with profuse sweats frequently with diarrhoea sometimes pains in various parts which exhausts the patient less of app. & nausea & vomiting occasionally aphthae (sometimes also as well as night sweats, before openings) may come on so also dropsical effusion of cellular membrane. The degree depends 1st on the nature of the part according to its power of restoration 2nd on the extent of the abscess e.g. occasionally it following the suppuration of an extensive burn 3d on the constitution of patient frequently mental causes have great effect [illegible] modifies hectic the old have less sweat & loss of appetite, but more diarrhoea Sometimes we are surprised to see so little constitutional affection. Such persons are generally very tranquil in mind. It is perhaps impossible to cure hectic 37 while the cause remains Some patients are exceeding by restless irritable & troublesome & [illegible] Prognosis this depends on our success in removing the cause. We may however moderate it by tonics e.g. sulph quinine, wine, opium This last invaluable, promoting sweats relieving [illegible] & supporting the vit. powers Keep the bowels free. Inflammation of the lymphatic vessels Causes may be ext. or internal 1st wounds acrid substances etc. Wounds have been given in bleeding Symptoms swelling, redness, hardness, a core may be felt a discharge of lymph, a swelling of the lymphatics in the axilla. Cured by touching by with caustic Sometimes a very small puncture will cause an inflammation extending upwards in the direction of the 38 lymphatics, indicated by red lines swelling soreness etc. frequently very troublesome sometimes an erysipelatous infl. & abscesses It may be occasioned by erysipelas Touch the small orifice (apparently in considerable) of the wound with caustic & apply adhesive plaster if this does not cure, blister the whole inflamed part, use compression etc. Open abscesses if there are any. Sometimes the inflammation extends from the heart instead of towards it in the course of the vessels. It appears in the throat in scarlatina. It may be caused by [sore lips] Frequently this disease comes on from an affection of a distant part is phlegmasia doleus from the uterus It may appear in the legs from consumption. Phlebitis infl. of the veins First pointed out by J. Hunter. It may be caused by venesection & by a ligature Vein appears like an inflamed cord Sometimes pus is found around the vein. Constitutional symptoms like those of erysipelas & very violent, accompanied with fainting palpitation 39 of the heart anxiety etc. Treatment venesection (some say ad deliquum) calomel & opium blisters Mr [Lizars] advises to destroy the vein above the part by caustic. Inflam of the arteries Not much is known respecting it. Ossification of the arteries, appears to a frequent result Mortification. The death of the part A cold ash coloured mass becoming black Gangrene is considered under this head Two kinds, acute & chronic hospital gangrene is a case The affected part from red becomes pale & cold the vessels filled not with watery but bloody serum. Pulse quick weak intermittent occasionally, sweat, singultus. Symptoms vary 1st according to the extent of the mortification. 2d acc. to the [illegible] of the part & 3d acc. to constitution 40 Chronic mortification frequently comes on as in the toes of old persons without pervious acute inflammation preceded by pains & heat. There comes on first a dark purple spot. Liable to be confounded at first view with shingles a skin disease. There first appears a redness then vesication, lastly mortification Two circumstances will always distinguish mort. 1st the coagulated state of the vessels, yielding no fluid 2nd no sensation being present in the part Causes external injury, a sudden cessation of vascular action in the limb!! bits of rattlesnakes wounds from dissection compression of bloodvessels from ligatures strang hernia etc. Inflammation more especially erysipelas & anthrax. Occurs oftenest in the old Ossification of the arteries is either a cause or after [illegible] There may such a degree of tumefaction or distention of vessels in violent infl. Case in which the skin was to much stretched as to cause mortif. Fire & frost bite after an operation for cancer of the breast as to cause mort. cause mortification IT has been attributed to the use of bad rye flour that which contained ergot. 41 Prognosis, difficult. All mort. is dangerous. Chronic mort. always dangerous Sometimes patients die when apparently almost recovered especially if old & when fasciae & tendons remain to be cast off. Sometimes patients are carried off by a new accession of erysipelatous infl. or a translation to an internal part It is a good symptom for the patient to go gently to sleep Treatment The attempt to imitate nature by endeavouring to excite an infl around the mort. part & so produce a line of demarcation & eventually the sloughing of the part, is to be considered Ind. 1st Venesection may be useful to moderate the violence of action Calomel for the disordered secretions in alterative doses Bark was formerly supposed to be a specific It is now discountenanced Acetate of lead & mur. amm. externally applied cold, as being more agreeable Emollient poultices, yest poultices will 42 correct fetor. Chlorate of lime & soda Bark was formerly used in poultice 2nd diminish irritation extract foreign bodies if there are any, open abscesses remove mortified sloughs. Calomel opium even with venesection, & especially when purgatives are required Emollient poultices 2d prevent the spreading of the mortification which spreads sometimes in the cellular membrane very rapidly. Bark may be useful but blisters are the great remedy. They should be extensive & on a limb, should extend above the part mortified except in case of mortified toes. Nitric acid (100 to 300-400 drops to 1 pt. water) may be used as a caustic application 4th support the patient by opium, bark wine ale porter, indulgence in nutritious diet. Keep the bowels in order, attend to the secretions etc. etc. After treatment of the part Keep on the external application etc. Clear away 43 the sloughs Case which terminated favorably related in which the whole gastro [illegible] muscle was lost. Near the close of the cure the following preparation may be used as a mild cerate. 2 drachms acetate of lead ½ oz. sulph. sodae, 2 ½ oz. simple cerate Mortification continued It may prove fatal from const. irritation either gradually or suddenly Case related of an old man who first had apparently an anthrax on the bottom of his foot There came on a phlebitis of the vena saphena. Mortif. affecting a whole limb will [rarely] be cured. Generally amputation is the best remedy. The const. irr. will be surprisingly relieved. Hiccup is generally a fatal symptom As to the propriety of amputation It must be done when the injury 44 has destroyed the principal blood vessels & limbs. Also in mortification of the toes extending over the foot for all such cases cannot be cured without too extensive a suppuration to be borne by the constitution As to the time of amputation. It is now settled that we are not to want for the mort. to stop spreading & for the mortified part to be sloughed off. The mortified toes of old people should not be taken off. If amputation is to be performed, it should be of the leg, or if this beings to be affected, of the thigh. Case of mortif. of finger of an intemperate shoemaker. When amputation is performed we almost always find the arteries ossified In compd fract. burns, frost bites etc. if the parts are likely to be dead, then operate immediately. Sometimes mort. extends along the cell. memb. under the skin, giving rise to a crackling feel & a sort of eymphyema. 45 Wounds in general. Solution of continuity in a part. They are of six kinds incised punctured lacerated poisoned contused & gunshot wounds. Extensive wounds may affect the system more or less according to various circumstances, one of which is the degree of confinement, e.g. wounds of the lower limbs affect the system more. The symptomatic fever will vary from a slight heat, to a high fever; sometimes we have chills sometimes erysipelatous inflammation The first indication respects the hemorrhage. This if slight may be stopped by cold air cold water, lint etc. If an artery is wounded, a ligature must be used, except that sometimes a small artery may be stopped by a total division of the vessel. Case of a man who had wounded the art. [illegible] 46 There came on a very troublesome & frequently recurring haem. Cured by opening the wound & totally dividing [the] partially divided artery. The temporal art. may, in this way, be totally divided & then stopped by compression Ligatures may be of silk, thread, or better of leather, rolled. Mr Lawrence has lately recommended a small silk lig. with the ends cut very close it is said they will come out by a small [pustule] Leather is absorbed. It is now [illegible] inadvisable to cut the internal coat of the artery by the ligature Mode od dressing. Bring the edges accurately together, apply adhesive plaster and a compress Leave the wound in this cond. for 4 to 5 days. The interrupted suture is used. 47 The sticking plasters may be used in addition to these, a strip between each two stitches In case of much heat & inflammation Prof. H. keeps up the practice of wetting the dressings even with ac. plumbi. Punctured wounds; of by a bayonet or similar instrument, they partake of the nature of others Considered dangerous yet often heal by the first intention. If pus collects at the bottom treat as in other cases of suppuration. Haemorrhage from wounds. The artery retracts when cut, the internal coat adheres & the [illegible] extends as far as the next collateral branch. This first led to the practice of using small round ligatures. Sometimes the needle & ligature is used when it is impracticable to use the tenaculum or forceps especially in punctured wounds, to avoid the necessity 48 of extensive incisions. We must be cautious about tying arteries in old wounds lest the tied part slough off & we have haemorrhage again to avoid this make a new incision. Be cautious about leaving any substance in the wound Sutures should be generally be left 4 or 6 days A proper posture is of importance. Horizontal for the lower limbs flexed if upon the back side of them. Union of parts totally divided as noses & fingers has not succeeded in Prof. H’s practice. When a little skin is left they do very well unless suppuration comes on Rest & simple diet are of importance. Rest is especially [so] in case of wounds of the lower limbs Contused & lacerated wounds may be treated under one head. The haem. is generally small. Do not hesitate to draw the edges of the wound 49 together instead of treating with fomentation & poultices to promote suppuration Poisoned wounds where a poisoned substance is applied to a puncture as stings and bites. It is difficult to say whether the effect is upon the nerves or the poison is absorbed The effects are very analogous to erysipelatous inflammation Excision should be performed as a prophylactic. Cupping has been practised. Caustics Among the French caustic acids are favorite applications If acetate of lead etc. fails Prof. H. would try blisters. For the general remedies use vol. alk. opium, alcohol camphor a variety if necessary of stimulants If violent inflammation comes on use venesection mercurials etc. If suppuration or gangrene ensue treat as usual for them. Case related in which 8 gr of arsenic were given in 4 hours cured. 50 Apparently phlebitis has been occasioned by bites of serpents Indian remedies are of little consequence. Stings of wasps & bees Bad case of a sting near the eye relieved by laudanum next day fever relieved by bleed. & mercurials Young woman in Toll. cty. stung in the leg by a wasp fainting & anxiety died in 15 or 20 m. Dissection wounds A wound seems to be necessary. Prof. H. does not think they can be explained by the predisposing causes of late hours, study etc. Symptoms finger very sore & painful soreness extends up the arm pain in the head & back, chills & fever. Swelling of the part up the arm in the axilla pus under the pectoral muscle & in the chest death. If the pus collects in the finger alone the case is less dangerous. Prof H. has known similar effects follow a puncture without morbid matter. Case of a boy wounded in the heel with a fish spear. red streaks abscesses in the foot & leg 51 suppuration under the pectoral muscle under the pleura death Very bad sores upon the fingers often have arisen from dressing ulcers. Prognosis varies upon the situation etc. Touching the wound with nit. silver has not always been successful Suppuration in the lungs following operations compd fractures etc. The treatment is the same as in other inflammations of the pleura bleeding etc. In two cases Prof. H. made an opening into the sac of the pleura one of them was fatal, the other recovered. Gunshot wounds The contusion must be very great. A spent ball will produce contusion merely. It was formerly supposed that the ball burned the parts judging from the appearance of the [illegible. This is a mistake Often the shock to the system is very great, but with some it is trifling The entering orifice will be smaller than the issuing The latter will have 52 ragged and projecting edges. Sometimes a ball may be pulled back by taking hold of a piece of silk, which was carried in before it. Its course may be very circuitous, being diverted by tendon sometimes as well as by bone. Abscesses and also cysts are formed around it. The effect formerly acribed to the wind of a ball are explained by the oblique stroke; the skin yielding & being unlacerated, while even the bones within are broken. That the wind does not produce the effect is proved by the fact of one leg’s being carried off without injury to the other, when both are in contact The contusion destroys the life of the adjacent parts. The hemorrhage is generally slight Balls may pass through the body without penetrating cavities, as of the chest. Baron Larrey told Dr [Heerman] that he had lost but two patients whose bodies had been perforated by a ball. 53 Necrosis is generally produced by a ball’s striking a long bone in other bones caries. Wounds of the lungs will often be followed by haemor. from the mouth of the bowels by feces issuing from the orifice. Wounds of the joints are dangerous Indications 1st suppress hemorrhage Do this by the tourniquet if possible Tie arteries as soon as possible, unless amputation is to be performed 2nd extract foreign bodies unless they are out of sight & of the reach of the finger or probe When the ball has passed nearly through cut down on the other side, while squeezing with the finger & thumb. Thread etc. will come out by suppuration A foreign body lodged in a bone is very dangerous. In a superf. bone trephine 3d prevent or remove irritation The French make incisions to take of the stricture & debridling the part. This is now discountenanced by the British In case of a fleshy wound, apply 54 merely lint and simple cerate. Many keep a moistened compress upon the orifice This is [illegible] cold water is generally the best application. For some days the wound will look ugly, with swelling & frequently a watery discharge. If suppuration comes on slowly, poultice but do not continue them after suppuration’ is fairly established, but absorb the pus with dry lint. The separation of the slough is another critical period if secondary hemor. then comes on apply a compress immediately. The plan of tying the artery at a distance has generally failed In an old wound we must make a new one. General treatment should be antiphlogistic Prof. H. uses calomel as a cathartic & the British surgeons are adopting the practice. If there is pain in the head fullness of the veins etc. bleed & purge In the latter stages opium is invaluable 55 to allay irritation Sometimes also in the first shock & then according to some bleeding must be conjoined. Amputation 1st as to the time 2nd as to the particular case. The unanimous testimony is now in favour of immediate amputation waiting however for recovery from a violent shock & administering a mouthful of wine & also consolation & encouragement. Baron Larrey & Prof H. prefer immed. amp. even when bad symptoms have come on 2nd the different cases 1st amp. is necessary when a limb has been shot off for a clean incised wound is made the patient will be more comfortable & mortif. less likely In fingers the injured phalanx only need be removed, at the joint. 2nd when a ball has passed through or lodged in a joint. 3d in some cases where a bone is fractured according to the degree of injury to the bone & also to the soft parts Even if the patient recovers, the limb will often be not so good as a wooden one Necrosis often comes on. The suffering will be great Often a bone will be fractured & split into the condyle 4th by extensive destruction of soft parts, to prevent gangrene, or extensive supp. & hectic & where the muscles are torn off the limb will be stiff. If the upper part of the femoris or os humeri is fractured amp. is necessary (at hip joint?) Consecutive amp. may be necessary The destruction of large arteries sometimes the skin will be unbroken in the meantime often indicates amputation Good accommodations for the wounded may enable us to save patients without amputation Be careful to amputate entirely above the fracture Mr. [illegible] says that after amp. death takes place 1st from infl of bloodvessels 2d [metastasis] to some important internal part most commonly to the thorax in our climate 3d from disease of the bone or joint 1st the veins may perhaps be tied 3nd pus has been found in the sac of the pleura 3d the hip joint Prof. H. would evacuate Suppuration of the liver more freq. take place in hot climates After amp. the end of the bone becomes round if the cure is favourable Paralysis is a frequent consequence of extensive gunshot wounds cured by moxa according to Bar. Lar. Tetanus Failure of success almost universal in acute tetanus more common in warm climates Bar. Lar. has had most success. It may be occasioned by tying up a nerve with an artery by exposure to night ari by suppression of suppuration acc. to Bar. Lar. Actual cautery has succeeded Amp. has generally failed Canthar. often fail It occurs oftenest in the young & in wounds of a [ginglim???] joint acc. to Bar. Lar.’ Emprosthotonas will follow an anterior wound & opisth. is a posterior & tetanus where there equal injury before & behind acc. to Bar. Lar. Warm & cold bathing have been much used Case of a young man wounded in the foot by a piece of glass. Bled. blister to the healed wound calomel opium cured was stiff for a year. Case 2d blacksmith hot iron upon foot corr. sub. into the wound blister over the foot calomel & opium the latter followed up cured. Make a powerful impression. A red hot ploughshare has been passed along the spine. Bite of mad dog Excise deeply it has never failed in Prof. H’s practice A finger may be cut off. He has cut out 6 days afterwards with success. Dr Physick says at any time before the [accession] of the symptom Contusions without breach of the skin It is an injury causing a rupture of vessels & effusion of their contents under the skin 1st swelling owing to extravasation next echymosis or discoloration which frequently extends some distance especially in the direction of gravity e.g. black eye from contusion on the forehead finger discol. after an injury of the arm very easily produced in old people. Commonly a considerable degree of soreness. The powers of absorption greater in the young Indications 1st prevent further effusion 2d reduce infl. 3d promote absorption 1st by wet lotions of water [mar.] [illegible] etc. 2d if much fever bleeding & cathartics & fiunally if necessary opium 3d Use warm applications (these also may be for the first indication after a while) Add to these bandages & compression. Also we can apply camphorated spirits opodeldoc etc. In many cases an incision must be made to let out the effused blood (called bloody abscesses by the French) We should however generally defer [illegible] One reason for which is that the vessels may continue to bleed. If the blood is coagulated a snapping will sometimes be felt as of something breaking & slipping away. [illegible] in this state it is though more likely to be absorbed. Before incision try remedies and [observe] if you appear to be gaining ground. Sometimes the effusion is in a bursa mucosa Case of it in the knee So [much] a [illegible] Make the incision on the outside of the tendon of the rectus musc Prof H has several times been obliged to open these bursae e.g. at the elbow. Upon the back he has had to make an incision & let out a quart of fluid tarlike blood. If the vitality of the skin is destroyed an incision will be advisable. We shall have a sloughing sore in either case. There is a bursa directly on the olecranon which is liable to be filled with effused blood Often there will be a second eff. when the orifice must be opened & the cavity injected with corr. sub as in [illegible] Contusions of abdomen. Death has been occasioned by blows on the epigastrium apparently caused by the shock alone Often the peristaltic motion suspended which denoted by swelling of the abdomen vomiting want of sup. anxiety of countenance etc. Sometimes blood is vomited It is generally best to avoid stimulants Case young man kicked by a [illegible] vomiting of blood 1 great pain & excessive thirst to stop the flow of blood cold wet cloths were applied to the abdomen bled ad deliq. pain ceased pain & vom. returned bled again calomel finally injections The bleeding relieved the pain the vom. & the thirst. cured in 2 or 3 days Venesection is the most important indication, the next is purgatives continued for some [time] Sprains not much treated of It is an unnatural extension of ligaments of a joint sometimes accompanied by dialysis or rupture. Joints most commonly affected are those which are not strongly defended & admit of little motion. They are the knee ankle wrist & hand. At first motion is free but it is soon hindered by effusion & swelling frequently there is effusion into bursae mucosa There is an effusion into a bursae of the foot which is often [illegible] for dislocation. It is apparently set by pressing & breaking the sac. Prognosis Some families are particularly liable to them Scrofula gives a tendency. In some constitutions a slight sprain will cause [hemorr.] for months Treatment Rest is more necessary than in contusions. Cold lotions to prevent infl. cold water or ac. plumb. A bandage is always proper moistened at first. In case of much pain use warm fomentations best by wringing out a cloth dipped in hot water, applying it & covering it with flannels to keep in the steam. Poultices may be used In case of stiffness apply opodeldoc & other stimulant applications friction passive & active exercise. Lameness is often caused by want of exercise. The violent wrenching of the natural bonesetters has some good in this way. Burns. Inflammation caused by heat The practice has been exceedingly empirical No advantage in dividing them into species Superficial burns of sufficiently extensive are of the highest consequence Case of a child blistered by cantharides over the whole body died in great agony. The British East India surgeons sometimes used hot water for blistering The [illegible] indication is to shut out the external air. Treatment like that for a blister Deep burns are generally [illegible] by a suppurative inflammation which is generally ascribed by the patient to taking cold. Sometimes flame is inhaled the viscera are affected, under the external injury, in some patients Consequences of extensive burns if the pat. survives the first shock, are fever, extensive [illegible] etc. This last is frequently fatal, hence the end of three weeks is a critical period Children are sometimes affected with convulsions When we find apparently comfort application already made, we should be careful about interfering with them Treatment has been opposite & empirical Cold water on one hand & spts turpentine on the other. Antiphlogistic & powerful internal stimulation For simple external burns anything that keeps out the external air perhaps as good as any is simple cerate. If there are vesicles [illegible] them Equal parts of basilicon (or common cerate) & spts turpentine is the best application in case of extensive sloughing & suppuration Prof H. has tried cold application & poultices, but does not like them [illegible] is the necessity frequent exposure to the air in dressing. The above cerate seems to promote a quick suppuration & so prevent gangrene. It must be laid aside (causing smarting etc.) as soon as suppuration is free, when simp. cerate should be dressing not oftener than once in 24 hours having the dressing ready for immediate application the cold air. Then granulations come on use Turners cerate Finally use ac. lead 1 oz beeswax & sulph. sod. 2 oz. This is called saturnine cerate. Turner’s cerate above is made of oxide of zinc. Often near the close of the cure adhesive straps & bandages are useful to keep the sides of the ulcer together Constitutional treatment. The shock is often very great. In children there is either violent distress with screeching [or a comatose] state with deadly coldness which indicates alcohol camphor ammonia etc. Opium also though Prof. H is afraid of it in coma. Next comes on fever treated by venesection cathartics etc. to be discontinued when suppuration comes on. In children it will be sufficient to keep the bowels open & bleed only incase of convulsions In adults the bleeding should not be copious. Bark [seems] to be irritative Opium is the principal remedy on account of the pain etc. Cotton seems to be advantageous only by keeping out the external air & keeping the parts warm & by being easily applied & kept on Case of a man who fell into a kettle of boiling potatoes Took a large quantity of spirits Was dressed with the turpentine cerate then with simple cerate opium [was given] the bowels kept free about the [2?] day there was a critical period his mouth was treated with borax & other means were adopted which cured him. If an extremity is burnt off then amputate the stump immediately Sometimes the bones come off themselves. Deformities from burns The fingers are liable to adhere This is to be prevented by dressing. Splints are to be used to keep parts in their place preventing [illegible] flexion of fingers etc. When the joints are affected they should [illegible] straight & when the sore is healed, practice flexing them. Case of a young man who scalded his legs Deformities following burns Case of a burn at 7 yrs. of age upon the back of the thigh troublesome with sores etc. at 47 yrs had been of latter years much troubled with a horny excretion which was softened with [poultices] & shave off [At] 47 yrs of age the limb was amputated IT was an old practice to cut across the cicatrix & stretch the parts in case of deformity caused by contraction The new practice is to cut out the scar entirely sometimes adding the taliacotian operation Case of a young man with a large & sore scar on his foot. A good foot was made Frost bites A degree of torpor is produced by severe & long continued cold amounting to drowsiness & irresistible inclination to rest. Case of Prof. H’s preceptor, an army surgeon Not suddenly to be brought into a warm room nor to be too free with cordials Immerse frozen limbs in cold water gradually warming the water after a little while. A limb thoroughly frozen cannot be restored to vitality, however The contrary treatment totally destroys the frozen part. The effects of frost are similar to a burn superficial redness mortification which commences with a purple & terminates with an ash colour in case of thoroughly frozen limbs In frost bites apply ac. plumbi etc. poultices, cerate in case of suppurations which may have liquid applications over them. Cold and warm applications are both used. In case of mortified extremities amputate without hesitation as soon as the line of mortification is distinct else we shall have suppurations abscesses etc. Case of Capt P. of Brooklyn was overturned, & [stunned], in extreme cold weather lay all night was put int a very warm room. The phys. attempted to bleed him no blood followed there was a wound on the eyebrow knee the other knee dislocated right hand frozen. Prof. H. bled him, & gave a dose of cal. & jal. Afterwards he grew more insensible & eventually comatose for several hours. An erysipelatous inflam. with delirium supervened. He was bled & treated on general principles. Eventually recovered The fingers & thumb of the right hand were amputated after about a fortnight This amputation was however too late as was proved by suppuration & abscesses taking place on the hand & arm. The patient was partially sensible & able to tell his name when he was first discovered by the road side. The effect of the warm room was to bring on complete insensibility & finally coma A foot or hand frostbitten if applied to the fire is followed often by violent infl. & mortification which when superficial merely will cause nothing more than the loss of nails skin & so on Tumors Varieties numerous 1st Encysted 2d sarcomatous 3d medullary Also malignant & non malignant the last however may become malignant We know little of their origin. Mr. Aber. attributes them to extravasated blood. Their progress is often similar to that of chronic inflammation The nature of the tumor will often be inflamed by that of the parts where they are situated e.g. they may contain hair when upon the scalp. The growth seems to depend upon the size of the bloodvessels of the part. They increase, in general, in geometrical progression They should be extirpated before they have arrived at any considerable size. 1st Encysted tumors contained in a cyst of more or less density, which encloses [stertomatous], or [illegible] mellitus, or is an [illegible], curdy matter being contained There is a kind affecting the red part of the lip having a think sac & contents resembling the white of an egg not larger than a musket ball. There is a tumour composed of adipose matter disposed in cells called sarcomatous Various discutient remedies, have been recommended. As far as they are effectual at all, they do injury. If the cyst is penetrated, a very troublesome sore follows & sometimes cancer Caustics instead of knife have been successful Cancer quacks cure small tumors in this way and call them cancers. In case of large tumors caustics often fail & the knife is always preferable. It was formerly advised to extract without opening the cyst this not always practicable without great difficulty. Sir A. Coop. opens the cyst presses out the contents & pulls out the cyst by inversion. If any portion of the cyst remains the tum. will be renewed. Sometimes a small tumour may be removed by caustic alkali upon lint introduced into the cyst. external injuries freq. cause these tumors Sarcomatous tum. In these the cyst is not strong enough to be pulled out. If the skin adheres firmly, make two semilunar incisions & take out a piece of skin Then separate the tumour from adjacent parts by the fingers as much as possible Membranous connecting bands often have to be divided. These tumors are troublesome from their size, from impeding motion etc. when pendulous, the skin is frequently affected with an erysipelatous infl. Cases of old woman & an old gentleman extirpated with safety. The arteries are usually very small in these fatty tumors sometimes however they give a troublesome haemorrhage They are divided into various kinds by Mr. Abernethy. All the kinds may become malignant Fungus haematode medullary tumors malignant from the commencement & liable to return even if thoroughly extirpated. Hence a portion of undiseased parts should be cut away After extirpation treat as for a simple wound. The largest [tumors] are the fatty even 40-50 pounds They feel like a bag filled with cotton Sometimes there is a puckering of the skin (caused by imperfect adhesions of the skin) under the fingers. This is a pathognomic symptom These adipose tumors must not be confounded with the steatomatous encysted tumors. It is a question whether the whole parotid gland has been extirpated. They will prove fatal (many of them) eventually & hence should be extirpated while small. The testicle & the fem. mam. are enlarged frequently & sometimes will become small again Medullary tumour or fungus haematodes the substance of them resembles that of the brain but is redder & harder found in every part of the body even in the bones & then called osteosarcoma There is at first an elastic feel caused by the binding down of fasciae Growth is very rapid, causing absorption of adjacent parts as bones Most common are they in the young they were all formerly called varieties of cancer In the testicle most taken for hydrocele It is found about the eye Prof H. has met with them oftenest about the hip. Case of mortification & death in three days in consequence of opening one, in search of pus. Case in which a small point was left, which grew in spite of caustics & proved fatal. Case in which it returned three times & was then left We must hence cut away sound parts also. If the bone is affected amputate. Prognosis is generally bad though the wound heals well enough. They may return in internal parts. They are not always pulsative nor generally painful except by pressure upon surrounding parts & by a general [illegible] of health loss of app. sallowness of continence etc. pain when a nerve is pressed on Diagnosis of medullary tumors Abscesses begin deep & are not painful and are circumscribed by a hard edge. fungous tumours have an elastic feel. The colour of the skin over a fungous tumour will be dark red, but not tender like that of an abscess, nor surrounded with a hard rim. We must also inquire into the previous symptoms fungous tum. begin without infl & pain & are indolent. Spots will be found in the neighborhood which if opened largely will prove fatal. Case of a fung. haem. of test. mistake for hydrocele. Though we have no remedy for this disease yet extirpation should be performed if possible cutting into the sound parts. Case of Dr Wood. of [Cast.] cutting out one of the thigh every few months the man able to labour. Case in which the most powerful caustics failed in killing the tumour, fast as it grew. Ulcers A solut. of cont. in soft parts with a discharge of fluid. The absorbent vessels remove the parts faster than the nutrient vessels renew them hence the opposite to healing Differs from mortif. by the dead parts remaining in the latter case Various classes of them Causes wounds abscesses external injuries (local) The constitutional causes are syphilis scrophula scurvy etc. also in some families from a predisposition e.g. hereditary sore legs An oedematous affection predisposes e.g. dropsy phlegmasia dolens 1st simple 2nd irritable 3d indolent 4th varicose 5th specific ulcers 1st simple discharge of mild inodorous pus small round granulations filling up the cavity finally a bluish skin (cuticle only) which makes cicatrization Formerly 3 stages were always expected in the healing of a wound viz. ulceration, granulation (restoration) & cicatrization. Much benefit arises in a simple ulcer from adhesive straps, as in a wound, to promote cicatrization. The bandage will keep the parts together & also prevent proud flesh (a luxuriant gran. protruding beyond the skin) which should by nit. sil. or if that fails by sul. cop., be reduced Irritable ulcers painful sore irregular shape (sometimes round when small) gran. irregular do not bear bandaging well. The irritability may generally be abated by touching with nit. sil. or by wash of corr. sub. or by 1 scr. corr. sub. to 1 pt water (called yellow wash) or sprinkle with calomel, or apply the black wash of cal. & lime water or wash with [illegible] op to 1 pt water 1 dr. ac. lad to 1 pt. mucilage will be cooling & lenient. Warm fomentations are apt to soften too much We frequently change our application Indolent discharge serous& curdy bottom smooth edges swollen surrounding cell mem. thickened often very large as large as a hand [illegible] patients will suffer little, and continue to labour. A farrago of remedies in popular use Nitr. ac. & nit. sil. & other caustics are used. The best rem. is MR. [Berts] plaster bandage, surrounding the limb. above & below with this bandage applying a compress wetting the whole with cold water. Sometimes leave a little vacancy for the discharge of matter The plaster may be common adhesive pl. or diachylon, or rosin pl. or [litharge] pl. sometimes in case of irritation from Soap plaster of the [illegible] is used rosin softening this last with tallow one half Dress once in 2 or 3 days only Sometimes an erysipelatous infl. & sloughing comes on Guard against this by diet etc. Improper to make a class of sloughing ulcers Indolent ulcers may be cured much sooner by confinement, as is practised in the hospitals. 3d Varicose ulcers. The veins will be found varicose. Some are irritable more commonly they are indolent. Treatment of the varicose veins is the particular indication. Proper bandages with confinement of the patient is always proper. However the cure will be more sure of being permanent when it is effected without Diet is of the highest importance The patients are generally plethoric more or less; hence use venesection or purgatives (mercurial). Where erysipelatous infl. come on treat as usual by ac. plum. blistering etc. Some patients are feeble with low pulse cold skin & pain in the affected limb. In this case give cal. [illegible] cal 1 ½ gr. op. 1 gr. also Dov. pow. bark & opium etc. Nitrate of silver relieves irritable [illegible] sloughing etc. better than any thing touching with it once in a few days. There is generally little hazard to life from sore legs. Cases in which by the continual application of caustics & irritatives caused enormous ulcerations cancers & affections of the bone which required the operation for necrosis, or amputation It has been proposed to be the vena saphema Sir A Coop. objects. Cutting across the vein is thought better by some also cutting with the convex cutting edge of a bistoury, so as not to wound the skin also cutting out a part of the vein & then bringing the edges of the wound together, as is practised with success in the Pennsylvania hospital. This latter mode probably the best. It has been supposed that the drain from old ulcers is very beneficial this opinion is probably derived from the fact of the stopping of the discarge in an acute disease as fever There is no danger in curing them Hence the old opinion, which is still the popular one, is to be entirely disregarded Plethora had better be relieved by venesection & cathartics than by ulcers. Specific ulcers e.g. venereal, noli metangere cancers etc. Anomalous ulcers Sore on the instep somewhat like elephantiasis. Benefitted by powdering with calomel. Nitrate silv. saturnine cerate acetate of lead & calomel with lard may be tried also. There is a thin watery discharge redness hardness thickening extending over the whole upper [surface] of the foot. Sometimes stopping in one direction & extending in another Fungous ulcers [ment.] by Sir. A. Coop. principally on the calf of the leg resembling a scrofulous affection of the metatarsal bones generally in young & corpulent women Apply bandages wet in case of heat when the fungous protrudes through the skin apply nit. sil. Also wash with ac. of lead etc. & prescribe for constitutional symptoms. Ulcers following scrofulous abscesses Fungous flesh overhanging, thin, dark purple skin they are oblong Apply nit. sil. in pencil under the skin if necessary that is if this first application does not cure then cut off the diseased skin & lay open the whole sore. Sometimes where the orifice is small, a director must be introduced & a long incision made it will not in this case be necessary to clip away the skin. These like other ulcers are often called cancers Schirrhus or cancer. A hard tumour without ulceration is called schirrous cancer, when ulceration comes on Schirrus may be fatal without running on to external ulceration Lower limbs & testes in males breasts & uterus most often affected When affecting the skin they begin with a blood war, or with a discoloration & tumour of the skin to be treated of afterwards. Scrofulous tum. are less hard, seldom single, oftener in young people, they are smooth, and attended with scrofulous habit. Young women are often affected with an induration of the mammary gland which is mistaken for schirrus. The latter is almost always found in adults. Cancer of the breast [Commences] with a painfulness When first examined there is found a hard tumor. An inflammation of the skin takes place. The nipple retracts & disappears eventually the hollow will discharge an ichorrous fluid. Or the cancer may commence with a small vesicle which breaks, discharges, & finally becomes an irregular knobby cancerous ulcer Cancers however, do appear to commence sometimes internally. The lymphatic glands & sometimes the lymph vessels, are affected when the ulcer opens. Sometimes the skin adheres to these inflamed lymphatic vessels Finally the manna adheres to the pectoral muscle & even to the periosteum of the ribs & sternum even attacking the other mamma with the same symptoms The lymphatic glands of the axilla are more affected & the arm sometimes is so oedematous as to require puncturation Great difficulty of respiration occurs The disease is fatal from hydrothorax or other affections of the thorax, as well as from hectic Sometimes without much ulceration the whole mammae are bound down at death with schirrhus. Sometimes the bones of the extremities become singularly brittle. Sometimes a paralysis of the limbs takes place The whole spinal narrow has been affected. Very numerous & various symptoms may come on in the sequel. Difference of opinion as to whether this disease is constitutional or local. For sometimes the disease returns in the same or another part & sometimes not Prognosis doubtful The more speedy the access the mor probable the return Sometimes in very old people from their slow progress & insensibility they give very little trouble. Their cure has been attempted by bleedings & low diet also by salivation No dependance can be placed on these remedies. So of the internal use of arsenic and of conium also. Iron internally & externally seems to have failed Pressure has been much tried, but fails The hard cartilaginous nature of the tumour would lead us to despair or resolving them by internal or external remedies Caustics have been successful in very small cancers, but generally they give so much irritation as to increase the disease making a loathsome sore Iodine has been proposed There are no accounts however of perfect cures by it. Prof Smith stated he never knew a woman survive the application of caustics to the mamma more than a year The sooner the knife is used the [better] Use the knife also even after ulceration has come on. We must not expect the infl. of the lymph gland to subside of itself, this tumour also must be cut out. Reexterpation Should be performed as often as the disease returns provided the patient can bear the operation Case of 4 times in a year & the patient is now well. Various remedies, or issues, have been tried to prevent the return of the cancer It is of no use to prescribe any thing except for the general health In other parts of the body cancer may begin in a manner similar to those of the breast In the lip, we may have first a crack in the lip ulceration the lymphatic glands of the neck are affected the gums are affected the cheek the bones the whole mouth consumed & sometimes the patient dies of starvation. Mode of extirpation take out a piece in the shape of the letter v. bringing the parts together. If the skin is not affected, we may cut away down to the skin, leaving the latter Mr [Richaraud] cuts away the whole with scissors instead of the knife Prof. H. has extirpated the diseased glands under the inferior maxillary but generally without success where the disease has proceeded so far. We must not be too solicitous to save skin, cutting away all that adheres for the disease may return in the skin. Even when the disease returns it is not generally so rapid & fatal as at first. We must be very careful not to confound cancer with other diseases of female mammae Hydatid or incysted tumour of the breast of Sir A. Cooper 1st an enlargement then a tumour which yields serum when punctured then returns again and may attain to the size of several pounds. When of this size it is found after extirpation to be composed of one or of several cysts & may be of other forms. Case of a woman who had one opened a second time the opening kept open by [illegible] died of extensive suppuration & const. irritation Another case was extirpated at the first time. The tumor was the enlarged mammary gland with a cyst in the centre. Diagnosis absence of pain If opened the fluid perfectly limpid Indication immediate extirpation Simple chronic tumour of the breast of Sir A. Cooper. Rather upon the breast, than in it moveable Not generally painful & does not affect the constitution It grows very slowly but may arrive at a large size. There is no difficulty in cutting off the tumour & it does not appear to be liable to return It may be either before or behind the mam. gland These tumours are composed of several cells resembling sweet bread a glistening & glandular appearance. The cause is unknown. The patients sometimes suppose them to be caused by the pressure of dress Caustics may have cured them. Adipose tumors sometimes many pounds in weight may be either before or behind the gland. They are to be extirpated Irritable tumours of the breast for 15 to 30 yrs. lobe of the breast swollen & painful the arm is affected, more painful during menstruation especially during difficult menstruation great irritability etc. If patient is plethoric, bleed, & purge apply spirit & water or a plaster the best external application is soft fur or cotton batting. Give opium Sir A. C. speaks of an ossific tumor of a cartilaginous nature to be extirpated Lacteal tumor after delivery a swelling, which when opened yield milk Caused by an obstruction in the duct of the gland. Treatment, open & let out the milk wean the child & so stop the secretion of milk. If the orifice does not heal, touch with nit. silv. Some women are very liable to small abscesses of breast during suckling If they continue to succeed one another the child must be weaned. Breast large & pendulous It may be diminished by bearing & nursing children also by suspension Sometimes there is an enlargement & inflammation of the breasts during pregnancy which often require opening to evacuate pus With the exception of the small chronic tumors upon the breast, the whole glandular portion of the breast should be removed. Mode of operation. Instruments 2 or 3 round edged scalpels tenaculums needles & ligatures adhesive straps from 1 ft. to 9 in. long & 1 inch wide Bandage by a broad band passed around the breast & crossed over the shoulder stitching down in front. Have also lint & compress. Cordials & cold water for fainting. This last is best remedied by dashing on cold water Place patient on a table, with feet in a chair arm extended sitting in a chair is apt to occasion fainting Make the first incision in the direction of the greatest length of the tumor Or make it in an oblique direction in that of the pectoral muscles. If the skin is affected semilunar incisions are necessary. Stretch the skin with your left hand & by that of an assistant Use a drawing stroke, from heel to point of the scalpel. Make your incisions long enough at first Use considerable force & repeat the stroke also until the incision is deep enough If two incisions are made, make the lower one first. Observe this rule also in your following dissections. If an artery bleeds, stop & tye it or have an assistant keep his finger on it. Be careful to examine the bottom of the wound & also the under surface of the tumour. Cutting away little additional portions does not give very great pain. Then proceed to take out the tumour from the axilla Sometimes the same incision will answer for both. They may sometimes be torn out by the fingers being imbedded in the cell. mem. merely we can generally get the fingers behind them When there is a diseased chord in the in the cell. membrane, take it out with the tumour in the axilla Spunge the wound out well & tie every bleeding artery wait sometime in order to prevent secondary hemorrhage The French direct us to wait ¾ of an hour Wipe dry & bring parts together with adhesive plaster, beginning at the top & leaving a small space for ligatures to come out, unless they be made of leather then apply lint & a compress, & bandages It has been the practice of some surgeons to tie the carotid previously to the operation There is no necessity for this Other tumours. Cutaneous tubercles of Mr Lawrence. Prof. H. has seen it often. Frequently beginning about the face especially of elderly people upon the eyelids, nose, & upon the generative organs of both sexes. It becomes ulcerative & resembles cancer. Sometimes resembles a wart & sometimes a vaccine vesicle, at the first Always reddish & without inflammation of the skin. Sometimes it grows very slowly & gives but little trouble. At other times, especially if irritated, its growth is rapid. Finally they ulcerate without any disposition to heal & indeed become cancers; they are covered with scabs. Menstruating females are liable to periodical evacuations from the uterus, intestines (hemorrhoids), lungs etc. produced by these tumours This disease is different from noli metanges Treatment. Extirpation is the only mode of cure, & appears to be effectual the disease apparently not liable to recur The health of females with periodical hemorrhages, will be much improved. Mode make two semilunar incisions & be careful to cut into the healthy skin They do not extend inward Subcutaneous tumor Vide Cheselden’s Anatomy & Mr. Wood in Ed. Med & Sur. Jour. A hard tumor surrounded & covered with emaciated & discolored skin excessively painful growing very slowly & continuing quite small, notwithstanding their painfulness They are of a cartilaginous hardness. They do not appear to tend to ulceration more painful during menstruation & pregnancy Extirpate without delay or hesitation [Naevus] materna called marks apparently composed almost wholly of enlarged blood vessels they may be red or purple, or brown sometimes without any elevation of the surface They are sometimes troublesome in after life the swelling increasing suddenly the tumour becoming pulsative swelling & pulsating when the child cries in this latter case however, there will generally be no trouble in after life from the [naeva] Sometimes they become aneurisms from anastomosis sometimes affecting the whole & sometimes only a part of the naeva sometimes ulcerating at the principal point the ulcer may also very extensive attended with frequent haemorrhage. Aneurisms from anastomosis may come on without being preceded by naevus they may be made almost to disappear by pressure they pulsate violently they are tumours composed of cell. sub. & blood vessels. They should be extirpated after extirpation they of course shrink to a very small size. They may ulcerate extensively & the ulcers are very difficult to cure (They pulsate upon exercise) They may grow to a very large size & are then liable to be confounded with fungus haematodes They may be distinguished by their origin, situation progress, pulsation etc. As ulceration sometimes cures these aneurisms, caustics have been recommended for their cure Extirpate the haemorrhage will be troublesome, hence cut around & avoid cutting into the tumour as much as possible, also cut quickly, stopping the arteries by the fingers of assistants If practicable, the better way is to surround the (small) tumour with a double ligature. A new way is by passing 2 or 3 times through them a white hot needle apparently successful in case of small ones Case in which a naevus on the head was cured by Prof. H. by ac. lead bandages & compression Inoculation with vaccine matter has succeeded, apparently caustic would be better however as a means of promoting ulceration Tying the principal artery leading to the tumour, has been practised when on the head the carotid has been tied apparently without success. 11 Theory Practice Physic (front) Surgery (rear) Nosology 1 Diseases of Children 5 Retention of meconium 6 Tumour of the head 7 Aphthae or Thrush 7 Red Gum 13 Strophilus candidus 14 Ulcerated mouth 14 Costiveness 16 Infantile Erysipelas 18 Anomalous Eruptions 19 Crusta Lactea 20 Venereal Eruption 22 Sore Ears 23 Diarrhoea 24a Vomiting 28 Hydrocele 29 Volvulus 30 Constipation with fever 32 Worms 36 Convulsions 46 Epilepsy 49 Chorea 51 Dentition 55 Ricketts 58 Cholera Infan. 60 Tinea Capitis 68 Catarrhal epidemic 70 Gangrene of mouth 80 Chillblains 81 Exposure to extreme cold without freezing 81 Mesenteric fever 82 Cutting frenum 85 Burns 86 Tympanitis 87 Neuralgic aff. of the lower limbs 88 Whooping cough 71 1 Theory & Practice of Physic Nosology Dr Rush condemned nosology but afterwards made use of a system of some sort. We must arrange our knowledge. Dr Ives believes the fundamental principles of the common systems are erroneous Disease is a derangement of some or all of the functions of the body. It is the opposite of health or dis-ease. We must compare it with health. Dr Ives condemns the classification into species general orders etc. as if they were entities or beings instead of merely modes of action Diseases change their seat and their form in the course of their progress Nosologists would have done better than they have if they had imitated the natural classification of the botanists. Very great error is committed in attempting to make the divisions mathematically exact. 2 All the present systems suppose definite diseases with specific modes of treatment this leads to an invariable mode of treatment & to the prescribing for the name of a disease. Still it must be confessed that nosology founded on anatomy and physiology are [latelly] acknowledged that diseases are mere modes of action A classification of epidemics formed upon [remote] causes is equally erroneous as the remote causes are disputed, and unknown Dr Ives divides epidemics into two great classes taxic & ataxic in irritation of the division of natural families into classes The term malignant has sometimes been used in the sense in which Dr Ives uses the term ataxic sometimes for rapid fevers, for those which have a gangrenous tendency & for those which more especially affect the vital fun. Ataxic a morbid state, beyond the power of reactions attacking the vital 3 function not putting on the ordinary forms of fever The first & most important indication in taxic fevers is to moderate the violence of reaction in ataxic, is to produce reaction It may be laid down as a principle that all ataxic epidemics resemble each other Ex. gr sometimes in the yellow fever the powers of life are attacked & prostration or exhaustion continues until death closes the scene. What are called the walking cases are of this kind in which the patient walks about until death. This kind is difficult to describe but when once seen is never forgotten eyes glassy countenance anxious etc. So of cholera of India also of pneumonia typhodes especially as it first appeared in this state It had four distinct varieties of which spotted fever 4 was one. No reaction no pain no heat such cases are said to occur in the plague A person who has treated one ataxic fever is able to manage any other All extreme cases may be classed together under this name, as they are in fact under that of malignant Dysentery of 1814 & 15 mild coma [gentle] sleep no apparent pain stools once in two or three hours not striated with blood etc. etc. when the patient was roused from sleep he said in a faint and indifferent tone of voice he was well immediately fell back into sleep. Yet here was dysentery [although] there was no dysenteric symptom for these cases were beyond question, of the same epidemic as others unequivocally dysenteric The indications were to excite reaction by external and internal irritants and to excite the action of the stomach and bowels by calomel ipecacuan etc. In this epidemic the stomach & duodenum appeared to be principally affected. 5 Diseases of Children Great attention has been paid to this subject within the last 30 or 40 years It was formerly almost entirely neglected owing to the exclusion of the faculty from the practice of midwifery to the prejudices of mothers and nurses & to the indifference of the family themselves Young physicians are more frequently called to the diseases of infants hence the importance of this subject to medical students. In Europe have the physicians been most negligent of this subject The French & Germans less so than the English The European practice differs from ours less so at present than formerly because our constitutions are coming to resemble theirs. Their practice is more mild In general chronic diseases require a milder treatment. Great difficulties result from infants being unable to tell of their complaints yet the 6 other symptoms are more easily understood They practice no disguise or concealment They are not made worse by mental aff. Many prejudices exist e.g. that the child is born with a morbid appetite inherited from the mother which appetite must be gratified This they infer from the natural crying of the child The mother sets herself to recollecting some former longing of her own. Story of a child fed upon this principle with mince pie It had to be physicked severely to save its life The mucous membrane of the al. can. is oftenest affected sometimes spasmodically Be on the watch with regard to the liver. The nervous system is more easily excited from irritation than in adults The vascular system less so. Fevers are generally more irritative than otherwise As a general rule preventive medicine should not be given. Evacuants may be given 7 with great safety Witness the long diarrhoeas & the salivations of dentition which they bear without emaciation The milder purgatives should be used. The drastic are irritative calomel is one of the best. 1st Retention of meconium & its consequent diseases. The meconium is a dark green matter resembling tar Its evacuation should be effected not by medicine but by the first milk of the mother. The act of crying also contributes to this effect. Instead of suffering the nurse to feed the child during the first two or three days the breast should soon be present If the child feeds, it is in danger o f losing the instinct to suck Evacuants are 1 gr. of carbonate soda to a teaspoonful of water until 10 gr. are given is a good cathartic Molasses & water may be used likewise The gall of animals 8 in a good cathartic as a substitute for the childs own bile. It may be given in catnip tea, milk etc. We may use also Decoction of the flowers of the dandelion and of the mullein. The best however is generally castor oil teaspoonfull at a time until evacuation is produce Senna likewise, in conjunction with some aromatic herbs & seeds 1 dr. of these to 4 of senna The operation of cathartics must be assisted by emollient injection & also by fomentations of the bowels & the warm bath. The blue pill may be used. Also 1 gr. calomel & 4 or 5 of chalk repeated once in 2 or 3 hours assisted by bitter & aromatic herbs in the way of injection These last thus will frequently answer by themselves. Blue pill & chalk & calomel rarely offend the stomach These measures must be pushed vigorously & used in conjunction also especially the warm & tepid baths 9 in cases of convulsions from retention of the meconium. Dr Ives has not known salivation produced in infants by mercury. This may be explained by the large quantity of mucous which defends the surface of the intestines and enabling infants to bear large doses of calomel. The abundance of meconium contributes also. Antispasmodics e.g. aqua amm. 3 or 4 drops also 3 or 4 gr. carb. amm. also asafoetida a teaspoonful of the tincture injected in milk & water into the rectum. These may be used Young children are often troubled with hiccups & irritation caused by acidity, which must be corrected by alkalies. Sometimes this must be corrected by regulating the diet of the nurse. If as is occasionally the fact the mothers milk disagrees, as is shown by the [illegible] stools & the obstinate crying of the child, then cows milk diluted with one third or one half water or with arrowroot mixed first 10 a table spoonful of cold & then of hot water in order to make a homogeneous mixture. Children fed on cows milk are more apt to be costive. To prevent this give a little magnesia, decoct. of dandelions etc. Peach tree blossoms are much used as a cathartic, but are too violent. Children are sometimes born with a tumour of the head occasioned by difficult labour This may be distinguished from a tumour occasioned by a defect in the bones of the cranium by a uniform hardness Aphthae or thrush Sometimes accompanied with a typhoid fever Sometimes idiopathic. It is a disease of debility, caused by disorder in the primal viae. In some families all the children are affected with it Among the poor bad air & among the rich too great warmth & confinement are the predisposing causes It is a vulgar but mistaken opinion that all children 11 must have this disorder at some period or other Symptoms 1st languor, then white specks or flocculi in the mouth, which finally affect the aesophagus, the rectum (for the orifices of the tabes are more sensitive) & perhaps also the whole alimentary canal though this is disputed. The white spots are succeeded by others of a darker colour. It is thought to be prevented by giving a teaspoonful of cold water soon after birth & subsequently repeating the remedy [illegible] [illegible] heat good Castor oil is objectionable because it does not affect the secretions & does soften & relax the mucous coat of the intestines 10 gr. to 1 dr. of magnesia chalk cal. Dissolve 4 or 5 gr. ipecac in 6 teasp. water & give one teasp. at a time If it does not evacuate the bowels calomel or rhubarb may be administered. If the ipecac moves 12 the bowels too freely given on a sixth or eighth of a drop of laudanum In case of acidity white decoction consisting of chalk ½ oz carb. pot 1 scruple 1 [illegible] or [illegible] [Comus] [cir] [sericia] & asking [illegible] Lime water & milk may be given for acidity 6 gr. chalk 1 gr. cal. with a little ginger for watery stools or a small quantity of rhubarb instead of the calomel No violen local application should be used It was formerly thought that the disease might be removed by rubbing off the aphthae by a swab of cloth Inflammation of the mouth was caused. A little borax and sugar equal quantities a drachm in a gill of 5 or 6 of [illegible] in [powder] put into the mouth water Or mucilages, of violets (v. pedata) decoc. of sassafras [illegible], or comfrey A small quantity of sugar lead in the mouth may be [illegible] In children more advanced thrush is sometimes a critical termination of diseased action & then frequently a favorable 13 symptom e.g. hydrocephalus Ipecacuanha in small quantities as an alterative is particularly to be recommended Strophilus intertinctus of William red gum papulae Nurses consider it the same disease with thrush Red gum comes from red gown made of [stom] on calicoe The vesicles rarely contain lymph terminating by scales & not attended with constitutional irritation It arises from heat bad air confinement & irritation of primae viae. When repelled followed by bowel complaint & convulsions The patient should be kept clean and daily washed with tepid water. The tepid bath may be continually used & is the most efficient remedy when the eruption is repelled from the skin 14 food Strophilus candidus Papulae with non inflamed base appearing like very small pearls under the skin about half the size of a millet seed continuing sometime Prof. I. has seen it following cholera infantum A close examination is necessary for its detection Reference made to Willan Ulceration of the mouth called canker Sometimes very troublesome called food is a cause Commences with an inflamed point in the mouth The edges of the ulcer inflamed & elevated Child drules much febricula torpor of intestines 1st excite al. can by magnesia or blue pill or calomel. Then use Moseley’s tonic solution. Compound tinct of vitrine (sulph cop. in alc. water of crystals 15 marsh rosemary geranium [rac.] tinct kino internal app [illegible] [illegible] sulph. cop prescription Nitrate silver corrosive sublimate Prof. I’s own case corr. sub. & op [illegible] astringent [illegible] rhus cornus Rx sulph. cupri 10 gr. carb. Peru a dr. given at 1 dr. Hon & dr water 2 touch the part with a pencil violets allied to ipecac So also asclepias particularly A [decumbens] 16 Costiveness in infants A physician is frequently called when the infant is perfectly well with the exception of costiveness. This will produce a variety of complaints e.g. watchfulness, starting, hiccup, & convulsions. Frequently the child is not observed to be unwell until the convulsions come on The remedy is injection. For we can only operate on the al. can. the lower part, & the skin the mouth being closed We must be careful to make our prescriptions for an enema, very definite. Case of a mason’s man hands & knees about 3 ft. off shooting fright, murder Simple warm wat. or milk & water or about a table spoonful of salt or thoroughwort catnip etc. or finally castor & other oils. Sometimes in extreme cases fill the rectum with lard. Sometimes as a nervine a teaspoonful of camphor in a gill of milk. If these do not 17 answer, used the tepid bath. The water should be heating, while the enema is administered. the water should be about blood warm. Be careful not to sprinkle or scatter water in the patient, instead of bathing. Time 5, 10, 15, or 20 minutes As soon as the patient can swallow, or while it is in the bath give calomel For a child 6 months old 6 or 8 even 10 gr. If improper food is the cause 20 gr. are not dangerous for infants will beat full doses of cathartics, but very small of narcotics Various articles of food are used to obviate costiveness. Oatmeal gruel rye-meal gruel, rye bran gruel Castor oil is the best cathartic a teaspoonful or tablespoonful Magnesia is good and may be given in milk Elixir salutis is one of the most common family medicines. Castile soap is a good cathartic but ½ oz or oz is required. The bile of other animals is a good remedy. Blue pill various vig. ext. e.g. fl. of [mullein], peach, dandelion etc. 18 It is better to cure by food than by medicine Mechanical means called suppositories e.g. candy introduced into the rectum] are common among families Infantile erysipelas Its classification is doubtful It answers tolerably well to the [illegible] of Good No species in Bateman & [Willan] like it Red patches A severe & dangerous disease apparently the same with the dangerous roseola or [illegible] of the West Indies. Elevation of the skin is not so great as in erysipelas Generally commencing on the legs and thighs, & extending like erysipelas. Attended with constipation tumefaction of the bowels, hiccup & severe fever & terminates fatally with come Give calomel 8 or 10 gr In two hours repeat the dose. Then evacuate with 19 senna mixed with aromatic seeds or if this is not sufficient, with castor oil senna or scammony Then keep the bowels open with blue pill External applications the best is flour or arrowroot. Prof. I has sometimes blistered in imitation of Dr Physic Probably every case would be fatal if treated with bad water and did not evacuate the bowels. If diarrhoea is produced give compd powder of chalk of the shops & other sim. articles In erysipelas of the head we may use the common discutients in conjunction with evacuants. Children are subject to various anomalous eruptions, in consequence of improper articles of food. This is frequently the case with adults e.g. fish & pokeweed An excessive quant. of food may cause them Always pat attention to the diet. This will 20 if persisted in, cure most eruptive diseases Avoid oily food such as nuts crusta lactea (milk [illegible]) Porrigo larvata of Bateman On the lips forehead scalp. First pustules yielding pus until a scab extends over the whole face. It never leaves a scar. We must be cautious of checking it especially when of considerable continuance. Sometimes it degenerates into a phagadenic ulcer, In such cases Prof. I. has used charcoal externally poultices, a variety, & has seen much advantage derived from roasted flour, it absorbs and excludes the air. It is proper to give a dose of calomel. The buckthorn is thought to be particularly serviceable in cut. aff. In case of great irritability chalk may be combined with 2 or 3 gr. of cal Diluted muriatic ether in doses of 5 or 10 drops in water 2 or three times a day, has been much used, and may be [recommended] It may ½ dr [illegible] 1 oz alcohol Ext. 2 dr cal 1 oz sim. cer. Oxygenated oint Nit. ac. & lard Nit. ac poured on warm lard Citron oint more efficacious When the [illegible] does not answer [illegible] [illegible] [illegible] app e.g. sulphuret of potash 2 dr. [illegible] in a pint of water smells like bilge water This may be [illegible] in doses of a table spoonful. prob. [illegible] to sulph [illegible] Others prefer sulphuret of soda. Sulph. of [illegible] is equally effic. fever ensues If the eruptions dry up suddenly give antimony & calomel [illegible] children have a [illegible] rash [illegible] 22 Teething in children is frequently attended with an eruption, resembling a fine rash This should not be interfered with lest it be translated to an internal part. It is an effort of the system to relieve itself An eruption resembling porrigo frequently comes on in summer consisting of watery pustules resembling the itch. It is not cured by dock root. It may be cured by diet & the warm bath. Eruptions translate action from the viscera especially the liver, as in gutta rosea of rum drinkers. Venereal eruptions Some think it may be inherited from ancestry instead of parents. Smooth hard circumscribed like of half a pea increase slowly for 2 or 3 wks. then become filled with a watery fluid, & become a ragged ulcer 23 Treatment. Change the nurse if derived from her 1/30 or 1/40 gr. corr. sub. in water blue pill in moderate quantities tepid bath sometimes tonics of iron mur. fer. tartrite fer. alk. solution of iron Sometimes patients resist the mercurial prep & the rem. for scrof. In this case send the patient into the country for air & try simple vegetable articles e.g. exp. juice of plantain, ext. & internally It is a popular remedy for poison & is apparently valuable. It has cured such infants, when conjoined with the country air Its virtue is owing to its bland & mucilaginous quality Sore ears Nature has chosen the back part of the ear to eliminate morbid secretions. It relieves affections of the brain Frequently there is a miliary eruption, followed by excoriation In most cases so mild as merely to require 24 washing If the discharge stops suddenly it is liable to be followed with torpid bowels fullness of fontanelles full tense pulse cold extremities. When infants are suddenly attacked with disease inquire if they have had sore ears which have suddenly dried up in this case apply a blister behind the ears, without this nothing will cure perhaps. This is true of old sore [leg]. The theory is not the necessity of the evacuation but of the habitual action in the system Sometimes troublesome ulcers, yielding an excoriating discharge; followed by gangrene & death Poultices & ac. plumb. are good Powdered gypsum is one of the best applications (alabaster is the finest kind) Case in which alabaster cured without red precipitate The oxygenated ointment is the mildest & best where ointments are proper for sometimes they disagree Bowels be kept 24a open with calomel. Frequently it is necessary to change the diet of the nurse & to confine her to a simple diet. A discharge from the nose or ear may frequently be cured by keeping up a discharge behind the ear by blisters A teaspoonful of myrrh to 1 gill of water is one of the mildest ext app. Sometimes use nit. sil. Diarrhoea Sometimes affects children for months & even years, in some families. Sometimes it arises from a bad constitution Caused also by want of cleanliness, bad food & want of cleanliness, bad food & want of air & exercise. Young animal (also vegetables e.g. fruit trees after a season without wind) need exercise Children need mental stimulants, from external objects. This is the principal secret of change of air. If the child 24b Bad air probably causes diarrhoea merely by its depressing influence is teething we must palliate not stop the diarrhoea. For this is an effort of the const. similar to tears from an irritated eye & mucous from the lung IN the commencement of diar. mentha vulgaris pounded the juice expressed, boiled, skinned & mixed with white sugar, will frequently cure. Ipecac will freq. cure. We must generally begin with a cathartic sometimes adding chalk to qualify calomel, when we give it for its deobstruent operat. Use blue pill for feeble & delicate children,. Prof. I could for many years take no other cathartic without griping. Often we must enquire particularly about the diet. Arrow root with a little spice, or a little laudanum, or wine. Sago tapioca, is a hydrate of flour moistened & dried by heat (probably) Roasted or baked flour & flour tied up tight & boiled, then grated, made into porridge is better than flour unaltered Rice in gruel, or thoroughly cooked by boiling 25 The worst cases have dry skin & feeble pulse. Use tep. bath & keep up an action of the skin by flannel In chronic stages absorbents will be needed chalk [illegible] oz cin zii [illegible] 4 oz carb pot zss. wat 1 pint Powerful means of counter irritation e.g. mustard horse radish, monarda punct. sp. turpent. about the precordia when the danger is very great, In case of something like cholera coming on By this means we can make articles stay upon the stomach [illegible] etc. will be grateful & stimulating As a tonic moselys 3 dr 1 al. pt. boil water cathartic [illegible] in [large] [illegible] 4 to 20 drops [somet.] [illegible][absor] Opium is often necessary, generally it is better, when qualified & rendered more diffusible in its action by ipecac. Invaluable in chronic cases of great irritability 26 Charcoal in fine powder, will correct the fetor of the stools & often cure. Particular attention should be paid to the stools for much may be known by them. Acid is formed in the whole al. can. Hence sour & curdled stools This will indicate lime water absorbents & aromatics. The acid may arise either from fomentation or (probably) from secretion. In case of clay coloured stools give opium to allay irritation ipecac. to equalize excitement & determine to the surface mercurials as deobstruents Give also mucilaginous or alkaline or laudanum (in starch) or (in case of griping) camomile injections. Often soap is useful also compd tinct. senna After the long continuance of the disease support the bowels by bandages, & apply a plaster of lead and soap. After great emaciation & when [illegible] [illegible] water softeness 27 tonics astringents (at least 50 ast) e.g. currant raspb. bark in milk oak bark chocolate of acorns Peculiarly adapted are spir. [illegible] & cornus [illegible] or [seria] (decoc in milk) [illegible] It equalizes excitement more white pine bark in milk watery urine In case of great craving as for salt provision etc. in extreme cases gratified Of mucilages are a variety for they will be worn out [typh??] latifolia sassafras bran flaxseed etc. etc. Great aversion & nausea & vomiting attending the administering of remedies will make them operate like tartar emetic, and debilitate. In such uses the gratification of the appetite will prove a stimulus especially to the mind & therefore the more powerful This is true of adults also. Case related of a patient who could retain no medicines & recovered upon bread and cheese. 28 In the latter stages acetate of lead may be given internally. The bowels are too much relaxed to admit of colic. A troublesome symptom is prolapsus ani The intestines should be immediately replaced Take the neck of a bladder or the crop of a fowl, filled with water, as the softest & best irritating thing to apply. A [illegible] cloth will irritate the sphincter & make it contract. Afterwards apply astringent washes e.g. white oak bark or the bark of any of our forest trees Cal mag ½ dr rhub 8 gr gum ar. 1 dr. wat. 1 oz pepper ol. [any] 6 drops [or] tablespoonful Vomiting It is very common in healthy children in consequence of over distention of the stomach. The child should not be allowed to nurse so long at a time Children & old people vomit with more 29 facility than the middle aged Vomiting from irritability of stomach is important feeble pulse, cold extremities must horse rad. 2 z chalk 1 z card. seeds ½ z carb pot or [illegible] [illegible] [illegible] 1 pt water tablespoon Prof Ives thinks the alkali creates an excitability. Frequently the irritation of the lower part of the bowels by an injection of salt & water, or a large bulk of warm water, or a calomel cathartic. The tepid bath & nervines are useful also Young physicians are often called on to prescribe for hydrocele in children Apply opium camphorated applications etc. In the morning apply cold water & spt. of nitre. Prof. I. has had to operate in but one case. 30 Volvulus or introsusception. Not commonly a primary disease. Prof. I. was at first very much perplexed with it, finding no satisfaction from the books. The upper is received into the lower portion Sometimes one involution is doubled in upon another 1st Involution of the small 2nd of the large intestines. It occurs in particular families of delicate constitution. Undoubtedly the bowels sometimes disengage themselves from slight degree of this involution The symptoms of the first kind are constant tendency to vomit, frequently attended with a sympathetic action of the rectum Throwing of the hands & feet paleness of countenance rolling of the head & other symptoms of extreme irritation like strong her. specks only of blood In the large intestines when a cathartic is given it passes down as far as the involution & is then thrown up 31 this act may frequently be heard Drastic cath. often are the causes hence where there is a liability to this disease do not give them In case of the small intestines being affected depend upon opium mixed with aromatics and depend upon this until the bowels restore themselves which however will be doubtful. In the second kind give all remedies by injection, apply the warm bath. By very copious injections, attempt the restoration mechanically. Case related of a young man cured by inserting a bougie of a spermaceti candle with opium at the extremity, & keep it up some time Another case cured in the same manner Sometimes the disease arises from a natural stricture of the bowels incurable 32 It may be caused by worms. Case of a worm involved in the fold of the intestine Case of a delicate school girl. Pulse low weak and small vomiting restlessness, throwing of the hands & feet. Great irritation about the urinary passage & fundament. Tongue not much affected. Deficiency of action in the liver & two or three volvula were discovered on post mort. exam. Ascaris tricocephalus was found to be the cause Cholera constipation of the bowels with fever bilious remittent fever, marasmus etc. etc. It is a common bilious fever, produced by causes affecting the bowels Symptoms pulse full, frequent, tongue furred skin hot. Bowels full and hard, urine small in quantity & high coloured, costiveness breathing laborious face flushed sometimes cough Evacuate the stomach & bowels by emesis & catharsis produced by 5, 10, or 15 gr. 33 of cal., in order to produce a strong impression upon the whole digestive canal & hance upon the system at large In enteric cases & vigorous habits a little tart. emet. may be added Repeat the cal. in 5 gr. doses every 3 or 4 hours leaves senna ½ oz manna 1 oz [pint] give senega blood root etc. if the lungs [illegible] z [seneca] [illegible] [root] may be [illegible] or 2 z [illegible] Give enemas or injections to assist the operation of the cathartics after giving the cath. time to operate The stools frequently contain flocculent portions of membrane. If the stools continue vary cath or [illegible] mag. sol. tartar phosphate of soda neutral salts to In the latter stages of the disease give blue pill instead of calomel 34 Sometimes Prof. I. has added acid to quicken the action of the mercury The fever abates in 48 hours It may continue f or weeks sometimes. The termination may be in volvulus in hydrocephalus If the disease continues for 2 or 3 month a regular remittent, the best remedy is Fowler’s solution in 2 or 3 drop doses If this produces edema & dropsical affec then give bark or Moseley’s tonic sol. beginning with about 4 drops After the inflammatory action has gone off give opium alone or combined with ipecac or antimony Blisters are useful in ass stages. They translate action to parts less essential to life & in the latter stages keep up the action of the system Use any of the irritants. If the lungs are affected apply a blister to the chest. The warm bath is useful. 35 If the head is affected apply a blister to or behind the ears Sometimes the mind is so affected that no medicine will be taken without great force. Then use tepid bath A large blister of aloes & ginger will move the bowels Frequently the derangement & revengeful disposition (according to Dr. Bush an affection of the moral faculty) that we must wait even for 24 hours or more without administering anything Great skill is in this case required to satisfy the parents If cathartics which first produce emesis are used we may be sure that the whole al. canal will be operated on We often also need a remedy more powerful than the disease just as in croup Case of a child 2 yrs. old. Pulse full & frequent tongue furred skin hot etc. After the paroxysms the opposite symptoms come on violently. The system was roused 36 by mustard to the feet & arches followed by blisters on the same parts blister on the chest ammonia in the mouth caustic ammonia in the nostrils to excite infl. Worms. This subject naturally follows that of intestinal diseases. Worms are not contained in the bowels of children under 2 mo. generally not while they suck if they are, they probably are introduced in water Worms in the int. can. are not so common as formerly. Said to be common among the aborigines owing to their crude diet. Derangement of the stomach & intestines produces all the symptoms of worms. It is undoubtedly the fact that healthy children have worms which produce no injury until the system is affected with disease. Case of a healthy child who fell from a great height coma a dose of calomel brought away 20 or 30 large worms 37 They may be injurious from their number consuming too much food 1st Tape worm (taenia) armed & unarmed. 2nd Tricocephalus (hair headed) these are the most irritating 3d Ascaris (round worm) lumbricoides, & vulgaris 4th Gordius rarely found in the human stomach Prof. I has known them coughed up from the lungs they probably came from an abscess in the liver. The gordius is sometimes found in the earth in great numbers they turn black on exposure to the air, and resemble a horse hair, hence called horsehair worm. All eruptive & even all contagious diseases have been attributed to insects. Even miasma has been explained by an Italian writer as consisting of insects vide N.Y. Rep. about the year 1815. Cancer & tooth ache have received this explanation 38 The symptoms of worms are very equivocal and coincide in general with the symp. of irrita Count. pale, flushed bloated sallow eyes dilated grinding of teeth in sleep, starting in sleep palp. of heart, pain in stomach when empty, relieved by food, urine pale coloured, or milky increased or diminished nausea, vomiting, irregular appetite, loss of appetite, costiveness Irritation about the neck of the bladder in the case of ascaris. Severe pain about small intestines & umbilicus, indicates tape worm Irritation at the rectum, indicates ascarides as do also irr. of urethra & increase of urine & milky urine Tape worm oftener affects adults than children. Sometimes it exists without the symptoms of worms. 2 quarts in a day have been brought away in a day, & yet they would return in a few days! They increase with wonderful rapidity. Case of a woman who kept passing them for months in great quantities finally diet was tried instead of medicine 39 All food was roasted or boiled even the water used for drink was boiled Cured Healthy bile or gastric fluid will destroy them. Hence an important indication. Spts of turpentine are an old remedy among the people Case of an old man who made himself drunk with half a gill or more of it. Fowler’s solutions 2 to 4 drops 3 or four times a day has cured. This is prescribed for the taenia or flukeworm [illegible] has been considered a specific Osmanda cinnam. has been given by us for this article. It is bitter astring. & sweet. Polyp. vulg. is a tonic & deob. Other forms may be used Ether, particularly in injection is good mad. [illegible] for [illegible] panada pound & half & 2 or three ounces of fresh butter if costive 1 pint of water salt & [illegible] olive oil or an injection in order to fill up the al. can. 8 or 9 hours after 3 oz [f.] m. in [illegible] 40 in water or decoc. of f.m. or [illegible] cal. & car. 12 gr. each [gamb.] 5 gr in a bolus. Oil is used to fill the respiratory holes of the tapeworm Ether had been added by French & Ger. Rue has been used. Pearl flowers. [illegible] power Amalgam of tin & mercury has been detained in the bowels. These mechanical remedies are not now used. Formerly crude mercury to the amount of a pound was frequently given as a cathartic Astringents have been used bark of milia azedarach of prunus virg. The former is given in decoction to the young negroes at the south who are much subject to worms It has much of its virtue when dry Symptoms of tape worm sense of weight (where the worm is in great quantities) irr. stom. nausea loss of app. irr. app. weak chylop. viscera bloated countenance 41 etc. All which however may arise from mere irritation of the stomach The irritation of the tricephalus amounts to derangement throwing of the hands etc. Prof. I. would prefer narcotics for this worm but cannot speak from his own experience he recommends an injection of a teaspoon or tablespoonful of ether in a gill of water or mucilage. Ether will undoubtedly pass the valves, when injected. Prof. Ives has thought that fern given in pieces operated mechanically especially [assmunda] Ascarides are said to in habit the rectum this is a mistake. They multiply abundantly & lodge in the rectum about the sphincter, as they daily pass off. Besides the irritation of the rectum they produce in the small intestines severe griping pain about the small intestines. Very troublesome to cure the best remedy 42 is injections always effectual for the time being. Relief for the time being by washing them out with injections of warm water. Aloes added will be better. The best however is camphor, as a nervine and narcotic & a poison to the worm Calomel is useful, not in destroying this worm but in restoring healthy secretions for worms will not live in healthy gastric liquor. All indigestible articles such as raw fruit, acids, cold water etc. will be injurious. Alcoholic tinctures aloes, elix. propr. or sol. tincture of hickory buds or bark in teaspoonful doses is one of the best things. To prevent the return of the worms use condiments pepper ginger etc. all warming & bitter things. In extreme cases avoid every thing which has not passed the fire. The eggs are exceedingly minute & yet each consists of numerous others probably they 43 are absorbed by the lymphatics carried into the circulation & deposited in various parts of the body especially upon the muc. memb. of the al. can. only upon the mucous parts. Dry & stimulant diet is better than cold & liquid. Some remedies act upon the worms themselves e.g. narcotics Some narcotics operate on some animals & not upon others e.g. sheep eat stramonium which poisons swine. Mechanical remedies are filings of iron & tin cut hair, & perhaps the prickly cowhage Other remedies are powerful cathartics merely others again tonics & deobstruents Ascaris lumbricoides requires no peculiar treatment Use spigelia, calomel etc. Spigelia is a narcotic it kills the worms & it may also be prescribed for the same set of symptoms where no worms are present. 44 When given to intoxicate the worms give from 2 z to ½ oz in decoction in the course of the night, accompany it with rhubarb, or follow it with calomel or any cathartic to drive the worms off while in a state of intoxication. Veratrum sabadilla is used as a narcotic Of tonics all the astringents & barks the min. acids sulp. zinc & iron etc. Cathartics the best is calomel also use the drastic, as scammony gall is good ether, asafoet. petroleum, seneca oil, barbadoes tar etc. as antispasmodics Chenopodium anthelminticum & ambrosioides are called worm seeds An essential oil is extracted from them. C. botrys or jerus. oak are useful as nervines & for the cough, but probably do little good as anthelmintics. The garlics are used (nerv.) They have considerable effect upon the intest. canal Artimisia santonica from Africa the tops of flowers, this is called wormseed It is a bitter 45 The asclepiades most of the common species as syriaca, pulchra, or [illegible] this latter is often used & has seemed to do good so A. incarnata & A. decumb. Podophyllum pelt. is used as a cathartic probably not better than others The best form is that of tincture The number of worm cases & colica is much less than formerly owing to the change in our mode of living Butternut bark decoction in tablespoonful doses is a popular remedy. It is intensely bitter The geraniums are used all the aromatics and bitters indeed which are found spontaneous Ether is used both by the mouth and by enema Butternut bark is cathartic & said to be narcotic 46 Convulsions Two kinds sympt. & idiop. Children are more subject than adults Causes all the causes of irritation Sudden suppression of evacuation. Teething irritation of excessive or indigestible food upon the nerves of the intestines. Acetous fermentation of food in the prima viae The predisp. said to be sometimes heredit. Said to be produced by change in the milk Also by agitation in the mind of the mother affecting the milk. The countenance also of the mother affects infants very much much more than is commonly supposed. So of the bystanders Treatment depends principally upon removing the exciting causes & then upon obviating effects If the cause is in the prim. viae give it first 5 or 6 of sulph. zinc or as much of ipecac. If the substance has passed into the duodenum give a cathartic, assisted 47 frequently by injection. OR use calomel as emetic & cathartic both. Enquire particularly about diet for a general answer may be false Frequently several large doses of cathartics are needed to overcome the torpor caused by excessive quantity of food Also the food diminishes the cathartic operation. Hence the French dinner pill calomel 5 to 10 jalap 1 to 3 scammony senna manna castor oil & neutral salts are the cathartics If the convulsions continue used [illegible] Calomel sometimes by irritation produces convulsions spasmodics one of the most efficient is the tepid bath. If the patient is much agitated by being put into water cover the tub with a blanket & lower the patient gradually: there is then no difficulty Potash, carb. pot. or aromatic herbs may be put in the water. Continue in from 5 min to ½ hour if exhausted to be taken out Wrap in a blanket & put in a bed keeping 48 up a uniform temperature Oil of amber was Dr Rush’s sheet anchor musk internally Articles applied the whole length of the spine as mustard, ol. origanum etc. etc. Empyreumatic oils hence soot tea is very useful It contains carbon amm. & pyrol. ac. Oil of valerian is a nervine Mineral oils as british oil petroleum etc. Ammonia is one of the best 2 to 6 drops in 1 oz water Applied also to nose & mouth & rectum Dippels an. oil owed its virt. to ammonia. It is very fetid & distilled from berries 10 to 20 drops tinct. asafoetida; or by enem. 2 z caustic potash, or the impure carbonate by injection is very valuable. So all the caustic alkalies Opium is a powerful antisp. may always be given unless contraindicated by other symptoms The frequent recurrence of spasms may be broken up by continual doses 49 of opium. IF they recur once in a few weeks give cathartics to prevent them. When called 1st inject. 2nd tepid bath with alkali in the water. 3d apply irritants as must. horserad. garlic, ginger etc. giving, even in the commencement ammonia by the nostrils. When the patient can swallow give calomel. When the stomach is overloaded, the child cannot swallow, & we wish to give an emetic, we can often succeed by irritating the throat with a feather laying the infant upon the hand & in this way supporting the abdominal muscles. Epilepsy a regular or irregular return of paroxysms of convulsions attacking suddenly falling twitching etc. followed by coma Causes in children generally diseased state of al. can. kept up by habit which last is frequently very difficult to break up 50 caused also by malformations tumors of brain malformation of brain etc. derangement of system produced before birth by syphilis from the same causes as rickets more rarely from mere irritation without some offending cause as suppressed evacuations Treatment generally the cathartic giving calomel 3 or 4 times a week If the canal is loaded with mucus conjoin 1 or 2 gr. gamboge 5 gr. scammony & 5 of jalap which yet will operate kindly though [illegible] The best evacuants are those which change the secretions If there is a deficiency of mucus an abrasion as it were give blue pill also cojoin chalk. Most cases are curable by careful management both of the physician & of the nurse Regulate the diet with great care. Generally however there is a morbid appetite & a sub derangement about eating & also about climbing & such things 51 They will be so active & artful as to be managed with great difficulty Catalepsy called still convulsions It is a tonic spasm Insensible & apparently asleep scarcely breathes sometimes a little motion of the eyes continues from a few minutes to several hours Treatment the same as in other convulsions It follows other convulsions & sometimes follows drastic cathartics. Whatever position the patient is in in that will he remain Prof. I. has had several cases Chorea Sancti Viti rarely fatal not difficult to cure under the age of puberty If it commences before & continues after that period seldom cured. The muscles are partly subject to the will. They also have involuntary motions. Caused in children often from irr. in prim. viae from 52 morbid irritability arising both from diminished & from increased action Said also to arise from infl. of the brain Indications narcotics & cathartics if arising from disease of al. can. tonics as iron, mineral acids & electricity if debility is the cause. Prof. I thinks the disease frequently runs its course & then the cure is attributed to the last used remedy. The cathartic treatment has not succeeded very well in his practice. It occurs oftenest in females of relaxed const. about the age of puberty especially if they have grown rapidly or been much confined to the needle or to study Ammonuret of copper 1 to 4 gr. was Cullens favorite remedy Case female treated with epispastics & narcotics took arnica 2 z to 1 pt boil. water doses increased till the head was affected (It is tonic & narcotic) Without benefit Next cathartics Next metallic antispasmodics 53 Next epispastics Finally recovered under bark in substance 1 oz a day. Sometimes arises from affection of the mind The presence of strangers is injurious the sensibility of the patients being very great When caused by epilepsy treat as for that disease Sometimes comes on very gradually & is not suspected causing apparently bad habits in walking etc. Case which had been coming on in this manner was brought to a high degree by dysentery & went so far as to present the peculiar symptoms of hydropohobia horror of water etc. Conium [illegible] & iron sulph. zinc sulph. copper & other metallic tonics have been principally used by Prof. I. Use various narcotics as nux vomica Use the antispasmodics as palliatives e.g. valerian asaf. musk Case in which the disease was broken up by elaterium 1/8 of a grain at a dose combined 54 with chalk. This is the only case which Prof. I. has broken up Case of a young man who had been confined as a clerk in N. York thrown into derangement & convulsions by a sight of distress on board of a packet Elaterium was given to prostrate the system & break up the habit successful. This led to its employment in chorea This disease may affect the mind causing it to run upon particular subjects especially numbers. Case of a book pedler with these odd motions & also this facility of calculation equal to Zerah Colburn. he was overtaken by Prof. I. in travelling. Zerah Colburn, though sent to Europe never improved agreeably to the predictions of Prof. I. who has seen several cases Their countenance & articulation are peculiar [memory] & judgment deficient 55 Nux vomica as a narcotic may be given in doses 1 to 2 gr. [illegible] in pill or 15 to 20 drops of alcoholic tincture Setons, issues tartar emetic ointment along the spine are used. The latter is not to be used where there is excessive irritation doing injury. Tepid bathing is seldom proper Cold bathing sometimes succeeds. Prof. I has known little success attend the employment of electricity. If the disease is not translatable it is made worse by counterirritants. Dentition of the highest importance always more or less affecting the bowels & the nervous system It affects also the glands the cell. memb. the brain the ears [illegible] in them the lungs etc. Adults are also affected Case of a young woman cutting 4 wisdom teeth who was thought to be consumptive. The period of cutting commences from the 4th to the 6th month. Some persons 56 never had but 2 incisions Children are occasionally born with teeth but the teeth sit loose in the gum without [fangs] & should be removed to prevent their being troublesome Some families are said to have no teeth their teeth being even with the gums such are very serviceable & are not subject to decay. Case of a family of this kind from Charleston Symptoms fretfulness biting slavering starting in sleep flushings of face fever hot head & cold feet diarrhoea sometimes costiveness green stools increased urine (sometimes diminished) bloating of hands feet & face contracted pupils eruptions on the skin all the symptoms of irritation the children are particularly subject o phlegomonous inflammations. Case of a child who was thought to have an aff. of brain. A tumor was found under the arm Treatment diarrhoea relieves the irritation Indications 1st divide the gums the operation 57 is not usually painful They will even bite the lancet It may be done in sleep without waking them The difficulty is to confine the child & avoid cutting its tongue. [Gum] lancets may be made with a guard. Make two incisions for the double teeth & sometimes it is necessary to divide a ligamentous band in the middle. It is an objection to cutting the teeth too early, that the scar formed by healing will be more difficult to be cut through by the teeth. This not true a scar has less vitality & is more easily broken through 2 or 3 cuttings may be necessary the symptoms continuing to return. For infl. use the antiphlogistic treatment sometimes bleed in the arm better generally to apply leeches behind the ear. Cathartics as magnesia & rhubarb conjoining aromatics & chalk where there is acidity. Equalise excitement by ipecac & antimony with or without opium 58 If a diarrhoea suddenly stops apply counterirritants to the pit of the stomach the warm bath. Avoid currents of air etc. Blisters behind the ear will be often serviceable & prevent hydrocephalus. They are sometimes applied to the arm. Use antispasmodics with or without ipec. etc. Rickets Caused by confinement too much clothing too much saccharine food etc. Generally there is an earlier mental development They do not make abler men however Hence the impression that precocious children # symptoms soft flesh paleness of countenance hectic fever, tumefact. of bowels muscles & cell subst. less joints larger head large fontanelles open veins of the head large & blue app. & dig. bad tendency to acidity The teeth are cut later Appears at about 6 months Nearly allied to scrofula in affecting the lymphatics & osseous system # will die early. They are in fact generally diseased 59 This is a disease of weak morbid action Indication strengthen the vital powers by stimulating & dry diet especially by cold bathing taking the patient out of the bed in the morning bathing & returning occasionally cal. & ipecac. general friction exercise open air mental stimulus of the open air vegetation etc. etc. This affects the secretions powerfully. Different tonics are given e.g. Fowler’s sol. sulph ferri bark (bark waist coat) Astringents & absorbents for there is frequently an acid smell Burnt bones phosphoric acid alkalies (pearlash) etc. Pearl ash is applied externally Of late iodine has been very serviceable 2 to to 4 drops alkoh. tinct. given in mucilage of gum arabic etc. The worst cases are the syphilitic these require mercurials. The deficiency of the phosphate of lime is an effect & not the cause. Hence burnt bones must have been useful as an absorbent & perhaps 60 as a tonic not as supplying the matter of bone The chylopoietic viscera are probably first affected & then the mesenteric glands & lymphatics. Avoid featherbeds etc. Sweet fern beds are very popular. They are hard & the odour corrects the acid smell of the disease. Muriate of lime & of barytis were formerly much used. Cholera infantum Appears in months of July Aug. & Sept. Sometimes in June & Oct. Approaches in various manners e.g. with a gradually increasing diarrhoea with vomiting & purging the stools being green, brown, slimy, watery, or with the smell of putrid meat a high fever may exist also great restlessness in bad cases cries of pain once in 1 or 2 hours pulse quick and weak fever remittent sometimes terminating in hydrocephalus or volvulus Eyes often languid & hollow half closed in sleep often in the latter stage preternaturally 61 There is sometimes a great degree of mental excitement bright (their eyes are half closed in various complaints) The vomiting may cease soon may alternate with the diarrhoea The disease sometimes ceases soon at others runs on for months This summer epidemic varies according to the season according to the changes in the air or the weather which affect children more than adults. The patient is carried off in convulsions or is worn out by emaciation and dies with aphthae or dies with hydroceph. volvulus & other diseases Causes bad atmosphere malaria (a general tern for miasma & [illegible]) Dentition is an exciting cause not the primary cause as some suppose. Children weaned in the spring are very apt to have cholera infantum in the summer. Children at the breast bear the disease better Hence let them be weaned in the fall 62 A disease it is of debility & has for predisposing causes bad food etc. both as remote & exciting causes It is a fever translated like dysentery from the surface to the viscera commencing at the skin & breaking up the balance of the system then attacking the mucous memb. of the intestines Indications 1st evacuate prim. viae 2nd translate action to surface & so equalize excitement 3d excite healthy secretory actions & [illegible] peristalt. action. 4 avoid causes of irritation & remove them where they exist 5 restore the tone of the system particularly of the stomach & bowels 1st Aromatics ess. peppermint counter irr. to stom. & bowels as must. horseradish injections of starch & laudanum & tepid bath must be used in case of vomiting, or attack like cholera of adults When there is a diarrhoea at the attack evacuate with deobstruent cathartics & ipecac. Give calomel & ipecac first giving 6 gr. cal. 63 Small doses of calomel will not answer instead of full doses & ipecac about an hour afterwards ipecac The southern physicians do not use cathartics so much depending upon stimulating injections e.g. of salt and water They give smaller doses of calomel This practice does not answer so well here # In case of small watery stools we have often reason to suspect that the bowels are constricted & confine a large quantity of fecal matter in this case give opium & then follow with cathartics which will often bring away a large quantity of faeces 2d by emetics & by small doses of ipecac with opium repeated also small doses of mercurials cal. qualified with chalk or blue pill (antimonials where there is much arterial action) by fomentations sinapisms blisters to the bowels burdock leaves etc. warm bath which used at night frequently gives a quiet night’s rest this is not to be used however in case of great exhaustion # The French expectant treatment adopted in Philadelphia will frequently be entirely inefficient 64 3d by small doses of mercurials & ipecac with opium Ipecac deserves the name of a specific if any remedy ever deserves this appellation. Still a man very successful with one remedy only may be compared to one very skillful & successful with a penknife About 4 gr. ipecac 4 drops tinct. opii 12 teasp. wat. about every 4th or 5th hour for a child 4 months old keeping the bowels open with mercurials blue pill producing an evacuation once or twice in 24 hours. Double the quantity for a child a year old in the same quantity of water. The quantity of opium must be greater when the child has been [illegible] the habit of taking it. Injections of laudanum & starch 1 tablespoonfuls of flour & 5 10, 15 or 20 drops of laudanum to stop diarrhoea at the same time applying to the abdomen 65 cloths dipped in brandy An eruption of strophilus [albidus] sometimes makes its appearance about the chest particularly in the latter stages 4th indication by dividing the gums if necessary regulating the diet the milk of a nurse is best the operation of sucking is soothing and gratifying operating as a nervine give arrowroot with a little brandy or wine as a condiment or tapioca roasted flour etc. If in the last stages the child craves any particular food, as salt fish or salt meat, it should be gratified Disgust exciting nausea will debilitate. Frequently we can succeed by a different mode of administering medicine the sight of a spoon for instance exciting nausea. A tumbler of wine whey with a teaspoonful of aquae ammonia will often be beneficial to fill the stomach & dilute its contents 66 Correct fetor in stools with charcoal Injections of carbonic acid are used with the same intention. Effervescing mixture may be drunk they are often very grateful Injections of soap suds are recommended to allay irritation. Dr Dewees recommends an injection of 3 teaspoonfuls of salt to a gill of water & also magnesia & rhubarb. 5. In the latter stages give tonics and astringents Prof. I prefers cornus circum. Use also spir. toment. in decoction or extract also geran. mac. which may be given in wine & then we have red wine Often it wil be advisable to support the abdomen with a bandage also with plasters e.g. one of soap & opium A most powerful remedy is change of air It is continually recommended by the Philadelphia & New York physician. Case of a child in articulo mortis apparently 67 brightened up upon being carried in a hack to the top of ah ill where it had a view of the sound etc. It had got beyond the reach of medicine & food While upon the hill it too food returned & recovered The case seems to be the direct opposite of nostalgia there being a sickness of home a despondency caused by the sight of the same domestic objects Erigeron can. is used it is pungent acrid bitter & stimulating & hence affects the kidneys as a diuretic. It seems to do goo in the latter stages of diarrhoea & dysentery It is called strangury weed. It has been long used Vide Barton N.Y. Physico Med. Trans. etc. The other species are also used give it in decoction White vitriol & alum are used as tonics and in doses of 6 to 8 drops as an anti emetic The various species of viburnum are 68 All the [???t? tillas] are astr. so [illegible] [illegible] root etc. used in this disease, as astringents Statica limonium is not so agreeable but frequently more efficacious boiled, sweetened & a little wine or brandy added. It has a taste of salt mud. It is used also as a wash in case of aphthae In the latter stages of the diarrhoea give mucilages made of any of the various articles in use The white pine bark will furnish a valuable mucilage from its being combined with a terebinthinate principle. Post mortem examinations show the seat of the disease to be the muc. mem. of the intestines. The liver is enlarged Scald head or porrigo or tinea capiti A local disease, yet affected by diet. Sometimes commences with scaly eruptions. I have the head & apply a bladder to exclude the air is about 69 the best treatment. Wash clean at all events tar oint. 4 oz. tar. ½ oz. was 1 oz sulph 1 oz sulphur melt & mix Sulphuret of potash has removed the disease in a few days Yeast poultice is efficacious let the head be first shaved. Different dock roots all the species have about the same properties. Apply externally & give internally it is acrid etc. Syrup of buckthorn is recommended as a cathartic. The practice is quite empirical in this complaint. Sulph. pot. is given internally also its solution resembles mineral spring water Mercurials should be used & pay particular attention to diet Asclepius tuberosa expect. diaph. & laxative is a valuable substitute for ipec. to equalize excitement etc. When the tepid bath is used keep a supply of hot & of cold water by in order to keep up a proper temperature 70 Catarrhal epidemic severe hoarse cough differing from coup in the quantity of mucus thrown off extremities cold head hot much febrile action By vomiting great quantities of mucus are thrown up & yet the patient will seem to be suffocating Confined to the lungs, & aesophagus No disease affects the bowels less than this. The stools are healthy Indications Cure the patient immediately by powerful remedies unless the system is too much affected to bear them. This is a general principle, viz. that of breaking up a disease before it has thoroughly attacked the system by means of a strong orgasm Tartar emetic at the commencement to break up after the violence of the disease has been overcome apply a blister to the chest to translate to the surface. Evacuate the bowels also & palliate & relieve the disease by small doses of tart. em. or with camphor & opium to create perspiration or by the 71 tepid bath keeping the patient in ½ an hour or covering patient & nurse both with a blanket, to keep in the steam & cause it to be respired also Sometimes vomiting must be excited by mechanical means. Do not depend upon palliating symptoms merely Hooping cough said to be contagious rarely attacks the second time, but sometimes does. Pres. Dwight had it a second time at 60 yrs of age It appears as an epidemic thought to arise form specific contagious 10 vol. Med. Trans. an account of its breaking out in Block Island without previous intercourse with the main land. Commences with precisely the same symptoms as ordinary catarrh. The peculiar symp. 3 or 4 week Several frequent expirations are made which exhaust the lungs then a 72 stricture takes place which causes a hoarse shrill wheezing during inspiration. The same sound is heard in croup during expiration A spasmodic stricture sometimes takes place in adults which produces the same sound Such patients should not try to breathe. These fits of coughing continue until mucus is thrown up But the mucus is not the cause of the coughing, which arises from irritated action. Continues from 1 to 6 months. During a paroxysm, haemorrage from mouth & nose may come on or convulsions & apoplexy may ensue Case in which an emetic caused convulsions which carried off the child. Most troublesome during the night Duration of paroxysms depends upon the facility with which the mucus is thrown off. Sometimes respiration 73 is laborious between the paroxysms Rarely fatal after 2 yrs. It may terminate in hectic or in marasmus in infl. of the lungs in visceral obstructions of liver, lymphatics etc. It produces a determination to the head Treat the fever, if any, according to diathesis Treatment In vigorous const. & when mild little need be done When there is considerable infl. give ant. & nitre keeping the bow. open in worse cases bleed cup & scarify Sometimes mercurial cath. sometimes cast. ol. etc. It is better however to accomplish this end by diet. Respiration may be promoted by blisters on the sternum Instead of [blist] [illegible] may use 1 oz mild tinct canth. 1 z tart ant. applied with a cloth until vesication comes on then dress with simple cerate Antimony may be combined with opium Godfrey’s cordial made of molasses & water 74 with a little laudanum & ol. anise this was very popular. Use diluents. If there Is danger of convulsions from vomiting give blood root & other such things. In some constitutions antimony produces peculiar symptoms e.g. severe spasmodic stricture, which if it comes on should be relieved by diluents & small doses of opium. In very young children it is difficult to get down much medicine the stomach becoming irritable In the latter stages use 5 or 6 grains of sulphate zinc with as much of ipecac instead of antimony Where this much viscid secretion an emetic of squills may be used or we may use the [illegible] seneca root bruised & squills each ½ pound water 8 pds boil & evap. to ½ strain & add 4 pts honey & boil again to 6 pts to every oz add 1 gr. tart. ant. dose 8 or 10 drops child 4 mo. old, every 15 m. This is called Hives syrup 75 Dried leaves in 1 gr. doses, in milk, of atropa bell. or 1/6 of a grain of the root has been used in Germany Objection that this disease has a tendency to run its course, is no good reason for not curing it. It has been prescribed for more empirically than any other proof of the difficulty of curing it El. par. 1 oz ant. vix. ½ oz 3 z glyc. ext. powd. g. at. 2 oz wat. 6 oz. triturate & boil dose ½ teaspoonful to a table spoonful This is called the Brown mixture It may be varied by using ipecac etc. 2d Antispasm. & tonics & narcotics are used in the latter stages e.g. sulph. zinc & copper & tinct. canth musk, fetid gum, petroleum etc. belladonna, hyoscyamus, opium artificial musk or oxygenated ol. amber Nitric 76 acid 3 ½ z ol. [illegible] 1 z place in the sun in tinct 1 z to pt. alc. dose 10 dr to a teasp. or 1 z to 1 oz ether dose few (2 or 3) drops upon sugar. It was very celebrated & afterwards was thought to be ill made The truth was the diathesis had changed. Copal gum, oxygenated by distillation, will be the same substance. Copal is probably the same with amber Case of a vein of olibanum or frankincence in S. America Opium should be qualified & determined to the skin by ant. & ipecac. Hyoscyamus is bitter, having no tendency to produce costiveness zi pearl ash with cochineal to colour it to pt. water 8s a popular remedy & useful The whole effect is owing to the pearl ash which is antispasmodic cochineal has no apparent virtues. Pearl ash is not only antacid but produces a peculiar 77 excitement upon the stomach & aesophagus making them susceptible to other articles Conium maculation has been much used A more commanding remedy is stramonium 1/10 gr. to 2 gr. of extract or seed for a dose. It counteracts that irritability which gives a tendency to convulsions Sulph. zinc has been most used as a tonic by Prof. I. either dissolved or in the form of Moseley’s tonic solution Sulph copper possesses about the same properties The compd vitriolic tinct. of sul. cop. & kino 10 to 30 drops is pleasant & has been much used. Flowers of zinc & also bismuth have been used. So also per. bark. Bark, canth. & sul. cop. in combination are recommended by Chalmers of S. Ca. Cantharides are indicated where the 78 system is relaxed & too low for inflammatory action in order to excite a healthy infl. action Something may be done by rubbing the spine with the stim. oils e.g. ol. caps. or orig. etc. or with [illegible] of ammonia to excite the nerves & spinal marrow in the latter stages. Change of scene, of air, riding etc. should be resorted to in bad cases to tranquillize & stimulate the patient. Sometimes the little patients will be in a constant tease & worry; until this is done. In the worst of such cases medicine does little good Even the irritation of administering the medicine may counteract the beneficial effects of the medicine. Prof. I. thinks a relaxation of the ventricles of the heart & of the sinuses of the head takes place owing to the violence of the cough Indicated 79 by resp. high count. bloated lips swollen & by a soft flowering & almost intermitting pulse In such cases give blood root 5 to 10 gr. in water alone or qualified Lead (acetate), also iodine, have been recommended. One year, the hoop. cough prevailed extensively in the spring but was Prussic ac. & arsenic occasionally cut the hoop. cough, short entirely The former is dangerous from want of uniformity of strength Fowler’s sol. is safe but does not answer so well in the first stages. It may leave the patient livid weak with swollen lips etc. which is to be cured by bark & other tonics 80 Gangrene in the mouth 81 Chilblains Exposure to extreme cold without freezing 82 Mesenteric fever tumefaction & pain of the bowels (distress rather than sharp pain) indigestion costiveness, loss of app. or [irreg.] app. Countenance pale except when flushed with fever sometimes a consequence of other fevers oftenest in scrofulous habits most common among the poor. It may become chronic. Indurated lump in the mesenteric glands Indications Act upon the bowels keeping up a peristaltic action evacuating the bow. changing the secretions & removing the obstructions of the lymphatic system. Give blue pill or calomel & chalk. In chronic cases friction once or twice a day will be beneficial Pill 4 parts blue pill 1 part ipecac or ½ part ipecac. Or 1 gr. ipecac in pill with a small quantity of opium Or tinct. rhubarb with aromatics & alkaline salts Burnt sponge is recommended perhaps it would be better to give iodine at once 83 in definite quantities Still the composition of articles existing in burnt sponge may be better [illegible] nodosus & vesiculosus (rockweed) are used Even the neutral salts with tonics have been useful Even as of camomile tea will relieve a paroxysm of pain Articles containing carbonic acid in a free state, sometimes with aromatics as ginger or spice, will be grateful and also useful From tinct muriate of iron martial flowers of iron or alkaline solution are used as tonics but iron is apt to irritate. Cold bath will invigorate the system Injections of mercury have been proposed Tepid bath will cleanse the skin etc. Muriate of lime with small doses of cal. or blue pill may be useful, but 84 is now generally superseded by iodine dissolve carb. lime in muriatic acid & give from 5 to 50 drops in water beginning with small doses, in case it may offend the stomach. Muriate of barytes might be used. Carb. barytes is used dose from 2 to 3 gr it being a powerful article The flesh brush thoroughly applied has a powerful effect A plaster of opium & diachylon or soap plaster, with an equal quantity of opium, applied to the abdomen has been very beneficial where opium did not agree. Or we may use 2 parts opium to 1 plaster. Diet dry toasted bread broiled meat use condiments farinaceous substances & sometimes the broth of lean meat Avoiding raw fruits potatoes corned beef etc. Take care 85 with wine Use farinaceous veg. well boiled not to interrupt digestion by distending the stomach with liquids The terebinthinates will benefit the mucous membrane of the ac. canal. The bests article is decoction of white pine bark which will be much milder than any preparation than any of the turpentine of the shops This disease may terminate in a peculiar hectic sometimes it commences with very considerable fever S. Cutting the fraenum. Very seldom practised now formerly thought to be almost always necessary. Complaints would be made that the child could not nurse on account of its being tongue tied. In such cases it was Dr Munson’s practice to apply the back of the knife, & thereby give very great satisfaction 86 Burns & scalds 87 Tympanitic abdomen a symptom in various diseases 88 Neuralgic affection of the lower limbs 1 Surgery Lecture 1st External injuries 1st Extensive injuries first produce a shock upon the system e.g. contusion upon the abdomen & frequently when a limb is carried off by a cannon ball the haemorrhage is slight & the patient dies of the shock Great difference in patients as to susceptibility of constitution. In the army it has hence been the custom to operate on some immediately and administer cordials & consolation to others State of the mind e.g. wounds after a defeat or after a victory. State of habit porter & gin drinkers in Soudan & debauchers in high life bad subjects The subsequent inflammation however is not in a direct proportion to the shock 2 1st of such injuries as prostrate the system beyond the point of reaction Coldness of surface faintness & prostration immediately follow large gun shot wounds The same effects follow the slight injury of important points e.g. punctures of the joints etc. These effects are through the medium of the nervous system The common people remark that extensive injuries of strike into the stomach This is merely part of the constitutional aff. Case of violent vomiting in a blacksmith whose eye was penetrated by a scale of iron & yet the eye recovered without difficulty Affected distress may be detected by the state of the pulse or respiration the ease with which the attention may be diverted. Sometimes die of the mortal inquietude even without internal haemorrhage Frequently difficult to test with respect to the propriety of amputation A navy 3 surgeon it has been said would probably have amputated Mr. [Huskisson’s] shattered thigh the constitutional irritation will be less after the operation The intellectual functions are suspended blindness sometimes continues for hours The food is not digested & the peristaltic motion suspended. Vomiting frequently favorable as marking a return of vital function. Case of a gentleman in a profound stupor from a fall from a horse no injury could be discovered Complaint of pain generally a favorable symptom particularly if an external part Infants frequently vomit etc. severely with paleness etc. & yet recover after a few hours sleep 1st indication restore warmth to the surface by frictions & the warm bath frictions should be dry, for moist cloths produce evaporation 4 warm blankets & may be applied especially by passing warm substances up & down the back 2nd indication restore the action of the pulse by brandy once an hour peppermint opium etc. [Discontinue] stimulants when reaction comes on as it may be excessive. 3d moderate pain & 4th const. irr. relieve pain by opium except (in Hubbard’s practice in cases of the head) One of the first things to be done is frequently to bleed which will be followed by a rise of the pulse It is a common practice in some places is to send immediately for a bleeder, who however in cases of a great shock is unable to obtain blood until after a surgeon has roused the vital powers Injections may be used. H. prefers among cathartics the mercurial in order to restore the peristaltic action These will answer the 4th indication also 5 We must be careful to examine for local injuries for frequently in cases of extreme prostration they are first mentioned by the patient after the return of consciousness Case of a man who was first unconscious next complained of his head after some hours of his knee & while he was recovering it was discovered that the orbit of the eye had splinters of pine in the flesh. Great caution frequently necessary in removing the sufferer for simple fractures are liable to be made compound. Cold is injurious The viscera are sometimes fractured in falls from great heights e.g. the liver Suppuration of the liver sometimes follows an external injury after a long interval The injury of a fall not necessarily proportioned the height. 8 or 10 drops of laudanum in gruel or starch by injection relied upon in Paris for the cure of traumatic delirium 6 apparently a trifling remedy recommended for trial relied upon implicitly by the French Mr. Travers is the only author who has treated regularly upon the subject of external injuries Inflammation Characterized by heat, pain, redness, tumefaction & soreness. When considerable or affecting important parts, it is [altered] with fever of constitutional irritation. This is different from the local fever which is called symptomatic. The pain usually precedes the heat & tumefaction The causes may be external or such as effect the system primarily. First of such as are caused by external injury or phlegmonous inflammation called also health inflammation This manner in which injury produces inflammation is not well understood 7 Phlegmonous infl. is characterised by a central spot & a circular outline Hunter speaks of healthy infl. considering it as a process set up by nature to accomplish a cure & believed that new vessels are formed An injury is generally followed by pain, which does not arise from inflammation for this has not yet come on, but from the separation of the parts. Great pain is produced by effused fluid as in sprains. After an injury there is pain etc. also there is a sense of distention & the action of the arteries in the neighborhood of the part is increased This extends to the whole arterial system, producing increased frequently fulness and even hardness of the pulse. The pain is caused by the nerves being affected. Mention should have been made of the cold stage which precedes extensive inflammation the cause of which seems to be unknown 8 Professor H. thinks fevers essentially different from inflammations, in opposition to the French physiologists. He thinks that at least at the commencement of infl. there is increased action of the vessels The pulse varies according to the part inflamed (vide below) Local causes of infl. may be heat, cold, mineral acids, acrid substances etc. the various sorts of external injuries Constitutional causes are fevers and various anomalous affections of the const. Prognosis Very violent inflammations are danger so also very extensive ones as burns. Infl. of important parts in the viscera is dangerous. In inf. of the bowels the pulse is quick small & tense & hard of the heart full The terminations are resolution suppuration adhesion & gangrene. Adhesive infl takes place in serous membranes & wounds that heal by the first intention Suppuration takes place when wounds 9 do not heal by the first intentions boils etc. Gangrene follows violent infl. which do not suppurate. It is the death of the part 1st indication is to remove the cause as splinters & in case of dislocation As much should be done by local remedies as possible. Reduce the temperature by cold or tepid lotions (according to the sensations of the patient) sometimes fomentations or poultices give more relief than any other mode of applying warmth especially in pelvic infl. & by the French in thoracic. The warm bath is frequently useful especially to children. In case of fomentations permanent moisture should be kept up. Warm applications may be made to reduce the heat of the part by evaporation if not too warm. The same thing may be accomplished by spirit. Acetate of lead sulphate of zinc vinegar and cold water 10 are used Perhaps the latter is generally as good as any of the patient will be satisfied with it. Narcotics sometimes are used externally but their utility is doubtful. Blisters are used especially in infl. of the joints & deep seated parts in general The first general remedy and the most powerful is bleeding it would seem to be one of the best arguments for it that those of opposites [illegible] recommend it viz. those who believe action to be increased & those who believe it to be diminished Of course not always necessary, as in trifling cases, & delicate habits, No rules can be given as to the extent to which it may be carried. The modes are venesection [arteriotones] leeches & cupping Venesection is the most common and most convenient. In children the veins of the hand or foot or the external jugular may be more convenient than those of the arm It is a good rule to draw blood until pain is relieved or faintness is produced provided the patient is in an erect position 11 There is no doubt of the propriety of taking a large amount of blood at once rather than by several small bleedings. The buffy coat not to be relied on Prof. H. thinks the heat of the extracted blood of more consequence Blood letting has been objected to in case of old persons. Prof. H. has often practised it with advantages. So of delicate constitutions if the patient is kept in a horizontal posture Arteriotomy from the temporal artery has apparently no advantages over venesection Prof. H. sees no advantage in the use of leeches in preference to venesection except in chronic inflammation Cupping seems to combine the advantages of depletion and counterirritation & is highly spoken of. Prof. H. has not used it much Cathartics are used next. also antimonials especially in the Italian way of beginning with small doses frequently repeated until the quantity which may be taken without nausea is very great 12 Narcotics are used for the same purpose Soreness is relieved by quiet etc. Pain may be diminished by elevating the part. Diet should be antiphlogistic, but generally the patient has not much appetite. Great difference is produced by the constitution and habits of the patient e.g. intemperate patients will not bear some things N.B. they do not bear bleeding well Frequently cordials and tonics are useful at the close of the cure. The best work on inflammation is Thompson on inflammation. Erysipelas an inflammation of the skin sometimes extending to the cellular membrane Distinguished by leaving a white spot after pressure by the finger & by being terminated by a definite [line] It has a tendency to spread sometimes leaving one part & spreading to another. Occasionally affecting various parts at the same time 13 When caused by a wound it frequently affects distant instead of adjacent parts colour dark & yellowish little swelling leathery feel. More yellowness towards the decline of the disease. This disease is liable to affect the mucous memb. of the mouth, & is said to affect int. parts It is accompanied with chills fever etc. & in erysip. of the head with delirium Sometimes the fever precedes. The fever is also followed by a bitter taste in the mouth Case of an old woman attacked with feverish symptoms, which, as was expected were soon followed by erysipelas. Various divisions have been made as phlegmonous bilious etc. Prof. H. divides into that affecting the skin & that extending to the cell. mem. 1st of the skin. it terminates by scales & affects the young It however may term. by sup. & also affects all ages The second is attended with more tumefaction & terminates in sloughing suppuration & in gangrene. It sometimes extends to the fascia & tendons so that they will slough. This kind of erysipelas 14 is oftenest met with with in old and intemperate persons as in cases of chronic sore leg Erysipelas is distinguished from phlegmonic infl. by the latter having a central spot its circumference being less defined, & its pus collected into a central cavity The nervous irritation of erysipelas is greater producing delirium etc. The heart & arteries are more irritated producing a sharp and quick pulse which is very weak when the infl. tends to gangrene. The al. can. is generally affected, producing sometimes dysenteric symptoms. The exciting causes are wounds contusions irritations of the skin by acrid substances by alterations of temperature etc. 15 The predisposing cause is in the constitution & is unknown from the yellowness of the skin some have ascribed it to the liver We know not why some wounds should be followed by phlegmonous & some by erysipelatous inflammation except that at the time the patient was not in good health. This may be caused by malaria, the bad air of hospitals etc. Case of Pomfret when the meadows were drained. From its prevailing in hospitals some have thought it contagious This not probable Though depending upon the state of constitution, yet the extent of the constitutional is proportioned that of the local affection. It sometimes seems to alternate with other diseases 16 Prognosis varies according to the age & habits of the patient & the extent of the infl. The most dangerous cases are those of the head which are frequently attended with delirium & coma. Coma is however a common symptom in ole people Indications 1st to promote a resolution 1st by topical 2nd by general remedies Some are opposed to topical application Prof. H. finds no danger in them. The best Is acetate of lead. Cold water, milk & water Also 2 dr. mur. amm. in a gill of water or corros. sublimate 10 or [illegible] sometimes a drachm of opium to a pint of water or of the solution of acetate of lead Mercurial ointments are best in the decline of the disease The lard by itself is good especially when the [branny] scales are abundant. To this is ascribed by come all the benefit of the mercurial ointment. One of the most common applications is dry wheat flour. Yet it is one of the worst 17 2nd General remedies. They should be always used to prevent the affection from being driven in & then returning 1st venesection Strongly urged & strongly opposed Prof. H. approves of it in case of strong constitutional affection but not when there is extensive suppuration & when the pulse is weak & small 2nd purgatives they have been universally used. The indication has by many been drawn from the yellowness etc. The mercurial cathartics are best Calomel may be combined with a little opium in case of great irritation Neutral salts sulphur & magnesia have been recommended Antimonials are much used, especially in the Italian mode of beginning’ with say 1/6 gr. & doubling the dose (of tartar em.) until even 4 gr. are given 3d Tonics their use is strongly urged upon the supposition of erys. being 18 an atonic disease In cases of malaria and gangrenous tendency bark is undoubtedly proper. Opium & Dovers powder are proper in one of great irritation & opium is given by some as a stimulant. The most common preventive remedy among the people is neutral salts. They generally do much injury. Even low diet is generally injurious when practised with this view Infants are frequently affected with this disease. Sometimes their pudenda are badly affected with it Treatment calomel internally acetate of lead externally etc. A new remedy is nitrate of silver externally applied by moistening & touching. Prof. H. has tried this and found it useful but not deserving so very high commendation as it has received Prof. H has found blisters very as have Dr. Rush & others 19 especially in violent cases & in those which affect the cell. mem. An old mode has been lately revived viz that of making long & deep incisions even to the extent of 6 or 9 inches. This is efficacious in violent cases especially when suppuration is suspected. This disease requires great care and attention. Sometimes the disease may without our knowledge attack another part hence the old patients affected with stupor & infants should be examined every day Abscesses When phlegmonous infl. does not terminate by resolution it does by suppuration. So of erysipelatous. The signs of suppuration are diminution of the pain & chills (the patient will say he has caught cold) in external phlegm. infl. a softness will be felt. This will increase & frequently be surrounded by a hard rim sometimes there is a sharp [illegible] or [illegible] pain Pus is discovered by its fluctuation. We must press 20 alternately with the fingers or better with the the thumbs. IN muscular parts we may be deceived by the fluctuation of the muscles under the fascia, if we press transversely. We nay be deceived by fungous tumours Tumours of the viscera are apt to be mistaken for a collection of pus Great mischief is done by opening fungous tumours. In a gland suppuration never takes place until after the skin has adhered to the gland. Prof H. know of no remedies for promoting suppuration but poultices & similar applications. On pus. It is a secretion. A French surgeon maintains that it is secreted by a membrane lining the internal surface of the abscess. (Delbecke) It is of very little consequence of what poultices are made. Fomentations, as by wringing out woollen cloths dipped in hot water & then applying them to the part. Venesection & evacuant remedies are contraindicated. The bowels should be 21 kept free. Tonics are not generally needed Opium may sometimes be used according to circumstances. Prof’s Smith & Hubbard approved of opening abscesses immediately & not waiting for them to burst In erysipelatous infl. the pus is diffused & not in a cavity of a circular form Abscesses tend towards the surface unless prevented by strong fasciae etc. The opening need not be very large but should allow of a free passage to the pus There are inflammations of the cellular membrane where there is no erysipelas of the skin. The inflamed part is hard & is sometimes very extensive The constitutional symptoms are very severe & resemble those of erysipelas The suppuration has a peculiar [illegible] irregular feel. [illegible] this kid very dangerous generally arising in bad habits Indications moderate the const. affect. by calomel opium etc. The best external 22 remedy is blistering extensively afterwards using external lotions etc. This kind of inflammation frequently follows wounds of dissection Case of a man who lay down under a haystack & fell asleep. Infl. in the thigh, leg, shoulder & knees confined to the cellular membrane & yielding quarts & pints of matter when opened finally recovered. Another upon whom numerous similar abscesses were opened on succession finally there was an effusion in the thorax & the man died. The two last kinds of inf. & much more dangerous than phlegmonous. Frequently they arise from a very slight cause as a scratch in the old & intemperate. In the latter, delirium tremens is frequently caused by such inflammations. Prof. H. does not open with caustic He does not call the furunculus a proper phlegmonic inflam. The core of a boil is a dead portion of 23 cell memb. There are no better remedies than poultices etc. After opening an abscess we may use pressure to expel the matter but too great violence must not be used. Then a plug of lint may sometimes be advantageously introduced & finally the sides of the abscess should be brought together by a bandage if possible Frequently by a skilfull application of bandages around the opening, pus may be expelled which could not otherwise be obtained When it is wished to make a second opening into an abscess near the first, instead of lifting up the skin upon a probe & then cutting down to the probe, it is better to close up the first opening & suffer the pus to accumulate so as to cause a protrusion an incision may then be made with ease 24 Anthrax Begins with a small pimple a vesicle filled with lymph. The burning heat and pain very great. The const. irr. very great. The redness is of a darker colour than in the furunculus There is an areola somewhat resembling that of [illegible] pox. This will be surrounded with small pimples, which become small holes filled with a yellow matter The swelling extends & with it the holes Sometimes a considerable portion of skin sloughs off Eventually a considerable portion of cell. memb. sloughs off with a copious discharge of pus & the patient recovers In fatal cases extensive gangrene takes place without suppuration. Sometimes before the cure large portions of cell memb. (rotten) may be extracted with the [illegible]. Const. aff. very great tongue white & eventually yellow 25 When the anthrax is near the head delirium & coma are produced The infl. seems to be more erysipelatous than phlegmonous. Some persons of broken const. are liable to be [illegible] Prognosis depends 1st on the situation & extent of the anthrax Apt to be fatal if on the head face & neck especially if nothing but serum is discharged. If upon the limbs & back with suppuration they are there it is dangerous 2nd the const. sympt. Violent pain severe fever old age & intemperance especially the latter are bad symptoms One of the best local applications is an extensive blister plaster followed by cerate & if there is much heat & inflammation apply over the cerate ac. plumbi or in bad cases, emollient poultices The sooner the pus is formed and discharged the better. It relieves the irrit. 26 Frequently pus may be felt through the sloughing skin. Caustics are used by some but Prof. H. prefers blistering & if the first application does not relieve the pain & irritation apply a second. Frequently a slight incision is necessary to evacuate the pus Const. remedies 1st Venes. in rigorous habits, and early in the disease Mercurial purges are always proper unless there is great exhaustion Opium when there is great irritation and towards the close when the patient is weak give bark. Give dov. powd. at first & afterwards opium alone. Farther remarks on abscesses. Sometimes after opening an abscess lunar caustic or a solution of cor. sub. must be introduced to promote the healing of the sides of the abscess Sometimes the pus is collected in the bursae mucosae, as on the olecranon 27 process. The thumb the knees. The serous membranes of the bursae are liable to inflammation followed by a rapid collection of pus, & violent const. irr. It is especially important to open abscess of this kind, near the joints. Acute inflammation of the joints sometimes occurs, essentially different from chronic infl. It occurs oftenest in the hip Sometimes it is fatal in a few days Caused occasionally by injuries. The mode of cure is to cut boldly into the joint, to save life. The female mammae are especially liable to abscesses. Sore breasts & broken breasts are not all the same disease 1st superficial phlegmonic abscess. There is infl. of the gland The skin adheres. Venesection purging & antimony may be used. Tartar emetic has been lately recommended very strongly The usual external remedies may be used 28 It is decidedly advisable to open these abscesses though there is a prejudice against the practice. Erysipelas of the breasts is common & treated as other erys. infl. Infl. in the bur. muc. which lies between the mammary gland & the pectoral muscles Sometimes the pus makes its way out between the two breasts. We must open with an abscess lancet & then promote the healing by injections of cor. sub. etc. If this fails, introduce a seton of several threads & extract one thread at a time (vide Dorsey) Chronic inflammation. Sometimes a sequel of acute infl. That which follow acute phlegmonous infl. will be circumscribed It will not be of the skin but of the cell memb. Glandular parts are those which generally run into chronic infl. e.g. testis mammary glands the lymphatics (scrofula) These last are frequently subjects of surgical treatment, they are occasionally 29 inflamed from wounds The joints are peculiarly liable to it. The constitutional symptoms are less severe, resembling hectic generally without sweat & chills. The tongue is commonly coated sometimes [illegible] appetite capricious emaciation restlessness Coagulable infl. is effused & causes rigidity & tumefact. Indications, lessen the action of the vessels & promote absorption Bleeding must be practised with caution. Cupping & leeches are most commonly used. Prof. H. has found occasional bleeding serviceable promoting absorption. Cathartics must be used moderately The mercurial most valuable & the stimulant as aloes Narcotics, opium, hyoscyamus conium to allay irritation. Frequently the mineral acids as tonics Iron & arsenic & other mineral tonics seem 30 to cease irritation Iodine is used. Blistering is the best local application Case of its application to infl. mammary Tartar em ointment setons moxa compression is valuable when practicable, especially in infl. of cell. mem. It may be alternated with blisters mur. amm. etc. If the limbs are inflamed, exercise is useful Stimulating liniments, opodeldoc etc. are applied Chronic abscess. One which has either not been preceded by violent symptoms or in which they have [illegible] off. The patients account will often be that at some previous time he had a fever etc. followed by a swelling The fever did not leave him well etc. Sometimes the chronic abscess will be found in a different part [from] that in which the pain was formerly felt. 31 Prof H. has never known a fair case of perfect absorption of pus Though the evacuations may have taken place only after years of continuance. The prognosis is difficult The French open by caustic. Prof H. has not tried it. Lumbar abscess, as an example of chronic abscesses in general. Arises from scrofula, from injury or from no apparent cause The lameness at first often is ascribed to rheumatism The patient bends forward & towards the part affected. A soreness may be felt Finally a collection & a tumour pointing to the top of the thigh or even down the leg The pus is contained in the bur. muc. which protrudes under [illegible] lig. This may be mistaken for hernia & even for aneurism of ext iliac. It sometimes bursts in the groin 32 By proper examination in a standing posture the fluctuation may be discovered. Open by placing the pat. on his side, making pressure & inserting an abscess lancet making the orifice of the cyst as large as that of the skin by a turn of the point of the lancet. The pus discharges better in a [standing] posture of the patient when the tumour points downwards. When the pus is all out apply a compressing bandage & heal the orifice by the first intention. Afterwards open the abscess again & so continue. Keep the bandage on to diminish the secretion of pus After three or four openings, the orifice will generally ulcerate, if the abscess is not healed Sometimes a seton must be used This practice is a great improvement of Abernethy’s. Various remedies were formerly tried to promote the absorption of pus. Prof. H. has never known the cure. Sudden deaths arise from unopened chronic 33 as well as acute abscesses. After great operations, abscesses of the lung frequently come on Hectic fever following the permanent opening of chronic lumbar abscesses Chills, heat feebleness, irritation soreness confinement to the bed nausea vomiting loss of appetite. This is frequently mistaken for a new disease John Hunter was the first to deny the doctrine that hectic fever is produced by the absorption of pus. James Rose’s son 13 or 14 yrs. of age Injured his back by lifting. Became lame, was treated for rheumatism. Became more lame, emaciation & sallowness Prof. H. found a coll. of pus extending half way down the thigh. By Abernethy’s mode, about 3 pts of pus came out. The attending physician did not pursue the same mode but kept the orifice open. Hectic fever confinement to bed 34 died miserably in about a year. Instead of being better, they may find themselves worse immediately after the opening Oxygen has been supposed to be the cause. Cold air likewise has been brought [illegible] 10 gr. corr. sub. to 1 pt. water is the best injection when a lumb. abscess remains open. If no benefit results after a few weeks it must be abandoned. Limewater has been recommended as an injection. Calomel is the best treatment for the symptomatic fever, except when the patient is exhausted Irritation may be relieved by Dov. powder, quietness etc. The cavity should be carefully cleaned out every day Slight ptyalism may follow the corr. sub. Prof. Smith was in the habit of using this injection immediately after opening Prognosis Some have ascribed lumb. abs. to an aff. of vertebrae Very probably this affection of the vertebrae may be an affect instead of a 35 cause Small chronic (as scrofulous) abscesses may be treated like acute abscesses In scrofula the abscesses will not be regular & round like phlegmon They should be opened as soon a pus is formed In abscesses of this kind granulations are frequently found which must be removed by caustic. Sometimes the skin must be cut away to get at them Case related to illustrate the danger of opening [chronic] abscesses by large incisions & keeping the orifice open. Died in a week Quality of the discharge Commonly mild & inodorous thick (sometimes curdy) before the healing, it becomes thin & whey like. Acute abscesses frequently furnish this thin discharge, especially if’ erysipelatous Hectic fever Blood drawn will generally exhibit the buffy coat, before the opening of the abscess. Afterwards 36 we have hectic fever Pulse quick (sometimes not in old persons) generally 2 paroxysms in a day the nightly one attended with profuse sweats frequently with diarrhoea sometimes pains in various parts which exhausts the patient less of app. & nausea & vomiting occasionally aphthae (sometimes also as well as night sweats, before openings) may come on so also dropsical effusion of cellular membrane. The degree depends 1st on the nature of the part according to its power of restoration 2nd on the extent of the abscess e.g. occasionally it following the suppuration of an extensive burn 3d on the constitution of patient frequently mental causes have great effect [illegible] modifies hectic the old have less sweat & loss of appetite, but more diarrhoea Sometimes we are surprised to see so little constitutional affection. Such persons are generally very tranquil in mind. It is perhaps impossible to cure hectic 37 while the cause remains Some patients are exceeding by restless irritable & troublesome & [illegible] Prognosis this depends on our success in removing the cause. We may however moderate it by tonics e.g. sulph quinine, wine, opium This last invaluable, promoting sweats relieving [illegible] & supporting the vit. powers Keep the bowels free. Inflammation of the lymphatic vessels Causes may be ext. or internal 1st wounds acrid substances etc. Wounds have been given in bleeding Symptoms swelling, redness, hardness, a core may be felt a discharge of lymph, a swelling of the lymphatics in the axilla. Cured by touching by with caustic Sometimes a very small puncture will cause an inflammation extending upwards in the direction of the 38 lymphatics, indicated by red lines swelling soreness etc. frequently very troublesome sometimes an erysipelatous infl. & abscesses It may be occasioned by erysipelas Touch the small orifice (apparently in considerable) of the wound with caustic & apply adhesive plaster if this does not cure, blister the whole inflamed part, use compression etc. Open abscesses if there are any. Sometimes the inflammation extends from the heart instead of towards it in the course of the vessels. It appears in the throat in scarlatina. It may be caused by [sore lips] Frequently this disease comes on from an affection of a distant part is phlegmasia doleus from the uterus It may appear in the legs from consumption. Phlebitis infl. of the veins First pointed out by J. Hunter. It may be caused by venesection & by a ligature Vein appears like an inflamed cord Sometimes pus is found around the vein. Constitutional symptoms like those of erysipelas & very violent, accompanied with fainting palpitation 39 of the heart anxiety etc. Treatment venesection (some say ad deliquum) calomel & opium blisters Mr [Lizars] advises to destroy the vein above the part by caustic. Inflam of the arteries Not much is known respecting it. Ossification of the arteries, appears to a frequent result Mortification. The death of the part A cold ash coloured mass becoming black Gangrene is considered under this head Two kinds, acute & chronic hospital gangrene is a case The affected part from red becomes pale & cold the vessels filled not with watery but bloody serum. Pulse quick weak intermittent occasionally, sweat, singultus. Symptoms vary 1st according to the extent of the mortification. 2d acc. to the [illegible] of the part & 3d acc. to constitution 40 Chronic mortification frequently comes on as in the toes of old persons without pervious acute inflammation preceded by pains & heat. There comes on first a dark purple spot. Liable to be confounded at first view with shingles a skin disease. There first appears a redness then vesication, lastly mortification Two circumstances will always distinguish mort. 1st the coagulated state of the vessels, yielding no fluid 2nd no sensation being present in the part Causes external injury, a sudden cessation of vascular action in the limb!! bits of rattlesnakes wounds from dissection compression of bloodvessels from ligatures strang hernia etc. Inflammation more especially erysipelas & anthrax. Occurs oftenest in the old Ossification of the arteries is either a cause or after [illegible] There may such a degree of tumefaction or distention of vessels in violent infl. Case in which the skin was to much stretched as to cause mortif. Fire & frost bite after an operation for cancer of the breast as to cause mort. cause mortification IT has been attributed to the use of bad rye flour that which contained ergot. 41 Prognosis, difficult. All mort. is dangerous. Chronic mort. always dangerous Sometimes patients die when apparently almost recovered especially if old & when fasciae & tendons remain to be cast off. Sometimes patients are carried off by a new accession of erysipelatous infl. or a translation to an internal part It is a good symptom for the patient to go gently to sleep Treatment The attempt to imitate nature by endeavouring to excite an infl around the mort. part & so produce a line of demarcation & eventually the sloughing of the part, is to be considered Ind. 1st Venesection may be useful to moderate the violence of action Calomel for the disordered secretions in alterative doses Bark was formerly supposed to be a specific It is now discountenanced Acetate of lead & mur. amm. externally applied cold, as being more agreeable Emollient poultices, yest poultices will 42 correct fetor. Chlorate of lime & soda Bark was formerly used in poultice 2nd diminish irritation extract foreign bodies if there are any, open abscesses remove mortified sloughs. Calomel opium even with venesection, & especially when purgatives are required Emollient poultices 2d prevent the spreading of the mortification which spreads sometimes in the cellular membrane very rapidly. Bark may be useful but blisters are the great remedy. They should be extensive & on a limb, should extend above the part mortified except in case of mortified toes. Nitric acid (100 to 300-400 drops to 1 pt. water) may be used as a caustic application 4th support the patient by opium, bark wine ale porter, indulgence in nutritious diet. Keep the bowels in order, attend to the secretions etc. etc. After treatment of the part Keep on the external application etc. Clear away 43 the sloughs Case which terminated favorably related in which the whole gastro [illegible] muscle was lost. Near the close of the cure the following preparation may be used as a mild cerate. 2 drachms acetate of lead ½ oz. sulph. sodae, 2 ½ oz. simple cerate Mortification continued It may prove fatal from const. irritation either gradually or suddenly Case related of an old man who first had apparently an anthrax on the bottom of his foot There came on a phlebitis of the vena saphena. Mortif. affecting a whole limb will [rarely] be cured. Generally amputation is the best remedy. The const. irr. will be surprisingly relieved. Hiccup is generally a fatal symptom As to the propriety of amputation It must be done when the injury 44 has destroyed the principal blood vessels & limbs. Also in mortification of the toes extending over the foot for all such cases cannot be cured without too extensive a suppuration to be borne by the constitution As to the time of amputation. It is now settled that we are not to want for the mort. to stop spreading & for the mortified part to be sloughed off. The mortified toes of old people should not be taken off. If amputation is to be performed, it should be of the leg, or if this beings to be affected, of the thigh. Case of mortif. of finger of an intemperate shoemaker. When amputation is performed we almost always find the arteries ossified In compd fract. burns, frost bites etc. if the parts are likely to be dead, then operate immediately. Sometimes mort. extends along the cell. memb. under the skin, giving rise to a crackling feel & a sort of eymphyema. 45 Wounds in general. Solution of continuity in a part. They are of six kinds incised punctured lacerated poisoned contused & gunshot wounds. Extensive wounds may affect the system more or less according to various circumstances, one of which is the degree of confinement, e.g. wounds of the lower limbs affect the system more. The symptomatic fever will vary from a slight heat, to a high fever; sometimes we have chills sometimes erysipelatous inflammation The first indication respects the hemorrhage. This if slight may be stopped by cold air cold water, lint etc. If an artery is wounded, a ligature must be used, except that sometimes a small artery may be stopped by a total division of the vessel. Case of a man who had wounded the art. [illegible] 46 There came on a very troublesome & frequently recurring haem. Cured by opening the wound & totally dividing [the] partially divided artery. The temporal art. may, in this way, be totally divided & then stopped by compression Ligatures may be of silk, thread, or better of leather, rolled. Mr Lawrence has lately recommended a small silk lig. with the ends cut very close it is said they will come out by a small [pustule] Leather is absorbed. It is now [illegible] inadvisable to cut the internal coat of the artery by the ligature Mode od dressing. Bring the edges accurately together, apply adhesive plaster and a compress Leave the wound in this cond. for 4 to 5 days. The interrupted suture is used. 47 The sticking plasters may be used in addition to these, a strip between each two stitches In case of much heat & inflammation Prof. H. keeps up the practice of wetting the dressings even with ac. plumbi. Punctured wounds; of by a bayonet or similar instrument, they partake of the nature of others Considered dangerous yet often heal by the first intention. If pus collects at the bottom treat as in other cases of suppuration. Haemorrhage from wounds. The artery retracts when cut, the internal coat adheres & the [illegible] extends as far as the next collateral branch. This first led to the practice of using small round ligatures. Sometimes the needle & ligature is used when it is impracticable to use the tenaculum or forceps especially in punctured wounds, to avoid the necessity 48 of extensive incisions. We must be cautious about tying arteries in old wounds lest the tied part slough off & we have haemorrhage again to avoid this make a new incision. Be cautious about leaving any substance in the wound Sutures should be generally be left 4 or 6 days A proper posture is of importance. Horizontal for the lower limbs flexed if upon the back side of them. Union of parts totally divided as noses & fingers has not succeeded in Prof. H’s practice. When a little skin is left they do very well unless suppuration comes on Rest & simple diet are of importance. Rest is especially [so] in case of wounds of the lower limbs Contused & lacerated wounds may be treated under one head. The haem. is generally small. Do not hesitate to draw the edges of the wound 49 together instead of treating with fomentation & poultices to promote suppuration Poisoned wounds where a poisoned substance is applied to a puncture as stings and bites. It is difficult to say whether the effect is upon the nerves or the poison is absorbed The effects are very analogous to erysipelatous inflammation Excision should be performed as a prophylactic. Cupping has been practised. Caustics Among the French caustic acids are favorite applications If acetate of lead etc. fails Prof. H. would try blisters. For the general remedies use vol. alk. opium, alcohol camphor a variety if necessary of stimulants If violent inflammation comes on use venesection mercurials etc. If suppuration or gangrene ensue treat as usual for them. Case related in which 8 gr of arsenic were given in 4 hours cured. 50 Apparently phlebitis has been occasioned by bites of serpents Indian remedies are of little consequence. Stings of wasps & bees Bad case of a sting near the eye relieved by laudanum next day fever relieved by bleed. & mercurials Young woman in Toll. cty. stung in the leg by a wasp fainting & anxiety died in 15 or 20 m. Dissection wounds A wound seems to be necessary. Prof. H. does not think they can be explained by the predisposing causes of late hours, study etc. Symptoms finger very sore & painful soreness extends up the arm pain in the head & back, chills & fever. Swelling of the part up the arm in the axilla pus under the pectoral muscle & in the chest death. If the pus collects in the finger alone the case is less dangerous. Prof H. has known similar effects follow a puncture without morbid matter. Case of a boy wounded in the heel with a fish spear. red streaks abscesses in the foot & leg 51 suppuration under the pectoral muscle under the pleura death Very bad sores upon the fingers often have arisen from dressing ulcers. Prognosis varies upon the situation etc. Touching the wound with nit. silver has not always been successful Suppuration in the lungs following operations compd fractures etc. The treatment is the same as in other inflammations of the pleura bleeding etc. In two cases Prof. H. made an opening into the sac of the pleura one of them was fatal, the other recovered. Gunshot wounds The contusion must be very great. A spent ball will produce contusion merely. It was formerly supposed that the ball burned the parts judging from the appearance of the [illegible. This is a mistake Often the shock to the system is very great, but with some it is trifling The entering orifice will be smaller than the issuing The latter will have 52 ragged and projecting edges. Sometimes a ball may be pulled back by taking hold of a piece of silk, which was carried in before it. Its course may be very circuitous, being diverted by tendon sometimes as well as by bone. Abscesses and also cysts are formed around it. The effect formerly acribed to the wind of a ball are explained by the oblique stroke; the skin yielding & being unlacerated, while even the bones within are broken. That the wind does not produce the effect is proved by the fact of one leg’s being carried off without injury to the other, when both are in contact The contusion destroys the life of the adjacent parts. The hemorrhage is generally slight Balls may pass through the body without penetrating cavities, as of the chest. Baron Larrey told Dr [Heerman] that he had lost but two patients whose bodies had been perforated by a ball. 53 Necrosis is generally produced by a ball’s striking a long bone in other bones caries. Wounds of the lungs will often be followed by haemor. from the mouth of the bowels by feces issuing from the orifice. Wounds of the joints are dangerous Indications 1st suppress hemorrhage Do this by the tourniquet if possible Tie arteries as soon as possible, unless amputation is to be performed 2nd extract foreign bodies unless they are out of sight & of the reach of the finger or probe When the ball has passed nearly through cut down on the other side, while squeezing with the finger & thumb. Thread etc. will come out by suppuration A foreign body lodged in a bone is very dangerous. In a superf. bone trephine 3d prevent or remove irritation The French make incisions to take of the stricture & debridling the part. This is now discountenanced by the British In case of a fleshy wound, apply 54 merely lint and simple cerate. Many keep a moistened compress upon the orifice This is [illegible] cold water is generally the best application. For some days the wound will look ugly, with swelling & frequently a watery discharge. If suppuration comes on slowly, poultice but do not continue them after suppuration’ is fairly established, but absorb the pus with dry lint. The separation of the slough is another critical period if secondary hemor. then comes on apply a compress immediately. The plan of tying the artery at a distance has generally failed In an old wound we must make a new one. General treatment should be antiphlogistic Prof. H. uses calomel as a cathartic & the British surgeons are adopting the practice. If there is pain in the head fullness of the veins etc. bleed & purge In the latter stages opium is invaluable 55 to allay irritation Sometimes also in the first shock & then according to some bleeding must be conjoined. Amputation 1st as to the time 2nd as to the particular case. The unanimous testimony is now in favour of immediate amputation waiting however for recovery from a violent shock & administering a mouthful of wine & also consolation & encouragement. Baron Larrey & Prof H. prefer immed. amp. even when bad symptoms have come on 2nd the different cases 1st amp. is necessary when a limb has been shot off for a clean incised wound is made the patient will be more comfortable & mortif. less likely In fingers the injured phalanx only need be removed, at the joint. 2nd when a ball has passed through or lodged in a joint. 3d in some cases where a bone is fractured according to the degree of injury to the bone & also to the soft parts Even if the patient recovers, the limb will often be not so good as a wooden one Necrosis often comes on. The suffering will be great Often a bone will be fractured & split into the condyle 4th by extensive destruction of soft parts, to prevent gangrene, or extensive supp. & hectic & where the muscles are torn off the limb will be stiff. If the upper part of the femoris or os humeri is fractured amp. is necessary (at hip joint?) Consecutive amp. may be necessary The destruction of large arteries sometimes the skin will be unbroken in the meantime often indicates amputation Good accommodations for the wounded may enable us to save patients without amputation Be careful to amputate entirely above the fracture Mr. [illegible] says that after amp. death takes place 1st from infl of bloodvessels 2d [metastasis] to some important internal part most commonly to the thorax in our climate 3d from disease of the bone or joint 1st the veins may perhaps be tied 3nd pus has been found in the sac of the pleura 3d the hip joint Prof. H. would evacuate Suppuration of the liver more freq. take place in hot climates After amp. the end of the bone becomes round if the cure is favourable Paralysis is a frequent consequence of extensive gunshot wounds cured by moxa according to Bar. Lar. Tetanus Failure of success almost universal in acute tetanus more common in warm climates Bar. Lar. has had most success. It may be occasioned by tying up a nerve with an artery by exposure to night ari by suppression of suppuration acc. to Bar. Lar. Actual cautery has succeeded Amp. has generally failed Canthar. often fail It occurs oftenest in the young & in wounds of a [ginglim???] joint acc. to Bar. Lar.’ Emprosthotonas will follow an anterior wound & opisth. is a posterior & tetanus where there equal injury before & behind acc. to Bar. Lar. Warm & cold bathing have been much used Case of a young man wounded in the foot by a piece of glass. Bled. blister to the healed wound calomel opium cured was stiff for a year. Case 2d blacksmith hot iron upon foot corr. sub. into the wound blister over the foot calomel & opium the latter followed up cured. Make a powerful impression. A red hot ploughshare has been passed along the spine. Bite of mad dog Excise deeply it has never failed in Prof. H’s practice A finger may be cut off. He has cut out 6 days afterwards with success. Dr Physick says at any time before the [accession] of the symptom Contusions without breach of the skin It is an injury causing a rupture of vessels & effusion of their contents under the skin 1st swelling owing to extravasation next echymosis or discoloration which frequently extends some distance especially in the direction of gravity e.g. black eye from contusion on the forehead finger discol. after an injury of the arm very easily produced in old people. Commonly a considerable degree of soreness. The powers of absorption greater in the young Indications 1st prevent further effusion 2d reduce infl. 3d promote absorption 1st by wet lotions of water [mar.] [illegible] etc. 2d if much fever bleeding & cathartics & fiunally if necessary opium 3d Use warm applications (these also may be for the first indication after a while) Add to these bandages & compression. Also we can apply camphorated spirits opodeldoc etc. In many cases an incision must be made to let out the effused blood (called bloody abscesses by the French) We should however generally defer [illegible] One reason for which is that the vessels may continue to bleed. If the blood is coagulated a snapping will sometimes be felt as of something breaking & slipping away. [illegible] in this state it is though more likely to be absorbed. Before incision try remedies and [observe] if you appear to be gaining ground. Sometimes the effusion is in a bursa mucosa Case of it in the knee So [much] a [illegible] Make the incision on the outside of the tendon of the rectus musc Prof H has several times been obliged to open these bursae e.g. at the elbow. Upon the back he has had to make an incision & let out a quart of fluid tarlike blood. If the vitality of the skin is destroyed an incision will be advisable. We shall have a sloughing sore in either case. There is a bursa directly on the olecranon which is liable to be filled with effused blood Often there will be a second eff. when the orifice must be opened & the cavity injected with corr. sub as in [illegible] Contusions of abdomen. Death has been occasioned by blows on the epigastrium apparently caused by the shock alone Often the peristaltic motion suspended which denoted by swelling of the abdomen vomiting want of sup. anxiety of countenance etc. Sometimes blood is vomited It is generally best to avoid stimulants Case young man kicked by a [illegible] vomiting of blood 1 great pain & excessive thirst to stop the flow of blood cold wet cloths were applied to the abdomen bled ad deliq. pain ceased pain & vom. returned bled again calomel finally injections The bleeding relieved the pain the vom. & the thirst. cured in 2 or 3 days Venesection is the most important indication, the next is purgatives continued for some [time] Sprains not much treated of It is an unnatural extension of ligaments of a joint sometimes accompanied by dialysis or rupture. Joints most commonly affected are those which are not strongly defended & admit of little motion. They are the knee ankle wrist & hand. At first motion is free but it is soon hindered by effusion & swelling frequently there is effusion into bursae mucosa There is an effusion into a bursae of the foot which is often [illegible] for dislocation. It is apparently set by pressing & breaking the sac. Prognosis Some families are particularly liable to them Scrofula gives a tendency. In some constitutions a slight sprain will cause [hemorr.] for months Treatment Rest is more necessary than in contusions. Cold lotions to prevent infl. cold water or ac. plumb. A bandage is always proper moistened at first. In case of much pain use warm fomentations best by wringing out a cloth dipped in hot water, applying it & covering it with flannels to keep in the steam. Poultices may be used In case of stiffness apply opodeldoc & other stimulant applications friction passive & active exercise. Lameness is often caused by want of exercise. The violent wrenching of the natural bonesetters has some good in this way. Burns. Inflammation caused by heat The practice has been exceedingly empirical No advantage in dividing them into species Superficial burns of sufficiently extensive are of the highest consequence Case of a child blistered by cantharides over the whole body died in great agony. The British East India surgeons sometimes used hot water for blistering The [illegible] indication is to shut out the external air. Treatment like that for a blister Deep burns are generally [illegible] by a suppurative inflammation which is generally ascribed by the patient to taking cold. Sometimes flame is inhaled the viscera are affected, under the external injury, in some patients Consequences of extensive burns if the pat. survives the first shock, are fever, extensive [illegible] etc. This last is frequently fatal, hence the end of three weeks is a critical period Children are sometimes affected with convulsions When we find apparently comfort application already made, we should be careful about interfering with them Treatment has been opposite & empirical Cold water on one hand & spts turpentine on the other. Antiphlogistic & powerful internal stimulation For simple external burns anything that keeps out the external air perhaps as good as any is simple cerate. If there are vesicles [illegible] them Equal parts of basilicon (or common cerate) & spts turpentine is the best application in case of extensive sloughing & suppuration Prof H. has tried cold application & poultices, but does not like them [illegible] is the necessity frequent exposure to the air in dressing. The above cerate seems to promote a quick suppuration & so prevent gangrene. It must be laid aside (causing smarting etc.) as soon as suppuration is free, when simp. cerate should be dressing not oftener than once in 24 hours having the dressing ready for immediate application the cold air. Then granulations come on use Turners cerate Finally use ac. lead 1 oz beeswax & sulph. sod. 2 oz. This is called saturnine cerate. Turner’s cerate above is made of oxide of zinc. Often near the close of the cure adhesive straps & bandages are useful to keep the sides of the ulcer together Constitutional treatment. The shock is often very great. In children there is either violent distress with screeching [or a comatose] state with deadly coldness which indicates alcohol camphor ammonia etc. Opium also though Prof. H is afraid of it in coma. Next comes on fever treated by venesection cathartics etc. to be discontinued when suppuration comes on. In children it will be sufficient to keep the bowels open & bleed only incase of convulsions In adults the bleeding should not be copious. Bark [seems] to be irritative Opium is the principal remedy on account of the pain etc. Cotton seems to be advantageous only by keeping out the external air & keeping the parts warm & by being easily applied & kept on Case of a man who fell into a kettle of boiling potatoes Took a large quantity of spirits Was dressed with the turpentine cerate then with simple cerate opium [was given] the bowels kept free about the [2?] day there was a critical period his mouth was treated with borax & other means were adopted which cured him. If an extremity is burnt off then amputate the stump immediately Sometimes the bones come off themselves. Deformities from burns The fingers are liable to adhere This is to be prevented by dressing. Splints are to be used to keep parts in their place preventing [illegible] flexion of fingers etc. When the joints are affected they should [illegible] straight & when the sore is healed, practice flexing them. Case of a young man who scalded his legs Deformities following burns Case of a burn at 7 yrs. of age upon the back of the thigh troublesome with sores etc. at 47 yrs had been of latter years much troubled with a horny excretion which was softened with [poultices] & shave off [At] 47 yrs of age the limb was amputated IT was an old practice to cut across the cicatrix & stretch the parts in case of deformity caused by contraction The new practice is to cut out the scar entirely sometimes adding the taliacotian operation Case of a young man with a large & sore scar on his foot. A good foot was made Frost bites A degree of torpor is produced by severe & long continued cold amounting to drowsiness & irresistible inclination to rest. Case of Prof. H’s preceptor, an army surgeon Not suddenly to be brought into a warm room nor to be too free with cordials Immerse frozen limbs in cold water gradually warming the water after a little while. A limb thoroughly frozen cannot be restored to vitality, however The contrary treatment totally destroys the frozen part. The effects of frost are similar to a burn superficial redness mortification which commences with a purple & terminates with an ash colour in case of thoroughly frozen limbs In frost bites apply ac. plumbi etc. poultices, cerate in case of suppurations which may have liquid applications over them. Cold and warm applications are both used. In case of mortified extremities amputate without hesitation as soon as the line of mortification is distinct else we shall have suppurations abscesses etc. Case of Capt P. of Brooklyn was overturned, & [stunned], in extreme cold weather lay all night was put int a very warm room. The phys. attempted to bleed him no blood followed there was a wound on the eyebrow knee the other knee dislocated right hand frozen. Prof. H. bled him, & gave a dose of cal. & jal. Afterwards he grew more insensible & eventually comatose for several hours. An erysipelatous inflam. with delirium supervened. He was bled & treated on general principles. Eventually recovered The fingers & thumb of the right hand were amputated after about a fortnight This amputation was however too late as was proved by suppuration & abscesses taking place on the hand & arm. The patient was partially sensible & able to tell his name when he was first discovered by the road side. The effect of the warm room was to bring on complete insensibility & finally coma A foot or hand frostbitten if applied to the fire is followed often by violent infl. & mortification which when superficial merely will cause nothing more than the loss of nails skin & so on Tumors Varieties numerous 1st Encysted 2d sarcomatous 3d medullary Also malignant & non malignant the last however may become malignant We know little of their origin. Mr. Aber. attributes them to extravasated blood. Their progress is often similar to that of chronic inflammation The nature of the tumor will often be inflamed by that of the parts where they are situated e.g. they may contain hair when upon the scalp. The growth seems to depend upon the size of the bloodvessels of the part. They increase, in general, in geometrical progression They should be extirpated before they have arrived at any considerable size. 1st Encysted tumors contained in a cyst of more or less density, which encloses [stertomatous], or [illegible] mellitus, or is an [illegible], curdy matter being contained There is a kind affecting the red part of the lip having a think sac & contents resembling the white of an egg not larger than a musket ball. There is a tumour composed of adipose matter disposed in cells called sarcomatous Various discutient remedies, have been recommended. As far as they are effectual at all, they do injury. If the cyst is penetrated, a very troublesome sore follows & sometimes cancer Caustics instead of knife have been successful Cancer quacks cure small tumors in this way and call them cancers. In case of large tumors caustics often fail & the knife is always preferable. It was formerly advised to extract without opening the cyst this not always practicable without great difficulty. Sir A. Coop. opens the cyst presses out the contents & pulls out the cyst by inversion. If any portion of the cyst remains the tum. will be renewed. Sometimes a small tumour may be removed by caustic alkali upon lint introduced into the cyst. external injuries freq. cause these tumors Sarcomatous tum. In these the cyst is not strong enough to be pulled out. If the skin adheres firmly, make two semilunar incisions & take out a piece of skin Then separate the tumour from adjacent parts by the fingers as much as possible Membranous connecting bands often have to be divided. These tumors are troublesome from their size, from impeding motion etc. when pendulous, the skin is frequently affected with an erysipelatous infl. Cases of old woman & an old gentleman extirpated with safety. The arteries are usually very small in these fatty tumors sometimes however they give a troublesome haemorrhage They are divided into various kinds by Mr. Abernethy. All the kinds may become malignant Fungus haematode medullary tumors malignant from the commencement & liable to return even if thoroughly extirpated. Hence a portion of undiseased parts should be cut away After extirpation treat as for a simple wound. The largest [tumors] are the fatty even 40-50 pounds They feel like a bag filled with cotton Sometimes there is a puckering of the skin (caused by imperfect adhesions of the skin) under the fingers. This is a pathognomic symptom These adipose tumors must not be confounded with the steatomatous encysted tumors. It is a question whether the whole parotid gland has been extirpated. They will prove fatal (many of them) eventually & hence should be extirpated while small. The testicle & the fem. mam. are enlarged frequently & sometimes will become small again Medullary tumour or fungus haematodes the substance of them resembles that of the brain but is redder & harder found in every part of the body even in the bones & then called osteosarcoma There is at first an elastic feel caused by the binding down of fasciae Growth is very rapid, causing absorption of adjacent parts as bones Most common are they in the young they were all formerly called varieties of cancer In the testicle most taken for hydrocele It is found about the eye Prof H. has met with them oftenest about the hip. Case of mortification & death in three days in consequence of opening one, in search of pus. Case in which a small point was left, which grew in spite of caustics & proved fatal. Case in which it returned three times & was then left We must hence cut away sound parts also. If the bone is affected amputate. Prognosis is generally bad though the wound heals well enough. They may return in internal parts. They are not always pulsative nor generally painful except by pressure upon surrounding parts & by a general [illegible] of health loss of app. sallowness of continence etc. pain when a nerve is pressed on Diagnosis of medullary tumors Abscesses begin deep & are not painful and are circumscribed by a hard edge. fungous tumours have an elastic feel. The colour of the skin over a fungous tumour will be dark red, but not tender like that of an abscess, nor surrounded with a hard rim. We must also inquire into the previous symptoms fungous tum. begin without infl & pain & are indolent. Spots will be found in the neighborhood which if opened largely will prove fatal. Case of a fung. haem. of test. mistake for hydrocele. Though we have no remedy for this disease yet extirpation should be performed if possible cutting into the sound parts. Case of Dr Wood. of [Cast.] cutting out one of the thigh every few months the man able to labour. Case in which the most powerful caustics failed in killing the tumour, fast as it grew. Ulcers A solut. of cont. in soft parts with a discharge of fluid. The absorbent vessels remove the parts faster than the nutrient vessels renew them hence the opposite to healing Differs from mortif. by the dead parts remaining in the latter case Various classes of them Causes wounds abscesses external injuries (local) The constitutional causes are syphilis scrophula scurvy etc. also in some families from a predisposition e.g. hereditary sore legs An oedematous affection predisposes e.g. dropsy phlegmasia dolens 1st simple 2nd irritable 3d indolent 4th varicose 5th specific ulcers 1st simple discharge of mild inodorous pus small round granulations filling up the cavity finally a bluish skin (cuticle only) which makes cicatrization Formerly 3 stages were always expected in the healing of a wound viz. ulceration, granulation (restoration) & cicatrization. Much benefit arises in a simple ulcer from adhesive straps, as in a wound, to promote cicatrization. The bandage will keep the parts together & also prevent proud flesh (a luxuriant gran. protruding beyond the skin) which should by nit. sil. or if that fails by sul. cop., be reduced Irritable ulcers painful sore irregular shape (sometimes round when small) gran. irregular do not bear bandaging well. The irritability may generally be abated by touching with nit. sil. or by wash of corr. sub. or by 1 scr. corr. sub. to 1 pt water (called yellow wash) or sprinkle with calomel, or apply the black wash of cal. & lime water or wash with [illegible] op to 1 pt water 1 dr. ac. lad to 1 pt. mucilage will be cooling & lenient. Warm fomentations are apt to soften too much We frequently change our application Indolent discharge serous& curdy bottom smooth edges swollen surrounding cell mem. thickened often very large as large as a hand [illegible] patients will suffer little, and continue to labour. A farrago of remedies in popular use Nitr. ac. & nit. sil. & other caustics are used. The best rem. is MR. [Berts] plaster bandage, surrounding the limb. above & below with this bandage applying a compress wetting the whole with cold water. Sometimes leave a little vacancy for the discharge of matter The plaster may be common adhesive pl. or diachylon, or rosin pl. or [litharge] pl. sometimes in case of irritation from Soap plaster of the [illegible] is used rosin softening this last with tallow one half Dress once in 2 or 3 days only Sometimes an erysipelatous infl. & sloughing comes on Guard against this by diet etc. Improper to make a class of sloughing ulcers Indolent ulcers may be cured much sooner by confinement, as is practised in the hospitals. 3d Varicose ulcers. The veins will be found varicose. Some are irritable more commonly they are indolent. Treatment of the varicose veins is the particular indication. Proper bandages with confinement of the patient is always proper. However the cure will be more sure of being permanent when it is effected without Diet is of the highest importance The patients are generally plethoric more or less; hence use venesection or purgatives (mercurial). Where erysipelatous infl. come on treat as usual by ac. plum. blistering etc. Some patients are feeble with low pulse cold skin & pain in the affected limb. In this case give cal. [illegible] cal 1 ½ gr. op. 1 gr. also Dov. pow. bark & opium etc. Nitrate of silver relieves irritable [illegible] sloughing etc. better than any thing touching with it once in a few days. There is generally little hazard to life from sore legs. Cases in which by the continual application of caustics & irritatives caused enormous ulcerations cancers & affections of the bone which required the operation for necrosis, or amputation It has been proposed to be the vena saphema Sir A Coop. objects. Cutting across the vein is thought better by some also cutting with the convex cutting edge of a bistoury, so as not to wound the skin also cutting out a part of the vein & then bringing the edges of the wound together, as is practised with success in the Pennsylvania hospital. This latter mode probably the best. It has been supposed that the drain from old ulcers is very beneficial this opinion is probably derived from the fact of the stopping of the discarge in an acute disease as fever There is no danger in curing them Hence the old opinion, which is still the popular one, is to be entirely disregarded Plethora had better be relieved by venesection & cathartics than by ulcers. Specific ulcers e.g. venereal, noli metangere cancers etc. Anomalous ulcers Sore on the instep somewhat like elephantiasis. Benefitted by powdering with calomel. Nitrate silv. saturnine cerate acetate of lead & calomel with lard may be tried also. There is a thin watery discharge redness hardness thickening extending over the whole upper [surface] of the foot. Sometimes stopping in one direction & extending in another Fungous ulcers [ment.] by Sir. A. Coop. principally on the calf of the leg resembling a scrofulous affection of the metatarsal bones generally in young & corpulent women Apply bandages wet in case of heat when the fungous protrudes through the skin apply nit. sil. Also wash with ac. of lead etc. & prescribe for constitutional symptoms. Ulcers following scrofulous abscesses Fungous flesh overhanging, thin, dark purple skin they are oblong Apply nit. sil. in pencil under the skin if necessary that is if this first application does not cure then cut off the diseased skin & lay open the whole sore. Sometimes where the orifice is small, a director must be introduced & a long incision made it will not in this case be necessary to clip away the skin. These like other ulcers are often called cancers Schirrhus or cancer. A hard tumour without ulceration is called schirrous cancer, when ulceration comes on Schirrus may be fatal without running on to external ulceration Lower limbs & testes in males breasts & uterus most often affected When affecting the skin they begin with a blood war, or with a discoloration & tumour of the skin to be treated of afterwards. Scrofulous tum. are less hard, seldom single, oftener in young people, they are smooth, and attended with scrofulous habit. Young women are often affected with an induration of the mammary gland which is mistaken for schirrus. The latter is almost always found in adults. Cancer of the breast [Commences] with a painfulness When first examined there is found a hard tumor. An inflammation of the skin takes place. The nipple retracts & disappears eventually the hollow will discharge an ichorrous fluid. Or the cancer may commence with a small vesicle which breaks, discharges, & finally becomes an irregular knobby cancerous ulcer Cancers however, do appear to commence sometimes internally. The lymphatic glands & sometimes the lymph vessels, are affected when the ulcer opens. Sometimes the skin adheres to these inflamed lymphatic vessels Finally the manna adheres to the pectoral muscle & even to the periosteum of the ribs & sternum even attacking the other mamma with the same symptoms The lymphatic glands of the axilla are more affected & the arm sometimes is so oedematous as to require puncturation Great difficulty of respiration occurs The disease is fatal from hydrothorax or other affections of the thorax, as well as from hectic Sometimes without much ulceration the whole mammae are bound down at death with schirrhus. Sometimes the bones of the extremities become singularly brittle. Sometimes a paralysis of the limbs takes place The whole spinal narrow has been affected. Very numerous & various symptoms may come on in the sequel. Difference of opinion as to whether this disease is constitutional or local. For sometimes the disease returns in the same or another part & sometimes not Prognosis doubtful The more speedy the access the mor probable the return Sometimes in very old people from their slow progress & insensibility they give very little trouble. Their cure has been attempted by bleedings & low diet also by salivation No dependance can be placed on these remedies. So of the internal use of arsenic and of conium also. Iron internally & externally seems to have failed Pressure has been much tried, but fails The hard cartilaginous nature of the tumour would lead us to despair or resolving them by internal or external remedies Caustics have been successful in very small cancers, but generally they give so much irritation as to increase the disease making a loathsome sore Iodine has been proposed There are no accounts however of perfect cures by it. Prof Smith stated he never knew a woman survive the application of caustics to the mamma more than a year The sooner the knife is used the [better] Use the knife also even after ulceration has come on. We must not expect the infl. of the lymph gland to subside of itself, this tumour also must be cut out. Reexterpation Should be performed as often as the disease returns provided the patient can bear the operation Case of 4 times in a year & the patient is now well. Various remedies, or issues, have been tried to prevent the return of the cancer It is of no use to prescribe any thing except for the general health In other parts of the body cancer may begin in a manner similar to those of the breast In the lip, we may have first a crack in the lip ulceration the lymphatic glands of the neck are affected the gums are affected the cheek the bones the whole mouth consumed & sometimes the patient dies of starvation. Mode of extirpation take out a piece in the shape of the letter v. bringing the parts together. If the skin is not affected, we may cut away down to the skin, leaving the latter Mr [Richaraud] cuts away the whole with scissors instead of the knife Prof. H. has extirpated the diseased glands under the inferior maxillary but generally without success where the disease has proceeded so far. We must not be too solicitous to save skin, cutting away all that adheres for the disease may return in the skin. Even when the disease returns it is not generally so rapid & fatal as at first. We must be very careful not to confound cancer with other diseases of female mammae Hydatid or incysted tumour of the breast of Sir A. Cooper 1st an enlargement then a tumour which yields serum when punctured then returns again and may attain to the size of several pounds. When of this size it is found after extirpation to be composed of one or of several cysts & may be of other forms. Case of a woman who had one opened a second time the opening kept open by [illegible] died of extensive suppuration & const. irritation Another case was extirpated at the first time. The tumor was the enlarged mammary gland with a cyst in the centre. Diagnosis absence of pain If opened the fluid perfectly limpid Indication immediate extirpation Simple chronic tumour of the breast of Sir A. Cooper. Rather upon the breast, than in it moveable Not generally painful & does not affect the constitution It grows very slowly but may arrive at a large size. There is no difficulty in cutting off the tumour & it does not appear to be liable to return It may be either before or behind the mam. gland These tumours are composed of several cells resembling sweet bread a glistening & glandular appearance. The cause is unknown. The patients sometimes suppose them to be caused by the pressure of dress Caustics may have cured them. Adipose tumors sometimes many pounds in weight may be either before or behind the gland. They are to be extirpated Irritable tumours of the breast for 15 to 30 yrs. lobe of the breast swollen & painful the arm is affected, more painful during menstruation especially during difficult menstruation great irritability etc. If patient is plethoric, bleed, & purge apply spirit & water or a plaster the best external application is soft fur or cotton batting. Give opium Sir A. C. speaks of an ossific tumor of a cartilaginous nature to be extirpated Lacteal tumor after delivery a swelling, which when opened yield milk Caused by an obstruction in the duct of the gland. Treatment, open & let out the milk wean the child & so stop the secretion of milk. If the orifice does not heal, touch with nit. silv. Some women are very liable to small abscesses of breast during suckling If they continue to succeed one another the child must be weaned. Breast large & pendulous It may be diminished by bearing & nursing children also by suspension Sometimes there is an enlargement & inflammation of the breasts during pregnancy which often require opening to evacuate pus With the exception of the small chronic tumors upon the breast, the whole glandular portion of the breast should be removed. Mode of operation. Instruments 2 or 3 round edged scalpels tenaculums needles & ligatures adhesive straps from 1 ft. to 9 in. long & 1 inch wide Bandage by a broad band passed around the breast & crossed over the shoulder stitching down in front. Have also lint & compress. Cordials & cold water for fainting. This last is best remedied by dashing on cold water Place patient on a table, with feet in a chair arm extended sitting in a chair is apt to occasion fainting Make the first incision in the direction of the greatest length of the tumor Or make it in an oblique direction in that of the pectoral muscles. If the skin is affected semilunar incisions are necessary. Stretch the skin with your left hand & by that of an assistant Use a drawing stroke, from heel to point of the scalpel. Make your incisions long enough at first Use considerable force & repeat the stroke also until the incision is deep enough If two incisions are made, make the lower one first. Observe this rule also in your following dissections. If an artery bleeds, stop & tye it or have an assistant keep his finger on it. Be careful to examine the bottom of the wound & also the under surface of the tumour. Cutting away little additional portions does not give very great pain. Then proceed to take out the tumour from the axilla Sometimes the same incision will answer for both. They may sometimes be torn out by the fingers being imbedded in the cell. mem. merely we can generally get the fingers behind them When there is a diseased chord in the in the cell. membrane, take it out with the tumour in the axilla Spunge the wound out well & tie every bleeding artery wait sometime in order to prevent secondary hemorrhage The French direct us to wait ¾ of an hour Wipe dry & bring parts together with adhesive plaster, beginning at the top & leaving a small space for ligatures to come out, unless they be made of leather then apply lint & a compress, & bandages It has been the practice of some surgeons to tie the carotid previously to the operation There is no necessity for this Other tumours. Cutaneous tubercles of Mr Lawrence. Prof. H. has seen it often. Frequently beginning about the face especially of elderly people upon the eyelids, nose, & upon the generative organs of both sexes. It becomes ulcerative & resembles cancer. Sometimes resembles a wart & sometimes a vaccine vesicle, at the first Always reddish & without inflammation of the skin. Sometimes it grows very slowly & gives but little trouble. At other times, especially if irritated, its growth is rapid. Finally they ulcerate without any disposition to heal & indeed become cancers; they are covered with scabs. Menstruating females are liable to periodical evacuations from the uterus, intestines (hemorrhoids), lungs etc. produced by these tumours This disease is different from noli metanges Treatment. Extirpation is the only mode of cure, & appears to be effectual the disease apparently not liable to recur The health of females with periodical hemorrhages, will be much improved. Mode make two semilunar incisions & be careful to cut into the healthy skin They do not extend inward Subcutaneous tumor Vide Cheselden’s Anatomy & Mr. Wood in Ed. Med & Sur. Jour. A hard tumor surrounded & covered with emaciated & discolored skin excessively painful growing very slowly & continuing quite small, notwithstanding their painfulness They are of a cartilaginous hardness. They do not appear to tend to ulceration more painful during menstruation & pregnancy Extirpate without delay or hesitation [Naevus] materna called marks apparently composed almost wholly of enlarged blood vessels they may be red or purple, or brown sometimes without any elevation of the surface They are sometimes troublesome in after life the swelling increasing suddenly the tumour becoming pulsative swelling & pulsating when the child cries in this latter case however, there will generally be no trouble in after life from the [naeva] Sometimes they become aneurisms from anastomosis sometimes affecting the whole & sometimes only a part of the naeva sometimes ulcerating at the principal point the ulcer may also very extensive attended with frequent haemorrhage. Aneurisms from anastomosis may come on without being preceded by naevus they may be made almost to disappear by pressure they pulsate violently they are tumours composed of cell. sub. & blood vessels. They should be extirpated after extirpation they of course shrink to a very small size. They may ulcerate extensively & the ulcers are very difficult to cure (They pulsate upon exercise) They may grow to a very large size & are then liable to be confounded with fungus haematodes They may be distinguished by their origin, situation progress, pulsation etc. As ulceration sometimes cures these aneurisms, caustics have been recommended for their cure Extirpate the haemorrhage will be troublesome, hence cut around & avoid cutting into the tumour as much as possible, also cut quickly, stopping the arteries by the fingers of assistants If practicable, the better way is to surround the (small) tumour with a double ligature. A new way is by passing 2 or 3 times through them a white hot needle apparently successful in case of small ones Case in which a naevus on the head was cured by Prof. H. by ac. lead bandages & compression Inoculation with vaccine matter has succeeded, apparently caustic would be better however as a means of promoting ulceration Tying the principal artery leading to the tumour, has been practised when on the head the carotid has been tied apparently without success. 11 Theory Practice Physic (front) Surgery (rear) Nosology 1 Diseases of Children 5 Retention of meconium 6 Tumour of the head 7 Aphthae or Thrush 7 Red Gum 13 Strophilus candidus 14 Ulcerated mouth 14 Costiveness 16 Infantile Erysipelas 18 Anomalous Eruptions 19 Crusta Lactea 20 Venereal Eruption 22 Sore Ears 23 Diarrhoea 24a Vomiting 28 Hydrocele 29 Volvulus 30 Constipation with fever 32 Worms 36 Convulsions 46 Epilepsy 49 Chorea 51 Dentition 55 Ricketts 58 Cholera Infan. 60 Tinea Capitis 68 Catarrhal epidemic 70 Gangrene of mouth 80 Chillblains 81 Exposure to extreme cold without freezing 81 Mesenteric fever 82 Cutting frenum 85 Burns 86 Tympanitis 87 Neuralgic aff. of the lower limbs 88 Whooping cough 71 1 Theory & Practice of Physic Nosology Dr Rush condemned nosology but afterwards made use of a system of some sort. We must arrange our knowledge. Dr Ives believes the fundamental principles of the common systems are erroneous Disease is a derangement of some or all of the functions of the body. It is the opposite of health or dis-ease. We must compare it with health. Dr Ives condemns the classification into species general orders etc. as if they were entities or beings instead of merely modes of action Diseases change their seat and their form in the course of their progress Nosologists would have done better than they have if they had imitated the natural classification of the botanists. Very great error is committed in attempting to make the divisions mathematically exact. 2 All the present systems suppose definite diseases with specific modes of treatment this leads to an invariable mode of treatment & to the prescribing for the name of a disease. Still it must be confessed that nosology founded on anatomy and physiology are [latelly] acknowledged that diseases are mere modes of action A classification of epidemics formed upon [remote] causes is equally erroneous as the remote causes are disputed, and unknown Dr Ives divides epidemics into two great classes taxic & ataxic in irritation of the division of natural families into classes The term malignant has sometimes been used in the sense in which Dr Ives uses the term ataxic sometimes for rapid fevers, for those which have a gangrenous tendency & for those which more especially affect the vital fun. Ataxic a morbid state, beyond the power of reactions attacking the vital 3 function not putting on the ordinary forms of fever The first & most important indication in taxic fevers is to moderate the violence of reaction in ataxic, is to produce reaction It may be laid down as a principle that all ataxic epidemics resemble each other Ex. gr sometimes in the yellow fever the powers of life are attacked & prostration or exhaustion continues until death closes the scene. What are called the walking cases are of this kind in which the patient walks about until death. This kind is difficult to describe but when once seen is never forgotten eyes glassy countenance anxious etc. So of cholera of India also of pneumonia typhodes especially as it first appeared in this state It had four distinct varieties of which spotted fever 4 was one. No reaction no pain no heat such cases are said to occur in the plague A person who has treated one ataxic fever is able to manage any other All extreme cases may be classed together under this name, as they are in fact under that of malignant Dysentery of 1814 & 15 mild coma [gentle] sleep no apparent pain stools once in two or three hours not striated with blood etc. etc. when the patient was roused from sleep he said in a faint and indifferent tone of voice he was well immediately fell back into sleep. Yet here was dysentery [although] there was no dysenteric symptom for these cases were beyond question, of the same epidemic as others unequivocally dysenteric The indications were to excite reaction by external and internal irritants and to excite the action of the stomach and bowels by calomel ipecacuan etc. In this epidemic the stomach & duodenum appeared to be principally affected. 5 Diseases of Children Great attention has been paid to this subject within the last 30 or 40 years It was formerly almost entirely neglected owing to the exclusion of the faculty from the practice of midwifery to the prejudices of mothers and nurses & to the indifference of the family themselves Young physicians are more frequently called to the diseases of infants hence the importance of this subject to medical students. In Europe have the physicians been most negligent of this subject The French & Germans less so than the English The European practice differs from ours less so at present than formerly because our constitutions are coming to resemble theirs. Their practice is more mild In general chronic diseases require a milder treatment. Great difficulties result from infants being unable to tell of their complaints yet the 6 other symptoms are more easily understood They practice no disguise or concealment They are not made worse by mental aff. Many prejudices exist e.g. that the child is born with a morbid appetite inherited from the mother which appetite must be gratified This they infer from the natural crying of the child The mother sets herself to recollecting some former longing of her own. Story of a child fed upon this principle with mince pie It had to be physicked severely to save its life The mucous membrane of the al. can. is oftenest affected sometimes spasmodically Be on the watch with regard to the liver. The nervous system is more easily excited from irritation than in adults The vascular system less so. Fevers are generally more irritative than otherwise As a general rule preventive medicine should not be given. Evacuants may be given 7 with great safety Witness the long diarrhoeas & the salivations of dentition which they bear without emaciation The milder purgatives should be used. The drastic are irritative calomel is one of the best. 1st Retention of meconium & its consequent diseases. The meconium is a dark green matter resembling tar Its evacuation should be effected not by medicine but by the first milk of the mother. The act of crying also contributes to this effect. Instead of suffering the nurse to feed the child during the first two or three days the breast should soon be present If the child feeds, it is in danger o f losing the instinct to suck Evacuants are 1 gr. of carbonate soda to a teaspoonful of water until 10 gr. are given is a good cathartic Molasses & water may be used likewise The gall of animals 8 in a good cathartic as a substitute for the childs own bile. It may be given in catnip tea, milk etc. We may use also Decoction of the flowers of the dandelion and of the mullein. The best however is generally castor oil teaspoonfull at a time until evacuation is produce Senna likewise, in conjunction with some aromatic herbs & seeds 1 dr. of these to 4 of senna The operation of cathartics must be assisted by emollient injection & also by fomentations of the bowels & the warm bath. The blue pill may be used. Also 1 gr. calomel & 4 or 5 of chalk repeated once in 2 or 3 hours assisted by bitter & aromatic herbs in the way of injection These last thus will frequently answer by themselves. Blue pill & chalk & calomel rarely offend the stomach These measures must be pushed vigorously & used in conjunction also especially the warm & tepid baths 9 in cases of convulsions from retention of the meconium. Dr Ives has not known salivation produced in infants by mercury. This may be explained by the large quantity of mucous which defends the surface of the intestines and enabling infants to bear large doses of calomel. The abundance of meconium contributes also. Antispasmodics e.g. aqua amm. 3 or 4 drops also 3 or 4 gr. carb. amm. also asafoetida a teaspoonful of the tincture injected in milk & water into the rectum. These may be used Young children are often troubled with hiccups & irritation caused by acidity, which must be corrected by alkalies. Sometimes this must be corrected by regulating the diet of the nurse. If as is occasionally the fact the mothers milk disagrees, as is shown by the [illegible] stools & the obstinate crying of the child, then cows milk diluted with one third or one half water or with arrowroot mixed first 10 a table spoonful of cold & then of hot water in order to make a homogeneous mixture. Children fed on cows milk are more apt to be costive. To prevent this give a little magnesia, decoct. of dandelions etc. Peach tree blossoms are much used as a cathartic, but are too violent. Children are sometimes born with a tumour of the head occasioned by difficult labour This may be distinguished from a tumour occasioned by a defect in the bones of the cranium by a uniform hardness Aphthae or thrush Sometimes accompanied with a typhoid fever Sometimes idiopathic. It is a disease of debility, caused by disorder in the primal viae. In some families all the children are affected with it Among the poor bad air & among the rich too great warmth & confinement are the predisposing causes It is a vulgar but mistaken opinion that all children 11 must have this disorder at some period or other Symptoms 1st languor, then white specks or flocculi in the mouth, which finally affect the aesophagus, the rectum (for the orifices of the tabes are more sensitive) & perhaps also the whole alimentary canal though this is disputed. The white spots are succeeded by others of a darker colour. It is thought to be prevented by giving a teaspoonful of cold water soon after birth & subsequently repeating the remedy [illegible] [illegible] heat good Castor oil is objectionable because it does not affect the secretions & does soften & relax the mucous coat of the intestines 10 gr. to 1 dr. of magnesia chalk cal. Dissolve 4 or 5 gr. ipecac in 6 teasp. water & give one teasp. at a time If it does not evacuate the bowels calomel or rhubarb may be administered. If the ipecac moves 12 the bowels too freely given on a sixth or eighth of a drop of laudanum In case of acidity white decoction consisting of chalk ½ oz carb. pot 1 scruple 1 [illegible] or [illegible] [Comus] [cir] [sericia] & asking [illegible] Lime water & milk may be given for acidity 6 gr. chalk 1 gr. cal. with a little ginger for watery stools or a small quantity of rhubarb instead of the calomel No violen local application should be used It was formerly thought that the disease might be removed by rubbing off the aphthae by a swab of cloth Inflammation of the mouth was caused. A little borax and sugar equal quantities a drachm in a gill of 5 or 6 of [illegible] in [powder] put into the mouth water Or mucilages, of violets (v. pedata) decoc. of sassafras [illegible], or comfrey A small quantity of sugar lead in the mouth may be [illegible] In children more advanced thrush is sometimes a critical termination of diseased action & then frequently a favorable 13 symptom e.g. hydrocephalus Ipecacuanha in small quantities as an alterative is particularly to be recommended Strophilus intertinctus of William red gum papulae Nurses consider it the same disease with thrush Red gum comes from red gown made of [stom] on calicoe The vesicles rarely contain lymph terminating by scales & not attended with constitutional irritation It arises from heat bad air confinement & irritation of primae viae. When repelled followed by bowel complaint & convulsions The patient should be kept clean and daily washed with tepid water. The tepid bath may be continually used & is the most efficient remedy when the eruption is repelled from the skin 14 food Strophilus candidus Papulae with non inflamed base appearing like very small pearls under the skin about half the size of a millet seed continuing sometime Prof. I. has seen it following cholera infantum A close examination is necessary for its detection Reference made to Willan Ulceration of the mouth called canker Sometimes very troublesome called food is a cause Commences with an inflamed point in the mouth The edges of the ulcer inflamed & elevated Child drules much febricula torpor of intestines 1st excite al. can by magnesia or blue pill or calomel. Then use Moseley’s tonic solution. Compound tinct of vitrine (sulph cop. in alc. water of crystals 15 marsh rosemary geranium [rac.] tinct kino internal app [illegible] [illegible] sulph. cop prescription Nitrate silver corrosive sublimate Prof. I’s own case corr. sub. & op [illegible] astringent [illegible] rhus cornus Rx sulph. cupri 10 gr. carb. Peru a dr. given at 1 dr. Hon & dr water 2 touch the part with a pencil violets allied to ipecac So also asclepias particularly A [decumbens] 16 Costiveness in infants A physician is frequently called when the infant is perfectly well with the exception of costiveness. This will produce a variety of complaints e.g. watchfulness, starting, hiccup, & convulsions. Frequently the child is not observed to be unwell until the convulsions come on The remedy is injection. For we can only operate on the al. can. the lower part, & the skin the mouth being closed We must be careful to make our prescriptions for an enema, very definite. Case of a mason’s man hands & knees about 3 ft. off shooting fright, murder Simple warm wat. or milk & water or about a table spoonful of salt or thoroughwort catnip etc. or finally castor & other oils. Sometimes in extreme cases fill the rectum with lard. Sometimes as a nervine a teaspoonful of camphor in a gill of milk. If these do not 17 answer, used the tepid bath. The water should be heating, while the enema is administered. the water should be about blood warm. Be careful not to sprinkle or scatter water in the patient, instead of bathing. Time 5, 10, 15, or 20 minutes As soon as the patient can swallow, or while it is in the bath give calomel For a child 6 months old 6 or 8 even 10 gr. If improper food is the cause 20 gr. are not dangerous for infants will beat full doses of cathartics, but very small of narcotics Various articles of food are used to obviate costiveness. Oatmeal gruel rye-meal gruel, rye bran gruel Castor oil is the best cathartic a teaspoonful or tablespoonful Magnesia is good and may be given in milk Elixir salutis is one of the most common family medicines. Castile soap is a good cathartic but ½ oz or oz is required. The bile of other animals is a good remedy. Blue pill various vig. ext. e.g. fl. of [mullein], peach, dandelion etc. 18 It is better to cure by food than by medicine Mechanical means called suppositories e.g. candy introduced into the rectum] are common among families Infantile erysipelas Its classification is doubtful It answers tolerably well to the [illegible] of Good No species in Bateman & [Willan] like it Red patches A severe & dangerous disease apparently the same with the dangerous roseola or [illegible] of the West Indies. Elevation of the skin is not so great as in erysipelas Generally commencing on the legs and thighs, & extending like erysipelas. Attended with constipation tumefaction of the bowels, hiccup & severe fever & terminates fatally with come Give calomel 8 or 10 gr In two hours repeat the dose. Then evacuate with 19 senna mixed with aromatic seeds or if this is not sufficient, with castor oil senna or scammony Then keep the bowels open with blue pill External applications the best is flour or arrowroot. Prof. I has sometimes blistered in imitation of Dr Physic Probably every case would be fatal if treated with bad water and did not evacuate the bowels. If diarrhoea is produced give compd powder of chalk of the shops & other sim. articles In erysipelas of the head we may use the common discutients in conjunction with evacuants. Children are subject to various anomalous eruptions, in consequence of improper articles of food. This is frequently the case with adults e.g. fish & pokeweed An excessive quant. of food may cause them Always pat attention to the diet. This will 20 if persisted in, cure most eruptive diseases Avoid oily food such as nuts crusta lactea (milk [illegible]) Porrigo larvata of Bateman On the lips forehead scalp. First pustules yielding pus until a scab extends over the whole face. It never leaves a scar. We must be cautious of checking it especially when of considerable continuance. Sometimes it degenerates into a phagadenic ulcer, In such cases Prof. I. has used charcoal externally poultices, a variety, & has seen much advantage derived from roasted flour, it absorbs and excludes the air. It is proper to give a dose of calomel. The buckthorn is thought to be particularly serviceable in cut. aff. In case of great irritability chalk may be combined with 2 or 3 gr. of cal Diluted muriatic ether in doses of 5 or 10 drops in water 2 or three times a day, has been much used, and may be [recommended] It may ½ dr [illegible] 1 oz alcohol Ext. 2 dr cal 1 oz sim. cer. Oxygenated oint Nit. ac. & lard Nit. ac poured on warm lard Citron oint more efficacious When the [illegible] does not answer [illegible] [illegible] [illegible] app e.g. sulphuret of potash 2 dr. [illegible] in a pint of water smells like bilge water This may be [illegible] in doses of a table spoonful. prob. [illegible] to sulph [illegible] Others prefer sulphuret of soda. Sulph. of [illegible] is equally effic. fever ensues If the eruptions dry up suddenly give antimony & calomel [illegible] children have a [illegible] rash [illegible] 22 Teething in children is frequently attended with an eruption, resembling a fine rash This should not be interfered with lest it be translated to an internal part. It is an effort of the system to relieve itself An eruption resembling porrigo frequently comes on in summer consisting of watery pustules resembling the itch. It is not cured by dock root. It may be cured by diet & the warm bath. Eruptions translate action from the viscera especially the liver, as in gutta rosea of rum drinkers. Venereal eruptions Some think it may be inherited from ancestry instead of parents. Smooth hard circumscribed like of half a pea increase slowly for 2 or 3 wks. then become filled with a watery fluid, & become a ragged ulcer 23 Treatment. Change the nurse if derived from her 1/30 or 1/40 gr. corr. sub. in water blue pill in moderate quantities tepid bath sometimes tonics of iron mur. fer. tartrite fer. alk. solution of iron Sometimes patients resist the mercurial prep & the rem. for scrof. In this case send the patient into the country for air & try simple vegetable articles e.g. exp. juice of plantain, ext. & internally It is a popular remedy for poison & is apparently valuable. It has cured such infants, when conjoined with the country air Its virtue is owing to its bland & mucilaginous quality Sore ears Nature has chosen the back part of the ear to eliminate morbid secretions. It relieves affections of the brain Frequently there is a miliary eruption, followed by excoriation In most cases so mild as merely to require 24 washing If the discharge stops suddenly it is liable to be followed with torpid bowels fullness of fontanelles full tense pulse cold extremities. When infants are suddenly attacked with disease inquire if they have had sore ears which have suddenly dried up in this case apply a blister behind the ears, without this nothing will cure perhaps. This is true of old sore [leg]. The theory is not the necessity of the evacuation but of the habitual action in the system Sometimes troublesome ulcers, yielding an excoriating discharge; followed by gangrene & death Poultices & ac. plumb. are good Powdered gypsum is one of the best applications (alabaster is the finest kind) Case in which alabaster cured without red precipitate The oxygenated ointment is the mildest & best where ointments are proper for sometimes they disagree Bowels be kept 24a open with calomel. Frequently it is necessary to change the diet of the nurse & to confine her to a simple diet. A discharge from the nose or ear may frequently be cured by keeping up a discharge behind the ear by blisters A teaspoonful of myrrh to 1 gill of water is one of the mildest ext app. Sometimes use nit. sil. Diarrhoea Sometimes affects children for months & even years, in some families. Sometimes it arises from a bad constitution Caused also by want of cleanliness, bad food & want of cleanliness, bad food & want of air & exercise. Young animal (also vegetables e.g. fruit trees after a season without wind) need exercise Children need mental stimulants, from external objects. This is the principal secret of change of air. If the child 24b Bad air probably causes diarrhoea merely by its depressing influence is teething we must palliate not stop the diarrhoea. For this is an effort of the const. similar to tears from an irritated eye & mucous from the lung IN the commencement of diar. mentha vulgaris pounded the juice expressed, boiled, skinned & mixed with white sugar, will frequently cure. Ipecac will freq. cure. We must generally begin with a cathartic sometimes adding chalk to qualify calomel, when we give it for its deobstruent operat. Use blue pill for feeble & delicate children,. Prof. I could for many years take no other cathartic without griping. Often we must enquire particularly about the diet. Arrow root with a little spice, or a little laudanum, or wine. Sago tapioca, is a hydrate of flour moistened & dried by heat (probably) Roasted or baked flour & flour tied up tight & boiled, then grated, made into porridge is better than flour unaltered Rice in gruel, or thoroughly cooked by boiling 25 The worst cases have dry skin & feeble pulse. Use tep. bath & keep up an action of the skin by flannel In chronic stages absorbents will be needed chalk [illegible] oz cin zii [illegible] 4 oz carb pot zss. wat 1 pint Powerful means of counter irritation e.g. mustard horse radish, monarda punct. sp. turpent. about the precordia when the danger is very great, In case of something like cholera coming on By this means we can make articles stay upon the stomach [illegible] etc. will be grateful & stimulating As a tonic moselys 3 dr 1 al. pt. boil water cathartic [illegible] in [large] [illegible] 4 to 20 drops [somet.] [illegible][absor] Opium is often necessary, generally it is better, when qualified & rendered more diffusible in its action by ipecac. Invaluable in chronic cases of great irritability 26 Charcoal in fine powder, will correct the fetor of the stools & often cure. Particular attention should be paid to the stools for much may be known by them. Acid is formed in the whole al. can. Hence sour & curdled stools This will indicate lime water absorbents & aromatics. The acid may arise either from fomentation or (probably) from secretion. In case of clay coloured stools give opium to allay irritation ipecac. to equalize excitement & determine to the surface mercurials as deobstruents Give also mucilaginous or alkaline or laudanum (in starch) or (in case of griping) camomile injections. Often soap is useful also compd tinct. senna After the long continuance of the disease support the bowels by bandages, & apply a plaster of lead and soap. After great emaciation & when [illegible] [illegible] water softeness 27 tonics astringents (at least 50 ast) e.g. currant raspb. bark in milk oak bark chocolate of acorns Peculiarly adapted are spir. [illegible] & cornus [illegible] or [seria] (decoc in milk) [illegible] It equalizes excitement more white pine bark in milk watery urine In case of great craving as for salt provision etc. in extreme cases gratified Of mucilages are a variety for they will be worn out [typh??] latifolia sassafras bran flaxseed etc. etc. Great aversion & nausea & vomiting attending the administering of remedies will make them operate like tartar emetic, and debilitate. In such uses the gratification of the appetite will prove a stimulus especially to the mind & therefore the more powerful This is true of adults also. Case related of a patient who could retain no medicines & recovered upon bread and cheese. 28 In the latter stages acetate of lead may be given internally. The bowels are too much relaxed to admit of colic. A troublesome symptom is prolapsus ani The intestines should be immediately replaced Take the neck of a bladder or the crop of a fowl, filled with water, as the softest & best irritating thing to apply. A [illegible] cloth will irritate the sphincter & make it contract. Afterwards apply astringent washes e.g. white oak bark or the bark of any of our forest trees Cal mag ½ dr rhub 8 gr gum ar. 1 dr. wat. 1 oz pepper ol. [any] 6 drops [or] tablespoonful Vomiting It is very common in healthy children in consequence of over distention of the stomach. The child should not be allowed to nurse so long at a time Children & old people vomit with more 29 facility than the middle aged Vomiting from irritability of stomach is important feeble pulse, cold extremities must horse rad. 2 z chalk 1 z card. seeds ½ z carb pot or [illegible] [illegible] [illegible] 1 pt water tablespoon Prof Ives thinks the alkali creates an excitability. Frequently the irritation of the lower part of the bowels by an injection of salt & water, or a large bulk of warm water, or a calomel cathartic. The tepid bath & nervines are useful also Young physicians are often called on to prescribe for hydrocele in children Apply opium camphorated applications etc. In the morning apply cold water & spt. of nitre. Prof. I. has had to operate in but one case. 30 Volvulus or introsusception. Not commonly a primary disease. Prof. I. was at first very much perplexed with it, finding no satisfaction from the books. The upper is received into the lower portion Sometimes one involution is doubled in upon another 1st Involution of the small 2nd of the large intestines. It occurs in particular families of delicate constitution. Undoubtedly the bowels sometimes disengage themselves from slight degree of this involution The symptoms of the first kind are constant tendency to vomit, frequently attended with a sympathetic action of the rectum Throwing of the hands & feet paleness of countenance rolling of the head & other symptoms of extreme irritation like strong her. specks only of blood In the large intestines when a cathartic is given it passes down as far as the involution & is then thrown up 31 this act may frequently be heard Drastic cath. often are the causes hence where there is a liability to this disease do not give them In case of the small intestines being affected depend upon opium mixed with aromatics and depend upon this until the bowels restore themselves which however will be doubtful. In the second kind give all remedies by injection, apply the warm bath. By very copious injections, attempt the restoration mechanically. Case related of a young man cured by inserting a bougie of a spermaceti candle with opium at the extremity, & keep it up some time Another case cured in the same manner Sometimes the disease arises from a natural stricture of the bowels incurable 32 It may be caused by worms. Case of a worm involved in the fold of the intestine Case of a delicate school girl. Pulse low weak and small vomiting restlessness, throwing of the hands & feet. Great irritation about the urinary passage & fundament. Tongue not much affected. Deficiency of action in the liver & two or three volvula were discovered on post mort. exam. Ascaris tricocephalus was found to be the cause Cholera constipation of the bowels with fever bilious remittent fever, marasmus etc. etc. It is a common bilious fever, produced by causes affecting the bowels Symptoms pulse full, frequent, tongue furred skin hot. Bowels full and hard, urine small in quantity & high coloured, costiveness breathing laborious face flushed sometimes cough Evacuate the stomach & bowels by emesis & catharsis produced by 5, 10, or 15 gr. 33 of cal., in order to produce a strong impression upon the whole digestive canal & hance upon the system at large In enteric cases & vigorous habits a little tart. emet. may be added Repeat the cal. in 5 gr. doses every 3 or 4 hours leaves senna ½ oz manna 1 oz [pint] give senega blood root etc. if the lungs [illegible] z [seneca] [illegible] [root] may be [illegible] or 2 z [illegible] Give enemas or injections to assist the operation of the cathartics after giving the cath. time to operate The stools frequently contain flocculent portions of membrane. If the stools continue vary cath or [illegible] mag. sol. tartar phosphate of soda neutral salts to In the latter stages of the disease give blue pill instead of calomel 34 Sometimes Prof. I. has added acid to quicken the action of the mercury The fever abates in 48 hours It may continue f or weeks sometimes. The termination may be in volvulus in hydrocephalus If the disease continues for 2 or 3 month a regular remittent, the best remedy is Fowler’s solution in 2 or 3 drop doses If this produces edema & dropsical affec then give bark or Moseley’s tonic sol. beginning with about 4 drops After the inflammatory action has gone off give opium alone or combined with ipecac or antimony Blisters are useful in ass stages. They translate action to parts less essential to life & in the latter stages keep up the action of the system Use any of the irritants. If the lungs are affected apply a blister to the chest. The warm bath is useful. 35 If the head is affected apply a blister to or behind the ears Sometimes the mind is so affected that no medicine will be taken without great force. Then use tepid bath A large blister of aloes & ginger will move the bowels Frequently the derangement & revengeful disposition (according to Dr. Bush an affection of the moral faculty) that we must wait even for 24 hours or more without administering anything Great skill is in this case required to satisfy the parents If cathartics which first produce emesis are used we may be sure that the whole al. canal will be operated on We often also need a remedy more powerful than the disease just as in croup Case of a child 2 yrs. old. Pulse full & frequent tongue furred skin hot etc. After the paroxysms the opposite symptoms come on violently. The system was roused 36 by mustard to the feet & arches followed by blisters on the same parts blister on the chest ammonia in the mouth caustic ammonia in the nostrils to excite infl. Worms. This subject naturally follows that of intestinal diseases. Worms are not contained in the bowels of children under 2 mo. generally not while they suck if they are, they probably are introduced in water Worms in the int. can. are not so common as formerly. Said to be common among the aborigines owing to their crude diet. Derangement of the stomach & intestines produces all the symptoms of worms. It is undoubtedly the fact that healthy children have worms which produce no injury until the system is affected with disease. Case of a healthy child who fell from a great height coma a dose of calomel brought away 20 or 30 large worms 37 They may be injurious from their number consuming too much food 1st Tape worm (taenia) armed & unarmed. 2nd Tricocephalus (hair headed) these are the most irritating 3d Ascaris (round worm) lumbricoides, & vulgaris 4th Gordius rarely found in the human stomach Prof. I has known them coughed up from the lungs they probably came from an abscess in the liver. The gordius is sometimes found in the earth in great numbers they turn black on exposure to the air, and resemble a horse hair, hence called horsehair worm. All eruptive & even all contagious diseases have been attributed to insects. Even miasma has been explained by an Italian writer as consisting of insects vide N.Y. Rep. about the year 1815. Cancer & tooth ache have received this explanation 38 The symptoms of worms are very equivocal and coincide in general with the symp. of irrita Count. pale, flushed bloated sallow eyes dilated grinding of teeth in sleep, starting in sleep palp. of heart, pain in stomach when empty, relieved by food, urine pale coloured, or milky increased or diminished nausea, vomiting, irregular appetite, loss of appetite, costiveness Irritation about the neck of the bladder in the case of ascaris. Severe pain about small intestines & umbilicus, indicates tape worm Irritation at the rectum, indicates ascarides as do also irr. of urethra & increase of urine & milky urine Tape worm oftener affects adults than children. Sometimes it exists without the symptoms of worms. 2 quarts in a day have been brought away in a day, & yet they would return in a few days! They increase with wonderful rapidity. Case of a woman who kept passing them for months in great quantities finally diet was tried instead of medicine 39 All food was roasted or boiled even the water used for drink was boiled Cured Healthy bile or gastric fluid will destroy them. Hence an important indication. Spts of turpentine are an old remedy among the people Case of an old man who made himself drunk with half a gill or more of it. Fowler’s solutions 2 to 4 drops 3 or four times a day has cured. This is prescribed for the taenia or flukeworm [illegible] has been considered a specific Osmanda cinnam. has been given by us for this article. It is bitter astring. & sweet. Polyp. vulg. is a tonic & deob. Other forms may be used Ether, particularly in injection is good mad. [illegible] for [illegible] panada pound & half & 2 or three ounces of fresh butter if costive 1 pint of water salt & [illegible] olive oil or an injection in order to fill up the al. can. 8 or 9 hours after 3 oz [f.] m. in [illegible] 40 in water or decoc. of f.m. or [illegible] cal. & car. 12 gr. each [gamb.] 5 gr in a bolus. Oil is used to fill the respiratory holes of the tapeworm Ether had been added by French & Ger. Rue has been used. Pearl flowers. [illegible] power Amalgam of tin & mercury has been detained in the bowels. These mechanical remedies are not now used. Formerly crude mercury to the amount of a pound was frequently given as a cathartic Astringents have been used bark of milia azedarach of prunus virg. The former is given in decoction to the young negroes at the south who are much subject to worms It has much of its virtue when dry Symptoms of tape worm sense of weight (where the worm is in great quantities) irr. stom. nausea loss of app. irr. app. weak chylop. viscera bloated countenance 41 etc. All which however may arise from mere irritation of the stomach The irritation of the tricephalus amounts to derangement throwing of the hands etc. Prof. I. would prefer narcotics for this worm but cannot speak from his own experience he recommends an injection of a teaspoon or tablespoonful of ether in a gill of water or mucilage. Ether will undoubtedly pass the valves, when injected. Prof. Ives has thought that fern given in pieces operated mechanically especially [assmunda] Ascarides are said to in habit the rectum this is a mistake. They multiply abundantly & lodge in the rectum about the sphincter, as they daily pass off. Besides the irritation of the rectum they produce in the small intestines severe griping pain about the small intestines. Very troublesome to cure the best remedy 42 is injections always effectual for the time being. Relief for the time being by washing them out with injections of warm water. Aloes added will be better. The best however is camphor, as a nervine and narcotic & a poison to the worm Calomel is useful, not in destroying this worm but in restoring healthy secretions for worms will not live in healthy gastric liquor. All indigestible articles such as raw fruit, acids, cold water etc. will be injurious. Alcoholic tinctures aloes, elix. propr. or sol. tincture of hickory buds or bark in teaspoonful doses is one of the best things. To prevent the return of the worms use condiments pepper ginger etc. all warming & bitter things. In extreme cases avoid every thing which has not passed the fire. The eggs are exceedingly minute & yet each consists of numerous others probably they 43 are absorbed by the lymphatics carried into the circulation & deposited in various parts of the body especially upon the muc. memb. of the al. can. only upon the mucous parts. Dry & stimulant diet is better than cold & liquid. Some remedies act upon the worms themselves e.g. narcotics Some narcotics operate on some animals & not upon others e.g. sheep eat stramonium which poisons swine. Mechanical remedies are filings of iron & tin cut hair, & perhaps the prickly cowhage Other remedies are powerful cathartics merely others again tonics & deobstruents Ascaris lumbricoides requires no peculiar treatment Use spigelia, calomel etc. Spigelia is a narcotic it kills the worms & it may also be prescribed for the same set of symptoms where no worms are present. 44 When given to intoxicate the worms give from 2 z to ½ oz in decoction in the course of the night, accompany it with rhubarb, or follow it with calomel or any cathartic to drive the worms off while in a state of intoxication. Veratrum sabadilla is used as a narcotic Of tonics all the astringents & barks the min. acids sulp. zinc & iron etc. Cathartics the best is calomel also use the drastic, as scammony gall is good ether, asafoet. petroleum, seneca oil, barbadoes tar etc. as antispasmodics Chenopodium anthelminticum & ambrosioides are called worm seeds An essential oil is extracted from them. C. botrys or jerus. oak are useful as nervines & for the cough, but probably do little good as anthelmintics. The garlics are used (nerv.) They have considerable effect upon the intest. canal Artimisia santonica from Africa the tops of flowers, this is called wormseed It is a bitter 45 The asclepiades most of the common species as syriaca, pulchra, or [illegible] this latter is often used & has seemed to do good so A. incarnata & A. decumb. Podophyllum pelt. is used as a cathartic probably not better than others The best form is that of tincture The number of worm cases & colica is much less than formerly owing to the change in our mode of living Butternut bark decoction in tablespoonful doses is a popular remedy. It is intensely bitter The geraniums are used all the aromatics and bitters indeed which are found spontaneous Ether is used both by the mouth and by enema Butternut bark is cathartic & said to be narcotic 46 Convulsions Two kinds sympt. & idiop. Children are more subject than adults Causes all the causes of irritation Sudden suppression of evacuation. Teething irritation of excessive or indigestible food upon the nerves of the intestines. Acetous fermentation of food in the prima viae The predisp. said to be sometimes heredit. Said to be produced by change in the milk Also by agitation in the mind of the mother affecting the milk. The countenance also of the mother affects infants very much much more than is commonly supposed. So of the bystanders Treatment depends principally upon removing the exciting causes & then upon obviating effects If the cause is in the prim. viae give it first 5 or 6 of sulph. zinc or as much of ipecac. If the substance has passed into the duodenum give a cathartic, assisted 47 frequently by injection. OR use calomel as emetic & cathartic both. Enquire particularly about diet for a general answer may be false Frequently several large doses of cathartics are needed to overcome the torpor caused by excessive quantity of food Also the food diminishes the cathartic operation. Hence the French dinner pill calomel 5 to 10 jalap 1 to 3 scammony senna manna castor oil & neutral salts are the cathartics If the convulsions continue used [illegible] Calomel sometimes by irritation produces convulsions spasmodics one of the most efficient is the tepid bath. If the patient is much agitated by being put into water cover the tub with a blanket & lower the patient gradually: there is then no difficulty Potash, carb. pot. or aromatic herbs may be put in the water. Continue in from 5 min to ½ hour if exhausted to be taken out Wrap in a blanket & put in a bed keeping 48 up a uniform temperature Oil of amber was Dr Rush’s sheet anchor musk internally Articles applied the whole length of the spine as mustard, ol. origanum etc. etc. Empyreumatic oils hence soot tea is very useful It contains carbon amm. & pyrol. ac. Oil of valerian is a nervine Mineral oils as british oil petroleum etc. Ammonia is one of the best 2 to 6 drops in 1 oz water Applied also to nose & mouth & rectum Dippels an. oil owed its virt. to ammonia. It is very fetid & distilled from berries 10 to 20 drops tinct. asafoetida; or by enem. 2 z caustic potash, or the impure carbonate by injection is very valuable. So all the caustic alkalies Opium is a powerful antisp. may always be given unless contraindicated by other symptoms The frequent recurrence of spasms may be broken up by continual doses 49 of opium. IF they recur once in a few weeks give cathartics to prevent them. When called 1st inject. 2nd tepid bath with alkali in the water. 3d apply irritants as must. horserad. garlic, ginger etc. giving, even in the commencement ammonia by the nostrils. When the patient can swallow give calomel. When the stomach is overloaded, the child cannot swallow, & we wish to give an emetic, we can often succeed by irritating the throat with a feather laying the infant upon the hand & in this way supporting the abdominal muscles. Epilepsy a regular or irregular return of paroxysms of convulsions attacking suddenly falling twitching etc. followed by coma Causes in children generally diseased state of al. can. kept up by habit which last is frequently very difficult to break up 50 caused also by malformations tumors of brain malformation of brain etc. derangement of system produced before birth by syphilis from the same causes as rickets more rarely from mere irritation without some offending cause as suppressed evacuations Treatment generally the cathartic giving calomel 3 or 4 times a week If the canal is loaded with mucus conjoin 1 or 2 gr. gamboge 5 gr. scammony & 5 of jalap which yet will operate kindly though [illegible] The best evacuants are those which change the secretions If there is a deficiency of mucus an abrasion as it were give blue pill also cojoin chalk. Most cases are curable by careful management both of the physician & of the nurse Regulate the diet with great care. Generally however there is a morbid appetite & a sub derangement about eating & also about climbing & such things 51 They will be so active & artful as to be managed with great difficulty Catalepsy called still convulsions It is a tonic spasm Insensible & apparently asleep scarcely breathes sometimes a little motion of the eyes continues from a few minutes to several hours Treatment the same as in other convulsions It follows other convulsions & sometimes follows drastic cathartics. Whatever position the patient is in in that will he remain Prof. I. has had several cases Chorea Sancti Viti rarely fatal not difficult to cure under the age of puberty If it commences before & continues after that period seldom cured. The muscles are partly subject to the will. They also have involuntary motions. Caused in children often from irr. in prim. viae from 52 morbid irritability arising both from diminished & from increased action Said also to arise from infl. of the brain Indications narcotics & cathartics if arising from disease of al. can. tonics as iron, mineral acids & electricity if debility is the cause. Prof. I thinks the disease frequently runs its course & then the cure is attributed to the last used remedy. The cathartic treatment has not succeeded very well in his practice. It occurs oftenest in females of relaxed const. about the age of puberty especially if they have grown rapidly or been much confined to the needle or to study Ammonuret of copper 1 to 4 gr. was Cullens favorite remedy Case female treated with epispastics & narcotics took arnica 2 z to 1 pt boil. water doses increased till the head was affected (It is tonic & narcotic) Without benefit Next cathartics Next metallic antispasmodics 53 Next epispastics Finally recovered under bark in substance 1 oz a day. Sometimes arises from affection of the mind The presence of strangers is injurious the sensibility of the patients being very great When caused by epilepsy treat as for that disease Sometimes comes on very gradually & is not suspected causing apparently bad habits in walking etc. Case which had been coming on in this manner was brought to a high degree by dysentery & went so far as to present the peculiar symptoms of hydropohobia horror of water etc. Conium [illegible] & iron sulph. zinc sulph. copper & other metallic tonics have been principally used by Prof. I. Use various narcotics as nux vomica Use the antispasmodics as palliatives e.g. valerian asaf. musk Case in which the disease was broken up by elaterium 1/8 of a grain at a dose combined 54 with chalk. This is the only case which Prof. I. has broken up Case of a young man who had been confined as a clerk in N. York thrown into derangement & convulsions by a sight of distress on board of a packet Elaterium was given to prostrate the system & break up the habit successful. This led to its employment in chorea This disease may affect the mind causing it to run upon particular subjects especially numbers. Case of a book pedler with these odd motions & also this facility of calculation equal to Zerah Colburn. he was overtaken by Prof. I. in travelling. Zerah Colburn, though sent to Europe never improved agreeably to the predictions of Prof. I. who has seen several cases Their countenance & articulation are peculiar [memory] & judgment deficient 55 Nux vomica as a narcotic may be given in doses 1 to 2 gr. [illegible] in pill or 15 to 20 drops of alcoholic tincture Setons, issues tartar emetic ointment along the spine are used. The latter is not to be used where there is excessive irritation doing injury. Tepid bathing is seldom proper Cold bathing sometimes succeeds. Prof. I has known little success attend the employment of electricity. If the disease is not translatable it is made worse by counterirritants. Dentition of the highest importance always more or less affecting the bowels & the nervous system It affects also the glands the cell. memb. the brain the ears [illegible] in them the lungs etc. Adults are also affected Case of a young woman cutting 4 wisdom teeth who was thought to be consumptive. The period of cutting commences from the 4th to the 6th month. Some persons 56 never had but 2 incisions Children are occasionally born with teeth but the teeth sit loose in the gum without [fangs] & should be removed to prevent their being troublesome Some families are said to have no teeth their teeth being even with the gums such are very serviceable & are not subject to decay. Case of a family of this kind from Charleston Symptoms fretfulness biting slavering starting in sleep flushings of face fever hot head & cold feet diarrhoea sometimes costiveness green stools increased urine (sometimes diminished) bloating of hands feet & face contracted pupils eruptions on the skin all the symptoms of irritation the children are particularly subject o phlegomonous inflammations. Case of a child who was thought to have an aff. of brain. A tumor was found under the arm Treatment diarrhoea relieves the irritation Indications 1st divide the gums the operation 57 is not usually painful They will even bite the lancet It may be done in sleep without waking them The difficulty is to confine the child & avoid cutting its tongue. [Gum] lancets may be made with a guard. Make two incisions for the double teeth & sometimes it is necessary to divide a ligamentous band in the middle. It is an objection to cutting the teeth too early, that the scar formed by healing will be more difficult to be cut through by the teeth. This not true a scar has less vitality & is more easily broken through 2 or 3 cuttings may be necessary the symptoms continuing to return. For infl. use the antiphlogistic treatment sometimes bleed in the arm better generally to apply leeches behind the ear. Cathartics as magnesia & rhubarb conjoining aromatics & chalk where there is acidity. Equalise excitement by ipecac & antimony with or without opium 58 If a diarrhoea suddenly stops apply counterirritants to the pit of the stomach the warm bath. Avoid currents of air etc. Blisters behind the ear will be often serviceable & prevent hydrocephalus. They are sometimes applied to the arm. Use antispasmodics with or without ipec. etc. Rickets Caused by confinement too much clothing too much saccharine food etc. Generally there is an earlier mental development They do not make abler men however Hence the impression that precocious children # symptoms soft flesh paleness of countenance hectic fever, tumefact. of bowels muscles & cell subst. less joints larger head large fontanelles open veins of the head large & blue app. & dig. bad tendency to acidity The teeth are cut later Appears at about 6 months Nearly allied to scrofula in affecting the lymphatics & osseous system # will die early. They are in fact generally diseased 59 This is a disease of weak morbid action Indication strengthen the vital powers by stimulating & dry diet especially by cold bathing taking the patient out of the bed in the morning bathing & returning occasionally cal. & ipecac. general friction exercise open air mental stimulus of the open air vegetation etc. etc. This affects the secretions powerfully. Different tonics are given e.g. Fowler’s sol. sulph ferri bark (bark waist coat) Astringents & absorbents for there is frequently an acid smell Burnt bones phosphoric acid alkalies (pearlash) etc. Pearl ash is applied externally Of late iodine has been very serviceable 2 to to 4 drops alkoh. tinct. given in mucilage of gum arabic etc. The worst cases are the syphilitic these require mercurials. The deficiency of the phosphate of lime is an effect & not the cause. Hence burnt bones must have been useful as an absorbent & perhaps 60 as a tonic not as supplying the matter of bone The chylopoietic viscera are probably first affected & then the mesenteric glands & lymphatics. Avoid featherbeds etc. Sweet fern beds are very popular. They are hard & the odour corrects the acid smell of the disease. Muriate of lime & of barytis were formerly much used. Cholera infantum Appears in months of July Aug. & Sept. Sometimes in June & Oct. Approaches in various manners e.g. with a gradually increasing diarrhoea with vomiting & purging the stools being green, brown, slimy, watery, or with the smell of putrid meat a high fever may exist also great restlessness in bad cases cries of pain once in 1 or 2 hours pulse quick and weak fever remittent sometimes terminating in hydrocephalus or volvulus Eyes often languid & hollow half closed in sleep often in the latter stage preternaturally 61 There is sometimes a great degree of mental excitement bright (their eyes are half closed in various complaints) The vomiting may cease soon may alternate with the diarrhoea The disease sometimes ceases soon at others runs on for months This summer epidemic varies according to the season according to the changes in the air or the weather which affect children more than adults. The patient is carried off in convulsions or is worn out by emaciation and dies with aphthae or dies with hydroceph. volvulus & other diseases Causes bad atmosphere malaria (a general tern for miasma & [illegible]) Dentition is an exciting cause not the primary cause as some suppose. Children weaned in the spring are very apt to have cholera infantum in the summer. Children at the breast bear the disease better Hence let them be weaned in the fall 62 A disease it is of debility & has for predisposing causes bad food etc. both as remote & exciting causes It is a fever translated like dysentery from the surface to the viscera commencing at the skin & breaking up the balance of the system then attacking the mucous memb. of the intestines Indications 1st evacuate prim. viae 2nd translate action to surface & so equalize excitement 3d excite healthy secretory actions & [illegible] peristalt. action. 4 avoid causes of irritation & remove them where they exist 5 restore the tone of the system particularly of the stomach & bowels 1st Aromatics ess. peppermint counter irr. to stom. & bowels as must. horseradish injections of starch & laudanum & tepid bath must be used in case of vomiting, or attack like cholera of adults When there is a diarrhoea at the attack evacuate with deobstruent cathartics & ipecac. Give calomel & ipecac first giving 6 gr. cal. 63 Small doses of calomel will not answer instead of full doses & ipecac about an hour afterwards ipecac The southern physicians do not use cathartics so much depending upon stimulating injections e.g. of salt and water They give smaller doses of calomel This practice does not answer so well here # In case of small watery stools we have often reason to suspect that the bowels are constricted & confine a large quantity of fecal matter in this case give opium & then follow with cathartics which will often bring away a large quantity of faeces 2d by emetics & by small doses of ipecac with opium repeated also small doses of mercurials cal. qualified with chalk or blue pill (antimonials where there is much arterial action) by fomentations sinapisms blisters to the bowels burdock leaves etc. warm bath which used at night frequently gives a quiet night’s rest this is not to be used however in case of great exhaustion # The French expectant treatment adopted in Philadelphia will frequently be entirely inefficient 64 3d by small doses of mercurials & ipecac with opium Ipecac deserves the name of a specific if any remedy ever deserves this appellation. Still a man very successful with one remedy only may be compared to one very skillful & successful with a penknife About 4 gr. ipecac 4 drops tinct. opii 12 teasp. wat. about every 4th or 5th hour for a child 4 months old keeping the bowels open with mercurials blue pill producing an evacuation once or twice in 24 hours. Double the quantity for a child a year old in the same quantity of water. The quantity of opium must be greater when the child has been [illegible] the habit of taking it. Injections of laudanum & starch 1 tablespoonfuls of flour & 5 10, 15 or 20 drops of laudanum to stop diarrhoea at the same time applying to the abdomen 65 cloths dipped in brandy An eruption of strophilus [albidus] sometimes makes its appearance about the chest particularly in the latter stages 4th indication by dividing the gums if necessary regulating the diet the milk of a nurse is best the operation of sucking is soothing and gratifying operating as a nervine give arrowroot with a little brandy or wine as a condiment or tapioca roasted flour etc. If in the last stages the child craves any particular food, as salt fish or salt meat, it should be gratified Disgust exciting nausea will debilitate. Frequently we can succeed by a different mode of administering medicine the sight of a spoon for instance exciting nausea. A tumbler of wine whey with a teaspoonful of aquae ammonia will often be beneficial to fill the stomach & dilute its contents 66 Correct fetor in stools with charcoal Injections of carbonic acid are used with the same intention. Effervescing mixture may be drunk they are often very grateful Injections of soap suds are recommended to allay irritation. Dr Dewees recommends an injection of 3 teaspoonfuls of salt to a gill of water & also magnesia & rhubarb. 5. In the latter stages give tonics and astringents Prof. I prefers cornus circum. Use also spir. toment. in decoction or extract also geran. mac. which may be given in wine & then we have red wine Often it wil be advisable to support the abdomen with a bandage also with plasters e.g. one of soap & opium A most powerful remedy is change of air It is continually recommended by the Philadelphia & New York physician. Case of a child in articulo mortis apparently 67 brightened up upon being carried in a hack to the top of ah ill where it had a view of the sound etc. It had got beyond the reach of medicine & food While upon the hill it too food returned & recovered The case seems to be the direct opposite of nostalgia there being a sickness of home a despondency caused by the sight of the same domestic objects Erigeron can. is used it is pungent acrid bitter & stimulating & hence affects the kidneys as a diuretic. It seems to do goo in the latter stages of diarrhoea & dysentery It is called strangury weed. It has been long used Vide Barton N.Y. Physico Med. Trans. etc. The other species are also used give it in decoction White vitriol & alum are used as tonics and in doses of 6 to 8 drops as an anti emetic The various species of viburnum are 68 All the [???t? tillas] are astr. so [illegible] [illegible] root etc. used in this disease, as astringents Statica limonium is not so agreeable but frequently more efficacious boiled, sweetened & a little wine or brandy added. It has a taste of salt mud. It is used also as a wash in case of aphthae In the latter stages of the diarrhoea give mucilages made of any of the various articles in use The white pine bark will furnish a valuable mucilage from its being combined with a terebinthinate principle. Post mortem examinations show the seat of the disease to be the muc. mem. of the intestines. The liver is enlarged Scald head or porrigo or tinea capiti A local disease, yet affected by diet. Sometimes commences with scaly eruptions. I have the head & apply a bladder to exclude the air is about 69 the best treatment. Wash clean at all events tar oint. 4 oz. tar. ½ oz. was 1 oz sulph 1 oz sulphur melt & mix Sulphuret of potash has removed the disease in a few days Yeast poultice is efficacious let the head be first shaved. Different dock roots all the species have about the same properties. Apply externally & give internally it is acrid etc. Syrup of buckthorn is recommended as a cathartic. The practice is quite empirical in this complaint. Sulph. pot. is given internally also its solution resembles mineral spring water Mercurials should be used & pay particular attention to diet Asclepius tuberosa expect. diaph. & laxative is a valuable substitute for ipec. to equalize excitement etc. When the tepid bath is used keep a supply of hot & of cold water by in order to keep up a proper temperature 70 Catarrhal epidemic severe hoarse cough differing from coup in the quantity of mucus thrown off extremities cold head hot much febrile action By vomiting great quantities of mucus are thrown up & yet the patient will seem to be suffocating Confined to the lungs, & aesophagus No disease affects the bowels less than this. The stools are healthy Indications Cure the patient immediately by powerful remedies unless the system is too much affected to bear them. This is a general principle, viz. that of breaking up a disease before it has thoroughly attacked the system by means of a strong orgasm Tartar emetic at the commencement to break up after the violence of the disease has been overcome apply a blister to the chest to translate to the surface. Evacuate the bowels also & palliate & relieve the disease by small doses of tart. em. or with camphor & opium to create perspiration or by the 71 tepid bath keeping the patient in ½ an hour or covering patient & nurse both with a blanket, to keep in the steam & cause it to be respired also Sometimes vomiting must be excited by mechanical means. Do not depend upon palliating symptoms merely Hooping cough said to be contagious rarely attacks the second time, but sometimes does. Pres. Dwight had it a second time at 60 yrs of age It appears as an epidemic thought to arise form specific contagious 10 vol. Med. Trans. an account of its breaking out in Block Island without previous intercourse with the main land. Commences with precisely the same symptoms as ordinary catarrh. The peculiar symp. 3 or 4 week Several frequent expirations are made which exhaust the lungs then a 72 stricture takes place which causes a hoarse shrill wheezing during inspiration. The same sound is heard in croup during expiration A spasmodic stricture sometimes takes place in adults which produces the same sound Such patients should not try to breathe. These fits of coughing continue until mucus is thrown up But the mucus is not the cause of the coughing, which arises from irritated action. Continues from 1 to 6 months. During a paroxysm, haemorrage from mouth & nose may come on or convulsions & apoplexy may ensue Case in which an emetic caused convulsions which carried off the child. Most troublesome during the night Duration of paroxysms depends upon the facility with which the mucus is thrown off. Sometimes respiration 73 is laborious between the paroxysms Rarely fatal after 2 yrs. It may terminate in hectic or in marasmus in infl. of the lungs in visceral obstructions of liver, lymphatics etc. It produces a determination to the head Treat the fever, if any, according to diathesis Treatment In vigorous const. & when mild little need be done When there is considerable infl. give ant. & nitre keeping the bow. open in worse cases bleed cup & scarify Sometimes mercurial cath. sometimes cast. ol. etc. It is better however to accomplish this end by diet. Respiration may be promoted by blisters on the sternum Instead of [blist] [illegible] may use 1 oz mild tinct canth. 1 z tart ant. applied with a cloth until vesication comes on then dress with simple cerate Antimony may be combined with opium Godfrey’s cordial made of molasses & water 74 with a little laudanum & ol. anise this was very popular. Use diluents. If there Is danger of convulsions from vomiting give blood root & other such things. In some constitutions antimony produces peculiar symptoms e.g. severe spasmodic stricture, which if it comes on should be relieved by diluents & small doses of opium. In very young children it is difficult to get down much medicine the stomach becoming irritable In the latter stages use 5 or 6 grains of sulphate zinc with as much of ipecac instead of antimony Where this much viscid secretion an emetic of squills may be used or we may use the [illegible] seneca root bruised & squills each ½ pound water 8 pds boil & evap. to ½ strain & add 4 pts honey & boil again to 6 pts to every oz add 1 gr. tart. ant. dose 8 or 10 drops child 4 mo. old, every 15 m. This is called Hives syrup 75 Dried leaves in 1 gr. doses, in milk, of atropa bell. or 1/6 of a grain of the root has been used in Germany Objection that this disease has a tendency to run its course, is no good reason for not curing it. It has been prescribed for more empirically than any other proof of the difficulty of curing it El. par. 1 oz ant. vix. ½ oz 3 z glyc. ext. powd. g. at. 2 oz wat. 6 oz. triturate & boil dose ½ teaspoonful to a table spoonful This is called the Brown mixture It may be varied by using ipecac etc. 2d Antispasm. & tonics & narcotics are used in the latter stages e.g. sulph. zinc & copper & tinct. canth musk, fetid gum, petroleum etc. belladonna, hyoscyamus, opium artificial musk or oxygenated ol. amber Nitric 76 acid 3 ½ z ol. [illegible] 1 z place in the sun in tinct 1 z to pt. alc. dose 10 dr to a teasp. or 1 z to 1 oz ether dose few (2 or 3) drops upon sugar. It was very celebrated & afterwards was thought to be ill made The truth was the diathesis had changed. Copal gum, oxygenated by distillation, will be the same substance. Copal is probably the same with amber Case of a vein of olibanum or frankincence in S. America Opium should be qualified & determined to the skin by ant. & ipecac. Hyoscyamus is bitter, having no tendency to produce costiveness zi pearl ash with cochineal to colour it to pt. water 8s a popular remedy & useful The whole effect is owing to the pearl ash which is antispasmodic cochineal has no apparent virtues. Pearl ash is not only antacid but produces a peculiar 77 excitement upon the stomach & aesophagus making them susceptible to other articles Conium maculation has been much used A more commanding remedy is stramonium 1/10 gr. to 2 gr. of extract or seed for a dose. It counteracts that irritability which gives a tendency to convulsions Sulph. zinc has been most used as a tonic by Prof. I. either dissolved or in the form of Moseley’s tonic solution Sulph copper possesses about the same properties The compd vitriolic tinct. of sul. cop. & kino 10 to 30 drops is pleasant & has been much used. Flowers of zinc & also bismuth have been used. So also per. bark. Bark, canth. & sul. cop. in combination are recommended by Chalmers of S. Ca. Cantharides are indicated where the 78 system is relaxed & too low for inflammatory action in order to excite a healthy infl. action Something may be done by rubbing the spine with the stim. oils e.g. ol. caps. or orig. etc. or with [illegible] of ammonia to excite the nerves & spinal marrow in the latter stages. Change of scene, of air, riding etc. should be resorted to in bad cases to tranquillize & stimulate the patient. Sometimes the little patients will be in a constant tease & worry; until this is done. In the worst of such cases medicine does little good Even the irritation of administering the medicine may counteract the beneficial effects of the medicine. Prof. I. thinks a relaxation of the ventricles of the heart & of the sinuses of the head takes place owing to the violence of the cough Indicated 79 by resp. high count. bloated lips swollen & by a soft flowering & almost intermitting pulse In such cases give blood root 5 to 10 gr. in water alone or qualified Lead (acetate), also iodine, have been recommended. One year, the hoop. cough prevailed extensively in the spring but was Prussic ac. & arsenic occasionally cut the hoop. cough, short entirely The former is dangerous from want of uniformity of strength Fowler’s sol. is safe but does not answer so well in the first stages. It may leave the patient livid weak with swollen lips etc. which is to be cured by bark & other tonics 80 Gangrene in the mouth 81 Chilblains Exposure to extreme cold without freezing 82 Mesenteric fever tumefaction & pain of the bowels (distress rather than sharp pain) indigestion costiveness, loss of app. or [irreg.] app. Countenance pale except when flushed with fever sometimes a consequence of other fevers oftenest in scrofulous habits most common among the poor. It may become chronic. Indurated lump in the mesenteric glands Indications Act upon the bowels keeping up a peristaltic action evacuating the bow. changing the secretions & removing the obstructions of the lymphatic system. Give blue pill or calomel & chalk. In chronic cases friction once or twice a day will be beneficial Pill 4 parts blue pill 1 part ipecac or ½ part ipecac. Or 1 gr. ipecac in pill with a small quantity of opium Or tinct. rhubarb with aromatics & alkaline salts Burnt sponge is recommended perhaps it would be better to give iodine at once 83 in definite quantities Still the composition of articles existing in burnt sponge may be better [illegible] nodosus & vesiculosus (rockweed) are used Even the neutral salts with tonics have been useful Even as of camomile tea will relieve a paroxysm of pain Articles containing carbonic acid in a free state, sometimes with aromatics as ginger or spice, will be grateful and also useful From tinct muriate of iron martial flowers of iron or alkaline solution are used as tonics but iron is apt to irritate. Cold bath will invigorate the system Injections of mercury have been proposed Tepid bath will cleanse the skin etc. Muriate of lime with small doses of cal. or blue pill may be useful, but 84 is now generally superseded by iodine dissolve carb. lime in muriatic acid & give from 5 to 50 drops in water beginning with small doses, in case it may offend the stomach. Muriate of barytes might be used. Carb. barytes is used dose from 2 to 3 gr it being a powerful article The flesh brush thoroughly applied has a powerful effect A plaster of opium & diachylon or soap plaster, with an equal quantity of opium, applied to the abdomen has been very beneficial where opium did not agree. Or we may use 2 parts opium to 1 plaster. Diet dry toasted bread broiled meat use condiments farinaceous substances & sometimes the broth of lean meat Avoiding raw fruits potatoes corned beef etc. Take care 85 with wine Use farinaceous veg. well boiled not to interrupt digestion by distending the stomach with liquids The terebinthinates will benefit the mucous membrane of the ac. canal. The bests article is decoction of white pine bark which will be much milder than any preparation than any of the turpentine of the shops This disease may terminate in a peculiar hectic sometimes it commences with very considerable fever S. Cutting the fraenum. Very seldom practised now formerly thought to be almost always necessary. Complaints would be made that the child could not nurse on account of its being tongue tied. In such cases it was Dr Munson’s practice to apply the back of the knife, & thereby give very great satisfaction 86 Burns & scalds 87 Tympanitic abdomen a symptom in various diseases 88 Neuralgic affection of the lower limbs 1 Surgery Lecture 1st External injuries 1st Extensive injuries first produce a shock upon the system e.g. contusion upon the abdomen & frequently when a limb is carried off by a cannon ball the haemorrhage is slight & the patient dies of the shock Great difference in patients as to susceptibility of constitution. In the army it has hence been the custom to operate on some immediately and administer cordials & consolation to others State of the mind e.g. wounds after a defeat or after a victory. State of habit porter & gin drinkers in Soudan & debauchers in high life bad subjects The subsequent inflammation however is not in a direct proportion to the shock 2 1st of such injuries as prostrate the system beyond the point of reaction Coldness of surface faintness & prostration immediately follow large gun shot wounds The same effects follow the slight injury of important points e.g. punctures of the joints etc. These effects are through the medium of the nervous system The common people remark that extensive injuries of strike into the stomach This is merely part of the constitutional aff. Case of violent vomiting in a blacksmith whose eye was penetrated by a scale of iron & yet the eye recovered without difficulty Affected distress may be detected by the state of the pulse or respiration the ease with which the attention may be diverted. Sometimes die of the mortal inquietude even without internal haemorrhage Frequently difficult to test with respect to the propriety of amputation A navy 3 surgeon it has been said would probably have amputated Mr. [Huskisson’s] shattered thigh the constitutional irritation will be less after the operation The intellectual functions are suspended blindness sometimes continues for hours The food is not digested & the peristaltic motion suspended. Vomiting frequently favorable as marking a return of vital function. Case of a gentleman in a profound stupor from a fall from a horse no injury could be discovered Complaint of pain generally a favorable symptom particularly if an external part Infants frequently vomit etc. severely with paleness etc. & yet recover after a few hours sleep 1st indication restore warmth to the surface by frictions & the warm bath frictions should be dry, for moist cloths produce evaporation 4 warm blankets & may be applied especially by passing warm substances up & down the back 2nd indication restore the action of the pulse by brandy once an hour peppermint opium etc. [Discontinue] stimulants when reaction comes on as it may be excessive. 3d moderate pain & 4th const. irr. relieve pain by opium except (in Hubbard’s practice in cases of the head) One of the first things to be done is frequently to bleed which will be followed by a rise of the pulse It is a common practice in some places is to send immediately for a bleeder, who however in cases of a great shock is unable to obtain blood until after a surgeon has roused the vital powers Injections may be used. H. prefers among cathartics the mercurial in order to restore the peristaltic action These will answer the 4th indication also 5 We must be careful to examine for local injuries for frequently in cases of extreme prostration they are first mentioned by the patient after the return of consciousness Case of a man who was first unconscious next complained of his head after some hours of his knee & while he was recovering it was discovered that the orbit of the eye had splinters of pine in the flesh. Great caution frequently necessary in removing the sufferer for simple fractures are liable to be made compound. Cold is injurious The viscera are sometimes fractured in falls from great heights e.g. the liver Suppuration of the liver sometimes follows an external injury after a long interval The injury of a fall not necessarily proportioned the height. 8 or 10 drops of laudanum in gruel or starch by injection relied upon in Paris for the cure of traumatic delirium 6 apparently a trifling remedy recommended for trial relied upon implicitly by the French Mr. Travers is the only author who has treated regularly upon the subject of external injuries Inflammation Characterized by heat, pain, redness, tumefaction & soreness. When considerable or affecting important parts, it is [altered] with fever of constitutional irritation. This is different from the local fever which is called symptomatic. The pain usually precedes the heat & tumefaction The causes may be external or such as effect the system primarily. First of such as are caused by external injury or phlegmonous inflammation called also health inflammation This manner in which injury produces inflammation is not well understood 7 Phlegmonous infl. is characterised by a central spot & a circular outline Hunter speaks of healthy infl. considering it as a process set up by nature to accomplish a cure & believed that new vessels are formed An injury is generally followed by pain, which does not arise from inflammation for this has not yet come on, but from the separation of the parts. Great pain is produced by effused fluid as in sprains. After an injury there is pain etc. also there is a sense of distention & the action of the arteries in the neighborhood of the part is increased This extends to the whole arterial system, producing increased frequently fulness and even hardness of the pulse. The pain is caused by the nerves being affected. Mention should have been made of the cold stage which precedes extensive inflammation the cause of which seems to be unknown 8 Professor H. thinks fevers essentially different from inflammations, in opposition to the French physiologists. He thinks that at least at the commencement of infl. there is increased action of the vessels The pulse varies according to the part inflamed (vide below) Local causes of infl. may be heat, cold, mineral acids, acrid substances etc. the various sorts of external injuries Constitutional causes are fevers and various anomalous affections of the const. Prognosis Very violent inflammations are danger so also very extensive ones as burns. Infl. of important parts in the viscera is dangerous. In inf. of the bowels the pulse is quick small & tense & hard of the heart full The terminations are resolution suppuration adhesion & gangrene. Adhesive infl takes place in serous membranes & wounds that heal by the first intention Suppuration takes place when wounds 9 do not heal by the first intentions boils etc. Gangrene follows violent infl. which do not suppurate. It is the death of the part 1st indication is to remove the cause as splinters & in case of dislocation As much should be done by local remedies as possible. Reduce the temperature by cold or tepid lotions (according to the sensations of the patient) sometimes fomentations or poultices give more relief than any other mode of applying warmth especially in pelvic infl. & by the French in thoracic. The warm bath is frequently useful especially to children. In case of fomentations permanent moisture should be kept up. Warm applications may be made to reduce the heat of the part by evaporation if not too warm. The same thing may be accomplished by spirit. Acetate of lead sulphate of zinc vinegar and cold water 10 are used Perhaps the latter is generally as good as any of the patient will be satisfied with it. Narcotics sometimes are used externally but their utility is doubtful. Blisters are used especially in infl. of the joints & deep seated parts in general The first general remedy and the most powerful is bleeding it would seem to be one of the best arguments for it that those of opposites [illegible] recommend it viz. those who believe action to be increased & those who believe it to be diminished Of course not always necessary, as in trifling cases, & delicate habits, No rules can be given as to the extent to which it may be carried. The modes are venesection [arteriotones] leeches & cupping Venesection is the most common and most convenient. In children the veins of the hand or foot or the external jugular may be more convenient than those of the arm It is a good rule to draw blood until pain is relieved or faintness is produced provided the patient is in an erect position 11 There is no doubt of the propriety of taking a large amount of blood at once rather than by several small bleedings. The buffy coat not to be relied on Prof. H. thinks the heat of the extracted blood of more consequence Blood letting has been objected to in case of old persons. Prof. H. has often practised it with advantages. So of delicate constitutions if the patient is kept in a horizontal posture Arteriotomy from the temporal artery has apparently no advantages over venesection Prof. H. sees no advantage in the use of leeches in preference to venesection except in chronic inflammation Cupping seems to combine the advantages of depletion and counterirritation & is highly spoken of. Prof. H. has not used it much Cathartics are used next. also antimonials especially in the Italian way of beginning with small doses frequently repeated until the quantity which may be taken without nausea is very great 12 Narcotics are used for the same purpose Soreness is relieved by quiet etc. Pain may be diminished by elevating the part. Diet should be antiphlogistic, but generally the patient has not much appetite. Great difference is produced by the constitution and habits of the patient e.g. intemperate patients will not bear some things N.B. they do not bear bleeding well Frequently cordials and tonics are useful at the close of the cure. The best work on inflammation is Thompson on inflammation. Erysipelas an inflammation of the skin sometimes extending to the cellular membrane Distinguished by leaving a white spot after pressure by the finger & by being terminated by a definite [line] It has a tendency to spread sometimes leaving one part & spreading to another. Occasionally affecting various parts at the same time 13 When caused by a wound it frequently affects distant instead of adjacent parts colour dark & yellowish little swelling leathery feel. More yellowness towards the decline of the disease. This disease is liable to affect the mucous memb. of the mouth, & is said to affect int. parts It is accompanied with chills fever etc. & in erysip. of the head with delirium Sometimes the fever precedes. The fever is also followed by a bitter taste in the mouth Case of an old woman attacked with feverish symptoms, which, as was expected were soon followed by erysipelas. Various divisions have been made as phlegmonous bilious etc. Prof. H. divides into that affecting the skin & that extending to the cell. mem. 1st of the skin. it terminates by scales & affects the young It however may term. by sup. & also affects all ages The second is attended with more tumefaction & terminates in sloughing suppuration & in gangrene. It sometimes extends to the fascia & tendons so that they will slough. This kind of erysipelas 14 is oftenest met with with in old and intemperate persons as in cases of chronic sore leg Erysipelas is distinguished from phlegmonic infl. by the latter having a central spot its circumference being less defined, & its pus collected into a central cavity The nervous irritation of erysipelas is greater producing delirium etc. The heart & arteries are more irritated producing a sharp and quick pulse which is very weak when the infl. tends to gangrene. The al. can. is generally affected, producing sometimes dysenteric symptoms. The exciting causes are wounds contusions irritations of the skin by acrid substances by alterations of temperature etc. 15 The predisposing cause is in the constitution & is unknown from the yellowness of the skin some have ascribed it to the liver We know not why some wounds should be followed by phlegmonous & some by erysipelatous inflammation except that at the time the patient was not in good health. This may be caused by malaria, the bad air of hospitals etc. Case of Pomfret when the meadows were drained. From its prevailing in hospitals some have thought it contagious This not probable Though depending upon the state of constitution, yet the extent of the constitutional is proportioned that of the local affection. It sometimes seems to alternate with other diseases 16 Prognosis varies according to the age & habits of the patient & the extent of the infl. The most dangerous cases are those of the head which are frequently attended with delirium & coma. Coma is however a common symptom in ole people Indications 1st to promote a resolution 1st by topical 2nd by general remedies Some are opposed to topical application Prof. H. finds no danger in them. The best Is acetate of lead. Cold water, milk & water Also 2 dr. mur. amm. in a gill of water or corros. sublimate 10 or [illegible] sometimes a drachm of opium to a pint of water or of the solution of acetate of lead Mercurial ointments are best in the decline of the disease The lard by itself is good especially when the [branny] scales are abundant. To this is ascribed by come all the benefit of the mercurial ointment. One of the most common applications is dry wheat flour. Yet it is one of the worst 17 2nd General remedies. They should be always used to prevent the affection from being driven in & then returning 1st venesection Strongly urged & strongly opposed Prof. H. approves of it in case of strong constitutional affection but not when there is extensive suppuration & when the pulse is weak & small 2nd purgatives they have been universally used. The indication has by many been drawn from the yellowness etc. The mercurial cathartics are best Calomel may be combined with a little opium in case of great irritation Neutral salts sulphur & magnesia have been recommended Antimonials are much used, especially in the Italian mode of beginning’ with say 1/6 gr. & doubling the dose (of tartar em.) until even 4 gr. are given 3d Tonics their use is strongly urged upon the supposition of erys. being 18 an atonic disease In cases of malaria and gangrenous tendency bark is undoubtedly proper. Opium & Dovers powder are proper in one of great irritation & opium is given by some as a stimulant. The most common preventive remedy among the people is neutral salts. They generally do much injury. Even low diet is generally injurious when practised with this view Infants are frequently affected with this disease. Sometimes their pudenda are badly affected with it Treatment calomel internally acetate of lead externally etc. A new remedy is nitrate of silver externally applied by moistening & touching. Prof. H. has tried this and found it useful but not deserving so very high commendation as it has received Prof. H has found blisters very as have Dr. Rush & others 19 especially in violent cases & in those which affect the cell. mem. An old mode has been lately revived viz that of making long & deep incisions even to the extent of 6 or 9 inches. This is efficacious in violent cases especially when suppuration is suspected. This disease requires great care and attention. Sometimes the disease may without our knowledge attack another part hence the old patients affected with stupor & infants should be examined every day Abscesses When phlegmonous infl. does not terminate by resolution it does by suppuration. So of erysipelatous. The signs of suppuration are diminution of the pain & chills (the patient will say he has caught cold) in external phlegm. infl. a softness will be felt. This will increase & frequently be surrounded by a hard rim sometimes there is a sharp [illegible] or [illegible] pain Pus is discovered by its fluctuation. We must press 20 alternately with the fingers or better with the the thumbs. IN muscular parts we may be deceived by the fluctuation of the muscles under the fascia, if we press transversely. We nay be deceived by fungous tumours Tumours of the viscera are apt to be mistaken for a collection of pus Great mischief is done by opening fungous tumours. In a gland suppuration never takes place until after the skin has adhered to the gland. Prof H. know of no remedies for promoting suppuration but poultices & similar applications. On pus. It is a secretion. A French surgeon maintains that it is secreted by a membrane lining the internal surface of the abscess. (Delbecke) It is of very little consequence of what poultices are made. Fomentations, as by wringing out woollen cloths dipped in hot water & then applying them to the part. Venesection & evacuant remedies are contraindicated. The bowels should be 21 kept free. Tonics are not generally needed Opium may sometimes be used according to circumstances. Prof’s Smith & Hubbard approved of opening abscesses immediately & not waiting for them to burst In erysipelatous infl. the pus is diffused & not in a cavity of a circular form Abscesses tend towards the surface unless prevented by strong fasciae etc. The opening need not be very large but should allow of a free passage to the pus There are inflammations of the cellular membrane where there is no erysipelas of the skin. The inflamed part is hard & is sometimes very extensive The constitutional symptoms are very severe & resemble those of erysipelas The suppuration has a peculiar [illegible] irregular feel. [illegible] this kid very dangerous generally arising in bad habits Indications moderate the const. affect. by calomel opium etc. The best external 22 remedy is blistering extensively afterwards using external lotions etc. This kind of inflammation frequently follows wounds of dissection Case of a man who lay down under a haystack & fell asleep. Infl. in the thigh, leg, shoulder & knees confined to the cellular membrane & yielding quarts & pints of matter when opened finally recovered. Another upon whom numerous similar abscesses were opened on succession finally there was an effusion in the thorax & the man died. The two last kinds of inf. & much more dangerous than phlegmonous. Frequently they arise from a very slight cause as a scratch in the old & intemperate. In the latter, delirium tremens is frequently caused by such inflammations. Prof. H. does not open with caustic He does not call the furunculus a proper phlegmonic inflam. The core of a boil is a dead portion of 23 cell memb. There are no better remedies than poultices etc. After opening an abscess we may use pressure to expel the matter but too great violence must not be used. Then a plug of lint may sometimes be advantageously introduced & finally the sides of the abscess should be brought together by a bandage if possible Frequently by a skilfull application of bandages around the opening, pus may be expelled which could not otherwise be obtained When it is wished to make a second opening into an abscess near the first, instead of lifting up the skin upon a probe & then cutting down to the probe, it is better to close up the first opening & suffer the pus to accumulate so as to cause a protrusion an incision may then be made with ease 24 Anthrax Begins with a small pimple a vesicle filled with lymph. The burning heat and pain very great. The const. irr. very great. The redness is of a darker colour than in the furunculus There is an areola somewhat resembling that of [illegible] pox. This will be surrounded with small pimples, which become small holes filled with a yellow matter The swelling extends & with it the holes Sometimes a considerable portion of skin sloughs off Eventually a considerable portion of cell. memb. sloughs off with a copious discharge of pus & the patient recovers In fatal cases extensive gangrene takes place without suppuration. Sometimes before the cure large portions of cell memb. (rotten) may be extracted with the [illegible]. Const. aff. very great tongue white & eventually yellow 25 When the anthrax is near the head delirium & coma are produced The infl. seems to be more erysipelatous than phlegmonous. Some persons of broken const. are liable to be [illegible] Prognosis depends 1st on the situation & extent of the anthrax Apt to be fatal if on the head face & neck especially if nothing but serum is discharged. If upon the limbs & back with suppuration they are there it is dangerous 2nd the const. sympt. Violent pain severe fever old age & intemperance especially the latter are bad symptoms One of the best local applications is an extensive blister plaster followed by cerate & if there is much heat & inflammation apply over the cerate ac. plumbi or in bad cases, emollient poultices The sooner the pus is formed and discharged the better. It relieves the irrit. 26 Frequently pus may be felt through the sloughing skin. Caustics are used by some but Prof. H. prefers blistering & if the first application does not relieve the pain & irritation apply a second. Frequently a slight incision is necessary to evacuate the pus Const. remedies 1st Venes. in rigorous habits, and early in the disease Mercurial purges are always proper unless there is great exhaustion Opium when there is great irritation and towards the close when the patient is weak give bark. Give dov. powd. at first & afterwards opium alone. Farther remarks on abscesses. Sometimes after opening an abscess lunar caustic or a solution of cor. sub. must be introduced to promote the healing of the sides of the abscess Sometimes the pus is collected in the bursae mucosae, as on the olecranon 27 process. The thumb the knees. The serous membranes of the bursae are liable to inflammation followed by a rapid collection of pus, & violent const. irr. It is especially important to open abscess of this kind, near the joints. Acute inflammation of the joints sometimes occurs, essentially different from chronic infl. It occurs oftenest in the hip Sometimes it is fatal in a few days Caused occasionally by injuries. The mode of cure is to cut boldly into the joint, to save life. The female mammae are especially liable to abscesses. Sore breasts & broken breasts are not all the same disease 1st superficial phlegmonic abscess. There is infl. of the gland The skin adheres. Venesection purging & antimony may be used. Tartar emetic has been lately recommended very strongly The usual external remedies may be used 28 It is decidedly advisable to open these abscesses though there is a prejudice against the practice. Erysipelas of the breasts is common & treated as other erys. infl. Infl. in the bur. muc. which lies between the mammary gland & the pectoral muscles Sometimes the pus makes its way out between the two breasts. We must open with an abscess lancet & then promote the healing by injections of cor. sub. etc. If this fails, introduce a seton of several threads & extract one thread at a time (vide Dorsey) Chronic inflammation. Sometimes a sequel of acute infl. That which follow acute phlegmonous infl. will be circumscribed It will not be of the skin but of the cell memb. Glandular parts are those which generally run into chronic infl. e.g. testis mammary glands the lymphatics (scrofula) These last are frequently subjects of surgical treatment, they are occasionally 29 inflamed from wounds The joints are peculiarly liable to it. The constitutional symptoms are less severe, resembling hectic generally without sweat & chills. The tongue is commonly coated sometimes [illegible] appetite capricious emaciation restlessness Coagulable infl. is effused & causes rigidity & tumefact. Indications, lessen the action of the vessels & promote absorption Bleeding must be practised with caution. Cupping & leeches are most commonly used. Prof. H. has found occasional bleeding serviceable promoting absorption. Cathartics must be used moderately The mercurial most valuable & the stimulant as aloes Narcotics, opium, hyoscyamus conium to allay irritation. Frequently the mineral acids as tonics Iron & arsenic & other mineral tonics seem 30 to cease irritation Iodine is used. Blistering is the best local application Case of its application to infl. mammary Tartar em ointment setons moxa compression is valuable when practicable, especially in infl. of cell. mem. It may be alternated with blisters mur. amm. etc. If the limbs are inflamed, exercise is useful Stimulating liniments, opodeldoc etc. are applied Chronic abscess. One which has either not been preceded by violent symptoms or in which they have [illegible] off. The patients account will often be that at some previous time he had a fever etc. followed by a swelling The fever did not leave him well etc. Sometimes the chronic abscess will be found in a different part [from] that in which the pain was formerly felt. 31 Prof H. has never known a fair case of perfect absorption of pus Though the evacuations may have taken place only after years of continuance. The prognosis is difficult The French open by caustic. Prof H. has not tried it. Lumbar abscess, as an example of chronic abscesses in general. Arises from scrofula, from injury or from no apparent cause The lameness at first often is ascribed to rheumatism The patient bends forward & towards the part affected. A soreness may be felt Finally a collection & a tumour pointing to the top of the thigh or even down the leg The pus is contained in the bur. muc. which protrudes under [illegible] lig. This may be mistaken for hernia & even for aneurism of ext iliac. It sometimes bursts in the groin 32 By proper examination in a standing posture the fluctuation may be discovered. Open by placing the pat. on his side, making pressure & inserting an abscess lancet making the orifice of the cyst as large as that of the skin by a turn of the point of the lancet. The pus discharges better in a [standing] posture of the patient when the tumour points downwards. When the pus is all out apply a compressing bandage & heal the orifice by the first intention. Afterwards open the abscess again & so continue. Keep the bandage on to diminish the secretion of pus After three or four openings, the orifice will generally ulcerate, if the abscess is not healed Sometimes a seton must be used This practice is a great improvement of Abernethy’s. Various remedies were formerly tried to promote the absorption of pus. Prof. H. has never known the cure. Sudden deaths arise from unopened chronic 33 as well as acute abscesses. After great operations, abscesses of the lung frequently come on Hectic fever following the permanent opening of chronic lumbar abscesses Chills, heat feebleness, irritation soreness confinement to the bed nausea vomiting loss of appetite. This is frequently mistaken for a new disease John Hunter was the first to deny the doctrine that hectic fever is produced by the absorption of pus. James Rose’s son 13 or 14 yrs. of age Injured his back by lifting. Became lame, was treated for rheumatism. Became more lame, emaciation & sallowness Prof. H. found a coll. of pus extending half way down the thigh. By Abernethy’s mode, about 3 pts of pus came out. The attending physician did not pursue the same mode but kept the orifice open. Hectic fever confinement to bed 34 died miserably in about a year. Instead of being better, they may find themselves worse immediately after the opening Oxygen has been supposed to be the cause. Cold air likewise has been brought [illegible] 10 gr. corr. sub. to 1 pt. water is the best injection when a lumb. abscess remains open. If no benefit results after a few weeks it must be abandoned. Limewater has been recommended as an injection. Calomel is the best treatment for the symptomatic fever, except when the patient is exhausted Irritation may be relieved by Dov. powder, quietness etc. The cavity should be carefully cleaned out every day Slight ptyalism may follow the corr. sub. Prof. Smith was in the habit of using this injection immediately after opening Prognosis Some have ascribed lumb. abs. to an aff. of vertebrae Very probably this affection of the vertebrae may be an affect instead of a 35 cause Small chronic (as scrofulous) abscesses may be treated like acute abscesses In scrofula the abscesses will not be regular & round like phlegmon They should be opened as soon a pus is formed In abscesses of this kind granulations are frequently found which must be removed by caustic. Sometimes the skin must be cut away to get at them Case related to illustrate the danger of opening [chronic] abscesses by large incisions & keeping the orifice open. Died in a week Quality of the discharge Commonly mild & inodorous thick (sometimes curdy) before the healing, it becomes thin & whey like. Acute abscesses frequently furnish this thin discharge, especially if’ erysipelatous Hectic fever Blood drawn will generally exhibit the buffy coat, before the opening of the abscess. Afterwards 36 we have hectic fever Pulse quick (sometimes not in old persons) generally 2 paroxysms in a day the nightly one attended with profuse sweats frequently with diarrhoea sometimes pains in various parts which exhausts the patient less of app. & nausea & vomiting occasionally aphthae (sometimes also as well as night sweats, before openings) may come on so also dropsical effusion of cellular membrane. The degree depends 1st on the nature of the part according to its power of restoration 2nd on the extent of the abscess e.g. occasionally it following the suppuration of an extensive burn 3d on the constitution of patient frequently mental causes have great effect [illegible] modifies hectic the old have less sweat & loss of appetite, but more diarrhoea Sometimes we are surprised to see so little constitutional affection. Such persons are generally very tranquil in mind. It is perhaps impossible to cure hectic 37 while the cause remains Some patients are exceeding by restless irritable & troublesome & [illegible] Prognosis this depends on our success in removing the cause. We may however moderate it by tonics e.g. sulph quinine, wine, opium This last invaluable, promoting sweats relieving [illegible] & supporting the vit. powers Keep the bowels free. Inflammation of the lymphatic vessels Causes may be ext. or internal 1st wounds acrid substances etc. Wounds have been given in bleeding Symptoms swelling, redness, hardness, a core may be felt a discharge of lymph, a swelling of the lymphatics in the axilla. Cured by touching by with caustic Sometimes a very small puncture will cause an inflammation extending upwards in the direction of the 38 lymphatics, indicated by red lines swelling soreness etc. frequently very troublesome sometimes an erysipelatous infl. & abscesses It may be occasioned by erysipelas Touch the small orifice (apparently in considerable) of the wound with caustic & apply adhesive plaster if this does not cure, blister the whole inflamed part, use compression etc. Open abscesses if there are any. Sometimes the inflammation extends from the heart instead of towards it in the course of the vessels. It appears in the throat in scarlatina. It may be caused by [sore lips] Frequently this disease comes on from an affection of a distant part is phlegmasia doleus from the uterus It may appear in the legs from consumption. Phlebitis infl. of the veins First pointed out by J. Hunter. It may be caused by venesection & by a ligature Vein appears like an inflamed cord Sometimes pus is found around the vein. Constitutional symptoms like those of erysipelas & very violent, accompanied with fainting palpitation 39 of the heart anxiety etc. Treatment venesection (some say ad deliquum) calomel & opium blisters Mr [Lizars] advises to destroy the vein above the part by caustic. Inflam of the arteries Not much is known respecting it. Ossification of the arteries, appears to a frequent result Mortification. The death of the part A cold ash coloured mass becoming black Gangrene is considered under this head Two kinds, acute & chronic hospital gangrene is a case The affected part from red becomes pale & cold the vessels filled not with watery but bloody serum. Pulse quick weak intermittent occasionally, sweat, singultus. Symptoms vary 1st according to the extent of the mortification. 2d acc. to the [illegible] of the part & 3d acc. to constitution 40 Chronic mortification frequently comes on as in the toes of old persons without pervious acute inflammation preceded by pains & heat. There comes on first a dark purple spot. Liable to be confounded at first view with shingles a skin disease. There first appears a redness then vesication, lastly mortification Two circumstances will always distinguish mort. 1st the coagulated state of the vessels, yielding no fluid 2nd no sensation being present in the part Causes external injury, a sudden cessation of vascular action in the limb!! bits of rattlesnakes wounds from dissection compression of bloodvessels from ligatures strang hernia etc. Inflammation more especially erysipelas & anthrax. Occurs oftenest in the old Ossification of the arteries is either a cause or after [illegible] There may such a degree of tumefaction or distention of vessels in violent infl. Case in which the skin was to much stretched as to cause mortif. Fire & frost bite after an operation for cancer of the breast as to cause mort. cause mortification IT has been attributed to the use of bad rye flour that which contained ergot. 41 Prognosis, difficult. All mort. is dangerous. Chronic mort. always dangerous Sometimes patients die when apparently almost recovered especially if old & when fasciae & tendons remain to be cast off. Sometimes patients are carried off by a new accession of erysipelatous infl. or a translation to an internal part It is a good symptom for the patient to go gently to sleep Treatment The attempt to imitate nature by endeavouring to excite an infl around the mort. part & so produce a line of demarcation & eventually the sloughing of the part, is to be considered Ind. 1st Venesection may be useful to moderate the violence of action Calomel for the disordered secretions in alterative doses Bark was formerly supposed to be a specific It is now discountenanced Acetate of lead & mur. amm. externally applied cold, as being more agreeable Emollient poultices, yest poultices will 42 correct fetor. Chlorate of lime & soda Bark was formerly used in poultice 2nd diminish irritation extract foreign bodies if there are any, open abscesses remove mortified sloughs. Calomel opium even with venesection, & especially when purgatives are required Emollient poultices 2d prevent the spreading of the mortification which spreads sometimes in the cellular membrane very rapidly. Bark may be useful but blisters are the great remedy. They should be extensive & on a limb, should extend above the part mortified except in case of mortified toes. Nitric acid (100 to 300-400 drops to 1 pt. water) may be used as a caustic application 4th support the patient by opium, bark wine ale porter, indulgence in nutritious diet. Keep the bowels in order, attend to the secretions etc. etc. After treatment of the part Keep on the external application etc. Clear away 43 the sloughs Case which terminated favorably related in which the whole gastro [illegible] muscle was lost. Near the close of the cure the following preparation may be used as a mild cerate. 2 drachms acetate of lead ½ oz. sulph. sodae, 2 ½ oz. simple cerate Mortification continued It may prove fatal from const. irritation either gradually or suddenly Case related of an old man who first had apparently an anthrax on the bottom of his foot There came on a phlebitis of the vena saphena. Mortif. affecting a whole limb will [rarely] be cured. Generally amputation is the best remedy. The const. irr. will be surprisingly relieved. Hiccup is generally a fatal symptom As to the propriety of amputation It must be done when the injury 44 has destroyed the principal blood vessels & limbs. Also in mortification of the toes extending over the foot for all such cases cannot be cured without too extensive a suppuration to be borne by the constitution As to the time of amputation. It is now settled that we are not to want for the mort. to stop spreading & for the mortified part to be sloughed off. The mortified toes of old people should not be taken off. If amputation is to be performed, it should be of the leg, or if this beings to be affected, of the thigh. Case of mortif. of finger of an intemperate shoemaker. When amputation is performed we almost always find the arteries ossified In compd fract. burns, frost bites etc. if the parts are likely to be dead, then operate immediately. Sometimes mort. extends along the cell. memb. under the skin, giving rise to a crackling feel & a sort of eymphyema. 45 Wounds in general. Solution of continuity in a part. They are of six kinds incised punctured lacerated poisoned contused & gunshot wounds. Extensive wounds may affect the system more or less according to various circumstances, one of which is the degree of confinement, e.g. wounds of the lower limbs affect the system more. The symptomatic fever will vary from a slight heat, to a high fever; sometimes we have chills sometimes erysipelatous inflammation The first indication respects the hemorrhage. This if slight may be stopped by cold air cold water, lint etc. If an artery is wounded, a ligature must be used, except that sometimes a small artery may be stopped by a total division of the vessel. Case of a man who had wounded the art. [illegible] 46 There came on a very troublesome & frequently recurring haem. Cured by opening the wound & totally dividing [the] partially divided artery. The temporal art. may, in this way, be totally divided & then stopped by compression Ligatures may be of silk, thread, or better of leather, rolled. Mr Lawrence has lately recommended a small silk lig. with the ends cut very close it is said they will come out by a small [pustule] Leather is absorbed. It is now [illegible] inadvisable to cut the internal coat of the artery by the ligature Mode od dressing. Bring the edges accurately together, apply adhesive plaster and a compress Leave the wound in this cond. for 4 to 5 days. The interrupted suture is used. 47 The sticking plasters may be used in addition to these, a strip between each two stitches In case of much heat & inflammation Prof. H. keeps up the practice of wetting the dressings even with ac. plumbi. Punctured wounds; of by a bayonet or similar instrument, they partake of the nature of others Considered dangerous yet often heal by the first intention. If pus collects at the bottom treat as in other cases of suppuration. Haemorrhage from wounds. The artery retracts when cut, the internal coat adheres & the [illegible] extends as far as the next collateral branch. This first led to the practice of using small round ligatures. Sometimes the needle & ligature is used when it is impracticable to use the tenaculum or forceps especially in punctured wounds, to avoid the necessity 48 of extensive incisions. We must be cautious about tying arteries in old wounds lest the tied part slough off & we have haemorrhage again to avoid this make a new incision. Be cautious about leaving any substance in the wound Sutures should be generally be left 4 or 6 days A proper posture is of importance. Horizontal for the lower limbs flexed if upon the back side of them. Union of parts totally divided as noses & fingers has not succeeded in Prof. H’s practice. When a little skin is left they do very well unless suppuration comes on Rest & simple diet are of importance. Rest is especially [so] in case of wounds of the lower limbs Contused & lacerated wounds may be treated under one head. The haem. is generally small. Do not hesitate to draw the edges of the wound 49 together instead of treating with fomentation & poultices to promote suppuration Poisoned wounds where a poisoned substance is applied to a puncture as stings and bites. It is difficult to say whether the effect is upon the nerves or the poison is absorbed The effects are very analogous to erysipelatous inflammation Excision should be performed as a prophylactic. Cupping has been practised. Caustics Among the French caustic acids are favorite applications If acetate of lead etc. fails Prof. H. would try blisters. For the general remedies use vol. alk. opium, alcohol camphor a variety if necessary of stimulants If violent inflammation comes on use venesection mercurials etc. If suppuration or gangrene ensue treat as usual for them. Case related in which 8 gr of arsenic were given in 4 hours cured. 50 Apparently phlebitis has been occasioned by bites of serpents Indian remedies are of little consequence. Stings of wasps & bees Bad case of a sting near the eye relieved by laudanum next day fever relieved by bleed. & mercurials Young woman in Toll. cty. stung in the leg by a wasp fainting & anxiety died in 15 or 20 m. Dissection wounds A wound seems to be necessary. Prof. H. does not think they can be explained by the predisposing causes of late hours, study etc. Symptoms finger very sore & painful soreness extends up the arm pain in the head & back, chills & fever. Swelling of the part up the arm in the axilla pus under the pectoral muscle & in the chest death. If the pus collects in the finger alone the case is less dangerous. Prof H. has known similar effects follow a puncture without morbid matter. Case of a boy wounded in the heel with a fish spear. red streaks abscesses in the foot & leg 51 suppuration under the pectoral muscle under the pleura death Very bad sores upon the fingers often have arisen from dressing ulcers. Prognosis varies upon the situation etc. Touching the wound with nit. silver has not always been successful Suppuration in the lungs following operations compd fractures etc. The treatment is the same as in other inflammations of the pleura bleeding etc. In two cases Prof. H. made an opening into the sac of the pleura one of them was fatal, the other recovered. Gunshot wounds The contusion must be very great. A spent ball will produce contusion merely. It was formerly supposed that the ball burned the parts judging from the appearance of the [illegible. This is a mistake Often the shock to the system is very great, but with some it is trifling The entering orifice will be smaller than the issuing The latter will have 52 ragged and projecting edges. Sometimes a ball may be pulled back by taking hold of a piece of silk, which was carried in before it. Its course may be very circuitous, being diverted by tendon sometimes as well as by bone. Abscesses and also cysts are formed around it. The effect formerly acribed to the wind of a ball are explained by the oblique stroke; the skin yielding & being unlacerated, while even the bones within are broken. That the wind does not produce the effect is proved by the fact of one leg’s being carried off without injury to the other, when both are in contact The contusion destroys the life of the adjacent parts. The hemorrhage is generally slight Balls may pass through the body without penetrating cavities, as of the chest. Baron Larrey told Dr [Heerman] that he had lost but two patients whose bodies had been perforated by a ball. 53 Necrosis is generally produced by a ball’s striking a long bone in other bones caries. Wounds of the lungs will often be followed by haemor. from the mouth of the bowels by feces issuing from the orifice. Wounds of the joints are dangerous Indications 1st suppress hemorrhage Do this by the tourniquet if possible Tie arteries as soon as possible, unless amputation is to be performed 2nd extract foreign bodies unless they are out of sight & of the reach of the finger or probe When the ball has passed nearly through cut down on the other side, while squeezing with the finger & thumb. Thread etc. will come out by suppuration A foreign body lodged in a bone is very dangerous. In a superf. bone trephine 3d prevent or remove irritation The French make incisions to take of the stricture & debridling the part. This is now discountenanced by the British In case of a fleshy wound, apply 54 merely lint and simple cerate. Many keep a moistened compress upon the orifice This is [illegible] cold water is generally the best application. For some days the wound will look ugly, with swelling & frequently a watery discharge. If suppuration comes on slowly, poultice but do not continue them after suppuration’ is fairly established, but absorb the pus with dry lint. The separation of the slough is another critical period if secondary hemor. then comes on apply a compress immediately. The plan of tying the artery at a distance has generally failed In an old wound we must make a new one. General treatment should be antiphlogistic Prof. H. uses calomel as a cathartic & the British surgeons are adopting the practice. If there is pain in the head fullness of the veins etc. bleed & purge In the latter stages opium is invaluable 55 to allay irritation Sometimes also in the first shock & then according to some bleeding must be conjoined. Amputation 1st as to the time 2nd as to the particular case. The unanimous testimony is now in favour of immediate amputation waiting however for recovery from a violent shock & administering a mouthful of wine & also consolation & encouragement. Baron Larrey & Prof H. prefer immed. amp. even when bad symptoms have come on 2nd the different cases 1st amp. is necessary when a limb has been shot off for a clean incised wound is made the patient will be more comfortable & mortif. less likely In fingers the injured phalanx only need be removed, at the joint. 2nd when a ball has passed through or lodged in a joint. 3d in some cases where a bone is fractured according to the degree of injury to the bone & also to the soft parts Even if the patient recovers, the limb will often be not so good as a wooden one Necrosis often comes on. The suffering will be great Often a bone will be fractured & split into the condyle 4th by extensive destruction of soft parts, to prevent gangrene, or extensive supp. & hectic & where the muscles are torn off the limb will be stiff. If the upper part of the femoris or os humeri is fractured amp. is necessary (at hip joint?) Consecutive amp. may be necessary The destruction of large arteries sometimes the skin will be unbroken in the meantime often indicates amputation Good accommodations for the wounded may enable us to save patients without amputation Be careful to amputate entirely above the fracture Mr. [illegible] says that after amp. death takes place 1st from infl of bloodvessels 2d [metastasis] to some important internal part most commonly to the thorax in our climate 3d from disease of the bone or joint 1st the veins may perhaps be tied 3nd pus has been found in the sac of the pleura 3d the hip joint Prof. H. would evacuate Suppuration of the liver more freq. take place in hot climates After amp. the end of the bone becomes round if the cure is favourable Paralysis is a frequent consequence of extensive gunshot wounds cured by moxa according to Bar. Lar. Tetanus Failure of success almost universal in acute tetanus more common in warm climates Bar. Lar. has had most success. It may be occasioned by tying up a nerve with an artery by exposure to night ari by suppression of suppuration acc. to Bar. Lar. Actual cautery has succeeded Amp. has generally failed Canthar. often fail It occurs oftenest in the young & in wounds of a [ginglim???] joint acc. to Bar. Lar.’ Emprosthotonas will follow an anterior wound & opisth. is a posterior & tetanus where there equal injury before & behind acc. to Bar. Lar. Warm & cold bathing have been much used Case of a young man wounded in the foot by a piece of glass. Bled. blister to the healed wound calomel opium cured was stiff for a year. Case 2d blacksmith hot iron upon foot corr. sub. into the wound blister over the foot calomel & opium the latter followed up cured. Make a powerful impression. A red hot ploughshare has been passed along the spine. Bite of mad dog Excise deeply it has never failed in Prof. H’s practice A finger may be cut off. He has cut out 6 days afterwards with success. Dr Physick says at any time before the [accession] of the symptom Contusions without breach of the skin It is an injury causing a rupture of vessels & effusion of their contents under the skin 1st swelling owing to extravasation next echymosis or discoloration which frequently extends some distance especially in the direction of gravity e.g. black eye from contusion on the forehead finger discol. after an injury of the arm very easily produced in old people. Commonly a considerable degree of soreness. The powers of absorption greater in the young Indications 1st prevent further effusion 2d reduce infl. 3d promote absorption 1st by wet lotions of water [mar.] [illegible] etc. 2d if much fever bleeding & cathartics & fiunally if necessary opium 3d Use warm applications (these also may be for the first indication after a while) Add to these bandages & compression. Also we can apply camphorated spirits opodeldoc etc. In many cases an incision must be made to let out the effused blood (called bloody abscesses by the French) We should however generally defer [illegible] One reason for which is that the vessels may continue to bleed. If the blood is coagulated a snapping will sometimes be felt as of something breaking & slipping away. [illegible] in this state it is though more likely to be absorbed. Before incision try remedies and [observe] if you appear to be gaining ground. Sometimes the effusion is in a bursa mucosa Case of it in the knee So [much] a [illegible] Make the incision on the outside of the tendon of the rectus musc Prof H has several times been obliged to open these bursae e.g. at the elbow. Upon the back he has had to make an incision & let out a quart of fluid tarlike blood. If the vitality of the skin is destroyed an incision will be advisable. We shall have a sloughing sore in either case. There is a bursa directly on the olecranon which is liable to be filled with effused blood Often there will be a second eff. when the orifice must be opened & the cavity injected with corr. sub as in [illegible] Contusions of abdomen. Death has been occasioned by blows on the epigastrium apparently caused by the shock alone Often the peristaltic motion suspended which denoted by swelling of the abdomen vomiting want of sup. anxiety of countenance etc. Sometimes blood is vomited It is generally best to avoid stimulants Case young man kicked by a [illegible] vomiting of blood 1 great pain & excessive thirst to stop the flow of blood cold wet cloths were applied to the abdomen bled ad deliq. pain ceased pain & vom. returned bled again calomel finally injections The bleeding relieved the pain the vom. & the thirst. cured in 2 or 3 days Venesection is the most important indication, the next is purgatives continued for some [time] Sprains not much treated of It is an unnatural extension of ligaments of a joint sometimes accompanied by dialysis or rupture. Joints most commonly affected are those which are not strongly defended & admit of little motion. They are the knee ankle wrist & hand. At first motion is free but it is soon hindered by effusion & swelling frequently there is effusion into bursae mucosa There is an effusion into a bursae of the foot which is often [illegible] for dislocation. It is apparently set by pressing & breaking the sac. Prognosis Some families are particularly liable to them Scrofula gives a tendency. In some constitutions a slight sprain will cause [hemorr.] for months Treatment Rest is more necessary than in contusions. Cold lotions to prevent infl. cold water or ac. plumb. A bandage is always proper moistened at first. In case of much pain use warm fomentations best by wringing out a cloth dipped in hot water, applying it & covering it with flannels to keep in the steam. Poultices may be used In case of stiffness apply opodeldoc & other stimulant applications friction passive & active exercise. Lameness is often caused by want of exercise. The violent wrenching of the natural bonesetters has some good in this way. Burns. Inflammation caused by heat The practice has been exceedingly empirical No advantage in dividing them into species Superficial burns of sufficiently extensive are of the highest consequence Case of a child blistered by cantharides over the whole body died in great agony. The British East India surgeons sometimes used hot water for blistering The [illegible] indication is to shut out the external air. Treatment like that for a blister Deep burns are generally [illegible] by a suppurative inflammation which is generally ascribed by the patient to taking cold. Sometimes flame is inhaled the viscera are affected, under the external injury, in some patients Consequences of extensive burns if the pat. survives the first shock, are fever, extensive [illegible] etc. This last is frequently fatal, hence the end of three weeks is a critical period Children are sometimes affected with convulsions When we find apparently comfort application already made, we should be careful about interfering with them Treatment has been opposite & empirical Cold water on one hand & spts turpentine on the other. Antiphlogistic & powerful internal stimulation For simple external burns anything that keeps out the external air perhaps as good as any is simple cerate. If there are vesicles [illegible] them Equal parts of basilicon (or common cerate) & spts turpentine is the best application in case of extensive sloughing & suppuration Prof H. has tried cold application & poultices, but does not like them [illegible] is the necessity frequent exposure to the air in dressing. The above cerate seems to promote a quick suppuration & so prevent gangrene. It must be laid aside (causing smarting etc.) as soon as suppuration is free, when simp. cerate should be dressing not oftener than once in 24 hours having the dressing ready for immediate application the cold air. Then granulations come on use Turners cerate Finally use ac. lead 1 oz beeswax & sulph. sod. 2 oz. This is called saturnine cerate. Turner’s cerate above is made of oxide of zinc. Often near the close of the cure adhesive straps & bandages are useful to keep the sides of the ulcer together Constitutional treatment. The shock is often very great. In children there is either violent distress with screeching [or a comatose] state with deadly coldness which indicates alcohol camphor ammonia etc. Opium also though Prof. H is afraid of it in coma. Next comes on fever treated by venesection cathartics etc. to be discontinued when suppuration comes on. In children it will be sufficient to keep the bowels open & bleed only incase of convulsions In adults the bleeding should not be copious. Bark [seems] to be irritative Opium is the principal remedy on account of the pain etc. Cotton seems to be advantageous only by keeping out the external air & keeping the parts warm & by being easily applied & kept on Case of a man who fell into a kettle of boiling potatoes Took a large quantity of spirits Was dressed with the turpentine cerate then with simple cerate opium [was given] the bowels kept free about the [2?] day there was a critical period his mouth was treated with borax & other means were adopted which cured him. If an extremity is burnt off then amputate the stump immediately Sometimes the bones come off themselves. Deformities from burns The fingers are liable to adhere This is to be prevented by dressing. Splints are to be used to keep parts in their place preventing [illegible] flexion of fingers etc. When the joints are affected they should [illegible] straight & when the sore is healed, practice flexing them. Case of a young man who scalded his legs Deformities following burns Case of a burn at 7 yrs. of age upon the back of the thigh troublesome with sores etc. at 47 yrs had been of latter years much troubled with a horny excretion which was softened with [poultices] & shave off [At] 47 yrs of age the limb was amputated IT was an old practice to cut across the cicatrix & stretch the parts in case of deformity caused by contraction The new practice is to cut out the scar entirely sometimes adding the taliacotian operation Case of a young man with a large & sore scar on his foot. A good foot was made Frost bites A degree of torpor is produced by severe & long continued cold amounting to drowsiness & irresistible inclination to rest. Case of Prof. H’s preceptor, an army surgeon Not suddenly to be brought into a warm room nor to be too free with cordials Immerse frozen limbs in cold water gradually warming the water after a little while. A limb thoroughly frozen cannot be restored to vitality, however The contrary treatment totally destroys the frozen part. The effects of frost are similar to a burn superficial redness mortification which commences with a purple & terminates with an ash colour in case of thoroughly frozen limbs In frost bites apply ac. plumbi etc. poultices, cerate in case of suppurations which may have liquid applications over them. Cold and warm applications are both used. In case of mortified extremities amputate without hesitation as soon as the line of mortification is distinct else we shall have suppurations abscesses etc. Case of Capt P. of Brooklyn was overturned, & [stunned], in extreme cold weather lay all night was put int a very warm room. The phys. attempted to bleed him no blood followed there was a wound on the eyebrow knee the other knee dislocated right hand frozen. Prof. H. bled him, & gave a dose of cal. & jal. Afterwards he grew more insensible & eventually comatose for several hours. An erysipelatous inflam. with delirium supervened. He was bled & treated on general principles. Eventually recovered The fingers & thumb of the right hand were amputated after about a fortnight This amputation was however too late as was proved by suppuration & abscesses taking place on the hand & arm. The patient was partially sensible & able to tell his name when he was first discovered by the road side. The effect of the warm room was to bring on complete insensibility & finally coma A foot or hand frostbitten if applied to the fire is followed often by violent infl. & mortification which when superficial merely will cause nothing more than the loss of nails skin & so on Tumors Varieties numerous 1st Encysted 2d sarcomatous 3d medullary Also malignant & non malignant the last however may become malignant We know little of their origin. Mr. Aber. attributes them to extravasated blood. Their progress is often similar to that of chronic inflammation The nature of the tumor will often be inflamed by that of the parts where they are situated e.g. they may contain hair when upon the scalp. The growth seems to depend upon the size of the bloodvessels of the part. They increase, in general, in geometrical progression They should be extirpated before they have arrived at any considerable size. 1st Encysted tumors contained in a cyst of more or less density, which encloses [stertomatous], or [illegible] mellitus, or is an [illegible], curdy matter being contained There is a kind affecting the red part of the lip having a think sac & contents resembling the white of an egg not larger than a musket ball. There is a tumour composed of adipose matter disposed in cells called sarcomatous Various discutient remedies, have been recommended. As far as they are effectual at all, they do injury. If the cyst is penetrated, a very troublesome sore follows & sometimes cancer Caustics instead of knife have been successful Cancer quacks cure small tumors in this way and call them cancers. In case of large tumors caustics often fail & the knife is always preferable. It was formerly advised to extract without opening the cyst this not always practicable without great difficulty. Sir A. Coop. opens the cyst presses out the contents & pulls out the cyst by inversion. If any portion of the cyst remains the tum. will be renewed. Sometimes a small tumour may be removed by caustic alkali upon lint introduced into the cyst. external injuries freq. cause these tumors Sarcomatous tum. In these the cyst is not strong enough to be pulled out. If the skin adheres firmly, make two semilunar incisions & take out a piece of skin Then separate the tumour from adjacent parts by the fingers as much as possible Membranous connecting bands often have to be divided. These tumors are troublesome from their size, from impeding motion etc. when pendulous, the skin is frequently affected with an erysipelatous infl. Cases of old woman & an old gentleman extirpated with safety. The arteries are usually very small in these fatty tumors sometimes however they give a troublesome haemorrhage They are divided into various kinds by Mr. Abernethy. All the kinds may become malignant Fungus haematode medullary tumors malignant from the commencement & liable to return even if thoroughly extirpated. Hence a portion of undiseased parts should be cut away After extirpation treat as for a simple wound. The largest [tumors] are the fatty even 40-50 pounds They feel like a bag filled with cotton Sometimes there is a puckering of the skin (caused by imperfect adhesions of the skin) under the fingers. This is a pathognomic symptom These adipose tumors must not be confounded with the steatomatous encysted tumors. It is a question whether the whole parotid gland has been extirpated. They will prove fatal (many of them) eventually & hence should be extirpated while small. The testicle & the fem. mam. are enlarged frequently & sometimes will become small again Medullary tumour or fungus haematodes the substance of them resembles that of the brain but is redder & harder found in every part of the body even in the bones & then called osteosarcoma There is at first an elastic feel caused by the binding down of fasciae Growth is very rapid, causing absorption of adjacent parts as bones Most common are they in the young they were all formerly called varieties of cancer In the testicle most taken for hydrocele It is found about the eye Prof H. has met with them oftenest about the hip. Case of mortification & death in three days in consequence of opening one, in search of pus. Case in which a small point was left, which grew in spite of caustics & proved fatal. Case in which it returned three times & was then left We must hence cut away sound parts also. If the bone is affected amputate. Prognosis is generally bad though the wound heals well enough. They may return in internal parts. They are not always pulsative nor generally painful except by pressure upon surrounding parts & by a general [illegible] of health loss of app. sallowness of continence etc. pain when a nerve is pressed on Diagnosis of medullary tumors Abscesses begin deep & are not painful and are circumscribed by a hard edge. fungous tumours have an elastic feel. The colour of the skin over a fungous tumour will be dark red, but not tender like that of an abscess, nor surrounded with a hard rim. We must also inquire into the previous symptoms fungous tum. begin without infl & pain & are indolent. Spots will be found in the neighborhood which if opened largely will prove fatal. Case of a fung. haem. of test. mistake for hydrocele. Though we have no remedy for this disease yet extirpation should be performed if possible cutting into the sound parts. Case of Dr Wood. of [Cast.] cutting out one of the thigh every few months the man able to labour. Case in which the most powerful caustics failed in killing the tumour, fast as it grew. Ulcers A solut. of cont. in soft parts with a discharge of fluid. The absorbent vessels remove the parts faster than the nutrient vessels renew them hence the opposite to healing Differs from mortif. by the dead parts remaining in the latter case Various classes of them Causes wounds abscesses external injuries (local) The constitutional causes are syphilis scrophula scurvy etc. also in some families from a predisposition e.g. hereditary sore legs An oedematous affection predisposes e.g. dropsy phlegmasia dolens 1st simple 2nd irritable 3d indolent 4th varicose 5th specific ulcers 1st simple discharge of mild inodorous pus small round granulations filling up the cavity finally a bluish skin (cuticle only) which makes cicatrization Formerly 3 stages were always expected in the healing of a wound viz. ulceration, granulation (restoration) & cicatrization. Much benefit arises in a simple ulcer from adhesive straps, as in a wound, to promote cicatrization. The bandage will keep the parts together & also prevent proud flesh (a luxuriant gran. protruding beyond the skin) which should by nit. sil. or if that fails by sul. cop., be reduced Irritable ulcers painful sore irregular shape (sometimes round when small) gran. irregular do not bear bandaging well. The irritability may generally be abated by touching with nit. sil. or by wash of corr. sub. or by 1 scr. corr. sub. to 1 pt water (called yellow wash) or sprinkle with calomel, or apply the black wash of cal. & lime water or wash with [illegible] op to 1 pt water 1 dr. ac. lad to 1 pt. mucilage will be cooling & lenient. Warm fomentations are apt to soften too much We frequently change our application Indolent discharge serous& curdy bottom smooth edges swollen surrounding cell mem. thickened often very large as large as a hand [illegible] patients will suffer little, and continue to labour. A farrago of remedies in popular use Nitr. ac. & nit. sil. & other caustics are used. The best rem. is MR. [Berts] plaster bandage, surrounding the limb. above & below with this bandage applying a compress wetting the whole with cold water. Sometimes leave a little vacancy for the discharge of matter The plaster may be common adhesive pl. or diachylon, or rosin pl. or [litharge] pl. sometimes in case of irritation from Soap plaster of the [illegible] is used rosin softening this last with tallow one half Dress once in 2 or 3 days only Sometimes an erysipelatous infl. & sloughing comes on Guard against this by diet etc. Improper to make a class of sloughing ulcers Indolent ulcers may be cured much sooner by confinement, as is practised in the hospitals. 3d Varicose ulcers. The veins will be found varicose. Some are irritable more commonly they are indolent. Treatment of the varicose veins is the particular indication. Proper bandages with confinement of the patient is always proper. However the cure will be more sure of being permanent when it is effected without Diet is of the highest importance The patients are generally plethoric more or less; hence use venesection or purgatives (mercurial). Where erysipelatous infl. come on treat as usual by ac. plum. blistering etc. Some patients are feeble with low pulse cold skin & pain in the affected limb. In this case give cal. [illegible] cal 1 ½ gr. op. 1 gr. also Dov. pow. bark & opium etc. Nitrate of silver relieves irritable [illegible] sloughing etc. better than any thing touching with it once in a few days. There is generally little hazard to life from sore legs. Cases in which by the continual application of caustics & irritatives caused enormous ulcerations cancers & affections of the bone which required the operation for necrosis, or amputation It has been proposed to be the vena saphema Sir A Coop. objects. Cutting across the vein is thought better by some also cutting with the convex cutting edge of a bistoury, so as not to wound the skin also cutting out a part of the vein & then bringing the edges of the wound together, as is practised with success in the Pennsylvania hospital. This latter mode probably the best. It has been supposed that the drain from old ulcers is very beneficial this opinion is probably derived from the fact of the stopping of the discarge in an acute disease as fever There is no danger in curing them Hence the old opinion, which is still the popular one, is to be entirely disregarded Plethora had better be relieved by venesection & cathartics than by ulcers. Specific ulcers e.g. venereal, noli metangere cancers etc. Anomalous ulcers Sore on the instep somewhat like elephantiasis. Benefitted by powdering with calomel. Nitrate silv. saturnine cerate acetate of lead & calomel with lard may be tried also. There is a thin watery discharge redness hardness thickening extending over the whole upper [surface] of the foot. Sometimes stopping in one direction & extending in another Fungous ulcers [ment.] by Sir. A. Coop. principally on the calf of the leg resembling a scrofulous affection of the metatarsal bones generally in young & corpulent women Apply bandages wet in case of heat when the fungous protrudes through the skin apply nit. sil. Also wash with ac. of lead etc. & prescribe for constitutional symptoms. Ulcers following scrofulous abscesses Fungous flesh overhanging, thin, dark purple skin they are oblong Apply nit. sil. in pencil under the skin if necessary that is if this first application does not cure then cut off the diseased skin & lay open the whole sore. Sometimes where the orifice is small, a director must be introduced & a long incision made it will not in this case be necessary to clip away the skin. These like other ulcers are often called cancers Schirrhus or cancer. A hard tumour without ulceration is called schirrous cancer, when ulceration comes on Schirrus may be fatal without running on to external ulceration Lower limbs & testes in males breasts & uterus most often affected When affecting the skin they begin with a blood war, or with a discoloration & tumour of the skin to be treated of afterwards. Scrofulous tum. are less hard, seldom single, oftener in young people, they are smooth, and attended with scrofulous habit. Young women are often affected with an induration of the mammary gland which is mistaken for schirrus. The latter is almost always found in adults. Cancer of the breast [Commences] with a painfulness When first examined there is found a hard tumor. An inflammation of the skin takes place. The nipple retracts & disappears eventually the hollow will discharge an ichorrous fluid. Or the cancer may commence with a small vesicle which breaks, discharges, & finally becomes an irregular knobby cancerous ulcer Cancers however, do appear to commence sometimes internally. The lymphatic glands & sometimes the lymph vessels, are affected when the ulcer opens. Sometimes the skin adheres to these inflamed lymphatic vessels Finally the manna adheres to the pectoral muscle & even to the periosteum of the ribs & sternum even attacking the other mamma with the same symptoms The lymphatic glands of the axilla are more affected & the arm sometimes is so oedematous as to require puncturation Great difficulty of respiration occurs The disease is fatal from hydrothorax or other affections of the thorax, as well as from hectic Sometimes without much ulceration the whole mammae are bound down at death with schirrhus. Sometimes the bones of the extremities become singularly brittle. Sometimes a paralysis of the limbs takes place The whole spinal narrow has been affected. Very numerous & various symptoms may come on in the sequel. Difference of opinion as to whether this disease is constitutional or local. For sometimes the disease returns in the same or another part & sometimes not Prognosis doubtful The more speedy the access the mor probable the return Sometimes in very old people from their slow progress & insensibility they give very little trouble. Their cure has been attempted by bleedings & low diet also by salivation No dependance can be placed on these remedies. So of the internal use of arsenic and of conium also. Iron internally & externally seems to have failed Pressure has been much tried, but fails The hard cartilaginous nature of the tumour would lead us to despair or resolving them by internal or external remedies Caustics have been successful in very small cancers, but generally they give so much irritation as to increase the disease making a loathsome sore Iodine has been proposed There are no accounts however of perfect cures by it. Prof Smith stated he never knew a woman survive the application of caustics to the mamma more than a year The sooner the knife is used the [better] Use the knife also even after ulceration has come on. We must not expect the infl. of the lymph gland to subside of itself, this tumour also must be cut out. Reexterpation Should be performed as often as the disease returns provided the patient can bear the operation Case of 4 times in a year & the patient is now well. Various remedies, or issues, have been tried to prevent the return of the cancer It is of no use to prescribe any thing except for the general health In other parts of the body cancer may begin in a manner similar to those of the breast In the lip, we may have first a crack in the lip ulceration the lymphatic glands of the neck are affected the gums are affected the cheek the bones the whole mouth consumed & sometimes the patient dies of starvation. Mode of extirpation take out a piece in the shape of the letter v. bringing the parts together. If the skin is not affected, we may cut away down to the skin, leaving the latter Mr [Richaraud] cuts away the whole with scissors instead of the knife Prof. H. has extirpated the diseased glands under the inferior maxillary but generally without success where the disease has proceeded so far. We must not be too solicitous to save skin, cutting away all that adheres for the disease may return in the skin. Even when the disease returns it is not generally so rapid & fatal as at first. We must be very careful not to confound cancer with other diseases of female mammae Hydatid or incysted tumour of the breast of Sir A. Cooper 1st an enlargement then a tumour which yields serum when punctured then returns again and may attain to the size of several pounds. When of this size it is found after extirpation to be composed of one or of several cysts & may be of other forms. Case of a woman who had one opened a second time the opening kept open by [illegible] died of extensive suppuration & const. irritation Another case was extirpated at the first time. The tumor was the enlarged mammary gland with a cyst in the centre. Diagnosis absence of pain If opened the fluid perfectly limpid Indication immediate extirpation Simple chronic tumour of the breast of Sir A. Cooper. Rather upon the breast, than in it moveable Not generally painful & does not affect the constitution It grows very slowly but may arrive at a large size. There is no difficulty in cutting off the tumour & it does not appear to be liable to return It may be either before or behind the mam. gland These tumours are composed of several cells resembling sweet bread a glistening & glandular appearance. The cause is unknown. The patients sometimes suppose them to be caused by the pressure of dress Caustics may have cured them. Adipose tumors sometimes many pounds in weight may be either before or behind the gland. They are to be extirpated Irritable tumours of the breast for 15 to 30 yrs. lobe of the breast swollen & painful the arm is affected, more painful during menstruation especially during difficult menstruation great irritability etc. If patient is plethoric, bleed, & purge apply spirit & water or a plaster the best external application is soft fur or cotton batting. Give opium Sir A. C. speaks of an ossific tumor of a cartilaginous nature to be extirpated Lacteal tumor after delivery a swelling, which when opened yield milk Caused by an obstruction in the duct of the gland. Treatment, open & let out the milk wean the child & so stop the secretion of milk. If the orifice does not heal, touch with nit. silv. Some women are very liable to small abscesses of breast during suckling If they continue to succeed one another the child must be weaned. Breast large & pendulous It may be diminished by bearing & nursing children also by suspension Sometimes there is an enlargement & inflammation of the breasts during pregnancy which often require opening to evacuate pus With the exception of the small chronic tumors upon the breast, the whole glandular portion of the breast should be removed. Mode of operation. Instruments 2 or 3 round edged scalpels tenaculums needles & ligatures adhesive straps from 1 ft. to 9 in. long & 1 inch wide Bandage by a broad band passed around the breast & crossed over the shoulder stitching down in front. Have also lint & compress. Cordials & cold water for fainting. This last is best remedied by dashing on cold water Place patient on a table, with feet in a chair arm extended sitting in a chair is apt to occasion fainting Make the first incision in the direction of the greatest length of the tumor Or make it in an oblique direction in that of the pectoral muscles. If the skin is affected semilunar incisions are necessary. Stretch the skin with your left hand & by that of an assistant Use a drawing stroke, from heel to point of the scalpel. Make your incisions long enough at first Use considerable force & repeat the stroke also until the incision is deep enough If two incisions are made, make the lower one first. Observe this rule also in your following dissections. If an artery bleeds, stop & tye it or have an assistant keep his finger on it. Be careful to examine the bottom of the wound & also the under surface of the tumour. Cutting away little additional portions does not give very great pain. Then proceed to take out the tumour from the axilla Sometimes the same incision will answer for both. They may sometimes be torn out by the fingers being imbedded in the cell. mem. merely we can generally get the fingers behind them When there is a diseased chord in the in the cell. membrane, take it out with the tumour in the axilla Spunge the wound out well & tie every bleeding artery wait sometime in order to prevent secondary hemorrhage The French direct us to wait ¾ of an hour Wipe dry & bring parts together with adhesive plaster, beginning at the top & leaving a small space for ligatures to come out, unless they be made of leather then apply lint & a compress, & bandages It has been the practice of some surgeons to tie the carotid previously to the operation There is no necessity for this Other tumours. Cutaneous tubercles of Mr Lawrence. Prof. H. has seen it often. Frequently beginning about the face especially of elderly people upon the eyelids, nose, & upon the generative organs of both sexes. It becomes ulcerative & resembles cancer. Sometimes resembles a wart & sometimes a vaccine vesicle, at the first Always reddish & without inflammation of the skin. Sometimes it grows very slowly & gives but little trouble. At other times, especially if irritated, its growth is rapid. Finally they ulcerate without any disposition to heal & indeed become cancers; they are covered with scabs. Menstruating females are liable to periodical evacuations from the uterus, intestines (hemorrhoids), lungs etc. produced by these tumours This disease is different from noli metanges Treatment. Extirpation is the only mode of cure, & appears to be effectual the disease apparently not liable to recur The health of females with periodical hemorrhages, will be much improved. Mode make two semilunar incisions & be careful to cut into the healthy skin They do not extend inward Subcutaneous tumor Vide Cheselden’s Anatomy & Mr. Wood in Ed. Med & Sur. Jour. A hard tumor surrounded & covered with emaciated & discolored skin excessively painful growing very slowly & continuing quite small, notwithstanding their painfulness They are of a cartilaginous hardness. They do not appear to tend to ulceration more painful during menstruation & pregnancy Extirpate without delay or hesitation [Naevus] materna called marks apparently composed almost wholly of enlarged blood vessels they may be red or purple, or brown sometimes without any elevation of the surface They are sometimes troublesome in after life the swelling increasing suddenly the tumour becoming pulsative swelling & pulsating when the child cries in this latter case however, there will generally be no trouble in after life from the [naeva] Sometimes they become aneurisms from anastomosis sometimes affecting the whole & sometimes only a part of the naeva sometimes ulcerating at the principal point the ulcer may also very extensive attended with frequent haemorrhage. Aneurisms from anastomosis may come on without being preceded by naevus they may be made almost to disappear by pressure they pulsate violently they are tumours composed of cell. sub. & blood vessels. They should be extirpated after extirpation they of course shrink to a very small size. They may ulcerate extensively & the ulcers are very difficult to cure (They pulsate upon exercise) They may grow to a very large size & are then liable to be confounded with fungus haematodes They may be distinguished by their origin, situation progress, pulsation etc. As ulceration sometimes cures these aneurisms, caustics have been recommended for their cure Extirpate the haemorrhage will be troublesome, hence cut around & avoid cutting into the tumour as much as possible, also cut quickly, stopping the arteries by the fingers of assistants If practicable, the better way is to surround the (small) tumour with a double ligature. A new way is by passing 2 or 3 times through them a white hot needle apparently successful in case of small ones Case in which a naevus on the head was cured by Prof. H. by ac. lead bandages & compression Inoculation with vaccine matter has succeeded, apparently caustic would be better however as a means of promoting ulceration Tying the principal artery leading to the tumour, has been practised when on the head the carotid has been tied apparently without success. 11 Theory Practice Physic (front) Surgery (rear) Nosology 1 Diseases of Children 5 Retention of meconium 6 Tumour of the head 7 Aphthae or Thrush 7 Red Gum 13 Strophilus candidus 14 Ulcerated mouth 14 Costiveness 16 Infantile Erysipelas 18 Anomalous Eruptions 19 Crusta Lactea 20 Venereal Eruption 22 Sore Ears 23 Diarrhoea 24a Vomiting 28 Hydrocele 29 Volvulus 30 Constipation with fever 32 Worms 36 Convulsions 46 Epilepsy 49 Chorea 51 Dentition 55 Ricketts 58 Cholera Infan. 60 Tinea Capitis 68 Catarrhal epidemic 70 Gangrene of mouth 80 Chillblains 81 Exposure to extreme cold without freezing 81 Mesenteric fever 82 Cutting frenum 85 Burns 86 Tympanitis 87 Neuralgic aff. of the lower limbs 88 Whooping cough 71 1 Theory & Practice of Physic Nosology Dr Rush condemned nosology but afterwards made use of a system of some sort. We must arrange our knowledge. Dr Ives believes the fundamental principles of the common systems are erroneous Disease is a derangement of some or all of the functions of the body. It is the opposite of health or dis-ease. We must compare it with health. Dr Ives condemns the classification into species general orders etc. as if they were entities or beings instead of merely modes of action Diseases change their seat and their form in the course of their progress Nosologists would have done better than they have if they had imitated the natural classification of the botanists. Very great error is committed in attempting to make the divisions mathematically exact. 2 All the present systems suppose definite diseases with specific modes of treatment this leads to an invariable mode of treatment & to the prescribing for the name of a disease. Still it must be confessed that nosology founded on anatomy and physiology are [latelly] acknowledged that diseases are mere modes of action A classification of epidemics formed upon [remote] causes is equally erroneous as the remote causes are disputed, and unknown Dr Ives divides epidemics into two great classes taxic & ataxic in irritation of the division of natural families into classes The term malignant has sometimes been used in the sense in which Dr Ives uses the term ataxic sometimes for rapid fevers, for those which have a gangrenous tendency & for those which more especially affect the vital fun. Ataxic a morbid state, beyond the power of reactions attacking the vital 3 function not putting on the ordinary forms of fever The first & most important indication in taxic fevers is to moderate the violence of reaction in ataxic, is to produce reaction It may be laid down as a principle that all ataxic epidemics resemble each other Ex. gr sometimes in the yellow fever the powers of life are attacked & prostration or exhaustion continues until death closes the scene. What are called the walking cases are of this kind in which the patient walks about until death. This kind is difficult to describe but when once seen is never forgotten eyes glassy countenance anxious etc. So of cholera of India also of pneumonia typhodes especially as it first appeared in this state It had four distinct varieties of which spotted fever 4 was one. No reaction no pain no heat such cases are said to occur in the plague A person who has treated one ataxic fever is able to manage any other All extreme cases may be classed together under this name, as they are in fact under that of malignant Dysentery of 1814 & 15 mild coma [gentle] sleep no apparent pain stools once in two or three hours not striated with blood etc. etc. when the patient was roused from sleep he said in a faint and indifferent tone of voice he was well immediately fell back into sleep. Yet here was dysentery [although] there was no dysenteric symptom for these cases were beyond question, of the same epidemic as others unequivocally dysenteric The indications were to excite reaction by external and internal irritants and to excite the action of the stomach and bowels by calomel ipecacuan etc. In this epidemic the stomach & duodenum appeared to be principally affected. 5 Diseases of Children Great attention has been paid to this subject within the last 30 or 40 years It was formerly almost entirely neglected owing to the exclusion of the faculty from the practice of midwifery to the prejudices of mothers and nurses & to the indifference of the family themselves Young physicians are more frequently called to the diseases of infants hence the importance of this subject to medical students. In Europe have the physicians been most negligent of this subject The French & Germans less so than the English The European practice differs from ours less so at present than formerly because our constitutions are coming to resemble theirs. Their practice is more mild In general chronic diseases require a milder treatment. Great difficulties result from infants being unable to tell of their complaints yet the 6 other symptoms are more easily understood They practice no disguise or concealment They are not made worse by mental aff. Many prejudices exist e.g. that the child is born with a morbid appetite inherited from the mother which appetite must be gratified This they infer from the natural crying of the child The mother sets herself to recollecting some former longing of her own. Story of a child fed upon this principle with mince pie It had to be physicked severely to save its life The mucous membrane of the al. can. is oftenest affected sometimes spasmodically Be on the watch with regard to the liver. The nervous system is more easily excited from irritation than in adults The vascular system less so. Fevers are generally more irritative than otherwise As a general rule preventive medicine should not be given. Evacuants may be given 7 with great safety Witness the long diarrhoeas & the salivations of dentition which they bear without emaciation The milder purgatives should be used. The drastic are irritative calomel is one of the best. 1st Retention of meconium & its consequent diseases. The meconium is a dark green matter resembling tar Its evacuation should be effected not by medicine but by the first milk of the mother. The act of crying also contributes to this effect. Instead of suffering the nurse to feed the child during the first two or three days the breast should soon be present If the child feeds, it is in danger o f losing the instinct to suck Evacuants are 1 gr. of carbonate soda to a teaspoonful of water until 10 gr. are given is a good cathartic Molasses & water may be used likewise The gall of animals 8 in a good cathartic as a substitute for the childs own bile. It may be given in catnip tea, milk etc. We may use also Decoction of the flowers of the dandelion and of the mullein. The best however is generally castor oil teaspoonfull at a time until evacuation is produce Senna likewise, in conjunction with some aromatic herbs & seeds 1 dr. of these to 4 of senna The operation of cathartics must be assisted by emollient injection & also by fomentations of the bowels & the warm bath. The blue pill may be used. Also 1 gr. calomel & 4 or 5 of chalk repeated once in 2 or 3 hours assisted by bitter & aromatic herbs in the way of injection These last thus will frequently answer by themselves. Blue pill & chalk & calomel rarely offend the stomach These measures must be pushed vigorously & used in conjunction also especially the warm & tepid baths 9 in cases of convulsions from retention of the meconium. Dr Ives has not known salivation produced in infants by mercury. This may be explained by the large quantity of mucous which defends the surface of the intestines and enabling infants to bear large doses of calomel. The abundance of meconium contributes also. Antispasmodics e.g. aqua amm. 3 or 4 drops also 3 or 4 gr. carb. amm. also asafoetida a teaspoonful of the tincture injected in milk & water into the rectum. These may be used Young children are often troubled with hiccups & irritation caused by acidity, which must be corrected by alkalies. Sometimes this must be corrected by regulating the diet of the nurse. If as is occasionally the fact the mothers milk disagrees, as is shown by the [illegible] stools & the obstinate crying of the child, then cows milk diluted with one third or one half water or with arrowroot mixed first 10 a table spoonful of cold & then of hot water in order to make a homogeneous mixture. Children fed on cows milk are more apt to be costive. To prevent this give a little magnesia, decoct. of dandelions etc. Peach tree blossoms are much used as a cathartic, but are too violent. Children are sometimes born with a tumour of the head occasioned by difficult labour This may be distinguished from a tumour occasioned by a defect in the bones of the cranium by a uniform hardness Aphthae or thrush Sometimes accompanied with a typhoid fever Sometimes idiopathic. It is a disease of debility, caused by disorder in the primal viae. In some families all the children are affected with it Among the poor bad air & among the rich too great warmth & confinement are the predisposing causes It is a vulgar but mistaken opinion that all children 11 must have this disorder at some period or other Symptoms 1st languor, then white specks or flocculi in the mouth, which finally affect the aesophagus, the rectum (for the orifices of the tabes are more sensitive) & perhaps also the whole alimentary canal though this is disputed. The white spots are succeeded by others of a darker colour. It is thought to be prevented by giving a teaspoonful of cold water soon after birth & subsequently repeating the remedy [illegible] [illegible] heat good Castor oil is objectionable because it does not affect the secretions & does soften & relax the mucous coat of the intestines 10 gr. to 1 dr. of magnesia chalk cal. Dissolve 4 or 5 gr. ipecac in 6 teasp. water & give one teasp. at a time If it does not evacuate the bowels calomel or rhubarb may be administered. If the ipecac moves 12 the bowels too freely given on a sixth or eighth of a drop of laudanum In case of acidity white decoction consisting of chalk ½ oz carb. pot 1 scruple 1 [illegible] or [illegible] [Comus] [cir] [sericia] & asking [illegible] Lime water & milk may be given for acidity 6 gr. chalk 1 gr. cal. with a little ginger for watery stools or a small quantity of rhubarb instead of the calomel No violen local application should be used It was formerly thought that the disease might be removed by rubbing off the aphthae by a swab of cloth Inflammation of the mouth was caused. A little borax and sugar equal quantities a drachm in a gill of 5 or 6 of [illegible] in [powder] put into the mouth water Or mucilages, of violets (v. pedata) decoc. of sassafras [illegible], or comfrey A small quantity of sugar lead in the mouth may be [illegible] In children more advanced thrush is sometimes a critical termination of diseased action & then frequently a favorable 13 symptom e.g. hydrocephalus Ipecacuanha in small quantities as an alterative is particularly to be recommended Strophilus intertinctus of William red gum papulae Nurses consider it the same disease with thrush Red gum comes from red gown made of [stom] on calicoe The vesicles rarely contain lymph terminating by scales & not attended with constitutional irritation It arises from heat bad air confinement & irritation of primae viae. When repelled followed by bowel complaint & convulsions The patient should be kept clean and daily washed with tepid water. The tepid bath may be continually used & is the most efficient remedy when the eruption is repelled from the skin 14 food Strophilus candidus Papulae with non inflamed base appearing like very small pearls under the skin about half the size of a millet seed continuing sometime Prof. I. has seen it following cholera infantum A close examination is necessary for its detection Reference made to Willan Ulceration of the mouth called canker Sometimes very troublesome called food is a cause Commences with an inflamed point in the mouth The edges of the ulcer inflamed & elevated Child drules much febricula torpor of intestines 1st excite al. can by magnesia or blue pill or calomel. Then use Moseley’s tonic solution. Compound tinct of vitrine (sulph cop. in alc. water of crystals 15 marsh rosemary geranium [rac.] tinct kino internal app [illegible] [illegible] sulph. cop prescription Nitrate silver corrosive sublimate Prof. I’s own case corr. sub. & op [illegible] astringent [illegible] rhus cornus Rx sulph. cupri 10 gr. carb. Peru a dr. given at 1 dr. Hon & dr water 2 touch the part with a pencil violets allied to ipecac So also asclepias particularly A [decumbens] 16 Costiveness in infants A physician is frequently called when the infant is perfectly well with the exception of costiveness. This will produce a variety of complaints e.g. watchfulness, starting, hiccup, & convulsions. Frequently the child is not observed to be unwell until the convulsions come on The remedy is injection. For we can only operate on the al. can. the lower part, & the skin the mouth being closed We must be careful to make our prescriptions for an enema, very definite. Case of a mason’s man hands & knees about 3 ft. off shooting fright, murder Simple warm wat. or milk & water or about a table spoonful of salt or thoroughwort catnip etc. or finally castor & other oils. Sometimes in extreme cases fill the rectum with lard. Sometimes as a nervine a teaspoonful of camphor in a gill of milk. If these do not 17 answer, used the tepid bath. The water should be heating, while the enema is administered. the water should be about blood warm. Be careful not to sprinkle or scatter water in the patient, instead of bathing. Time 5, 10, 15, or 20 minutes As soon as the patient can swallow, or while it is in the bath give calomel For a child 6 months old 6 or 8 even 10 gr. If improper food is the cause 20 gr. are not dangerous for infants will beat full doses of cathartics, but very small of narcotics Various articles of food are used to obviate costiveness. Oatmeal gruel rye-meal gruel, rye bran gruel Castor oil is the best cathartic a teaspoonful or tablespoonful Magnesia is good and may be given in milk Elixir salutis is one of the most common family medicines. Castile soap is a good cathartic but ½ oz or oz is required. The bile of other animals is a good remedy. Blue pill various vig. ext. e.g. fl. of [mullein], peach, dandelion etc. 18 It is better to cure by food than by medicine Mechanical means called suppositories e.g. candy introduced into the rectum] are common among families Infantile erysipelas Its classification is doubtful It answers tolerably well to the [illegible] of Good No species in Bateman & [Willan] like it Red patches A severe & dangerous disease apparently the same with the dangerous roseola or [illegible] of the West Indies. Elevation of the skin is not so great as in erysipelas Generally commencing on the legs and thighs, & extending like erysipelas. Attended with constipation tumefaction of the bowels, hiccup & severe fever & terminates fatally with come Give calomel 8 or 10 gr In two hours repeat the dose. Then evacuate with 19 senna mixed with aromatic seeds or if this is not sufficient, with castor oil senna or scammony Then keep the bowels open with blue pill External applications the best is flour or arrowroot. Prof. I has sometimes blistered in imitation of Dr Physic Probably every case would be fatal if treated with bad water and did not evacuate the bowels. If diarrhoea is produced give compd powder of chalk of the shops & other sim. articles In erysipelas of the head we may use the common discutients in conjunction with evacuants. Children are subject to various anomalous eruptions, in consequence of improper articles of food. This is frequently the case with adults e.g. fish & pokeweed An excessive quant. of food may cause them Always pat attention to the diet. This will 20 if persisted in, cure most eruptive diseases Avoid oily food such as nuts crusta lactea (milk [illegible]) Porrigo larvata of Bateman On the lips forehead scalp. First pustules yielding pus until a scab extends over the whole face. It never leaves a scar. We must be cautious of checking it especially when of considerable continuance. Sometimes it degenerates into a phagadenic ulcer, In such cases Prof. I. has used charcoal externally poultices, a variety, & has seen much advantage derived from roasted flour, it absorbs and excludes the air. It is proper to give a dose of calomel. The buckthorn is thought to be particularly serviceable in cut. aff. In case of great irritability chalk may be combined with 2 or 3 gr. of cal Diluted muriatic ether in doses of 5 or 10 drops in water 2 or three times a day, has been much used, and may be [recommended] It may ½ dr [illegible] 1 oz alcohol Ext. 2 dr cal 1 oz sim. cer. Oxygenated oint Nit. ac. & lard Nit. ac poured on warm lard Citron oint more efficacious When the [illegible] does not answer [illegible] [illegible] [illegible] app e.g. sulphuret of potash 2 dr. [illegible] in a pint of water smells like bilge water This may be [illegible] in doses of a table spoonful. prob. [illegible] to sulph [illegible] Others prefer sulphuret of soda. Sulph. of [illegible] is equally effic. fever ensues If the eruptions dry up suddenly give antimony & calomel [illegible] children have a [illegible] rash [illegible] 22 Teething in children is frequently attended with an eruption, resembling a fine rash This should not be interfered with lest it be translated to an internal part. It is an effort of the system to relieve itself An eruption resembling porrigo frequently comes on in summer consisting of watery pustules resembling the itch. It is not cured by dock root. It may be cured by diet & the warm bath. Eruptions translate action from the viscera especially the liver, as in gutta rosea of rum drinkers. Venereal eruptions Some think it may be inherited from ancestry instead of parents. Smooth hard circumscribed like of half a pea increase slowly for 2 or 3 wks. then become filled with a watery fluid, & become a ragged ulcer 23 Treatment. Change the nurse if derived from her 1/30 or 1/40 gr. corr. sub. in water blue pill in moderate quantities tepid bath sometimes tonics of iron mur. fer. tartrite fer. alk. solution of iron Sometimes patients resist the mercurial prep & the rem. for scrof. In this case send the patient into the country for air & try simple vegetable articles e.g. exp. juice of plantain, ext. & internally It is a popular remedy for poison & is apparently valuable. It has cured such infants, when conjoined with the country air Its virtue is owing to its bland & mucilaginous quality Sore ears Nature has chosen the back part of the ear to eliminate morbid secretions. It relieves affections of the brain Frequently there is a miliary eruption, followed by excoriation In most cases so mild as merely to require 24 washing If the discharge stops suddenly it is liable to be followed with torpid bowels fullness of fontanelles full tense pulse cold extremities. When infants are suddenly attacked with disease inquire if they have had sore ears which have suddenly dried up in this case apply a blister behind the ears, without this nothing will cure perhaps. This is true of old sore [leg]. The theory is not the necessity of the evacuation but of the habitual action in the system Sometimes troublesome ulcers, yielding an excoriating discharge; followed by gangrene & death Poultices & ac. plumb. are good Powdered gypsum is one of the best applications (alabaster is the finest kind) Case in which alabaster cured without red precipitate The oxygenated ointment is the mildest & best where ointments are proper for sometimes they disagree Bowels be kept 24a open with calomel. Frequently it is necessary to change the diet of the nurse & to confine her to a simple diet. A discharge from the nose or ear may frequently be cured by keeping up a discharge behind the ear by blisters A teaspoonful of myrrh to 1 gill of water is one of the mildest ext app. Sometimes use nit. sil. Diarrhoea Sometimes affects children for months & even years, in some families. Sometimes it arises from a bad constitution Caused also by want of cleanliness, bad food & want of cleanliness, bad food & want of air & exercise. Young animal (also vegetables e.g. fruit trees after a season without wind) need exercise Children need mental stimulants, from external objects. This is the principal secret of change of air. If the child 24b Bad air probably causes diarrhoea merely by its depressing influence is teething we must palliate not stop the diarrhoea. For this is an effort of the const. similar to tears from an irritated eye & mucous from the lung IN the commencement of diar. mentha vulgaris pounded the juice expressed, boiled, skinned & mixed with white sugar, will frequently cure. Ipecac will freq. cure. We must generally begin with a cathartic sometimes adding chalk to qualify calomel, when we give it for its deobstruent operat. Use blue pill for feeble & delicate children,. Prof. I could for many years take no other cathartic without griping. Often we must enquire particularly about the diet. Arrow root with a little spice, or a little laudanum, or wine. Sago tapioca, is a hydrate of flour moistened & dried by heat (probably) Roasted or baked flour & flour tied up tight & boiled, then grated, made into porridge is better than flour unaltered Rice in gruel, or thoroughly cooked by boiling 25 The worst cases have dry skin & feeble pulse. Use tep. bath & keep up an action of the skin by flannel In chronic stages absorbents will be needed chalk [illegible] oz cin zii [illegible] 4 oz carb pot zss. wat 1 pint Powerful means of counter irritation e.g. mustard horse radish, monarda punct. sp. turpent. about the precordia when the danger is very great, In case of something like cholera coming on By this means we can make articles stay upon the stomach [illegible] etc. will be grateful & stimulating As a tonic moselys 3 dr 1 al. pt. boil water cathartic [illegible] in [large] [illegible] 4 to 20 drops [somet.] [illegible][absor] Opium is often necessary, generally it is better, when qualified & rendered more diffusible in its action by ipecac. Invaluable in chronic cases of great irritability 26 Charcoal in fine powder, will correct the fetor of the stools & often cure. Particular attention should be paid to the stools for much may be known by them. Acid is formed in the whole al. can. Hence sour & curdled stools This will indicate lime water absorbents & aromatics. The acid may arise either from fomentation or (probably) from secretion. In case of clay coloured stools give opium to allay irritation ipecac. to equalize excitement & determine to the surface mercurials as deobstruents Give also mucilaginous or alkaline or laudanum (in starch) or (in case of griping) camomile injections. Often soap is useful also compd tinct. senna After the long continuance of the disease support the bowels by bandages, & apply a plaster of lead and soap. After great emaciation & when [illegible] [illegible] water softeness 27 tonics astringents (at least 50 ast) e.g. currant raspb. bark in milk oak bark chocolate of acorns Peculiarly adapted are spir. [illegible] & cornus [illegible] or [seria] (decoc in milk) [illegible] It equalizes excitement more white pine bark in milk watery urine In case of great craving as for salt provision etc. in extreme cases gratified Of mucilages are a variety for they will be worn out [typh??] latifolia sassafras bran flaxseed etc. etc. Great aversion & nausea & vomiting attending the administering of remedies will make them operate like tartar emetic, and debilitate. In such uses the gratification of the appetite will prove a stimulus especially to the mind & therefore the more powerful This is true of adults also. Case related of a patient who could retain no medicines & recovered upon bread and cheese. 28 In the latter stages acetate of lead may be given internally. The bowels are too much relaxed to admit of colic. A troublesome symptom is prolapsus ani The intestines should be immediately replaced Take the neck of a bladder or the crop of a fowl, filled with water, as the softest & best irritating thing to apply. A [illegible] cloth will irritate the sphincter & make it contract. Afterwards apply astringent washes e.g. white oak bark or the bark of any of our forest trees Cal mag ½ dr rhub 8 gr gum ar. 1 dr. wat. 1 oz pepper ol. [any] 6 drops [or] tablespoonful Vomiting It is very common in healthy children in consequence of over distention of the stomach. The child should not be allowed to nurse so long at a time Children & old people vomit with more 29 facility than the middle aged Vomiting from irritability of stomach is important feeble pulse, cold extremities must horse rad. 2 z chalk 1 z card. seeds ½ z carb pot or [illegible] [illegible] [illegible] 1 pt water tablespoon Prof Ives thinks the alkali creates an excitability. Frequently the irritation of the lower part of the bowels by an injection of salt & water, or a large bulk of warm water, or a calomel cathartic. The tepid bath & nervines are useful also Young physicians are often called on to prescribe for hydrocele in children Apply opium camphorated applications etc. In the morning apply cold water & spt. of nitre. Prof. I. has had to operate in but one case. 30 Volvulus or introsusception. Not commonly a primary disease. Prof. I. was at first very much perplexed with it, finding no satisfaction from the books. The upper is received into the lower portion Sometimes one involution is doubled in upon another 1st Involution of the small 2nd of the large intestines. It occurs in particular families of delicate constitution. Undoubtedly the bowels sometimes disengage themselves from slight degree of this involution The symptoms of the first kind are constant tendency to vomit, frequently attended with a sympathetic action of the rectum Throwing of the hands & feet paleness of countenance rolling of the head & other symptoms of extreme irritation like strong her. specks only of blood In the large intestines when a cathartic is given it passes down as far as the involution & is then thrown up 31 this act may frequently be heard Drastic cath. often are the causes hence where there is a liability to this disease do not give them In case of the small intestines being affected depend upon opium mixed with aromatics and depend upon this until the bowels restore themselves which however will be doubtful. In the second kind give all remedies by injection, apply the warm bath. By very copious injections, attempt the restoration mechanically. Case related of a young man cured by inserting a bougie of a spermaceti candle with opium at the extremity, & keep it up some time Another case cured in the same manner Sometimes the disease arises from a natural stricture of the bowels incurable 32 It may be caused by worms. Case of a worm involved in the fold of the intestine Case of a delicate school girl. Pulse low weak and small vomiting restlessness, throwing of the hands & feet. Great irritation about the urinary passage & fundament. Tongue not much affected. Deficiency of action in the liver & two or three volvula were discovered on post mort. exam. Ascaris tricocephalus was found to be the cause Cholera constipation of the bowels with fever bilious remittent fever, marasmus etc. etc. It is a common bilious fever, produced by causes affecting the bowels Symptoms pulse full, frequent, tongue furred skin hot. Bowels full and hard, urine small in quantity & high coloured, costiveness breathing laborious face flushed sometimes cough Evacuate the stomach & bowels by emesis & catharsis produced by 5, 10, or 15 gr. 33 of cal., in order to produce a strong impression upon the whole digestive canal & hance upon the system at large In enteric cases & vigorous habits a little tart. emet. may be added Repeat the cal. in 5 gr. doses every 3 or 4 hours leaves senna ½ oz manna 1 oz [pint] give senega blood root etc. if the lungs [illegible] z [seneca] [illegible] [root] may be [illegible] or 2 z [illegible] Give enemas or injections to assist the operation of the cathartics after giving the cath. time to operate The stools frequently contain flocculent portions of membrane. If the stools continue vary cath or [illegible] mag. sol. tartar phosphate of soda neutral salts to In the latter stages of the disease give blue pill instead of calomel 34 Sometimes Prof. I. has added acid to quicken the action of the mercury The fever abates in 48 hours It may continue f or weeks sometimes. The termination may be in volvulus in hydrocephalus If the disease continues for 2 or 3 month a regular remittent, the best remedy is Fowler’s solution in 2 or 3 drop doses If this produces edema & dropsical affec then give bark or Moseley’s tonic sol. beginning with about 4 drops After the inflammatory action has gone off give opium alone or combined with ipecac or antimony Blisters are useful in ass stages. They translate action to parts less essential to life & in the latter stages keep up the action of the system Use any of the irritants. If the lungs are affected apply a blister to the chest. The warm bath is useful. 35 If the head is affected apply a blister to or behind the ears Sometimes the mind is so affected that no medicine will be taken without great force. Then use tepid bath A large blister of aloes & ginger will move the bowels Frequently the derangement & revengeful disposition (according to Dr. Bush an affection of the moral faculty) that we must wait even for 24 hours or more without administering anything Great skill is in this case required to satisfy the parents If cathartics which first produce emesis are used we may be sure that the whole al. canal will be operated on We often also need a remedy more powerful than the disease just as in croup Case of a child 2 yrs. old. Pulse full & frequent tongue furred skin hot etc. After the paroxysms the opposite symptoms come on violently. The system was roused 36 by mustard to the feet & arches followed by blisters on the same parts blister on the chest ammonia in the mouth caustic ammonia in the nostrils to excite infl. Worms. This subject naturally follows that of intestinal diseases. Worms are not contained in the bowels of children under 2 mo. generally not while they suck if they are, they probably are introduced in water Worms in the int. can. are not so common as formerly. Said to be common among the aborigines owing to their crude diet. Derangement of the stomach & intestines produces all the symptoms of worms. It is undoubtedly the fact that healthy children have worms which produce no injury until the system is affected with disease. Case of a healthy child who fell from a great height coma a dose of calomel brought away 20 or 30 large worms 37 They may be injurious from their number consuming too much food 1st Tape worm (taenia) armed & unarmed. 2nd Tricocephalus (hair headed) these are the most irritating 3d Ascaris (round worm) lumbricoides, & vulgaris 4th Gordius rarely found in the human stomach Prof. I has known them coughed up from the lungs they probably came from an abscess in the liver. The gordius is sometimes found in the earth in great numbers they turn black on exposure to the air, and resemble a horse hair, hence called horsehair worm. All eruptive & even all contagious diseases have been attributed to insects. Even miasma has been explained by an Italian writer as consisting of insects vide N.Y. Rep. about the year 1815. Cancer & tooth ache have received this explanation 38 The symptoms of worms are very equivocal and coincide in general with the symp. of irrita Count. pale, flushed bloated sallow eyes dilated grinding of teeth in sleep, starting in sleep palp. of heart, pain in stomach when empty, relieved by food, urine pale coloured, or milky increased or diminished nausea, vomiting, irregular appetite, loss of appetite, costiveness Irritation about the neck of the bladder in the case of ascaris. Severe pain about small intestines & umbilicus, indicates tape worm Irritation at the rectum, indicates ascarides as do also irr. of urethra & increase of urine & milky urine Tape worm oftener affects adults than children. Sometimes it exists without the symptoms of worms. 2 quarts in a day have been brought away in a day, & yet they would return in a few days! They increase with wonderful rapidity. Case of a woman who kept passing them for months in great quantities finally diet was tried instead of medicine 39 All food was roasted or boiled even the water used for drink was boiled Cured Healthy bile or gastric fluid will destroy them. Hence an important indication. Spts of turpentine are an old remedy among the people Case of an old man who made himself drunk with half a gill or more of it. Fowler’s solutions 2 to 4 drops 3 or four times a day has cured. This is prescribed for the taenia or flukeworm [illegible] has been considered a specific Osmanda cinnam. has been given by us for this article. It is bitter astring. & sweet. Polyp. vulg. is a tonic & deob. Other forms may be used Ether, particularly in injection is good mad. [illegible] for [illegible] panada pound & half & 2 or three ounces of fresh butter if costive 1 pint of water salt & [illegible] olive oil or an injection in order to fill up the al. can. 8 or 9 hours after 3 oz [f.] m. in [illegible] 40 in water or decoc. of f.m. or [illegible] cal. & car. 12 gr. each [gamb.] 5 gr in a bolus. Oil is used to fill the respiratory holes of the tapeworm Ether had been added by French & Ger. Rue has been used. Pearl flowers. [illegible] power Amalgam of tin & mercury has been detained in the bowels. These mechanical remedies are not now used. Formerly crude mercury to the amount of a pound was frequently given as a cathartic Astringents have been used bark of milia azedarach of prunus virg. The former is given in decoction to the young negroes at the south who are much subject to worms It has much of its virtue when dry Symptoms of tape worm sense of weight (where the worm is in great quantities) irr. stom. nausea loss of app. irr. app. weak chylop. viscera bloated countenance 41 etc. All which however may arise from mere irritation of the stomach The irritation of the tricephalus amounts to derangement throwing of the hands etc. Prof. I. would prefer narcotics for this worm but cannot speak from his own experience he recommends an injection of a teaspoon or tablespoonful of ether in a gill of water or mucilage. Ether will undoubtedly pass the valves, when injected. Prof. Ives has thought that fern given in pieces operated mechanically especially [assmunda] Ascarides are said to in habit the rectum this is a mistake. They multiply abundantly & lodge in the rectum about the sphincter, as they daily pass off. Besides the irritation of the rectum they produce in the small intestines severe griping pain about the small intestines. Very troublesome to cure the best remedy 42 is injections always effectual for the time being. Relief for the time being by washing them out with injections of warm water. Aloes added will be better. The best however is camphor, as a nervine and narcotic & a poison to the worm Calomel is useful, not in destroying this worm but in restoring healthy secretions for worms will not live in healthy gastric liquor. All indigestible articles such as raw fruit, acids, cold water etc. will be injurious. Alcoholic tinctures aloes, elix. propr. or sol. tincture of hickory buds or bark in teaspoonful doses is one of the best things. To prevent the return of the worms use condiments pepper ginger etc. all warming & bitter things. In extreme cases avoid every thing which has not passed the fire. The eggs are exceedingly minute & yet each consists of numerous others probably they 43 are absorbed by the lymphatics carried into the circulation & deposited in various parts of the body especially upon the muc. memb. of the al. can. only upon the mucous parts. Dry & stimulant diet is better than cold & liquid. Some remedies act upon the worms themselves e.g. narcotics Some narcotics operate on some animals & not upon others e.g. sheep eat stramonium which poisons swine. Mechanical remedies are filings of iron & tin cut hair, & perhaps the prickly cowhage Other remedies are powerful cathartics merely others again tonics & deobstruents Ascaris lumbricoides requires no peculiar treatment Use spigelia, calomel etc. Spigelia is a narcotic it kills the worms & it may also be prescribed for the same set of symptoms where no worms are present. 44 When given to intoxicate the worms give from 2 z to ½ oz in decoction in the course of the night, accompany it with rhubarb, or follow it with calomel or any cathartic to drive the worms off while in a state of intoxication. Veratrum sabadilla is used as a narcotic Of tonics all the astringents & barks the min. acids sulp. zinc & iron etc. Cathartics the best is calomel also use the drastic, as scammony gall is good ether, asafoet. petroleum, seneca oil, barbadoes tar etc. as antispasmodics Chenopodium anthelminticum & ambrosioides are called worm seeds An essential oil is extracted from them. C. botrys or jerus. oak are useful as nervines & for the cough, but probably do little good as anthelmintics. The garlics are used (nerv.) They have considerable effect upon the intest. canal Artimisia santonica from Africa the tops of flowers, this is called wormseed It is a bitter 45 The asclepiades most of the common species as syriaca, pulchra, or [illegible] this latter is often used & has seemed to do good so A. incarnata & A. decumb. Podophyllum pelt. is used as a cathartic probably not better than others The best form is that of tincture The number of worm cases & colica is much less than formerly owing to the change in our mode of living Butternut bark decoction in tablespoonful doses is a popular remedy. It is intensely bitter The geraniums are used all the aromatics and bitters indeed which are found spontaneous Ether is used both by the mouth and by enema Butternut bark is cathartic & said to be narcotic 46 Convulsions Two kinds sympt. & idiop. Children are more subject than adults Causes all the causes of irritation Sudden suppression of evacuation. Teething irritation of excessive or indigestible food upon the nerves of the intestines. Acetous fermentation of food in the prima viae The predisp. said to be sometimes heredit. Said to be produced by change in the milk Also by agitation in the mind of the mother affecting the milk. The countenance also of the mother affects infants very much much more than is commonly supposed. So of the bystanders Treatment depends principally upon removing the exciting causes & then upon obviating effects If the cause is in the prim. viae give it first 5 or 6 of sulph. zinc or as much of ipecac. If the substance has passed into the duodenum give a cathartic, assisted 47 frequently by injection. OR use calomel as emetic & cathartic both. Enquire particularly about diet for a general answer may be false Frequently several large doses of cathartics are needed to overcome the torpor caused by excessive quantity of food Also the food diminishes the cathartic operation. Hence the French dinner pill calomel 5 to 10 jalap 1 to 3 scammony senna manna castor oil & neutral salts are the cathartics If the convulsions continue used [illegible] Calomel sometimes by irritation produces convulsions spasmodics one of the most efficient is the tepid bath. If the patient is much agitated by being put into water cover the tub with a blanket & lower the patient gradually: there is then no difficulty Potash, carb. pot. or aromatic herbs may be put in the water. Continue in from 5 min to ½ hour if exhausted to be taken out Wrap in a blanket & put in a bed keeping 48 up a uniform temperature Oil of amber was Dr Rush’s sheet anchor musk internally Articles applied the whole length of the spine as mustard, ol. origanum etc. etc. Empyreumatic oils hence soot tea is very useful It contains carbon amm. & pyrol. ac. Oil of valerian is a nervine Mineral oils as british oil petroleum etc. Ammonia is one of the best 2 to 6 drops in 1 oz water Applied also to nose & mouth & rectum Dippels an. oil owed its virt. to ammonia. It is very fetid & distilled from berries 10 to 20 drops tinct. asafoetida; or by enem. 2 z caustic potash, or the impure carbonate by injection is very valuable. So all the caustic alkalies Opium is a powerful antisp. may always be given unless contraindicated by other symptoms The frequent recurrence of spasms may be broken up by continual doses 49 of opium. IF they recur once in a few weeks give cathartics to prevent them. When called 1st inject. 2nd tepid bath with alkali in the water. 3d apply irritants as must. horserad. garlic, ginger etc. giving, even in the commencement ammonia by the nostrils. When the patient can swallow give calomel. When the stomach is overloaded, the child cannot swallow, & we wish to give an emetic, we can often succeed by irritating the throat with a feather laying the infant upon the hand & in this way supporting the abdominal muscles. Epilepsy a regular or irregular return of paroxysms of convulsions attacking suddenly falling twitching etc. followed by coma Causes in children generally diseased state of al. can. kept up by habit which last is frequently very difficult to break up 50 caused also by malformations tumors of brain malformation of brain etc. derangement of system produced before birth by syphilis from the same causes as rickets more rarely from mere irritation without some offending cause as suppressed evacuations Treatment generally the cathartic giving calomel 3 or 4 times a week If the canal is loaded with mucus conjoin 1 or 2 gr. gamboge 5 gr. scammony & 5 of jalap which yet will operate kindly though [illegible] The best evacuants are those which change the secretions If there is a deficiency of mucus an abrasion as it were give blue pill also cojoin chalk. Most cases are curable by careful management both of the physician & of the nurse Regulate the diet with great care. Generally however there is a morbid appetite & a sub derangement about eating & also about climbing & such things 51 They will be so active & artful as to be managed with great difficulty Catalepsy called still convulsions It is a tonic spasm Insensible & apparently asleep scarcely breathes sometimes a little motion of the eyes continues from a few minutes to several hours Treatment the same as in other convulsions It follows other convulsions & sometimes follows drastic cathartics. Whatever position the patient is in in that will he remain Prof. I. has had several cases Chorea Sancti Viti rarely fatal not difficult to cure under the age of puberty If it commences before & continues after that period seldom cured. The muscles are partly subject to the will. They also have involuntary motions. Caused in children often from irr. in prim. viae from 52 morbid irritability arising both from diminished & from increased action Said also to arise from infl. of the brain Indications narcotics & cathartics if arising from disease of al. can. tonics as iron, mineral acids & electricity if debility is the cause. Prof. I thinks the disease frequently runs its course & then the cure is attributed to the last used remedy. The cathartic treatment has not succeeded very well in his practice. It occurs oftenest in females of relaxed const. about the age of puberty especially if they have grown rapidly or been much confined to the needle or to study Ammonuret of copper 1 to 4 gr. was Cullens favorite remedy Case female treated with epispastics & narcotics took arnica 2 z to 1 pt boil. water doses increased till the head was affected (It is tonic & narcotic) Without benefit Next cathartics Next metallic antispasmodics 53 Next epispastics Finally recovered under bark in substance 1 oz a day. Sometimes arises from affection of the mind The presence of strangers is injurious the sensibility of the patients being very great When caused by epilepsy treat as for that disease Sometimes comes on very gradually & is not suspected causing apparently bad habits in walking etc. Case which had been coming on in this manner was brought to a high degree by dysentery & went so far as to present the peculiar symptoms of hydropohobia horror of water etc. Conium [illegible] & iron sulph. zinc sulph. copper & other metallic tonics have been principally used by Prof. I. Use various narcotics as nux vomica Use the antispasmodics as palliatives e.g. valerian asaf. musk Case in which the disease was broken up by elaterium 1/8 of a grain at a dose combined 54 with chalk. This is the only case which Prof. I. has broken up Case of a young man who had been confined as a clerk in N. York thrown into derangement & convulsions by a sight of distress on board of a packet Elaterium was given to prostrate the system & break up the habit successful. This led to its employment in chorea This disease may affect the mind causing it to run upon particular subjects especially numbers. Case of a book pedler with these odd motions & also this facility of calculation equal to Zerah Colburn. he was overtaken by Prof. I. in travelling. Zerah Colburn, though sent to Europe never improved agreeably to the predictions of Prof. I. who has seen several cases Their countenance & articulation are peculiar [memory] & judgment deficient 55 Nux vomica as a narcotic may be given in doses 1 to 2 gr. [illegible] in pill or 15 to 20 drops of alcoholic tincture Setons, issues tartar emetic ointment along the spine are used. The latter is not to be used where there is excessive irritation doing injury. Tepid bathing is seldom proper Cold bathing sometimes succeeds. Prof. I has known little success attend the employment of electricity. If the disease is not translatable it is made worse by counterirritants. Dentition of the highest importance always more or less affecting the bowels & the nervous system It affects also the glands the cell. memb. the brain the ears [illegible] in them the lungs etc. Adults are also affected Case of a young woman cutting 4 wisdom teeth who was thought to be consumptive. The period of cutting commences from the 4th to the 6th month. Some persons 56 never had but 2 incisions Children are occasionally born with teeth but the teeth sit loose in the gum without [fangs] & should be removed to prevent their being troublesome Some families are said to have no teeth their teeth being even with the gums such are very serviceable & are not subject to decay. Case of a family of this kind from Charleston Symptoms fretfulness biting slavering starting in sleep flushings of face fever hot head & cold feet diarrhoea sometimes costiveness green stools increased urine (sometimes diminished) bloating of hands feet & face contracted pupils eruptions on the skin all the symptoms of irritation the children are particularly subject o phlegomonous inflammations. Case of a child who was thought to have an aff. of brain. A tumor was found under the arm Treatment diarrhoea relieves the irritation Indications 1st divide the gums the operation 57 is not usually painful They will even bite the lancet It may be done in sleep without waking them The difficulty is to confine the child & avoid cutting its tongue. [Gum] lancets may be made with a guard. Make two incisions for the double teeth & sometimes it is necessary to divide a ligamentous band in the middle. It is an objection to cutting the teeth too early, that the scar formed by healing will be more difficult to be cut through by the teeth. This not true a scar has less vitality & is more easily broken through 2 or 3 cuttings may be necessary the symptoms continuing to return. For infl. use the antiphlogistic treatment sometimes bleed in the arm better generally to apply leeches behind the ear. Cathartics as magnesia & rhubarb conjoining aromatics & chalk where there is acidity. Equalise excitement by ipecac & antimony with or without opium 58 If a diarrhoea suddenly stops apply counterirritants to the pit of the stomach the warm bath. Avoid currents of air etc. Blisters behind the ear will be often serviceable & prevent hydrocephalus. They are sometimes applied to the arm. Use antispasmodics with or without ipec. etc. Rickets Caused by confinement too much clothing too much saccharine food etc. Generally there is an earlier mental development They do not make abler men however Hence the impression that precocious children # symptoms soft flesh paleness of countenance hectic fever, tumefact. of bowels muscles & cell subst. less joints larger head large fontanelles open veins of the head large & blue app. & dig. bad tendency to acidity The teeth are cut later Appears at about 6 months Nearly allied to scrofula in affecting the lymphatics & osseous system # will die early. They are in fact generally diseased 59 This is a disease of weak morbid action Indication strengthen the vital powers by stimulating & dry diet especially by cold bathing taking the patient out of the bed in the morning bathing & returning occasionally cal. & ipecac. general friction exercise open air mental stimulus of the open air vegetation etc. etc. This affects the secretions powerfully. Different tonics are given e.g. Fowler’s sol. sulph ferri bark (bark waist coat) Astringents & absorbents for there is frequently an acid smell Burnt bones phosphoric acid alkalies (pearlash) etc. Pearl ash is applied externally Of late iodine has been very serviceable 2 to to 4 drops alkoh. tinct. given in mucilage of gum arabic etc. The worst cases are the syphilitic these require mercurials. The deficiency of the phosphate of lime is an effect & not the cause. Hence burnt bones must have been useful as an absorbent & perhaps 60 as a tonic not as supplying the matter of bone The chylopoietic viscera are probably first affected & then the mesenteric glands & lymphatics. Avoid featherbeds etc. Sweet fern beds are very popular. They are hard & the odour corrects the acid smell of the disease. Muriate of lime & of barytis were formerly much used. Cholera infantum Appears in months of July Aug. & Sept. Sometimes in June & Oct. Approaches in various manners e.g. with a gradually increasing diarrhoea with vomiting & purging the stools being green, brown, slimy, watery, or with the smell of putrid meat a high fever may exist also great restlessness in bad cases cries of pain once in 1 or 2 hours pulse quick and weak fever remittent sometimes terminating in hydrocephalus or volvulus Eyes often languid & hollow half closed in sleep often in the latter stage preternaturally 61 There is sometimes a great degree of mental excitement bright (their eyes are half closed in various complaints) The vomiting may cease soon may alternate with the diarrhoea The disease sometimes ceases soon at others runs on for months This summer epidemic varies according to the season according to the changes in the air or the weather which affect children more than adults. The patient is carried off in convulsions or is worn out by emaciation and dies with aphthae or dies with hydroceph. volvulus & other diseases Causes bad atmosphere malaria (a general tern for miasma & [illegible]) Dentition is an exciting cause not the primary cause as some suppose. Children weaned in the spring are very apt to have cholera infantum in the summer. Children at the breast bear the disease better Hence let them be weaned in the fall 62 A disease it is of debility & has for predisposing causes bad food etc. both as remote & exciting causes It is a fever translated like dysentery from the surface to the viscera commencing at the skin & breaking up the balance of the system then attacking the mucous memb. of the intestines Indications 1st evacuate prim. viae 2nd translate action to surface & so equalize excitement 3d excite healthy secretory actions & [illegible] peristalt. action. 4 avoid causes of irritation & remove them where they exist 5 restore the tone of the system particularly of the stomach & bowels 1st Aromatics ess. peppermint counter irr. to stom. & bowels as must. horseradish injections of starch & laudanum & tepid bath must be used in case of vomiting, or attack like cholera of adults When there is a diarrhoea at the attack evacuate with deobstruent cathartics & ipecac. Give calomel & ipecac first giving 6 gr. cal. 63 Small doses of calomel will not answer instead of full doses & ipecac about an hour afterwards ipecac The southern physicians do not use cathartics so much depending upon stimulating injections e.g. of salt and water They give smaller doses of calomel This practice does not answer so well here # In case of small watery stools we have often reason to suspect that the bowels are constricted & confine a large quantity of fecal matter in this case give opium & then follow with cathartics which will often bring away a large quantity of faeces 2d by emetics & by small doses of ipecac with opium repeated also small doses of mercurials cal. qualified with chalk or blue pill (antimonials where there is much arterial action) by fomentations sinapisms blisters to the bowels burdock leaves etc. warm bath which used at night frequently gives a quiet night’s rest this is not to be used however in case of great exhaustion # The French expectant treatment adopted in Philadelphia will frequently be entirely inefficient 64 3d by small doses of mercurials & ipecac with opium Ipecac deserves the name of a specific if any remedy ever deserves this appellation. Still a man very successful with one remedy only may be compared to one very skillful & successful with a penknife About 4 gr. ipecac 4 drops tinct. opii 12 teasp. wat. about every 4th or 5th hour for a child 4 months old keeping the bowels open with mercurials blue pill producing an evacuation once or twice in 24 hours. Double the quantity for a child a year old in the same quantity of water. The quantity of opium must be greater when the child has been [illegible] the habit of taking it. Injections of laudanum & starch 1 tablespoonfuls of flour & 5 10, 15 or 20 drops of laudanum to stop diarrhoea at the same time applying to the abdomen 65 cloths dipped in brandy An eruption of strophilus [albidus] sometimes makes its appearance about the chest particularly in the latter stages 4th indication by dividing the gums if necessary regulating the diet the milk of a nurse is best the operation of sucking is soothing and gratifying operating as a nervine give arrowroot with a little brandy or wine as a condiment or tapioca roasted flour etc. If in the last stages the child craves any particular food, as salt fish or salt meat, it should be gratified Disgust exciting nausea will debilitate. Frequently we can succeed by a different mode of administering medicine the sight of a spoon for instance exciting nausea. A tumbler of wine whey with a teaspoonful of aquae ammonia will often be beneficial to fill the stomach & dilute its contents 66 Correct fetor in stools with charcoal Injections of carbonic acid are used with the same intention. Effervescing mixture may be drunk they are often very grateful Injections of soap suds are recommended to allay irritation. Dr Dewees recommends an injection of 3 teaspoonfuls of salt to a gill of water & also magnesia & rhubarb. 5. In the latter stages give tonics and astringents Prof. I prefers cornus circum. Use also spir. toment. in decoction or extract also geran. mac. which may be given in wine & then we have red wine Often it wil be advisable to support the abdomen with a bandage also with plasters e.g. one of soap & opium A most powerful remedy is change of air It is continually recommended by the Philadelphia & New York physician. Case of a child in articulo mortis apparently 67 brightened up upon being carried in a hack to the top of ah ill where it had a view of the sound etc. It had got beyond the reach of medicine & food While upon the hill it too food returned & recovered The case seems to be the direct opposite of nostalgia there being a sickness of home a despondency caused by the sight of the same domestic objects Erigeron can. is used it is pungent acrid bitter & stimulating & hence affects the kidneys as a diuretic. It seems to do goo in the latter stages of diarrhoea & dysentery It is called strangury weed. It has been long used Vide Barton N.Y. Physico Med. Trans. etc. The other species are also used give it in decoction White vitriol & alum are used as tonics and in doses of 6 to 8 drops as an anti emetic The various species of viburnum are 68 All the [???t? tillas] are astr. so [illegible] [illegible] root etc. used in this disease, as astringents Statica limonium is not so agreeable but frequently more efficacious boiled, sweetened & a little wine or brandy added. It has a taste of salt mud. It is used also as a wash in case of aphthae In the latter stages of the diarrhoea give mucilages made of any of the various articles in use The white pine bark will furnish a valuable mucilage from its being combined with a terebinthinate principle. Post mortem examinations show the seat of the disease to be the muc. mem. of the intestines. The liver is enlarged Scald head or porrigo or tinea capiti A local disease, yet affected by diet. Sometimes commences with scaly eruptions. I have the head & apply a bladder to exclude the air is about 69 the best treatment. Wash clean at all events tar oint. 4 oz. tar. ½ oz. was 1 oz sulph 1 oz sulphur melt & mix Sulphuret of potash has removed the disease in a few days Yeast poultice is efficacious let the head be first shaved. Different dock roots all the species have about the same properties. Apply externally & give internally it is acrid etc. Syrup of buckthorn is recommended as a cathartic. The practice is quite empirical in this complaint. Sulph. pot. is given internally also its solution resembles mineral spring water Mercurials should be used & pay particular attention to diet Asclepius tuberosa expect. diaph. & laxative is a valuable substitute for ipec. to equalize excitement etc. When the tepid bath is used keep a supply of hot & of cold water by in order to keep up a proper temperature 70 Catarrhal epidemic severe hoarse cough differing from coup in the quantity of mucus thrown off extremities cold head hot much febrile action By vomiting great quantities of mucus are thrown up & yet the patient will seem to be suffocating Confined to the lungs, & aesophagus No disease affects the bowels less than this. The stools are healthy Indications Cure the patient immediately by powerful remedies unless the system is too much affected to bear them. This is a general principle, viz. that of breaking up a disease before it has thoroughly attacked the system by means of a strong orgasm Tartar emetic at the commencement to break up after the violence of the disease has been overcome apply a blister to the chest to translate to the surface. Evacuate the bowels also & palliate & relieve the disease by small doses of tart. em. or with camphor & opium to create perspiration or by the 71 tepid bath keeping the patient in ½ an hour or covering patient & nurse both with a blanket, to keep in the steam & cause it to be respired also Sometimes vomiting must be excited by mechanical means. Do not depend upon palliating symptoms merely Hooping cough said to be contagious rarely attacks the second time, but sometimes does. Pres. Dwight had it a second time at 60 yrs of age It appears as an epidemic thought to arise form specific contagious 10 vol. Med. Trans. an account of its breaking out in Block Island without previous intercourse with the main land. Commences with precisely the same symptoms as ordinary catarrh. The peculiar symp. 3 or 4 week Several frequent expirations are made which exhaust the lungs then a 72 stricture takes place which causes a hoarse shrill wheezing during inspiration. The same sound is heard in croup during expiration A spasmodic stricture sometimes takes place in adults which produces the same sound Such patients should not try to breathe. These fits of coughing continue until mucus is thrown up But the mucus is not the cause of the coughing, which arises from irritated action. Continues from 1 to 6 months. During a paroxysm, haemorrage from mouth & nose may come on or convulsions & apoplexy may ensue Case in which an emetic caused convulsions which carried off the child. Most troublesome during the night Duration of paroxysms depends upon the facility with which the mucus is thrown off. Sometimes respiration 73 is laborious between the paroxysms Rarely fatal after 2 yrs. It may terminate in hectic or in marasmus in infl. of the lungs in visceral obstructions of liver, lymphatics etc. It produces a determination to the head Treat the fever, if any, according to diathesis Treatment In vigorous const. & when mild little need be done When there is considerable infl. give ant. & nitre keeping the bow. open in worse cases bleed cup & scarify Sometimes mercurial cath. sometimes cast. ol. etc. It is better however to accomplish this end by diet. Respiration may be promoted by blisters on the sternum Instead of [blist] [illegible] may use 1 oz mild tinct canth. 1 z tart ant. applied with a cloth until vesication comes on then dress with simple cerate Antimony may be combined with opium Godfrey’s cordial made of molasses & water 74 with a little laudanum & ol. anise this was very popular. Use diluents. If there Is danger of convulsions from vomiting give blood root & other such things. In some constitutions antimony produces peculiar symptoms e.g. severe spasmodic stricture, which if it comes on should be relieved by diluents & small doses of opium. In very young children it is difficult to get down much medicine the stomach becoming irritable In the latter stages use 5 or 6 grains of sulphate zinc with as much of ipecac instead of antimony Where this much viscid secretion an emetic of squills may be used or we may use the [illegible] seneca root bruised & squills each ½ pound water 8 pds boil & evap. to ½ strain & add 4 pts honey & boil again to 6 pts to every oz add 1 gr. tart. ant. dose 8 or 10 drops child 4 mo. old, every 15 m. This is called Hives syrup 75 Dried leaves in 1 gr. doses, in milk, of atropa bell. or 1/6 of a grain of the root has been used in Germany Objection that this disease has a tendency to run its course, is no good reason for not curing it. It has been prescribed for more empirically than any other proof of the difficulty of curing it El. par. 1 oz ant. vix. ½ oz 3 z glyc. ext. powd. g. at. 2 oz wat. 6 oz. triturate & boil dose ½ teaspoonful to a table spoonful This is called the Brown mixture It may be varied by using ipecac etc. 2d Antispasm. & tonics & narcotics are used in the latter stages e.g. sulph. zinc & copper & tinct. canth musk, fetid gum, petroleum etc. belladonna, hyoscyamus, opium artificial musk or oxygenated ol. amber Nitric 76 acid 3 ½ z ol. [illegible] 1 z place in the sun in tinct 1 z to pt. alc. dose 10 dr to a teasp. or 1 z to 1 oz ether dose few (2 or 3) drops upon sugar. It was very celebrated & afterwards was thought to be ill made The truth was the diathesis had changed. Copal gum, oxygenated by distillation, will be the same substance. Copal is probably the same with amber Case of a vein of olibanum or frankincence in S. America Opium should be qualified & determined to the skin by ant. & ipecac. Hyoscyamus is bitter, having no tendency to produce costiveness zi pearl ash with cochineal to colour it to pt. water 8s a popular remedy & useful The whole effect is owing to the pearl ash which is antispasmodic cochineal has no apparent virtues. Pearl ash is not only antacid but produces a peculiar 77 excitement upon the stomach & aesophagus making them susceptible to other articles Conium maculation has been much used A more commanding remedy is stramonium 1/10 gr. to 2 gr. of extract or seed for a dose. It counteracts that irritability which gives a tendency to convulsions Sulph. zinc has been most used as a tonic by Prof. I. either dissolved or in the form of Moseley’s tonic solution Sulph copper possesses about the same properties The compd vitriolic tinct. of sul. cop. & kino 10 to 30 drops is pleasant & has been much used. Flowers of zinc & also bismuth have been used. So also per. bark. Bark, canth. & sul. cop. in combination are recommended by Chalmers of S. Ca. Cantharides are indicated where the 78 system is relaxed & too low for inflammatory action in order to excite a healthy infl. action Something may be done by rubbing the spine with the stim. oils e.g. ol. caps. or orig. etc. or with [illegible] of ammonia to excite the nerves & spinal marrow in the latter stages. Change of scene, of air, riding etc. should be resorted to in bad cases to tranquillize & stimulate the patient. Sometimes the little patients will be in a constant tease & worry; until this is done. In the worst of such cases medicine does little good Even the irritation of administering the medicine may counteract the beneficial effects of the medicine. Prof. I. thinks a relaxation of the ventricles of the heart & of the sinuses of the head takes place owing to the violence of the cough Indicated 79 by resp. high count. bloated lips swollen & by a soft flowering & almost intermitting pulse In such cases give blood root 5 to 10 gr. in water alone or qualified Lead (acetate), also iodine, have been recommended. One year, the hoop. cough prevailed extensively in the spring but was Prussic ac. & arsenic occasionally cut the hoop. cough, short entirely The former is dangerous from want of uniformity of strength Fowler’s sol. is safe but does not answer so well in the first stages. It may leave the patient livid weak with swollen lips etc. which is to be cured by bark & other tonics 80 Gangrene in the mouth 81 Chilblains Exposure to extreme cold without freezing 82 Mesenteric fever tumefaction & pain of the bowels (distress rather than sharp pain) indigestion costiveness, loss of app. or [irreg.] app. Countenance pale except when flushed with fever sometimes a consequence of other fevers oftenest in scrofulous habits most common among the poor. It may become chronic. Indurated lump in the mesenteric glands Indications Act upon the bowels keeping up a peristaltic action evacuating the bow. changing the secretions & removing the obstructions of the lymphatic system. Give blue pill or calomel & chalk. In chronic cases friction once or twice a day will be beneficial Pill 4 parts blue pill 1 part ipecac or ½ part ipecac. Or 1 gr. ipecac in pill with a small quantity of opium Or tinct. rhubarb with aromatics & alkaline salts Burnt sponge is recommended perhaps it would be better to give iodine at once 83 in definite quantities Still the composition of articles existing in burnt sponge may be better [illegible] nodosus & vesiculosus (rockweed) are used Even the neutral salts with tonics have been useful Even as of camomile tea will relieve a paroxysm of pain Articles containing carbonic acid in a free state, sometimes with aromatics as ginger or spice, will be grateful and also useful From tinct muriate of iron martial flowers of iron or alkaline solution are used as tonics but iron is apt to irritate. Cold bath will invigorate the system Injections of mercury have been proposed Tepid bath will cleanse the skin etc. Muriate of lime with small doses of cal. or blue pill may be useful, but 84 is now generally superseded by iodine dissolve carb. lime in muriatic acid & give from 5 to 50 drops in water beginning with small doses, in case it may offend the stomach. Muriate of barytes might be used. Carb. barytes is used dose from 2 to 3 gr it being a powerful article The flesh brush thoroughly applied has a powerful effect A plaster of opium & diachylon or soap plaster, with an equal quantity of opium, applied to the abdomen has been very beneficial where opium did not agree. Or we may use 2 parts opium to 1 plaster. Diet dry toasted bread broiled meat use condiments farinaceous substances & sometimes the broth of lean meat Avoiding raw fruits potatoes corned beef etc. Take care 85 with wine Use farinaceous veg. well boiled not to interrupt digestion by distending the stomach with liquids The terebinthinates will benefit the mucous membrane of the ac. canal. The bests article is decoction of white pine bark which will be much milder than any preparation than any of the turpentine of the shops This disease may terminate in a peculiar hectic sometimes it commences with very considerable fever S. Cutting the fraenum. Very seldom practised now formerly thought to be almost always necessary. Complaints would be made that the child could not nurse on account of its being tongue tied. In such cases it was Dr Munson’s practice to apply the back of the knife, & thereby give very great satisfaction 86 Burns & scalds 87 Tympanitic abdomen a symptom in various diseases 88 Neuralgic affection of the lower limbs 1 Surgery Lecture 1st External injuries 1st Extensive injuries first produce a shock upon the system e.g. contusion upon the abdomen & frequently when a limb is carried off by a cannon ball the haemorrhage is slight & the patient dies of the shock Great difference in patients as to susceptibility of constitution. In the army it has hence been the custom to operate on some immediately and administer cordials & consolation to others State of the mind e.g. wounds after a defeat or after a victory. State of habit porter & gin drinkers in Soudan & debauchers in high life bad subjects The subsequent inflammation however is not in a direct proportion to the shock 2 1st of such injuries as prostrate the system beyond the point of reaction Coldness of surface faintness & prostration immediately follow large gun shot wounds The same effects follow the slight injury of important points e.g. punctures of the joints etc. These effects are through the medium of the nervous system The common people remark that extensive injuries of strike into the stomach This is merely part of the constitutional aff. Case of violent vomiting in a blacksmith whose eye was penetrated by a scale of iron & yet the eye recovered without difficulty Affected distress may be detected by the state of the pulse or respiration the ease with which the attention may be diverted. Sometimes die of the mortal inquietude even without internal haemorrhage Frequently difficult to test with respect to the propriety of amputation A navy 3 surgeon it has been said would probably have amputated Mr. [Huskisson’s] shattered thigh the constitutional irritation will be less after the operation The intellectual functions are suspended blindness sometimes continues for hours The food is not digested & the peristaltic motion suspended. Vomiting frequently favorable as marking a return of vital function. Case of a gentleman in a profound stupor from a fall from a horse no injury could be discovered Complaint of pain generally a favorable symptom particularly if an external part Infants frequently vomit etc. severely with paleness etc. & yet recover after a few hours sleep 1st indication restore warmth to the surface by frictions & the warm bath frictions should be dry, for moist cloths produce evaporation 4 warm blankets & may be applied especially by passing warm substances up & down the back 2nd indication restore the action of the pulse by brandy once an hour peppermint opium etc. [Discontinue] stimulants when reaction comes on as it may be excessive. 3d moderate pain & 4th const. irr. relieve pain by opium except (in Hubbard’s practice in cases of the head) One of the first things to be done is frequently to bleed which will be followed by a rise of the pulse It is a common practice in some places is to send immediately for a bleeder, who however in cases of a great shock is unable to obtain blood until after a surgeon has roused the vital powers Injections may be used. H. prefers among cathartics the mercurial in order to restore the peristaltic action These will answer the 4th indication also 5 We must be careful to examine for local injuries for frequently in cases of extreme prostration they are first mentioned by the patient after the return of consciousness Case of a man who was first unconscious next complained of his head after some hours of his knee & while he was recovering it was discovered that the orbit of the eye had splinters of pine in the flesh. Great caution frequently necessary in removing the sufferer for simple fractures are liable to be made compound. Cold is injurious The viscera are sometimes fractured in falls from great heights e.g. the liver Suppuration of the liver sometimes follows an external injury after a long interval The injury of a fall not necessarily proportioned the height. 8 or 10 drops of laudanum in gruel or starch by injection relied upon in Paris for the cure of traumatic delirium 6 apparently a trifling remedy recommended for trial relied upon implicitly by the French Mr. Travers is the only author who has treated regularly upon the subject of external injuries Inflammation Characterized by heat, pain, redness, tumefaction & soreness. When considerable or affecting important parts, it is [altered] with fever of constitutional irritation. This is different from the local fever which is called symptomatic. The pain usually precedes the heat & tumefaction The causes may be external or such as effect the system primarily. First of such as are caused by external injury or phlegmonous inflammation called also health inflammation This manner in which injury produces inflammation is not well understood 7 Phlegmonous infl. is characterised by a central spot & a circular outline Hunter speaks of healthy infl. considering it as a process set up by nature to accomplish a cure & believed that new vessels are formed An injury is generally followed by pain, which does not arise from inflammation for this has not yet come on, but from the separation of the parts. Great pain is produced by effused fluid as in sprains. After an injury there is pain etc. also there is a sense of distention & the action of the arteries in the neighborhood of the part is increased This extends to the whole arterial system, producing increased frequently fulness and even hardness of the pulse. The pain is caused by the nerves being affected. Mention should have been made of the cold stage which precedes extensive inflammation the cause of which seems to be unknown 8 Professor H. thinks fevers essentially different from inflammations, in opposition to the French physiologists. He thinks that at least at the commencement of infl. there is increased action of the vessels The pulse varies according to the part inflamed (vide below) Local causes of infl. may be heat, cold, mineral acids, acrid substances etc. the various sorts of external injuries Constitutional causes are fevers and various anomalous affections of the const. Prognosis Very violent inflammations are danger so also very extensive ones as burns. Infl. of important parts in the viscera is dangerous. In inf. of the bowels the pulse is quick small & tense & hard of the heart full The terminations are resolution suppuration adhesion & gangrene. Adhesive infl takes place in serous membranes & wounds that heal by the first intention Suppuration takes place when wounds 9 do not heal by the first intentions boils etc. Gangrene follows violent infl. which do not suppurate. It is the death of the part 1st indication is to remove the cause as splinters & in case of dislocation As much should be done by local remedies as possible. Reduce the temperature by cold or tepid lotions (according to the sensations of the patient) sometimes fomentations or poultices give more relief than any other mode of applying warmth especially in pelvic infl. & by the French in thoracic. The warm bath is frequently useful especially to children. In case of fomentations permanent moisture should be kept up. Warm applications may be made to reduce the heat of the part by evaporation if not too warm. The same thing may be accomplished by spirit. Acetate of lead sulphate of zinc vinegar and cold water 10 are used Perhaps the latter is generally as good as any of the patient will be satisfied with it. Narcotics sometimes are used externally but their utility is doubtful. Blisters are used especially in infl. of the joints & deep seated parts in general The first general remedy and the most powerful is bleeding it would seem to be one of the best arguments for it that those of opposites [illegible] recommend it viz. those who believe action to be increased & those who believe it to be diminished Of course not always necessary, as in trifling cases, & delicate habits, No rules can be given as to the extent to which it may be carried. The modes are venesection [arteriotones] leeches & cupping Venesection is the most common and most convenient. In children the veins of the hand or foot or the external jugular may be more convenient than those of the arm It is a good rule to draw blood until pain is relieved or faintness is produced provided the patient is in an erect position 11 There is no doubt of the propriety of taking a large amount of blood at once rather than by several small bleedings. The buffy coat not to be relied on Prof. H. thinks the heat of the extracted blood of more consequence Blood letting has been objected to in case of old persons. Prof. H. has often practised it with advantages. So of delicate constitutions if the patient is kept in a horizontal posture Arteriotomy from the temporal artery has apparently no advantages over venesection Prof. H. sees no advantage in the use of leeches in preference to venesection except in chronic inflammation Cupping seems to combine the advantages of depletion and counterirritation & is highly spoken of. Prof. H. has not used it much Cathartics are used next. also antimonials especially in the Italian way of beginning with small doses frequently repeated until the quantity which may be taken without nausea is very great 12 Narcotics are used for the same purpose Soreness is relieved by quiet etc. Pain may be diminished by elevating the part. Diet should be antiphlogistic, but generally the patient has not much appetite. Great difference is produced by the constitution and habits of the patient e.g. intemperate patients will not bear some things N.B. they do not bear bleeding well Frequently cordials and tonics are useful at the close of the cure. The best work on inflammation is Thompson on inflammation. Erysipelas an inflammation of the skin sometimes extending to the cellular membrane Distinguished by leaving a white spot after pressure by the finger & by being terminated by a definite [line] It has a tendency to spread sometimes leaving one part & spreading to another. Occasionally affecting various parts at the same time 13 When caused by a wound it frequently affects distant instead of adjacent parts colour dark & yellowish little swelling leathery feel. More yellowness towards the decline of the disease. This disease is liable to affect the mucous memb. of the mouth, & is said to affect int. parts It is accompanied with chills fever etc. & in erysip. of the head with delirium Sometimes the fever precedes. The fever is also followed by a bitter taste in the mouth Case of an old woman attacked with feverish symptoms, which, as was expected were soon followed by erysipelas. Various divisions have been made as phlegmonous bilious etc. Prof. H. divides into that affecting the skin & that extending to the cell. mem. 1st of the skin. it terminates by scales & affects the young It however may term. by sup. & also affects all ages The second is attended with more tumefaction & terminates in sloughing suppuration & in gangrene. It sometimes extends to the fascia & tendons so that they will slough. This kind of erysipelas 14 is oftenest met with with in old and intemperate persons as in cases of chronic sore leg Erysipelas is distinguished from phlegmonic infl. by the latter having a central spot its circumference being less defined, & its pus collected into a central cavity The nervous irritation of erysipelas is greater producing delirium etc. The heart & arteries are more irritated producing a sharp and quick pulse which is very weak when the infl. tends to gangrene. The al. can. is generally affected, producing sometimes dysenteric symptoms. The exciting causes are wounds contusions irritations of the skin by acrid substances by alterations of temperature etc. 15 The predisposing cause is in the constitution & is unknown from the yellowness of the skin some have ascribed it to the liver We know not why some wounds should be followed by phlegmonous & some by erysipelatous inflammation except that at the time the patient was not in good health. This may be caused by malaria, the bad air of hospitals etc. Case of Pomfret when the meadows were drained. From its prevailing in hospitals some have thought it contagious This not probable Though depending upon the state of constitution, yet the extent of the constitutional is proportioned that of the local affection. It sometimes seems to alternate with other diseases 16 Prognosis varies according to the age & habits of the patient & the extent of the infl. The most dangerous cases are those of the head which are frequently attended with delirium & coma. Coma is however a common symptom in ole people Indications 1st to promote a resolution 1st by topical 2nd by general remedies Some are opposed to topical application Prof. H. finds no danger in them. The best Is acetate of lead. Cold water, milk & water Also 2 dr. mur. amm. in a gill of water or corros. sublimate 10 or [illegible] sometimes a drachm of opium to a pint of water or of the solution of acetate of lead Mercurial ointments are best in the decline of the disease The lard by itself is good especially when the [branny] scales are abundant. To this is ascribed by come all the benefit of the mercurial ointment. One of the most common applications is dry wheat flour. Yet it is one of the worst 17 2nd General remedies. They should be always used to prevent the affection from being driven in & then returning 1st venesection Strongly urged & strongly opposed Prof. H. approves of it in case of strong constitutional affection but not when there is extensive suppuration & when the pulse is weak & small 2nd purgatives they have been universally used. The indication has by many been drawn from the yellowness etc. The mercurial cathartics are best Calomel may be combined with a little opium in case of great irritation Neutral salts sulphur & magnesia have been recommended Antimonials are much used, especially in the Italian mode of beginning’ with say 1/6 gr. & doubling the dose (of tartar em.) until even 4 gr. are given 3d Tonics their use is strongly urged upon the supposition of erys. being 18 an atonic disease In cases of malaria and gangrenous tendency bark is undoubtedly proper. Opium & Dovers powder are proper in one of great irritation & opium is given by some as a stimulant. The most common preventive remedy among the people is neutral salts. They generally do much injury. Even low diet is generally injurious when practised with this view Infants are frequently affected with this disease. Sometimes their pudenda are badly affected with it Treatment calomel internally acetate of lead externally etc. A new remedy is nitrate of silver externally applied by moistening & touching. Prof. H. has tried this and found it useful but not deserving so very high commendation as it has received Prof. H has found blisters very as have Dr. Rush & others 19 especially in violent cases & in those which affect the cell. mem. An old mode has been lately revived viz that of making long & deep incisions even to the extent of 6 or 9 inches. This is efficacious in violent cases especially when suppuration is suspected. This disease requires great care and attention. Sometimes the disease may without our knowledge attack another part hence the old patients affected with stupor & infants should be examined every day Abscesses When phlegmonous infl. does not terminate by resolution it does by suppuration. So of erysipelatous. The signs of suppuration are diminution of the pain & chills (the patient will say he has caught cold) in external phlegm. infl. a softness will be felt. This will increase & frequently be surrounded by a hard rim sometimes there is a sharp [illegible] or [illegible] pain Pus is discovered by its fluctuation. We must press 20 alternately with the fingers or better with the the thumbs. IN muscular parts we may be deceived by the fluctuation of the muscles under the fascia, if we press transversely. We nay be deceived by fungous tumours Tumours of the viscera are apt to be mistaken for a collection of pus Great mischief is done by opening fungous tumours. In a gland suppuration never takes place until after the skin has adhered to the gland. Prof H. know of no remedies for promoting suppuration but poultices & similar applications. On pus. It is a secretion. A French surgeon maintains that it is secreted by a membrane lining the internal surface of the abscess. (Delbecke) It is of very little consequence of what poultices are made. Fomentations, as by wringing out woollen cloths dipped in hot water & then applying them to the part. Venesection & evacuant remedies are contraindicated. The bowels should be 21 kept free. Tonics are not generally needed Opium may sometimes be used according to circumstances. Prof’s Smith & Hubbard approved of opening abscesses immediately & not waiting for them to burst In erysipelatous infl. the pus is diffused & not in a cavity of a circular form Abscesses tend towards the surface unless prevented by strong fasciae etc. The opening need not be very large but should allow of a free passage to the pus There are inflammations of the cellular membrane where there is no erysipelas of the skin. The inflamed part is hard & is sometimes very extensive The constitutional symptoms are very severe & resemble those of erysipelas The suppuration has a peculiar [illegible] irregular feel. [illegible] this kid very dangerous generally arising in bad habits Indications moderate the const. affect. by calomel opium etc. The best external 22 remedy is blistering extensively afterwards using external lotions etc. This kind of inflammation frequently follows wounds of dissection Case of a man who lay down under a haystack & fell asleep. Infl. in the thigh, leg, shoulder & knees confined to the cellular membrane & yielding quarts & pints of matter when opened finally recovered. Another upon whom numerous similar abscesses were opened on succession finally there was an effusion in the thorax & the man died. The two last kinds of inf. & much more dangerous than phlegmonous. Frequently they arise from a very slight cause as a scratch in the old & intemperate. In the latter, delirium tremens is frequently caused by such inflammations. Prof. H. does not open with caustic He does not call the furunculus a proper phlegmonic inflam. The core of a boil is a dead portion of 23 cell memb. There are no better remedies than poultices etc. After opening an abscess we may use pressure to expel the matter but too great violence must not be used. Then a plug of lint may sometimes be advantageously introduced & finally the sides of the abscess should be brought together by a bandage if possible Frequently by a skilfull application of bandages around the opening, pus may be expelled which could not otherwise be obtained When it is wished to make a second opening into an abscess near the first, instead of lifting up the skin upon a probe & then cutting down to the probe, it is better to close up the first opening & suffer the pus to accumulate so as to cause a protrusion an incision may then be made with ease 24 Anthrax Begins with a small pimple a vesicle filled with lymph. The burning heat and pain very great. The const. irr. very great. The redness is of a darker colour than in the furunculus There is an areola somewhat resembling that of [illegible] pox. This will be surrounded with small pimples, which become small holes filled with a yellow matter The swelling extends & with it the holes Sometimes a considerable portion of skin sloughs off Eventually a considerable portion of cell. memb. sloughs off with a copious discharge of pus & the patient recovers In fatal cases extensive gangrene takes place without suppuration. Sometimes before the cure large portions of cell memb. (rotten) may be extracted with the [illegible]. Const. aff. very great tongue white & eventually yellow 25 When the anthrax is near the head delirium & coma are produced The infl. seems to be more erysipelatous than phlegmonous. Some persons of broken const. are liable to be [illegible] Prognosis depends 1st on the situation & extent of the anthrax Apt to be fatal if on the head face & neck especially if nothing but serum is discharged. If upon the limbs & back with suppuration they are there it is dangerous 2nd the const. sympt. Violent pain severe fever old age & intemperance especially the latter are bad symptoms One of the best local applications is an extensive blister plaster followed by cerate & if there is much heat & inflammation apply over the cerate ac. plumbi or in bad cases, emollient poultices The sooner the pus is formed and discharged the better. It relieves the irrit. 26 Frequently pus may be felt through the sloughing skin. Caustics are used by some but Prof. H. prefers blistering & if the first application does not relieve the pain & irritation apply a second. Frequently a slight incision is necessary to evacuate the pus Const. remedies 1st Venes. in rigorous habits, and early in the disease Mercurial purges are always proper unless there is great exhaustion Opium when there is great irritation and towards the close when the patient is weak give bark. Give dov. powd. at first & afterwards opium alone. Farther remarks on abscesses. Sometimes after opening an abscess lunar caustic or a solution of cor. sub. must be introduced to promote the healing of the sides of the abscess Sometimes the pus is collected in the bursae mucosae, as on the olecranon 27 process. The thumb the knees. The serous membranes of the bursae are liable to inflammation followed by a rapid collection of pus, & violent const. irr. It is especially important to open abscess of this kind, near the joints. Acute inflammation of the joints sometimes occurs, essentially different from chronic infl. It occurs oftenest in the hip Sometimes it is fatal in a few days Caused occasionally by injuries. The mode of cure is to cut boldly into the joint, to save life. The female mammae are especially liable to abscesses. Sore breasts & broken breasts are not all the same disease 1st superficial phlegmonic abscess. There is infl. of the gland The skin adheres. Venesection purging & antimony may be used. Tartar emetic has been lately recommended very strongly The usual external remedies may be used 28 It is decidedly advisable to open these abscesses though there is a prejudice against the practice. Erysipelas of the breasts is common & treated as other erys. infl. Infl. in the bur. muc. which lies between the mammary gland & the pectoral muscles Sometimes the pus makes its way out between the two breasts. We must open with an abscess lancet & then promote the healing by injections of cor. sub. etc. If this fails, introduce a seton of several threads & extract one thread at a time (vide Dorsey) Chronic inflammation. Sometimes a sequel of acute infl. That which follow acute phlegmonous infl. will be circumscribed It will not be of the skin but of the cell memb. Glandular parts are those which generally run into chronic infl. e.g. testis mammary glands the lymphatics (scrofula) These last are frequently subjects of surgical treatment, they are occasionally 29 inflamed from wounds The joints are peculiarly liable to it. The constitutional symptoms are less severe, resembling hectic generally without sweat & chills. The tongue is commonly coated sometimes [illegible] appetite capricious emaciation restlessness Coagulable infl. is effused & causes rigidity & tumefact. Indications, lessen the action of the vessels & promote absorption Bleeding must be practised with caution. Cupping & leeches are most commonly used. Prof. H. has found occasional bleeding serviceable promoting absorption. Cathartics must be used moderately The mercurial most valuable & the stimulant as aloes Narcotics, opium, hyoscyamus conium to allay irritation. Frequently the mineral acids as tonics Iron & arsenic & other mineral tonics seem 30 to cease irritation Iodine is used. Blistering is the best local application Case of its application to infl. mammary Tartar em ointment setons moxa compression is valuable when practicable, especially in infl. of cell. mem. It may be alternated with blisters mur. amm. etc. If the limbs are inflamed, exercise is useful Stimulating liniments, opodeldoc etc. are applied Chronic abscess. One which has either not been preceded by violent symptoms or in which they have [illegible] off. The patients account will often be that at some previous time he had a fever etc. followed by a swelling The fever did not leave him well etc. Sometimes the chronic abscess will be found in a different part [from] that in which the pain was formerly felt. 31 Prof H. has never known a fair case of perfect absorption of pus Though the evacuations may have taken place only after years of continuance. The prognosis is difficult The French open by caustic. Prof H. has not tried it. Lumbar abscess, as an example of chronic abscesses in general. Arises from scrofula, from injury or from no apparent cause The lameness at first often is ascribed to rheumatism The patient bends forward & towards the part affected. A soreness may be felt Finally a collection & a tumour pointing to the top of the thigh or even down the leg The pus is contained in the bur. muc. which protrudes under [illegible] lig. This may be mistaken for hernia & even for aneurism of ext iliac. It sometimes bursts in the groin 32 By proper examination in a standing posture the fluctuation may be discovered. Open by placing the pat. on his side, making pressure & inserting an abscess lancet making the orifice of the cyst as large as that of the skin by a turn of the point of the lancet. The pus discharges better in a [standing] posture of the patient when the tumour points downwards. When the pus is all out apply a compressing bandage & heal the orifice by the first intention. Afterwards open the abscess again & so continue. Keep the bandage on to diminish the secretion of pus After three or four openings, the orifice will generally ulcerate, if the abscess is not healed Sometimes a seton must be used This practice is a great improvement of Abernethy’s. Various remedies were formerly tried to promote the absorption of pus. Prof. H. has never known the cure. Sudden deaths arise from unopened chronic 33 as well as acute abscesses. After great operations, abscesses of the lung frequently come on Hectic fever following the permanent opening of chronic lumbar abscesses Chills, heat feebleness, irritation soreness confinement to the bed nausea vomiting loss of appetite. This is frequently mistaken for a new disease John Hunter was the first to deny the doctrine that hectic fever is produced by the absorption of pus. James Rose’s son 13 or 14 yrs. of age Injured his back by lifting. Became lame, was treated for rheumatism. Became more lame, emaciation & sallowness Prof. H. found a coll. of pus extending half way down the thigh. By Abernethy’s mode, about 3 pts of pus came out. The attending physician did not pursue the same mode but kept the orifice open. Hectic fever confinement to bed 34 died miserably in about a year. Instead of being better, they may find themselves worse immediately after the opening Oxygen has been supposed to be the cause. Cold air likewise has been brought [illegible] 10 gr. corr. sub. to 1 pt. water is the best injection when a lumb. abscess remains open. If no benefit results after a few weeks it must be abandoned. Limewater has been recommended as an injection. Calomel is the best treatment for the symptomatic fever, except when the patient is exhausted Irritation may be relieved by Dov. powder, quietness etc. The cavity should be carefully cleaned out every day Slight ptyalism may follow the corr. sub. Prof. Smith was in the habit of using this injection immediately after opening Prognosis Some have ascribed lumb. abs. to an aff. of vertebrae Very probably this affection of the vertebrae may be an affect instead of a 35 cause Small chronic (as scrofulous) abscesses may be treated like acute abscesses In scrofula the abscesses will not be regular & round like phlegmon They should be opened as soon a pus is formed In abscesses of this kind granulations are frequently found which must be removed by caustic. Sometimes the skin must be cut away to get at them Case related to illustrate the danger of opening [chronic] abscesses by large incisions & keeping the orifice open. Died in a week Quality of the discharge Commonly mild & inodorous thick (sometimes curdy) before the healing, it becomes thin & whey like. Acute abscesses frequently furnish this thin discharge, especially if’ erysipelatous Hectic fever Blood drawn will generally exhibit the buffy coat, before the opening of the abscess. Afterwards 36 we have hectic fever Pulse quick (sometimes not in old persons) generally 2 paroxysms in a day the nightly one attended with profuse sweats frequently with diarrhoea sometimes pains in various parts which exhausts the patient less of app. & nausea & vomiting occasionally aphthae (sometimes also as well as night sweats, before openings) may come on so also dropsical effusion of cellular membrane. The degree depends 1st on the nature of the part according to its power of restoration 2nd on the extent of the abscess e.g. occasionally it following the suppuration of an extensive burn 3d on the constitution of patient frequently mental causes have great effect [illegible] modifies hectic the old have less sweat & loss of appetite, but more diarrhoea Sometimes we are surprised to see so little constitutional affection. Such persons are generally very tranquil in mind. It is perhaps impossible to cure hectic 37 while the cause remains Some patients are exceeding by restless irritable & troublesome & [illegible] Prognosis this depends on our success in removing the cause. We may however moderate it by tonics e.g. sulph quinine, wine, opium This last invaluable, promoting sweats relieving [illegible] & supporting the vit. powers Keep the bowels free. Inflammation of the lymphatic vessels Causes may be ext. or internal 1st wounds acrid substances etc. Wounds have been given in bleeding Symptoms swelling, redness, hardness, a core may be felt a discharge of lymph, a swelling of the lymphatics in the axilla. Cured by touching by with caustic Sometimes a very small puncture will cause an inflammation extending upwards in the direction of the 38 lymphatics, indicated by red lines swelling soreness etc. frequently very troublesome sometimes an erysipelatous infl. & abscesses It may be occasioned by erysipelas Touch the small orifice (apparently in considerable) of the wound with caustic & apply adhesive plaster if this does not cure, blister the whole inflamed part, use compression etc. Open abscesses if there are any. Sometimes the inflammation extends from the heart instead of towards it in the course of the vessels. It appears in the throat in scarlatina. It may be caused by [sore lips] Frequently this disease comes on from an affection of a distant part is phlegmasia doleus from the uterus It may appear in the legs from consumption. Phlebitis infl. of the veins First pointed out by J. Hunter. It may be caused by venesection & by a ligature Vein appears like an inflamed cord Sometimes pus is found around the vein. Constitutional symptoms like those of erysipelas & very violent, accompanied with fainting palpitation 39 of the heart anxiety etc. Treatment venesection (some say ad deliquum) calomel & opium blisters Mr [Lizars] advises to destroy the vein above the part by caustic. Inflam of the arteries Not much is known respecting it. Ossification of the arteries, appears to a frequent result Mortification. The death of the part A cold ash coloured mass becoming black Gangrene is considered under this head Two kinds, acute & chronic hospital gangrene is a case The affected part from red becomes pale & cold the vessels filled not with watery but bloody serum. Pulse quick weak intermittent occasionally, sweat, singultus. Symptoms vary 1st according to the extent of the mortification. 2d acc. to the [illegible] of the part & 3d acc. to constitution 40 Chronic mortification frequently comes on as in the toes of old persons without pervious acute inflammation preceded by pains & heat. There comes on first a dark purple spot. Liable to be confounded at first view with shingles a skin disease. There first appears a redness then vesication, lastly mortification Two circumstances will always distinguish mort. 1st the coagulated state of the vessels, yielding no fluid 2nd no sensation being present in the part Causes external injury, a sudden cessation of vascular action in the limb!! bits of rattlesnakes wounds from dissection compression of bloodvessels from ligatures strang hernia etc. Inflammation more especially erysipelas & anthrax. Occurs oftenest in the old Ossification of the arteries is either a cause or after [illegible] There may such a degree of tumefaction or distention of vessels in violent infl. Case in which the skin was to much stretched as to cause mortif. Fire & frost bite after an operation for cancer of the breast as to cause mort. cause mortification IT has been attributed to the use of bad rye flour that which contained ergot. 41 Prognosis, difficult. All mort. is dangerous. Chronic mort. always dangerous Sometimes patients die when apparently almost recovered especially if old & when fasciae & tendons remain to be cast off. Sometimes patients are carried off by a new accession of erysipelatous infl. or a translation to an internal part It is a good symptom for the patient to go gently to sleep Treatment The attempt to imitate nature by endeavouring to excite an infl around the mort. part & so produce a line of demarcation & eventually the sloughing of the part, is to be considered Ind. 1st Venesection may be useful to moderate the violence of action Calomel for the disordered secretions in alterative doses Bark was formerly supposed to be a specific It is now discountenanced Acetate of lead & mur. amm. externally applied cold, as being more agreeable Emollient poultices, yest poultices will 42 correct fetor. Chlorate of lime & soda Bark was formerly used in poultice 2nd diminish irritation extract foreign bodies if there are any, open abscesses remove mortified sloughs. Calomel opium even with venesection, & especially when purgatives are required Emollient poultices 2d prevent the spreading of the mortification which spreads sometimes in the cellular membrane very rapidly. Bark may be useful but blisters are the great remedy. They should be extensive & on a limb, should extend above the part mortified except in case of mortified toes. Nitric acid (100 to 300-400 drops to 1 pt. water) may be used as a caustic application 4th support the patient by opium, bark wine ale porter, indulgence in nutritious diet. Keep the bowels in order, attend to the secretions etc. etc. After treatment of the part Keep on the external application etc. Clear away 43 the sloughs Case which terminated favorably related in which the whole gastro [illegible] muscle was lost. Near the close of the cure the following preparation may be used as a mild cerate. 2 drachms acetate of lead ½ oz. sulph. sodae, 2 ½ oz. simple cerate Mortification continued It may prove fatal from const. irritation either gradually or suddenly Case related of an old man who first had apparently an anthrax on the bottom of his foot There came on a phlebitis of the vena saphena. Mortif. affecting a whole limb will [rarely] be cured. Generally amputation is the best remedy. The const. irr. will be surprisingly relieved. Hiccup is generally a fatal symptom As to the propriety of amputation It must be done when the injury 44 has destroyed the principal blood vessels & limbs. Also in mortification of the toes extending over the foot for all such cases cannot be cured without too extensive a suppuration to be borne by the constitution As to the time of amputation. It is now settled that we are not to want for the mort. to stop spreading & for the mortified part to be sloughed off. The mortified toes of old people should not be taken off. If amputation is to be performed, it should be of the leg, or if this beings to be affected, of the thigh. Case of mortif. of finger of an intemperate shoemaker. When amputation is performed we almost always find the arteries ossified In compd fract. burns, frost bites etc. if the parts are likely to be dead, then operate immediately. Sometimes mort. extends along the cell. memb. under the skin, giving rise to a crackling feel & a sort of eymphyema. 45 Wounds in general. Solution of continuity in a part. They are of six kinds incised punctured lacerated poisoned contused & gunshot wounds. Extensive wounds may affect the system more or less according to various circumstances, one of which is the degree of confinement, e.g. wounds of the lower limbs affect the system more. The symptomatic fever will vary from a slight heat, to a high fever; sometimes we have chills sometimes erysipelatous inflammation The first indication respects the hemorrhage. This if slight may be stopped by cold air cold water, lint etc. If an artery is wounded, a ligature must be used, except that sometimes a small artery may be stopped by a total division of the vessel. Case of a man who had wounded the art. [illegible] 46 There came on a very troublesome & frequently recurring haem. Cured by opening the wound & totally dividing [the] partially divided artery. The temporal art. may, in this way, be totally divided & then stopped by compression Ligatures may be of silk, thread, or better of leather, rolled. Mr Lawrence has lately recommended a small silk lig. with the ends cut very close it is said they will come out by a small [pustule] Leather is absorbed. It is now [illegible] inadvisable to cut the internal coat of the artery by the ligature Mode od dressing. Bring the edges accurately together, apply adhesive plaster and a compress Leave the wound in this cond. for 4 to 5 days. The interrupted suture is used. 47 The sticking plasters may be used in addition to these, a strip between each two stitches In case of much heat & inflammation Prof. H. keeps up the practice of wetting the dressings even with ac. plumbi. Punctured wounds; of by a bayonet or similar instrument, they partake of the nature of others Considered dangerous yet often heal by the first intention. If pus collects at the bottom treat as in other cases of suppuration. Haemorrhage from wounds. The artery retracts when cut, the internal coat adheres & the [illegible] extends as far as the next collateral branch. This first led to the practice of using small round ligatures. Sometimes the needle & ligature is used when it is impracticable to use the tenaculum or forceps especially in punctured wounds, to avoid the necessity 48 of extensive incisions. We must be cautious about tying arteries in old wounds lest the tied part slough off & we have haemorrhage again to avoid this make a new incision. Be cautious about leaving any substance in the wound Sutures should be generally be left 4 or 6 days A proper posture is of importance. Horizontal for the lower limbs flexed if upon the back side of them. Union of parts totally divided as noses & fingers has not succeeded in Prof. H’s practice. When a little skin is left they do very well unless suppuration comes on Rest & simple diet are of importance. Rest is especially [so] in case of wounds of the lower limbs Contused & lacerated wounds may be treated under one head. The haem. is generally small. Do not hesitate to draw the edges of the wound 49 together instead of treating with fomentation & poultices to promote suppuration Poisoned wounds where a poisoned substance is applied to a puncture as stings and bites. It is difficult to say whether the effect is upon the nerves or the poison is absorbed The effects are very analogous to erysipelatous inflammation Excision should be performed as a prophylactic. Cupping has been practised. Caustics Among the French caustic acids are favorite applications If acetate of lead etc. fails Prof. H. would try blisters. For the general remedies use vol. alk. opium, alcohol camphor a variety if necessary of stimulants If violent inflammation comes on use venesection mercurials etc. If suppuration or gangrene ensue treat as usual for them. Case related in which 8 gr of arsenic were given in 4 hours cured. 50 Apparently phlebitis has been occasioned by bites of serpents Indian remedies are of little consequence. Stings of wasps & bees Bad case of a sting near the eye relieved by laudanum next day fever relieved by bleed. & mercurials Young woman in Toll. cty. stung in the leg by a wasp fainting & anxiety died in 15 or 20 m. Dissection wounds A wound seems to be necessary. Prof. H. does not think they can be explained by the predisposing causes of late hours, study etc. Symptoms finger very sore & painful soreness extends up the arm pain in the head & back, chills & fever. Swelling of the part up the arm in the axilla pus under the pectoral muscle & in the chest death. If the pus collects in the finger alone the case is less dangerous. Prof H. has known similar effects follow a puncture without morbid matter. Case of a boy wounded in the heel with a fish spear. red streaks abscesses in the foot & leg 51 suppuration under the pectoral muscle under the pleura death Very bad sores upon the fingers often have arisen from dressing ulcers. Prognosis varies upon the situation etc. Touching the wound with nit. silver has not always been successful Suppuration in the lungs following operations compd fractures etc. The treatment is the same as in other inflammations of the pleura bleeding etc. In two cases Prof. H. made an opening into the sac of the pleura one of them was fatal, the other recovered. Gunshot wounds The contusion must be very great. A spent ball will produce contusion merely. It was formerly supposed that the ball burned the parts judging from the appearance of the [illegible. This is a mistake Often the shock to the system is very great, but with some it is trifling The entering orifice will be smaller than the issuing The latter will have 52 ragged and projecting edges. Sometimes a ball may be pulled back by taking hold of a piece of silk, which was carried in before it. Its course may be very circuitous, being diverted by tendon sometimes as well as by bone. Abscesses and also cysts are formed around it. The effect formerly acribed to the wind of a ball are explained by the oblique stroke; the skin yielding & being unlacerated, while even the bones within are broken. That the wind does not produce the effect is proved by the fact of one leg’s being carried off without injury to the other, when both are in contact The contusion destroys the life of the adjacent parts. The hemorrhage is generally slight Balls may pass through the body without penetrating cavities, as of the chest. Baron Larrey told Dr [Heerman] that he had lost but two patients whose bodies had been perforated by a ball. 53 Necrosis is generally produced by a ball’s striking a long bone in other bones caries. Wounds of the lungs will often be followed by haemor. from the mouth of the bowels by feces issuing from the orifice. Wounds of the joints are dangerous Indications 1st suppress hemorrhage Do this by the tourniquet if possible Tie arteries as soon as possible, unless amputation is to be performed 2nd extract foreign bodies unless they are out of sight & of the reach of the finger or probe When the ball has passed nearly through cut down on the other side, while squeezing with the finger & thumb. Thread etc. will come out by suppuration A foreign body lodged in a bone is very dangerous. In a superf. bone trephine 3d prevent or remove irritation The French make incisions to take of the stricture & debridling the part. This is now discountenanced by the British In case of a fleshy wound, apply 54 merely lint and simple cerate. Many keep a moistened compress upon the orifice This is [illegible] cold water is generally the best application. For some days the wound will look ugly, with swelling & frequently a watery discharge. If suppuration comes on slowly, poultice but do not continue them after suppuration’ is fairly established, but absorb the pus with dry lint. The separation of the slough is another critical period if secondary hemor. then comes on apply a compress immediately. The plan of tying the artery at a distance has generally failed In an old wound we must make a new one. General treatment should be antiphlogistic Prof. H. uses calomel as a cathartic & the British surgeons are adopting the practice. If there is pain in the head fullness of the veins etc. bleed & purge In the latter stages opium is invaluable 55 to allay irritation Sometimes also in the first shock & then according to some bleeding must be conjoined. Amputation 1st as to the time 2nd as to the particular case. The unanimous testimony is now in favour of immediate amputation waiting however for recovery from a violent shock & administering a mouthful of wine & also consolation & encouragement. Baron Larrey & Prof H. prefer immed. amp. even when bad symptoms have come on 2nd the different cases 1st amp. is necessary when a limb has been shot off for a clean incised wound is made the patient will be more comfortable & mortif. less likely In fingers the injured phalanx only need be removed, at the joint. 2nd when a ball has passed through or lodged in a joint. 3d in some cases where a bone is fractured according to the degree of injury to the bone & also to the soft parts Even if the patient recovers, the limb will often be not so good as a wooden one Necrosis often comes on. The suffering will be great Often a bone will be fractured & split into the condyle 4th by extensive destruction of soft parts, to prevent gangrene, or extensive supp. & hectic & where the muscles are torn off the limb will be stiff. If the upper part of the femoris or os humeri is fractured amp. is necessary (at hip joint?) Consecutive amp. may be necessary The destruction of large arteries sometimes the skin will be unbroken in the meantime often indicates amputation Good accommodations for the wounded may enable us to save patients without amputation Be careful to amputate entirely above the fracture Mr. [illegible] says that after amp. death takes place 1st from infl of bloodvessels 2d [metastasis] to some important internal part most commonly to the thorax in our climate 3d from disease of the bone or joint 1st the veins may perhaps be tied 3nd pus has been found in the sac of the pleura 3d the hip joint Prof. H. would evacuate Suppuration of the liver more freq. take place in hot climates After amp. the end of the bone becomes round if the cure is favourable Paralysis is a frequent consequence of extensive gunshot wounds cured by moxa according to Bar. Lar. Tetanus Failure of success almost universal in acute tetanus more common in warm climates Bar. Lar. has had most success. It may be occasioned by tying up a nerve with an artery by exposure to night ari by suppression of suppuration acc. to Bar. Lar. Actual cautery has succeeded Amp. has generally failed Canthar. often fail It occurs oftenest in the young & in wounds of a [ginglim???] joint acc. to Bar. Lar.’ Emprosthotonas will follow an anterior wound & opisth. is a posterior & tetanus where there equal injury before & behind acc. to Bar. Lar. Warm & cold bathing have been much used Case of a young man wounded in the foot by a piece of glass. Bled. blister to the healed wound calomel opium cured was stiff for a year. Case 2d blacksmith hot iron upon foot corr. sub. into the wound blister over the foot calomel & opium the latter followed up cured. Make a powerful impression. A red hot ploughshare has been passed along the spine. Bite of mad dog Excise deeply it has never failed in Prof. H’s practice A finger may be cut off. He has cut out 6 days afterwards with success. Dr Physick says at any time before the [accession] of the symptom Contusions without breach of the skin It is an injury causing a rupture of vessels & effusion of their contents under the skin 1st swelling owing to extravasation next echymosis or discoloration which frequently extends some distance especially in the direction of gravity e.g. black eye from contusion on the forehead finger discol. after an injury of the arm very easily produced in old people. Commonly a considerable degree of soreness. The powers of absorption greater in the young Indications 1st prevent further effusion 2d reduce infl. 3d promote absorption 1st by wet lotions of water [mar.] [illegible] etc. 2d if much fever bleeding & cathartics & fiunally if necessary opium 3d Use warm applications (these also may be for the first indication after a while) Add to these bandages & compression. Also we can apply camphorated spirits opodeldoc etc. In many cases an incision must be made to let out the effused blood (called bloody abscesses by the French) We should however generally defer [illegible] One reason for which is that the vessels may continue to bleed. If the blood is coagulated a snapping will sometimes be felt as of something breaking & slipping away. [illegible] in this state it is though more likely to be absorbed. Before incision try remedies and [observe] if you appear to be gaining ground. Sometimes the effusion is in a bursa mucosa Case of it in the knee So [much] a [illegible] Make the incision on the outside of the tendon of the rectus musc Prof H has several times been obliged to open these bursae e.g. at the elbow. Upon the back he has had to make an incision & let out a quart of fluid tarlike blood. If the vitality of the skin is destroyed an incision will be advisable. We shall have a sloughing sore in either case. There is a bursa directly on the olecranon which is liable to be filled with effused blood Often there will be a second eff. when the orifice must be opened & the cavity injected with corr. sub as in [illegible] Contusions of abdomen. Death has been occasioned by blows on the epigastrium apparently caused by the shock alone Often the peristaltic motion suspended which denoted by swelling of the abdomen vomiting want of sup. anxiety of countenance etc. Sometimes blood is vomited It is generally best to avoid stimulants Case young man kicked by a [illegible] vomiting of blood 1 great pain & excessive thirst to stop the flow of blood cold wet cloths were applied to the abdomen bled ad deliq. pain ceased pain & vom. returned bled again calomel finally injections The bleeding relieved the pain the vom. & the thirst. cured in 2 or 3 days Venesection is the most important indication, the next is purgatives continued for some [time] Sprains not much treated of It is an unnatural extension of ligaments of a joint sometimes accompanied by dialysis or rupture. Joints most commonly affected are those which are not strongly defended & admit of little motion. They are the knee ankle wrist & hand. At first motion is free but it is soon hindered by effusion & swelling frequently there is effusion into bursae mucosa There is an effusion into a bursae of the foot which is often [illegible] for dislocation. It is apparently set by pressing & breaking the sac. Prognosis Some families are particularly liable to them Scrofula gives a tendency. In some constitutions a slight sprain will cause [hemorr.] for months Treatment Rest is more necessary than in contusions. Cold lotions to prevent infl. cold water or ac. plumb. A bandage is always proper moistened at first. In case of much pain use warm fomentations best by wringing out a cloth dipped in hot water, applying it & covering it with flannels to keep in the steam. Poultices may be used In case of stiffness apply opodeldoc & other stimulant applications friction passive & active exercise. Lameness is often caused by want of exercise. The violent wrenching of the natural bonesetters has some good in this way. Burns. Inflammation caused by heat The practice has been exceedingly empirical No advantage in dividing them into species Superficial burns of sufficiently extensive are of the highest consequence Case of a child blistered by cantharides over the whole body died in great agony. The British East India surgeons sometimes used hot water for blistering The [illegible] indication is to shut out the external air. Treatment like that for a blister Deep burns are generally [illegible] by a suppurative inflammation which is generally ascribed by the patient to taking cold. Sometimes flame is inhaled the viscera are affected, under the external injury, in some patients Consequences of extensive burns if the pat. survives the first shock, are fever, extensive [illegible] etc. This last is frequently fatal, hence the end of three weeks is a critical period Children are sometimes affected with convulsions When we find apparently comfort application already made, we should be careful about interfering with them Treatment has been opposite & empirical Cold water on one hand & spts turpentine on the other. Antiphlogistic & powerful internal stimulation For simple external burns anything that keeps out the external air perhaps as good as any is simple cerate. If there are vesicles [illegible] them Equal parts of basilicon (or common cerate) & spts turpentine is the best application in case of extensive sloughing & suppuration Prof H. has tried cold application & poultices, but does not like them [illegible] is the necessity frequent exposure to the air in dressing. The above cerate seems to promote a quick suppuration & so prevent gangrene. It must be laid aside (causing smarting etc.) as soon as suppuration is free, when simp. cerate should be dressing not oftener than once in 24 hours having the dressing ready for immediate application the cold air. Then granulations come on use Turners cerate Finally use ac. lead 1 oz beeswax & sulph. sod. 2 oz. This is called saturnine cerate. Turner’s cerate above is made of oxide of zinc. Often near the close of the cure adhesive straps & bandages are useful to keep the sides of the ulcer together Constitutional treatment. The shock is often very great. In children there is either violent distress with screeching [or a comatose] state with deadly coldness which indicates alcohol camphor ammonia etc. Opium also though Prof. H is afraid of it in coma. Next comes on fever treated by venesection cathartics etc. to be discontinued when suppuration comes on. In children it will be sufficient to keep the bowels open & bleed only incase of convulsions In adults the bleeding should not be copious. Bark [seems] to be irritative Opium is the principal remedy on account of the pain etc. Cotton seems to be advantageous only by keeping out the external air & keeping the parts warm & by being easily applied & kept on Case of a man who fell into a kettle of boiling potatoes Took a large quantity of spirits Was dressed with the turpentine cerate then with simple cerate opium [was given] the bowels kept free about the [2?] day there was a critical period his mouth was treated with borax & other means were adopted which cured him. If an extremity is burnt off then amputate the stump immediately Sometimes the bones come off themselves. Deformities from burns The fingers are liable to adhere This is to be prevented by dressing. Splints are to be used to keep parts in their place preventing [illegible] flexion of fingers etc. When the joints are affected they should [illegible] straight & when the sore is healed, practice flexing them. Case of a young man who scalded his legs Deformities following burns Case of a burn at 7 yrs. of age upon the back of the thigh troublesome with sores etc. at 47 yrs had been of latter years much troubled with a horny excretion which was softened with [poultices] & shave off [At] 47 yrs of age the limb was amputated IT was an old practice to cut across the cicatrix & stretch the parts in case of deformity caused by contraction The new practice is to cut out the scar entirely sometimes adding the taliacotian operation Case of a young man with a large & sore scar on his foot. A good foot was made Frost bites A degree of torpor is produced by severe & long continued cold amounting to drowsiness & irresistible inclination to rest. Case of Prof. H’s preceptor, an army surgeon Not suddenly to be brought into a warm room nor to be too free with cordials Immerse frozen limbs in cold water gradually warming the water after a little while. A limb thoroughly frozen cannot be restored to vitality, however The contrary treatment totally destroys the frozen part. The effects of frost are similar to a burn superficial redness mortification which commences with a purple & terminates with an ash colour in case of thoroughly frozen limbs In frost bites apply ac. plumbi etc. poultices, cerate in case of suppurations which may have liquid applications over them. Cold and warm applications are both used. In case of mortified extremities amputate without hesitation as soon as the line of mortification is distinct else we shall have suppurations abscesses etc. Case of Capt P. of Brooklyn was overturned, & [stunned], in extreme cold weather lay all night was put int a very warm room. The phys. attempted to bleed him no blood followed there was a wound on the eyebrow knee the other knee dislocated right hand frozen. Prof. H. bled him, & gave a dose of cal. & jal. Afterwards he grew more insensible & eventually comatose for several hours. An erysipelatous inflam. with delirium supervened. He was bled & treated on general principles. Eventually recovered The fingers & thumb of the right hand were amputated after about a fortnight This amputation was however too late as was proved by suppuration & abscesses taking place on the hand & arm. The patient was partially sensible & able to tell his name when he was first discovered by the road side. The effect of the warm room was to bring on complete insensibility & finally coma A foot or hand frostbitten if applied to the fire is followed often by violent infl. & mortification which when superficial merely will cause nothing more than the loss of nails skin & so on Tumors Varieties numerous 1st Encysted 2d sarcomatous 3d medullary Also malignant & non malignant the last however may become malignant We know little of their origin. Mr. Aber. attributes them to extravasated blood. Their progress is often similar to that of chronic inflammation The nature of the tumor will often be inflamed by that of the parts where they are situated e.g. they may contain hair when upon the scalp. The growth seems to depend upon the size of the bloodvessels of the part. They increase, in general, in geometrical progression They should be extirpated before they have arrived at any considerable size. 1st Encysted tumors contained in a cyst of more or less density, which encloses [stertomatous], or [illegible] mellitus, or is an [illegible], curdy matter being contained There is a kind affecting the red part of the lip having a think sac & contents resembling the white of an egg not larger than a musket ball. There is a tumour composed of adipose matter disposed in cells called sarcomatous Various discutient remedies, have been recommended. As far as they are effectual at all, they do injury. If the cyst is penetrated, a very troublesome sore follows & sometimes cancer Caustics instead of knife have been successful Cancer quacks cure small tumors in this way and call them cancers. In case of large tumors caustics often fail & the knife is always preferable. It was formerly advised to extract without opening the cyst this not always practicable without great difficulty. Sir A. Coop. opens the cyst presses out the contents & pulls out the cyst by inversion. If any portion of the cyst remains the tum. will be renewed. Sometimes a small tumour may be removed by caustic alkali upon lint introduced into the cyst. external injuries freq. cause these tumors Sarcomatous tum. In these the cyst is not strong enough to be pulled out. If the skin adheres firmly, make two semilunar incisions & take out a piece of skin Then separate the tumour from adjacent parts by the fingers as much as possible Membranous connecting bands often have to be divided. These tumors are troublesome from their size, from impeding motion etc. when pendulous, the skin is frequently affected with an erysipelatous infl. Cases of old woman & an old gentleman extirpated with safety. The arteries are usually very small in these fatty tumors sometimes however they give a troublesome haemorrhage They are divided into various kinds by Mr. Abernethy. All the kinds may become malignant Fungus haematode medullary tumors malignant from the commencement & liable to return even if thoroughly extirpated. Hence a portion of undiseased parts should be cut away After extirpation treat as for a simple wound. The largest [tumors] are the fatty even 40-50 pounds They feel like a bag filled with cotton Sometimes there is a puckering of the skin (caused by imperfect adhesions of the skin) under the fingers. This is a pathognomic symptom These adipose tumors must not be confounded with the steatomatous encysted tumors. It is a question whether the whole parotid gland has been extirpated. They will prove fatal (many of them) eventually & hence should be extirpated while small. The testicle & the fem. mam. are enlarged frequently & sometimes will become small again Medullary tumour or fungus haematodes the substance of them resembles that of the brain but is redder & harder found in every part of the body even in the bones & then called osteosarcoma There is at first an elastic feel caused by the binding down of fasciae Growth is very rapid, causing absorption of adjacent parts as bones Most common are they in the young they were all formerly called varieties of cancer In the testicle most taken for hydrocele It is found about the eye Prof H. has met with them oftenest about the hip. Case of mortification & death in three days in consequence of opening one, in search of pus. Case in which a small point was left, which grew in spite of caustics & proved fatal. Case in which it returned three times & was then left We must hence cut away sound parts also. If the bone is affected amputate. Prognosis is generally bad though the wound heals well enough. They may return in internal parts. They are not always pulsative nor generally painful except by pressure upon surrounding parts & by a general [illegible] of health loss of app. sallowness of continence etc. pain when a nerve is pressed on Diagnosis of medullary tumors Abscesses begin deep & are not painful and are circumscribed by a hard edge. fungous tumours have an elastic feel. The colour of the skin over a fungous tumour will be dark red, but not tender like that of an abscess, nor surrounded with a hard rim. We must also inquire into the previous symptoms fungous tum. begin without infl & pain & are indolent. Spots will be found in the neighborhood which if opened largely will prove fatal. Case of a fung. haem. of test. mistake for hydrocele. Though we have no remedy for this disease yet extirpation should be performed if possible cutting into the sound parts. Case of Dr Wood. of [Cast.] cutting out one of the thigh every few months the man able to labour. Case in which the most powerful caustics failed in killing the tumour, fast as it grew. Ulcers A solut. of cont. in soft parts with a discharge of fluid. The absorbent vessels remove the parts faster than the nutrient vessels renew them hence the opposite to healing Differs from mortif. by the dead parts remaining in the latter case Various classes of them Causes wounds abscesses external injuries (local) The constitutional causes are syphilis scrophula scurvy etc. also in some families from a predisposition e.g. hereditary sore legs An oedematous affection predisposes e.g. dropsy phlegmasia dolens 1st simple 2nd irritable 3d indolent 4th varicose 5th specific ulcers 1st simple discharge of mild inodorous pus small round granulations filling up the cavity finally a bluish skin (cuticle only) which makes cicatrization Formerly 3 stages were always expected in the healing of a wound viz. ulceration, granulation (restoration) & cicatrization. Much benefit arises in a simple ulcer from adhesive straps, as in a wound, to promote cicatrization. The bandage will keep the parts together & also prevent proud flesh (a luxuriant gran. protruding beyond the skin) which should by nit. sil. or if that fails by sul. cop., be reduced Irritable ulcers painful sore irregular shape (sometimes round when small) gran. irregular do not bear bandaging well. The irritability may generally be abated by touching with nit. sil. or by wash of corr. sub. or by 1 scr. corr. sub. to 1 pt water (called yellow wash) or sprinkle with calomel, or apply the black wash of cal. & lime water or wash with [illegible] op to 1 pt water 1 dr. ac. lad to 1 pt. mucilage will be cooling & lenient. Warm fomentations are apt to soften too much We frequently change our application Indolent discharge serous& curdy bottom smooth edges swollen surrounding cell mem. thickened often very large as large as a hand [illegible] patients will suffer little, and continue to labour. A farrago of remedies in popular use Nitr. ac. & nit. sil. & other caustics are used. The best rem. is MR. [Berts] plaster bandage, surrounding the limb. above & below with this bandage applying a compress wetting the whole with cold water. Sometimes leave a little vacancy for the discharge of matter The plaster may be common adhesive pl. or diachylon, or rosin pl. or [litharge] pl. sometimes in case of irritation from Soap plaster of the [illegible] is used rosin softening this last with tallow one half Dress once in 2 or 3 days only Sometimes an erysipelatous infl. & sloughing comes on Guard against this by diet etc. Improper to make a class of sloughing ulcers Indolent ulcers may be cured much sooner by confinement, as is practised in the hospitals. 3d Varicose ulcers. The veins will be found varicose. Some are irritable more commonly they are indolent. Treatment of the varicose veins is the particular indication. Proper bandages with confinement of the patient is always proper. However the cure will be more sure of being permanent when it is effected without Diet is of the highest importance The patients are generally plethoric more or less; hence use venesection or purgatives (mercurial). Where erysipelatous infl. come on treat as usual by ac. plum. blistering etc. Some patients are feeble with low pulse cold skin & pain in the affected limb. In this case give cal. [illegible] cal 1 ½ gr. op. 1 gr. also Dov. pow. bark & opium etc. Nitrate of silver relieves irritable [illegible] sloughing etc. better than any thing touching with it once in a few days. There is generally little hazard to life from sore legs. Cases in which by the continual application of caustics & irritatives caused enormous ulcerations cancers & affections of the bone which required the operation for necrosis, or amputation It has been proposed to be the vena saphema Sir A Coop. objects. Cutting across the vein is thought better by some also cutting with the convex cutting edge of a bistoury, so as not to wound the skin also cutting out a part of the vein & then bringing the edges of the wound together, as is practised with success in the Pennsylvania hospital. This latter mode probably the best. It has been supposed that the drain from old ulcers is very beneficial this opinion is probably derived from the fact of the stopping of the discarge in an acute disease as fever There is no danger in curing them Hence the old opinion, which is still the popular one, is to be entirely disregarded Plethora had better be relieved by venesection & cathartics than by ulcers. Specific ulcers e.g. venereal, noli metangere cancers etc. Anomalous ulcers Sore on the instep somewhat like elephantiasis. Benefitted by powdering with calomel. Nitrate silv. saturnine cerate acetate of lead & calomel with lard may be tried also. There is a thin watery discharge redness hardness thickening extending over the whole upper [surface] of the foot. Sometimes stopping in one direction & extending in another Fungous ulcers [ment.] by Sir. A. Coop. principally on the calf of the leg resembling a scrofulous affection of the metatarsal bones generally in young & corpulent women Apply bandages wet in case of heat when the fungous protrudes through the skin apply nit. sil. Also wash with ac. of lead etc. & prescribe for constitutional symptoms. Ulcers following scrofulous abscesses Fungous flesh overhanging, thin, dark purple skin they are oblong Apply nit. sil. in pencil under the skin if necessary that is if this first application does not cure then cut off the diseased skin & lay open the whole sore. Sometimes where the orifice is small, a director must be introduced & a long incision made it will not in this case be necessary to clip away the skin. These like other ulcers are often called cancers Schirrhus or cancer. A hard tumour without ulceration is called schirrous cancer, when ulceration comes on Schirrus may be fatal without running on to external ulceration Lower limbs & testes in males breasts & uterus most often affected When affecting the skin they begin with a blood war, or with a discoloration & tumour of the skin to be treated of afterwards. Scrofulous tum. are less hard, seldom single, oftener in young people, they are smooth, and attended with scrofulous habit. Young women are often affected with an induration of the mammary gland which is mistaken for schirrus. The latter is almost always found in adults. Cancer of the breast [Commences] with a painfulness When first examined there is found a hard tumor. An inflammation of the skin takes place. The nipple retracts & disappears eventually the hollow will discharge an ichorrous fluid. Or the cancer may commence with a small vesicle which breaks, discharges, & finally becomes an irregular knobby cancerous ulcer Cancers however, do appear to commence sometimes internally. The lymphatic glands & sometimes the lymph vessels, are affected when the ulcer opens. Sometimes the skin adheres to these inflamed lymphatic vessels Finally the manna adheres to the pectoral muscle & even to the periosteum of the ribs & sternum even attacking the other mamma with the same symptoms The lymphatic glands of the axilla are more affected & the arm sometimes is so oedematous as to require puncturation Great difficulty of respiration occurs The disease is fatal from hydrothorax or other affections of the thorax, as well as from hectic Sometimes without much ulceration the whole mammae are bound down at death with schirrhus. Sometimes the bones of the extremities become singularly brittle. Sometimes a paralysis of the limbs takes place The whole spinal narrow has been affected. Very numerous & various symptoms may come on in the sequel. Difference of opinion as to whether this disease is constitutional or local. For sometimes the disease returns in the same or another part & sometimes not Prognosis doubtful The more speedy the access the mor probable the return Sometimes in very old people from their slow progress & insensibility they give very little trouble. Their cure has been attempted by bleedings & low diet also by salivation No dependance can be placed on these remedies. So of the internal use of arsenic and of conium also. Iron internally & externally seems to have failed Pressure has been much tried, but fails The hard cartilaginous nature of the tumour would lead us to despair or resolving them by internal or external remedies Caustics have been successful in very small cancers, but generally they give so much irritation as to increase the disease making a loathsome sore Iodine has been proposed There are no accounts however of perfect cures by it. Prof Smith stated he never knew a woman survive the application of caustics to the mamma more than a year The sooner the knife is used the [better] Use the knife also even after ulceration has come on. We must not expect the infl. of the lymph gland to subside of itself, this tumour also must be cut out. Reexterpation Should be performed as often as the disease returns provided the patient can bear the operation Case of 4 times in a year & the patient is now well. Various remedies, or issues, have been tried to prevent the return of the cancer It is of no use to prescribe any thing except for the general health In other parts of the body cancer may begin in a manner similar to those of the breast In the lip, we may have first a crack in the lip ulceration the lymphatic glands of the neck are affected the gums are affected the cheek the bones the whole mouth consumed & sometimes the patient dies of starvation. Mode of extirpation take out a piece in the shape of the letter v. bringing the parts together. If the skin is not affected, we may cut away down to the skin, leaving the latter Mr [Richaraud] cuts away the whole with scissors instead of the knife Prof. H. has extirpated the diseased glands under the inferior maxillary but generally without success where the disease has proceeded so far. We must not be too solicitous to save skin, cutting away all that adheres for the disease may return in the skin. Even when the disease returns it is not generally so rapid & fatal as at first. We must be very careful not to confound cancer with other diseases of female mammae Hydatid or incysted tumour of the breast of Sir A. Cooper 1st an enlargement then a tumour which yields serum when punctured then returns again and may attain to the size of several pounds. When of this size it is found after extirpation to be composed of one or of several cysts & may be of other forms. Case of a woman who had one opened a second time the opening kept open by [illegible] died of extensive suppuration & const. irritation Another case was extirpated at the first time. The tumor was the enlarged mammary gland with a cyst in the centre. Diagnosis absence of pain If opened the fluid perfectly limpid Indication immediate extirpation Simple chronic tumour of the breast of Sir A. Cooper. Rather upon the breast, than in it moveable Not generally painful & does not affect the constitution It grows very slowly but may arrive at a large size. There is no difficulty in cutting off the tumour & it does not appear to be liable to return It may be either before or behind the mam. gland These tumours are composed of several cells resembling sweet bread a glistening & glandular appearance. The cause is unknown. The patients sometimes suppose them to be caused by the pressure of dress Caustics may have cured them. Adipose tumors sometimes many pounds in weight may be either before or behind the gland. They are to be extirpated Irritable tumours of the breast for 15 to 30 yrs. lobe of the breast swollen & painful the arm is affected, more painful during menstruation especially during difficult menstruation great irritability etc. If patient is plethoric, bleed, & purge apply spirit & water or a plaster the best external application is soft fur or cotton batting. Give opium Sir A. C. speaks of an ossific tumor of a cartilaginous nature to be extirpated Lacteal tumor after delivery a swelling, which when opened yield milk Caused by an obstruction in the duct of the gland. Treatment, open & let out the milk wean the child & so stop the secretion of milk. If the orifice does not heal, touch with nit. silv. Some women are very liable to small abscesses of breast during suckling If they continue to succeed one another the child must be weaned. Breast large & pendulous It may be diminished by bearing & nursing children also by suspension Sometimes there is an enlargement & inflammation of the breasts during pregnancy which often require opening to evacuate pus With the exception of the small chronic tumors upon the breast, the whole glandular portion of the breast should be removed. Mode of operation. Instruments 2 or 3 round edged scalpels tenaculums needles & ligatures adhesive straps from 1 ft. to 9 in. long & 1 inch wide Bandage by a broad band passed around the breast & crossed over the shoulder stitching down in front. Have also lint & compress. Cordials & cold water for fainting. This last is best remedied by dashing on cold water Place patient on a table, with feet in a chair arm extended sitting in a chair is apt to occasion fainting Make the first incision in the direction of the greatest length of the tumor Or make it in an oblique direction in that of the pectoral muscles. If the skin is affected semilunar incisions are necessary. Stretch the skin with your left hand & by that of an assistant Use a drawing stroke, from heel to point of the scalpel. Make your incisions long enough at first Use considerable force & repeat the stroke also until the incision is deep enough If two incisions are made, make the lower one first. Observe this rule also in your following dissections. If an artery bleeds, stop & tye it or have an assistant keep his finger on it. Be careful to examine the bottom of the wound & also the under surface of the tumour. Cutting away little additional portions does not give very great pain. Then proceed to take out the tumour from the axilla Sometimes the same incision will answer for both. They may sometimes be torn out by the fingers being imbedded in the cell. mem. merely we can generally get the fingers behind them When there is a diseased chord in the in the cell. membrane, take it out with the tumour in the axilla Spunge the wound out well & tie every bleeding artery wait sometime in order to prevent secondary hemorrhage The French direct us to wait ¾ of an hour Wipe dry & bring parts together with adhesive plaster, beginning at the top & leaving a small space for ligatures to come out, unless they be made of leather then apply lint & a compress, & bandages It has been the practice of some surgeons to tie the carotid previously to the operation There is no necessity for this Other tumours. Cutaneous tubercles of Mr Lawrence. Prof. H. has seen it often. Frequently beginning about the face especially of elderly people upon the eyelids, nose, & upon the generative organs of both sexes. It becomes ulcerative & resembles cancer. Sometimes resembles a wart & sometimes a vaccine vesicle, at the first Always reddish & without inflammation of the skin. Sometimes it grows very slowly & gives but little trouble. At other times, especially if irritated, its growth is rapid. Finally they ulcerate without any disposition to heal & indeed become cancers; they are covered with scabs. Menstruating females are liable to periodical evacuations from the uterus, intestines (hemorrhoids), lungs etc. produced by these tumours This disease is different from noli metanges Treatment. Extirpation is the only mode of cure, & appears to be effectual the disease apparently not liable to recur The health of females with periodical hemorrhages, will be much improved. Mode make two semilunar incisions & be careful to cut into the healthy skin They do not extend inward Subcutaneous tumor Vide Cheselden’s Anatomy & Mr. Wood in Ed. Med & Sur. Jour. A hard tumor surrounded & covered with emaciated & discolored skin excessively painful growing very slowly & continuing quite small, notwithstanding their painfulness They are of a cartilaginous hardness. They do not appear to tend to ulceration more painful during menstruation & pregnancy Extirpate without delay or hesitation [Naevus] materna called marks apparently composed almost wholly of enlarged blood vessels they may be red or purple, or brown sometimes without any elevation of the surface They are sometimes troublesome in after life the swelling increasing suddenly the tumour becoming pulsative swelling & pulsating when the child cries in this latter case however, there will generally be no trouble in after life from the [naeva] Sometimes they become aneurisms from anastomosis sometimes affecting the whole & sometimes only a part of the naeva sometimes ulcerating at the principal point the ulcer may also very extensive attended with frequent haemorrhage. Aneurisms from anastomosis may come on without being preceded by naevus they may be made almost to disappear by pressure they pulsate violently they are tumours composed of cell. sub. & blood vessels. They should be extirpated after extirpation they of course shrink to a very small size. They may ulcerate extensively & the ulcers are very difficult to cure (They pulsate upon exercise) They may grow to a very large size & are then liable to be confounded with fungus haematodes They may be distinguished by their origin, situation progress, pulsation etc. As ulceration sometimes cures these aneurisms, caustics have been recommended for their cure Extirpate the haemorrhage will be troublesome, hence cut around & avoid cutting into the tumour as much as possible, also cut quickly, stopping the arteries by the fingers of assistants If practicable, the better way is to surround the (small) tumour with a double ligature. A new way is by passing 2 or 3 times through them a white hot needle apparently successful in case of small ones Case in which a naevus on the head was cured by Prof. H. by ac. lead bandages & compression Inoculation with vaccine matter has succeeded, apparently caustic would be better however as a means of promoting ulceration Tying the principal artery leading to the tumour, has been practised when on the head the carotid has been tied apparently without success. 11 Theory Practice Physic (front) Surgery (rear) Nosology 1 Diseases of Children 5 Retention of meconium 6 Tumour of the head 7 Aphthae or Thrush 7 Red Gum 13 Strophilus candidus 14 Ulcerated mouth 14 Costiveness 16 Infantile Erysipelas 18 Anomalous Eruptions 19 Crusta Lactea 20 Venereal Eruption 22 Sore Ears 23 Diarrhoea 24a Vomiting 28 Hydrocele 29 Volvulus 30 Constipation with fever 32 Worms 36 Convulsions 46 Epilepsy 49 Chorea 51 Dentition 55 Ricketts 58 Cholera Infan. 60 Tinea Capitis 68 Catarrhal epidemic 70 Gangrene of mouth 80 Chillblains 81 Exposure to extreme cold without freezing 81 Mesenteric fever 82 Cutting frenum 85 Burns 86 Tympanitis 87 Neuralgic aff. of the lower limbs 88 Whooping cough 71 1 Theory & Practice of Physic Nosology Dr Rush condemned nosology but afterwards made use of a system of some sort. We must arrange our knowledge. Dr Ives believes the fundamental principles of the common systems are erroneous Disease is a derangement of some or all of the functions of the body. It is the opposite of health or dis-ease. We must compare it with health. Dr Ives condemns the classification into species general orders etc. as if they were entities or beings instead of merely modes of action Diseases change their seat and their form in the course of their progress Nosologists would have done better than they have if they had imitated the natural classification of the botanists. Very great error is committed in attempting to make the divisions mathematically exact. 2 All the present systems suppose definite diseases with specific modes of treatment this leads to an invariable mode of treatment & to the prescribing for the name of a disease. Still it must be confessed that nosology founded on anatomy and physiology are [latelly] acknowledged that diseases are mere modes of action A classification of epidemics formed upon [remote] causes is equally erroneous as the remote causes are disputed, and unknown Dr Ives divides epidemics into two great classes taxic & ataxic in irritation of the division of natural families into classes The term malignant has sometimes been used in the sense in which Dr Ives uses the term ataxic sometimes for rapid fevers, for those which have a gangrenous tendency & for those which more especially affect the vital fun. Ataxic a morbid state, beyond the power of reactions attacking the vital 3 function not putting on the ordinary forms of fever The first & most important indication in taxic fevers is to moderate the violence of reaction in ataxic, is to produce reaction It may be laid down as a principle that all ataxic epidemics resemble each other Ex. gr sometimes in the yellow fever the powers of life are attacked & prostration or exhaustion continues until death closes the scene. What are called the walking cases are of this kind in which the patient walks about until death. This kind is difficult to describe but when once seen is never forgotten eyes glassy countenance anxious etc. So of cholera of India also of pneumonia typhodes especially as it first appeared in this state It had four distinct varieties of which spotted fever 4 was one. No reaction no pain no heat such cases are said to occur in the plague A person who has treated one ataxic fever is able to manage any other All extreme cases may be classed together under this name, as they are in fact under that of malignant Dysentery of 1814 & 15 mild coma [gentle] sleep no apparent pain stools once in two or three hours not striated with blood etc. etc. when the patient was roused from sleep he said in a faint and indifferent tone of voice he was well immediately fell back into sleep. Yet here was dysentery [although] there was no dysenteric symptom for these cases were beyond question, of the same epidemic as others unequivocally dysenteric The indications were to excite reaction by external and internal irritants and to excite the action of the stomach and bowels by calomel ipecacuan etc. In this epidemic the stomach & duodenum appeared to be principally affected. 5 Diseases of Children Great attention has been paid to this subject within the last 30 or 40 years It was formerly almost entirely neglected owing to the exclusion of the faculty from the practice of midwifery to the prejudices of mothers and nurses & to the indifference of the family themselves Young physicians are more frequently called to the diseases of infants hence the importance of this subject to medical students. In Europe have the physicians been most negligent of this subject The French & Germans less so than the English The European practice differs from ours less so at present than formerly because our constitutions are coming to resemble theirs. Their practice is more mild In general chronic diseases require a milder treatment. Great difficulties result from infants being unable to tell of their complaints yet the 6 other symptoms are more easily understood They practice no disguise or concealment They are not made worse by mental aff. Many prejudices exist e.g. that the child is born with a morbid appetite inherited from the mother which appetite must be gratified This they infer from the natural crying of the child The mother sets herself to recollecting some former longing of her own. Story of a child fed upon this principle with mince pie It had to be physicked severely to save its life The mucous membrane of the al. can. is oftenest affected sometimes spasmodically Be on the watch with regard to the liver. The nervous system is more easily excited from irritation than in adults The vascular system less so. Fevers are generally more irritative than otherwise As a general rule preventive medicine should not be given. Evacuants may be given 7 with great safety Witness the long diarrhoeas & the salivations of dentition which they bear without emaciation The milder purgatives should be used. The drastic are irritative calomel is one of the best. 1st Retention of meconium & its consequent diseases. The meconium is a dark green matter resembling tar Its evacuation should be effected not by medicine but by the first milk of the mother. The act of crying also contributes to this effect. Instead of suffering the nurse to feed the child during the first two or three days the breast should soon be present If the child feeds, it is in danger o f losing the instinct to suck Evacuants are 1 gr. of carbonate soda to a teaspoonful of water until 10 gr. are given is a good cathartic Molasses & water may be used likewise The gall of animals 8 in a good cathartic as a substitute for the childs own bile. It may be given in catnip tea, milk etc. We may use also Decoction of the flowers of the dandelion and of the mullein. The best however is generally castor oil teaspoonfull at a time until evacuation is produce Senna likewise, in conjunction with some aromatic herbs & seeds 1 dr. of these to 4 of senna The operation of cathartics must be assisted by emollient injection & also by fomentations of the bowels & the warm bath. The blue pill may be used. Also 1 gr. calomel & 4 or 5 of chalk repeated once in 2 or 3 hours assisted by bitter & aromatic herbs in the way of injection These last thus will frequently answer by themselves. Blue pill & chalk & calomel rarely offend the stomach These measures must be pushed vigorously & used in conjunction also especially the warm & tepid baths 9 in cases of convulsions from retention of the meconium. Dr Ives has not known salivation produced in infants by mercury. This may be explained by the large quantity of mucous which defends the surface of the intestines and enabling infants to bear large doses of calomel. The abundance of meconium contributes also. Antispasmodics e.g. aqua amm. 3 or 4 drops also 3 or 4 gr. carb. amm. also asafoetida a teaspoonful of the tincture injected in milk & water into the rectum. These may be used Young children are often troubled with hiccups & irritation caused by acidity, which must be corrected by alkalies. Sometimes this must be corrected by regulating the diet of the nurse. If as is occasionally the fact the mothers milk disagrees, as is shown by the [illegible] stools & the obstinate crying of the child, then cows milk diluted with one third or one half water or with arrowroot mixed first 10 a table spoonful of cold & then of hot water in order to make a homogeneous mixture. Children fed on cows milk are more apt to be costive. To prevent this give a little magnesia, decoct. of dandelions etc. Peach tree blossoms are much used as a cathartic, but are too violent. Children are sometimes born with a tumour of the head occasioned by difficult labour This may be distinguished from a tumour occasioned by a defect in the bones of the cranium by a uniform hardness Aphthae or thrush Sometimes accompanied with a typhoid fever Sometimes idiopathic. It is a disease of debility, caused by disorder in the primal viae. In some families all the children are affected with it Among the poor bad air & among the rich too great warmth & confinement are the predisposing causes It is a vulgar but mistaken opinion that all children 11 must have this disorder at some period or other Symptoms 1st languor, then white specks or flocculi in the mouth, which finally affect the aesophagus, the rectum (for the orifices of the tabes are more sensitive) & perhaps also the whole alimentary canal though this is disputed. The white spots are succeeded by others of a darker colour. It is thought to be prevented by giving a teaspoonful of cold water soon after birth & subsequently repeating the remedy [illegible] [illegible] heat good Castor oil is objectionable because it does not affect the secretions & does soften & relax the mucous coat of the intestines 10 gr. to 1 dr. of magnesia chalk cal. Dissolve 4 or 5 gr. ipecac in 6 teasp. water & give one teasp. at a time If it does not evacuate the bowels calomel or rhubarb may be administered. If the ipecac moves 12 the bowels too freely given on a sixth or eighth of a drop of laudanum In case of acidity white decoction consisting of chalk ½ oz carb. pot 1 scruple 1 [illegible] or [illegible] [Comus] [cir] [sericia] & asking [illegible] Lime water & milk may be given for acidity 6 gr. chalk 1 gr. cal. with a little ginger for watery stools or a small quantity of rhubarb instead of the calomel No violen local application should be used It was formerly thought that the disease might be removed by rubbing off the aphthae by a swab of cloth Inflammation of the mouth was caused. A little borax and sugar equal quantities a drachm in a gill of 5 or 6 of [illegible] in [powder] put into the mouth water Or mucilages, of violets (v. pedata) decoc. of sassafras [illegible], or comfrey A small quantity of sugar lead in the mouth may be [illegible] In children more advanced thrush is sometimes a critical termination of diseased action & then frequently a favorable 13 symptom e.g. hydrocephalus Ipecacuanha in small quantities as an alterative is particularly to be recommended Strophilus intertinctus of William red gum papulae Nurses consider it the same disease with thrush Red gum comes from red gown made of [stom] on calicoe The vesicles rarely contain lymph terminating by scales & not attended with constitutional irritation It arises from heat bad air confinement & irritation of primae viae. When repelled followed by bowel complaint & convulsions The patient should be kept clean and daily washed with tepid water. The tepid bath may be continually used & is the most efficient remedy when the eruption is repelled from the skin 14 food Strophilus candidus Papulae with non inflamed base appearing like very small pearls under the skin about half the size of a millet seed continuing sometime Prof. I. has seen it following cholera infantum A close examination is necessary for its detection Reference made to Willan Ulceration of the mouth called canker Sometimes very troublesome called food is a cause Commences with an inflamed point in the mouth The edges of the ulcer inflamed & elevated Child drules much febricula torpor of intestines 1st excite al. can by magnesia or blue pill or calomel. Then use Moseley’s tonic solution. Compound tinct of vitrine (sulph cop. in alc. water of crystals 15 marsh rosemary geranium [rac.] tinct kino internal app [illegible] [illegible] sulph. cop prescription Nitrate silver corrosive sublimate Prof. I’s own case corr. sub. & op [illegible] astringent [illegible] rhus cornus Rx sulph. cupri 10 gr. carb. Peru a dr. given at 1 dr. Hon & dr water 2 touch the part with a pencil violets allied to ipecac So also asclepias particularly A [decumbens] 16 Costiveness in infants A physician is frequently called when the infant is perfectly well with the exception of costiveness. This will produce a variety of complaints e.g. watchfulness, starting, hiccup, & convulsions. Frequently the child is not observed to be unwell until the convulsions come on The remedy is injection. For we can only operate on the al. can. the lower part, & the skin the mouth being closed We must be careful to make our prescriptions for an enema, very definite. Case of a mason’s man hands & knees about 3 ft. off shooting fright, murder Simple warm wat. or milk & water or about a table spoonful of salt or thoroughwort catnip etc. or finally castor & other oils. Sometimes in extreme cases fill the rectum with lard. Sometimes as a nervine a teaspoonful of camphor in a gill of milk. If these do not 17 answer, used the tepid bath. The water should be heating, while the enema is administered. the water should be about blood warm. Be careful not to sprinkle or scatter water in the patient, instead of bathing. Time 5, 10, 15, or 20 minutes As soon as the patient can swallow, or while it is in the bath give calomel For a child 6 months old 6 or 8 even 10 gr. If improper food is the cause 20 gr. are not dangerous for infants will beat full doses of cathartics, but very small of narcotics Various articles of food are used to obviate costiveness. Oatmeal gruel rye-meal gruel, rye bran gruel Castor oil is the best cathartic a teaspoonful or tablespoonful Magnesia is good and may be given in milk Elixir salutis is one of the most common family medicines. Castile soap is a good cathartic but ½ oz or oz is required. The bile of other animals is a good remedy. Blue pill various vig. ext. e.g. fl. of [mullein], peach, dandelion etc. 18 It is better to cure by food than by medicine Mechanical means called suppositories e.g. candy introduced into the rectum] are common among families Infantile erysipelas Its classification is doubtful It answers tolerably well to the [illegible] of Good No species in Bateman & [Willan] like it Red patches A severe & dangerous disease apparently the same with the dangerous roseola or [illegible] of the West Indies. Elevation of the skin is not so great as in erysipelas Generally commencing on the legs and thighs, & extending like erysipelas. Attended with constipation tumefaction of the bowels, hiccup & severe fever & terminates fatally with come Give calomel 8 or 10 gr In two hours repeat the dose. Then evacuate with 19 senna mixed with aromatic seeds or if this is not sufficient, with castor oil senna or scammony Then keep the bowels open with blue pill External applications the best is flour or arrowroot. Prof. I has sometimes blistered in imitation of Dr Physic Probably every case would be fatal if treated with bad water and did not evacuate the bowels. If diarrhoea is produced give compd powder of chalk of the shops & other sim. articles In erysipelas of the head we may use the common discutients in conjunction with evacuants. Children are subject to various anomalous eruptions, in consequence of improper articles of food. This is frequently the case with adults e.g. fish & pokeweed An excessive quant. of food may cause them Always pat attention to the diet. This will 20 if persisted in, cure most eruptive diseases Avoid oily food such as nuts crusta lactea (milk [illegible]) Porrigo larvata of Bateman On the lips forehead scalp. First pustules yielding pus until a scab extends over the whole face. It never leaves a scar. We must be cautious of checking it especially when of considerable continuance. Sometimes it degenerates into a phagadenic ulcer, In such cases Prof. I. has used charcoal externally poultices, a variety, & has seen much advantage derived from roasted flour, it absorbs and excludes the air. It is proper to give a dose of calomel. The buckthorn is thought to be particularly serviceable in cut. aff. In case of great irritability chalk may be combined with 2 or 3 gr. of cal Diluted muriatic ether in doses of 5 or 10 drops in water 2 or three times a day, has been much used, and may be [recommended] It may ½ dr [illegible] 1 oz alcohol Ext. 2 dr cal 1 oz sim. cer. Oxygenated oint Nit. ac. & lard Nit. ac poured on warm lard Citron oint more efficacious When the [illegible] does not answer [illegible] [illegible] [illegible] app e.g. sulphuret of potash 2 dr. [illegible] in a pint of water smells like bilge water This may be [illegible] in doses of a table spoonful. prob. [illegible] to sulph [illegible] Others prefer sulphuret of soda. Sulph. of [illegible] is equally effic. fever ensues If the eruptions dry up suddenly give antimony & calomel [illegible] children have a [illegible] rash [illegible] 22 Teething in children is frequently attended with an eruption, resembling a fine rash This should not be interfered with lest it be translated to an internal part. It is an effort of the system to relieve itself An eruption resembling porrigo frequently comes on in summer consisting of watery pustules resembling the itch. It is not cured by dock root. It may be cured by diet & the warm bath. Eruptions translate action from the viscera especially the liver, as in gutta rosea of rum drinkers. Venereal eruptions Some think it may be inherited from ancestry instead of parents. Smooth hard circumscribed like of half a pea increase slowly for 2 or 3 wks. then become filled with a watery fluid, & become a ragged ulcer 23 Treatment. Change the nurse if derived from her 1/30 or 1/40 gr. corr. sub. in water blue pill in moderate quantities tepid bath sometimes tonics of iron mur. fer. tartrite fer. alk. solution of iron Sometimes patients resist the mercurial prep & the rem. for scrof. In this case send the patient into the country for air & try simple vegetable articles e.g. exp. juice of plantain, ext. & internally It is a popular remedy for poison & is apparently valuable. It has cured such infants, when conjoined with the country air Its virtue is owing to its bland & mucilaginous quality Sore ears Nature has chosen the back part of the ear to eliminate morbid secretions. It relieves affections of the brain Frequently there is a miliary eruption, followed by excoriation In most cases so mild as merely to require 24 washing If the discharge stops suddenly it is liable to be followed with torpid bowels fullness of fontanelles full tense pulse cold extremities. When infants are suddenly attacked with disease inquire if they have had sore ears which have suddenly dried up in this case apply a blister behind the ears, without this nothing will cure perhaps. This is true of old sore [leg]. The theory is not the necessity of the evacuation but of the habitual action in the system Sometimes troublesome ulcers, yielding an excoriating discharge; followed by gangrene & death Poultices & ac. plumb. are good Powdered gypsum is one of the best applications (alabaster is the finest kind) Case in which alabaster cured without red precipitate The oxygenated ointment is the mildest & best where ointments are proper for sometimes they disagree Bowels be kept 24a open with calomel. Frequently it is necessary to change the diet of the nurse & to confine her to a simple diet. A discharge from the nose or ear may frequently be cured by keeping up a discharge behind the ear by blisters A teaspoonful of myrrh to 1 gill of water is one of the mildest ext app. Sometimes use nit. sil. Diarrhoea Sometimes affects children for months & even years, in some families. Sometimes it arises from a bad constitution Caused also by want of cleanliness, bad food & want of cleanliness, bad food & want of air & exercise. Young animal (also vegetables e.g. fruit trees after a season without wind) need exercise Children need mental stimulants, from external objects. This is the principal secret of change of air. If the child 24b Bad air probably causes diarrhoea merely by its depressing influence is teething we must palliate not stop the diarrhoea. For this is an effort of the const. similar to tears from an irritated eye & mucous from the lung IN the commencement of diar. mentha vulgaris pounded the juice expressed, boiled, skinned & mixed with white sugar, will frequently cure. Ipecac will freq. cure. We must generally begin with a cathartic sometimes adding chalk to qualify calomel, when we give it for its deobstruent operat. Use blue pill for feeble & delicate children,. Prof. I could for many years take no other cathartic without griping. Often we must enquire particularly about the diet. Arrow root with a little spice, or a little laudanum, or wine. Sago tapioca, is a hydrate of flour moistened & dried by heat (probably) Roasted or baked flour & flour tied up tight & boiled, then grated, made into porridge is better than flour unaltered Rice in gruel, or thoroughly cooked by boiling 25 The worst cases have dry skin & feeble pulse. Use tep. bath & keep up an action of the skin by flannel In chronic stages absorbents will be needed chalk [illegible] oz cin zii [illegible] 4 oz carb pot zss. wat 1 pint Powerful means of counter irritation e.g. mustard horse radish, monarda punct. sp. turpent. about the precordia when the danger is very great, In case of something like cholera coming on By this means we can make articles stay upon the stomach [illegible] etc. will be grateful & stimulating As a tonic moselys 3 dr 1 al. pt. boil water cathartic [illegible] in [large] [illegible] 4 to 20 drops [somet.] [illegible][absor] Opium is often necessary, generally it is better, when qualified & rendered more diffusible in its action by ipecac. Invaluable in chronic cases of great irritability 26 Charcoal in fine powder, will correct the fetor of the stools & often cure. Particular attention should be paid to the stools for much may be known by them. Acid is formed in the whole al. can. Hence sour & curdled stools This will indicate lime water absorbents & aromatics. The acid may arise either from fomentation or (probably) from secretion. In case of clay coloured stools give opium to allay irritation ipecac. to equalize excitement & determine to the surface mercurials as deobstruents Give also mucilaginous or alkaline or laudanum (in starch) or (in case of griping) camomile injections. Often soap is useful also compd tinct. senna After the long continuance of the disease support the bowels by bandages, & apply a plaster of lead and soap. After great emaciation & when [illegible] [illegible] water softeness 27 tonics astringents (at least 50 ast) e.g. currant raspb. bark in milk oak bark chocolate of acorns Peculiarly adapted are spir. [illegible] & cornus [illegible] or [seria] (decoc in milk) [illegible] It equalizes excitement more white pine bark in milk watery urine In case of great craving as for salt provision etc. in extreme cases gratified Of mucilages are a variety for they will be worn out [typh??] latifolia sassafras bran flaxseed etc. etc. Great aversion & nausea & vomiting attending the administering of remedies will make them operate like tartar emetic, and debilitate. In such uses the gratification of the appetite will prove a stimulus especially to the mind & therefore the more powerful This is true of adults also. Case related of a patient who could retain no medicines & recovered upon bread and cheese. 28 In the latter stages acetate of lead may be given internally. The bowels are too much relaxed to admit of colic. A troublesome symptom is prolapsus ani The intestines should be immediately replaced Take the neck of a bladder or the crop of a fowl, filled with water, as the softest & best irritating thing to apply. A [illegible] cloth will irritate the sphincter & make it contract. Afterwards apply astringent washes e.g. white oak bark or the bark of any of our forest trees Cal mag ½ dr rhub 8 gr gum ar. 1 dr. wat. 1 oz pepper ol. [any] 6 drops [or] tablespoonful Vomiting It is very common in healthy children in consequence of over distention of the stomach. The child should not be allowed to nurse so long at a time Children & old people vomit with more 29 facility than the middle aged Vomiting from irritability of stomach is important feeble pulse, cold extremities must horse rad. 2 z chalk 1 z card. seeds ½ z carb pot or [illegible] [illegible] [illegible] 1 pt water tablespoon Prof Ives thinks the alkali creates an excitability. Frequently the irritation of the lower part of the bowels by an injection of salt & water, or a large bulk of warm water, or a calomel cathartic. The tepid bath & nervines are useful also Young physicians are often called on to prescribe for hydrocele in children Apply opium camphorated applications etc. In the morning apply cold water & spt. of nitre. Prof. I. has had to operate in but one case. 30 Volvulus or introsusception. Not commonly a primary disease. Prof. I. was at first very much perplexed with it, finding no satisfaction from the books. The upper is received into the lower portion Sometimes one involution is doubled in upon another 1st Involution of the small 2nd of the large intestines. It occurs in particular families of delicate constitution. Undoubtedly the bowels sometimes disengage themselves from slight degree of this involution The symptoms of the first kind are constant tendency to vomit, frequently attended with a sympathetic action of the rectum Throwing of the hands & feet paleness of countenance rolling of the head & other symptoms of extreme irritation like strong her. specks only of blood In the large intestines when a cathartic is given it passes down as far as the involution & is then thrown up 31 this act may frequently be heard Drastic cath. often are the causes hence where there is a liability to this disease do not give them In case of the small intestines being affected depend upon opium mixed with aromatics and depend upon this until the bowels restore themselves which however will be doubtful. In the second kind give all remedies by injection, apply the warm bath. By very copious injections, attempt the restoration mechanically. Case related of a young man cured by inserting a bougie of a spermaceti candle with opium at the extremity, & keep it up some time Another case cured in the same manner Sometimes the disease arises from a natural stricture of the bowels incurable 32 It may be caused by worms. Case of a worm involved in the fold of the intestine Case of a delicate school girl. Pulse low weak and small vomiting restlessness, throwing of the hands & feet. Great irritation about the urinary passage & fundament. Tongue not much affected. Deficiency of action in the liver & two or three volvula were discovered on post mort. exam. Ascaris tricocephalus was found to be the cause Cholera constipation of the bowels with fever bilious remittent fever, marasmus etc. etc. It is a common bilious fever, produced by causes affecting the bowels Symptoms pulse full, frequent, tongue furred skin hot. Bowels full and hard, urine small in quantity & high coloured, costiveness breathing laborious face flushed sometimes cough Evacuate the stomach & bowels by emesis & catharsis produced by 5, 10, or 15 gr. 33 of cal., in order to produce a strong impression upon the whole digestive canal & hance upon the system at large In enteric cases & vigorous habits a little tart. emet. may be added Repeat the cal. in 5 gr. doses every 3 or 4 hours leaves senna ½ oz manna 1 oz [pint] give senega blood root etc. if the lungs [illegible] z [seneca] [illegible] [root] may be [illegible] or 2 z [illegible] Give enemas or injections to assist the operation of the cathartics after giving the cath. time to operate The stools frequently contain flocculent portions of membrane. If the stools continue vary cath or [illegible] mag. sol. tartar phosphate of soda neutral salts to In the latter stages of the disease give blue pill instead of calomel 34 Sometimes Prof. I. has added acid to quicken the action of the mercury The fever abates in 48 hours It may continue f or weeks sometimes. The termination may be in volvulus in hydrocephalus If the disease continues for 2 or 3 month a regular remittent, the best remedy is Fowler’s solution in 2 or 3 drop doses If this produces edema & dropsical affec then give bark or Moseley’s tonic sol. beginning with about 4 drops After the inflammatory action has gone off give opium alone or combined with ipecac or antimony Blisters are useful in ass stages. They translate action to parts less essential to life & in the latter stages keep up the action of the system Use any of the irritants. If the lungs are affected apply a blister to the chest. The warm bath is useful. 35 If the head is affected apply a blister to or behind the ears Sometimes the mind is so affected that no medicine will be taken without great force. Then use tepid bath A large blister of aloes & ginger will move the bowels Frequently the derangement & revengeful disposition (according to Dr. Bush an affection of the moral faculty) that we must wait even for 24 hours or more without administering anything Great skill is in this case required to satisfy the parents If cathartics which first produce emesis are used we may be sure that the whole al. canal will be operated on We often also need a remedy more powerful than the disease just as in croup Case of a child 2 yrs. old. Pulse full & frequent tongue furred skin hot etc. After the paroxysms the opposite symptoms come on violently. The system was roused 36 by mustard to the feet & arches followed by blisters on the same parts blister on the chest ammonia in the mouth caustic ammonia in the nostrils to excite infl. Worms. This subject naturally follows that of intestinal diseases. Worms are not contained in the bowels of children under 2 mo. generally not while they suck if they are, they probably are introduced in water Worms in the int. can. are not so common as formerly. Said to be common among the aborigines owing to their crude diet. Derangement of the stomach & intestines produces all the symptoms of worms. It is undoubtedly the fact that healthy children have worms which produce no injury until the system is affected with disease. Case of a healthy child who fell from a great height coma a dose of calomel brought away 20 or 30 large worms 37 They may be injurious from their number consuming too much food 1st Tape worm (taenia) armed & unarmed. 2nd Tricocephalus (hair headed) these are the most irritating 3d Ascaris (round worm) lumbricoides, & vulgaris 4th Gordius rarely found in the human stomach Prof. I has known them coughed up from the lungs they probably came from an abscess in the liver. The gordius is sometimes found in the earth in great numbers they turn black on exposure to the air, and resemble a horse hair, hence called horsehair worm. All eruptive & even all contagious diseases have been attributed to insects. Even miasma has been explained by an Italian writer as consisting of insects vide N.Y. Rep. about the year 1815. Cancer & tooth ache have received this explanation 38 The symptoms of worms are very equivocal and coincide in general with the symp. of irrita Count. pale, flushed bloated sallow eyes dilated grinding of teeth in sleep, starting in sleep palp. of heart, pain in stomach when empty, relieved by food, urine pale coloured, or milky increased or diminished nausea, vomiting, irregular appetite, loss of appetite, costiveness Irritation about the neck of the bladder in the case of ascaris. Severe pain about small intestines & umbilicus, indicates tape worm Irritation at the rectum, indicates ascarides as do also irr. of urethra & increase of urine & milky urine Tape worm oftener affects adults than children. Sometimes it exists without the symptoms of worms. 2 quarts in a day have been brought away in a day, & yet they would return in a few days! They increase with wonderful rapidity. Case of a woman who kept passing them for months in great quantities finally diet was tried instead of medicine 39 All food was roasted or boiled even the water used for drink was boiled Cured Healthy bile or gastric fluid will destroy them. Hence an important indication. Spts of turpentine are an old remedy among the people Case of an old man who made himself drunk with half a gill or more of it. Fowler’s solutions 2 to 4 drops 3 or four times a day has cured. This is prescribed for the taenia or flukeworm [illegible] has been considered a specific Osmanda cinnam. has been given by us for this article. It is bitter astring. & sweet. Polyp. vulg. is a tonic & deob. Other forms may be used Ether, particularly in injection is good mad. [illegible] for [illegible] panada pound & half & 2 or three ounces of fresh butter if costive 1 pint of water salt & [illegible] olive oil or an injection in order to fill up the al. can. 8 or 9 hours after 3 oz [f.] m. in [illegible] 40 in water or decoc. of f.m. or [illegible] cal. & car. 12 gr. each [gamb.] 5 gr in a bolus. Oil is used to fill the respiratory holes of the tapeworm Ether had been added by French & Ger. Rue has been used. Pearl flowers. [illegible] power Amalgam of tin & mercury has been detained in the bowels. These mechanical remedies are not now used. Formerly crude mercury to the amount of a pound was frequently given as a cathartic Astringents have been used bark of milia azedarach of prunus virg. The former is given in decoction to the young negroes at the south who are much subject to worms It has much of its virtue when dry Symptoms of tape worm sense of weight (where the worm is in great quantities) irr. stom. nausea loss of app. irr. app. weak chylop. viscera bloated countenance 41 etc. All which however may arise from mere irritation of the stomach The irritation of the tricephalus amounts to derangement throwing of the hands etc. Prof. I. would prefer narcotics for this worm but cannot speak from his own experience he recommends an injection of a teaspoon or tablespoonful of ether in a gill of water or mucilage. Ether will undoubtedly pass the valves, when injected. Prof. Ives has thought that fern given in pieces operated mechanically especially [assmunda] Ascarides are said to in habit the rectum this is a mistake. They multiply abundantly & lodge in the rectum about the sphincter, as they daily pass off. Besides the irritation of the rectum they produce in the small intestines severe griping pain about the small intestines. Very troublesome to cure the best remedy 42 is injections always effectual for the time being. Relief for the time being by washing them out with injections of warm water. Aloes added will be better. The best however is camphor, as a nervine and narcotic & a poison to the worm Calomel is useful, not in destroying this worm but in restoring healthy secretions for worms will not live in healthy gastric liquor. All indigestible articles such as raw fruit, acids, cold water etc. will be injurious. Alcoholic tinctures aloes, elix. propr. or sol. tincture of hickory buds or bark in teaspoonful doses is one of the best things. To prevent the return of the worms use condiments pepper ginger etc. all warming & bitter things. In extreme cases avoid every thing which has not passed the fire. The eggs are exceedingly minute & yet each consists of numerous others probably they 43 are absorbed by the lymphatics carried into the circulation & deposited in various parts of the body especially upon the muc. memb. of the al. can. only upon the mucous parts. Dry & stimulant diet is better than cold & liquid. Some remedies act upon the worms themselves e.g. narcotics Some narcotics operate on some animals & not upon others e.g. sheep eat stramonium which poisons swine. Mechanical remedies are filings of iron & tin cut hair, & perhaps the prickly cowhage Other remedies are powerful cathartics merely others again tonics & deobstruents Ascaris lumbricoides requires no peculiar treatment Use spigelia, calomel etc. Spigelia is a narcotic it kills the worms & it may also be prescribed for the same set of symptoms where no worms are present. 44 When given to intoxicate the worms give from 2 z to ½ oz in decoction in the course of the night, accompany it with rhubarb, or follow it with calomel or any cathartic to drive the worms off while in a state of intoxication. Veratrum sabadilla is used as a narcotic Of tonics all the astringents & barks the min. acids sulp. zinc & iron etc. Cathartics the best is calomel also use the drastic, as scammony gall is good ether, asafoet. petroleum, seneca oil, barbadoes tar etc. as antispasmodics Chenopodium anthelminticum & ambrosioides are called worm seeds An essential oil is extracted from them. C. botrys or jerus. oak are useful as nervines & for the cough, but probably do little good as anthelmintics. The garlics are used (nerv.) They have considerable effect upon the intest. canal Artimisia santonica from Africa the tops of flowers, this is called wormseed It is a bitter 45 The asclepiades most of the common species as syriaca, pulchra, or [illegible] this latter is often used & has seemed to do good so A. incarnata & A. decumb. Podophyllum pelt. is used as a cathartic probably not better than others The best form is that of tincture The number of worm cases & colica is much less than formerly owing to the change in our mode of living Butternut bark decoction in tablespoonful doses is a popular remedy. It is intensely bitter The geraniums are used all the aromatics and bitters indeed which are found spontaneous Ether is used both by the mouth and by enema Butternut bark is cathartic & said to be narcotic 46 Convulsions Two kinds sympt. & idiop. Children are more subject than adults Causes all the causes of irritation Sudden suppression of evacuation. Teething irritation of excessive or indigestible food upon the nerves of the intestines. Acetous fermentation of food in the prima viae The predisp. said to be sometimes heredit. Said to be produced by change in the milk Also by agitation in the mind of the mother affecting the milk. The countenance also of the mother affects infants very much much more than is commonly supposed. So of the bystanders Treatment depends principally upon removing the exciting causes & then upon obviating effects If the cause is in the prim. viae give it first 5 or 6 of sulph. zinc or as much of ipecac. If the substance has passed into the duodenum give a cathartic, assisted 47 frequently by injection. OR use calomel as emetic & cathartic both. Enquire particularly about diet for a general answer may be false Frequently several large doses of cathartics are needed to overcome the torpor caused by excessive quantity of food Also the food diminishes the cathartic operation. Hence the French dinner pill calomel 5 to 10 jalap 1 to 3 scammony senna manna castor oil & neutral salts are the cathartics If the convulsions continue used [illegible] Calomel sometimes by irritation produces convulsions spasmodics one of the most efficient is the tepid bath. If the patient is much agitated by being put into water cover the tub with a blanket & lower the patient gradually: there is then no difficulty Potash, carb. pot. or aromatic herbs may be put in the water. Continue in from 5 min to ½ hour if exhausted to be taken out Wrap in a blanket & put in a bed keeping 48 up a uniform temperature Oil of amber was Dr Rush’s sheet anchor musk internally Articles applied the whole length of the spine as mustard, ol. origanum etc. etc. Empyreumatic oils hence soot tea is very useful It contains carbon amm. & pyrol. ac. Oil of valerian is a nervine Mineral oils as british oil petroleum etc. Ammonia is one of the best 2 to 6 drops in 1 oz water Applied also to nose & mouth & rectum Dippels an. oil owed its virt. to ammonia. It is very fetid & distilled from berries 10 to 20 drops tinct. asafoetida; or by enem. 2 z caustic potash, or the impure carbonate by injection is very valuable. So all the caustic alkalies Opium is a powerful antisp. may always be given unless contraindicated by other symptoms The frequent recurrence of spasms may be broken up by continual doses 49 of opium. IF they recur once in a few weeks give cathartics to prevent them. When called 1st inject. 2nd tepid bath with alkali in the water. 3d apply irritants as must. horserad. garlic, ginger etc. giving, even in the commencement ammonia by the nostrils. When the patient can swallow give calomel. When the stomach is overloaded, the child cannot swallow, & we wish to give an emetic, we can often succeed by irritating the throat with a feather laying the infant upon the hand & in this way supporting the abdominal muscles. Epilepsy a regular or irregular return of paroxysms of convulsions attacking suddenly falling twitching etc. followed by coma Causes in children generally diseased state of al. can. kept up by habit which last is frequently very difficult to break up 50 caused also by malformations tumors of brain malformation of brain etc. derangement of system produced before birth by syphilis from the same causes as rickets more rarely from mere irritation without some offending cause as suppressed evacuations Treatment generally the cathartic giving calomel 3 or 4 times a week If the canal is loaded with mucus conjoin 1 or 2 gr. gamboge 5 gr. scammony & 5 of jalap which yet will operate kindly though [illegible] The best evacuants are those which change the secretions If there is a deficiency of mucus an abrasion as it were give blue pill also cojoin chalk. Most cases are curable by careful management both of the physician & of the nurse Regulate the diet with great care. Generally however there is a morbid appetite & a sub derangement about eating & also about climbing & such things 51 They will be so active & artful as to be managed with great difficulty Catalepsy called still convulsions It is a tonic spasm Insensible & apparently asleep scarcely breathes sometimes a little motion of the eyes continues from a few minutes to several hours Treatment the same as in other convulsions It follows other convulsions & sometimes follows drastic cathartics. Whatever position the patient is in in that will he remain Prof. I. has had several cases Chorea Sancti Viti rarely fatal not difficult to cure under the age of puberty If it commences before & continues after that period seldom cured. The muscles are partly subject to the will. They also have involuntary motions. Caused in children often from irr. in prim. viae from 52 morbid irritability arising both from diminished & from increased action Said also to arise from infl. of the brain Indications narcotics & cathartics if arising from disease of al. can. tonics as iron, mineral acids & electricity if debility is the cause. Prof. I thinks the disease frequently runs its course & then the cure is attributed to the last used remedy. The cathartic treatment has not succeeded very well in his practice. It occurs oftenest in females of relaxed const. about the age of puberty especially if they have grown rapidly or been much confined to the needle or to study Ammonuret of copper 1 to 4 gr. was Cullens favorite remedy Case female treated with epispastics & narcotics took arnica 2 z to 1 pt boil. water doses increased till the head was affected (It is tonic & narcotic) Without benefit Next cathartics Next metallic antispasmodics 53 Next epispastics Finally recovered under bark in substance 1 oz a day. Sometimes arises from affection of the mind The presence of strangers is injurious the sensibility of the patients being very great When caused by epilepsy treat as for that disease Sometimes comes on very gradually & is not suspected causing apparently bad habits in walking etc. Case which had been coming on in this manner was brought to a high degree by dysentery & went so far as to present the peculiar symptoms of hydropohobia horror of water etc. Conium [illegible] & iron sulph. zinc sulph. copper & other metallic tonics have been principally used by Prof. I. Use various narcotics as nux vomica Use the antispasmodics as palliatives e.g. valerian asaf. musk Case in which the disease was broken up by elaterium 1/8 of a grain at a dose combined 54 with chalk. This is the only case which Prof. I. has broken up Case of a young man who had been confined as a clerk in N. York thrown into derangement & convulsions by a sight of distress on board of a packet Elaterium was given to prostrate the system & break up the habit successful. This led to its employment in chorea This disease may affect the mind causing it to run upon particular subjects especially numbers. Case of a book pedler with these odd motions & also this facility of calculation equal to Zerah Colburn. he was overtaken by Prof. I. in travelling. Zerah Colburn, though sent to Europe never improved agreeably to the predictions of Prof. I. who has seen several cases Their countenance & articulation are peculiar [memory] & judgment deficient 55 Nux vomica as a narcotic may be given in doses 1 to 2 gr. [illegible] in pill or 15 to 20 drops of alcoholic tincture Setons, issues tartar emetic ointment along the spine are used. The latter is not to be used where there is excessive irritation doing injury. Tepid bathing is seldom proper Cold bathing sometimes succeeds. Prof. I has known little success attend the employment of electricity. If the disease is not translatable it is made worse by counterirritants. Dentition of the highest importance always more or less affecting the bowels & the nervous system It affects also the glands the cell. memb. the brain the ears [illegible] in them the lungs etc. Adults are also affected Case of a young woman cutting 4 wisdom teeth who was thought to be consumptive. The period of cutting commences from the 4th to the 6th month. Some persons 56 never had but 2 incisions Children are occasionally born with teeth but the teeth sit loose in the gum without [fangs] & should be removed to prevent their being troublesome Some families are said to have no teeth their teeth being even with the gums such are very serviceable & are not subject to decay. Case of a family of this kind from Charleston Symptoms fretfulness biting slavering starting in sleep flushings of face fever hot head & cold feet diarrhoea sometimes costiveness green stools increased urine (sometimes diminished) bloating of hands feet & face contracted pupils eruptions on the skin all the symptoms of irritation the children are particularly subject o phlegomonous inflammations. Case of a child who was thought to have an aff. of brain. A tumor was found under the arm Treatment diarrhoea relieves the irritation Indications 1st divide the gums the operation 57 is not usually painful They will even bite the lancet It may be done in sleep without waking them The difficulty is to confine the child & avoid cutting its tongue. [Gum] lancets may be made with a guard. Make two incisions for the double teeth & sometimes it is necessary to divide a ligamentous band in the middle. It is an objection to cutting the teeth too early, that the scar formed by healing will be more difficult to be cut through by the teeth. This not true a scar has less vitality & is more easily broken through 2 or 3 cuttings may be necessary the symptoms continuing to return. For infl. use the antiphlogistic treatment sometimes bleed in the arm better generally to apply leeches behind the ear. Cathartics as magnesia & rhubarb conjoining aromatics & chalk where there is acidity. Equalise excitement by ipecac & antimony with or without opium 58 If a diarrhoea suddenly stops apply counterirritants to the pit of the stomach the warm bath. Avoid currents of air etc. Blisters behind the ear will be often serviceable & prevent hydrocephalus. They are sometimes applied to the arm. Use antispasmodics with or without ipec. etc. Rickets Caused by confinement too much clothing too much saccharine food etc. Generally there is an earlier mental development They do not make abler men however Hence the impression that precocious children # symptoms soft flesh paleness of countenance hectic fever, tumefact. of bowels muscles & cell subst. less joints larger head large fontanelles open veins of the head large & blue app. & dig. bad tendency to acidity The teeth are cut later Appears at about 6 months Nearly allied to scrofula in affecting the lymphatics & osseous system # will die early. They are in fact generally diseased 59 This is a disease of weak morbid action Indication strengthen the vital powers by stimulating & dry diet especially by cold bathing taking the patient out of the bed in the morning bathing & returning occasionally cal. & ipecac. general friction exercise open air mental stimulus of the open air vegetation etc. etc. This affects the secretions powerfully. Different tonics are given e.g. Fowler’s sol. sulph ferri bark (bark waist coat) Astringents & absorbents for there is frequently an acid smell Burnt bones phosphoric acid alkalies (pearlash) etc. Pearl ash is applied externally Of late iodine has been very serviceable 2 to to 4 drops alkoh. tinct. given in mucilage of gum arabic etc. The worst cases are the syphilitic these require mercurials. The deficiency of the phosphate of lime is an effect & not the cause. Hence burnt bones must have been useful as an absorbent & perhaps 60 as a tonic not as supplying the matter of bone The chylopoietic viscera are probably first affected & then the mesenteric glands & lymphatics. Avoid featherbeds etc. Sweet fern beds are very popular. They are hard & the odour corrects the acid smell of the disease. Muriate of lime & of barytis were formerly much used. Cholera infantum Appears in months of July Aug. & Sept. Sometimes in June & Oct. Approaches in various manners e.g. with a gradually increasing diarrhoea with vomiting & purging the stools being green, brown, slimy, watery, or with the smell of putrid meat a high fever may exist also great restlessness in bad cases cries of pain once in 1 or 2 hours pulse quick and weak fever remittent sometimes terminating in hydrocephalus or volvulus Eyes often languid & hollow half closed in sleep often in the latter stage preternaturally 61 There is sometimes a great degree of mental excitement bright (their eyes are half closed in various complaints) The vomiting may cease soon may alternate with the diarrhoea The disease sometimes ceases soon at others runs on for months This summer epidemic varies according to the season according to the changes in the air or the weather which affect children more than adults. The patient is carried off in convulsions or is worn out by emaciation and dies with aphthae or dies with hydroceph. volvulus & other diseases Causes bad atmosphere malaria (a general tern for miasma & [illegible]) Dentition is an exciting cause not the primary cause as some suppose. Children weaned in the spring are very apt to have cholera infantum in the summer. Children at the breast bear the disease better Hence let them be weaned in the fall 62 A disease it is of debility & has for predisposing causes bad food etc. both as remote & exciting causes It is a fever translated like dysentery from the surface to the viscera commencing at the skin & breaking up the balance of the system then attacking the mucous memb. of the intestines Indications 1st evacuate prim. viae 2nd translate action to surface & so equalize excitement 3d excite healthy secretory actions & [illegible] peristalt. action. 4 avoid causes of irritation & remove them where they exist 5 restore the tone of the system particularly of the stomach & bowels 1st Aromatics ess. peppermint counter irr. to stom. & bowels as must. horseradish injections of starch & laudanum & tepid bath must be used in case of vomiting, or attack like cholera of adults When there is a diarrhoea at the attack evacuate with deobstruent cathartics & ipecac. Give calomel & ipecac first giving 6 gr. cal. 63 Small doses of calomel will not answer instead of full doses & ipecac about an hour afterwards ipecac The southern physicians do not use cathartics so much depending upon stimulating injections e.g. of salt and water They give smaller doses of calomel This practice does not answer so well here # In case of small watery stools we have often reason to suspect that the bowels are constricted & confine a large quantity of fecal matter in this case give opium & then follow with cathartics which will often bring away a large quantity of faeces 2d by emetics & by small doses of ipecac with opium repeated also small doses of mercurials cal. qualified with chalk or blue pill (antimonials where there is much arterial action) by fomentations sinapisms blisters to the bowels burdock leaves etc. warm bath which used at night frequently gives a quiet night’s rest this is not to be used however in case of great exhaustion # The French expectant treatment adopted in Philadelphia will frequently be entirely inefficient 64 3d by small doses of mercurials & ipecac with opium Ipecac deserves the name of a specific if any remedy ever deserves this appellation. Still a man very successful with one remedy only may be compared to one very skillful & successful with a penknife About 4 gr. ipecac 4 drops tinct. opii 12 teasp. wat. about every 4th or 5th hour for a child 4 months old keeping the bowels open with mercurials blue pill producing an evacuation once or twice in 24 hours. Double the quantity for a child a year old in the same quantity of water. The quantity of opium must be greater when the child has been [illegible] the habit of taking it. Injections of laudanum & starch 1 tablespoonfuls of flour & 5 10, 15 or 20 drops of laudanum to stop diarrhoea at the same time applying to the abdomen 65 cloths dipped in brandy An eruption of strophilus [albidus] sometimes makes its appearance about the chest particularly in the latter stages 4th indication by dividing the gums if necessary regulating the diet the milk of a nurse is best the operation of sucking is soothing and gratifying operating as a nervine give arrowroot with a little brandy or wine as a condiment or tapioca roasted flour etc. If in the last stages the child craves any particular food, as salt fish or salt meat, it should be gratified Disgust exciting nausea will debilitate. Frequently we can succeed by a different mode of administering medicine the sight of a spoon for instance exciting nausea. A tumbler of wine whey with a teaspoonful of aquae ammonia will often be beneficial to fill the stomach & dilute its contents 66 Correct fetor in stools with charcoal Injections of carbonic acid are used with the same intention. Effervescing mixture may be drunk they are often very grateful Injections of soap suds are recommended to allay irritation. Dr Dewees recommends an injection of 3 teaspoonfuls of salt to a gill of water & also magnesia & rhubarb. 5. In the latter stages give tonics and astringents Prof. I prefers cornus circum. Use also spir. toment. in decoction or extract also geran. mac. which may be given in wine & then we have red wine Often it wil be advisable to support the abdomen with a bandage also with plasters e.g. one of soap & opium A most powerful remedy is change of air It is continually recommended by the Philadelphia & New York physician. Case of a child in articulo mortis apparently 67 brightened up upon being carried in a hack to the top of ah ill where it had a view of the sound etc. It had got beyond the reach of medicine & food While upon the hill it too food returned & recovered The case seems to be the direct opposite of nostalgia there being a sickness of home a despondency caused by the sight of the same domestic objects Erigeron can. is used it is pungent acrid bitter & stimulating & hence affects the kidneys as a diuretic. It seems to do goo in the latter stages of diarrhoea & dysentery It is called strangury weed. It has been long used Vide Barton N.Y. Physico Med. Trans. etc. The other species are also used give it in decoction White vitriol & alum are used as tonics and in doses of 6 to 8 drops as an anti emetic The various species of viburnum are 68 All the [???t? tillas] are astr. so [illegible] [illegible] root etc. used in this disease, as astringents Statica limonium is not so agreeable but frequently more efficacious boiled, sweetened & a little wine or brandy added. It has a taste of salt mud. It is used also as a wash in case of aphthae In the latter stages of the diarrhoea give mucilages made of any of the various articles in use The white pine bark will furnish a valuable mucilage from its being combined with a terebinthinate principle. Post mortem examinations show the seat of the disease to be the muc. mem. of the intestines. The liver is enlarged Scald head or porrigo or tinea capiti A local disease, yet affected by diet. Sometimes commences with scaly eruptions. I have the head & apply a bladder to exclude the air is about 69 the best treatment. Wash clean at all events tar oint. 4 oz. tar. ½ oz. was 1 oz sulph 1 oz sulphur melt & mix Sulphuret of potash has removed the disease in a few days Yeast poultice is efficacious let the head be first shaved. Different dock roots all the species have about the same properties. Apply externally & give internally it is acrid etc. Syrup of buckthorn is recommended as a cathartic. The practice is quite empirical in this complaint. Sulph. pot. is given internally also its solution resembles mineral spring water Mercurials should be used & pay particular attention to diet Asclepius tuberosa expect. diaph. & laxative is a valuable substitute for ipec. to equalize excitement etc. When the tepid bath is used keep a supply of hot & of cold water by in order to keep up a proper temperature 70 Catarrhal epidemic severe hoarse cough differing from coup in the quantity of mucus thrown off extremities cold head hot much febrile action By vomiting great quantities of mucus are thrown up & yet the patient will seem to be suffocating Confined to the lungs, & aesophagus No disease affects the bowels less than this. The stools are healthy Indications Cure the patient immediately by powerful remedies unless the system is too much affected to bear them. This is a general principle, viz. that of breaking up a disease before it has thoroughly attacked the system by means of a strong orgasm Tartar emetic at the commencement to break up after the violence of the disease has been overcome apply a blister to the chest to translate to the surface. Evacuate the bowels also & palliate & relieve the disease by small doses of tart. em. or with camphor & opium to create perspiration or by the 71 tepid bath keeping the patient in ½ an hour or covering patient & nurse both with a blanket, to keep in the steam & cause it to be respired also Sometimes vomiting must be excited by mechanical means. Do not depend upon palliating symptoms merely Hooping cough said to be contagious rarely attacks the second time, but sometimes does. Pres. Dwight had it a second time at 60 yrs of age It appears as an epidemic thought to arise form specific contagious 10 vol. Med. Trans. an account of its breaking out in Block Island without previous intercourse with the main land. Commences with precisely the same symptoms as ordinary catarrh. The peculiar symp. 3 or 4 week Several frequent expirations are made which exhaust the lungs then a 72 stricture takes place which causes a hoarse shrill wheezing during inspiration. The same sound is heard in croup during expiration A spasmodic stricture sometimes takes place in adults which produces the same sound Such patients should not try to breathe. These fits of coughing continue until mucus is thrown up But the mucus is not the cause of the coughing, which arises from irritated action. Continues from 1 to 6 months. During a paroxysm, haemorrage from mouth & nose may come on or convulsions & apoplexy may ensue Case in which an emetic caused convulsions which carried off the child. Most troublesome during the night Duration of paroxysms depends upon the facility with which the mucus is thrown off. Sometimes respiration 73 is laborious between the paroxysms Rarely fatal after 2 yrs. It may terminate in hectic or in marasmus in infl. of the lungs in visceral obstructions of liver, lymphatics etc. It produces a determination to the head Treat the fever, if any, according to diathesis Treatment In vigorous const. & when mild little need be done When there is considerable infl. give ant. & nitre keeping the bow. open in worse cases bleed cup & scarify Sometimes mercurial cath. sometimes cast. ol. etc. It is better however to accomplish this end by diet. Respiration may be promoted by blisters on the sternum Instead of [blist] [illegible] may use 1 oz mild tinct canth. 1 z tart ant. applied with a cloth until vesication comes on then dress with simple cerate Antimony may be combined with opium Godfrey’s cordial made of molasses & water 74 with a little laudanum & ol. anise this was very popular. Use diluents. If there Is danger of convulsions from vomiting give blood root & other such things. In some constitutions antimony produces peculiar symptoms e.g. severe spasmodic stricture, which if it comes on should be relieved by diluents & small doses of opium. In very young children it is difficult to get down much medicine the stomach becoming irritable In the latter stages use 5 or 6 grains of sulphate zinc with as much of ipecac instead of antimony Where this much viscid secretion an emetic of squills may be used or we may use the [illegible] seneca root bruised & squills each ½ pound water 8 pds boil & evap. to ½ strain & add 4 pts honey & boil again to 6 pts to every oz add 1 gr. tart. ant. dose 8 or 10 drops child 4 mo. old, every 15 m. This is called Hives syrup 75 Dried leaves in 1 gr. doses, in milk, of atropa bell. or 1/6 of a grain of the root has been used in Germany Objection that this disease has a tendency to run its course, is no good reason for not curing it. It has been prescribed for more empirically than any other proof of the difficulty of curing it El. par. 1 oz ant. vix. ½ oz 3 z glyc. ext. powd. g. at. 2 oz wat. 6 oz. triturate & boil dose ½ teaspoonful to a table spoonful This is called the Brown mixture It may be varied by using ipecac etc. 2d Antispasm. & tonics & narcotics are used in the latter stages e.g. sulph. zinc & copper & tinct. canth musk, fetid gum, petroleum etc. belladonna, hyoscyamus, opium artificial musk or oxygenated ol. amber Nitric 76 acid 3 ½ z ol. [illegible] 1 z place in the sun in tinct 1 z to pt. alc. dose 10 dr to a teasp. or 1 z to 1 oz ether dose few (2 or 3) drops upon sugar. It was very celebrated & afterwards was thought to be ill made The truth was the diathesis had changed. Copal gum, oxygenated by distillation, will be the same substance. Copal is probably the same with amber Case of a vein of olibanum or frankincence in S. America Opium should be qualified & determined to the skin by ant. & ipecac. Hyoscyamus is bitter, having no tendency to produce costiveness zi pearl ash with cochineal to colour it to pt. water 8s a popular remedy & useful The whole effect is owing to the pearl ash which is antispasmodic cochineal has no apparent virtues. Pearl ash is not only antacid but produces a peculiar 77 excitement upon the stomach & aesophagus making them susceptible to other articles Conium maculation has been much used A more commanding remedy is stramonium 1/10 gr. to 2 gr. of extract or seed for a dose. It counteracts that irritability which gives a tendency to convulsions Sulph. zinc has been most used as a tonic by Prof. I. either dissolved or in the form of Moseley’s tonic solution Sulph copper possesses about the same properties The compd vitriolic tinct. of sul. cop. & kino 10 to 30 drops is pleasant & has been much used. Flowers of zinc & also bismuth have been used. So also per. bark. Bark, canth. & sul. cop. in combination are recommended by Chalmers of S. Ca. Cantharides are indicated where the 78 system is relaxed & too low for inflammatory action in order to excite a healthy infl. action Something may be done by rubbing the spine with the stim. oils e.g. ol. caps. or orig. etc. or with [illegible] of ammonia to excite the nerves & spinal marrow in the latter stages. Change of scene, of air, riding etc. should be resorted to in bad cases to tranquillize & stimulate the patient. Sometimes the little patients will be in a constant tease & worry; until this is done. In the worst of such cases medicine does little good Even the irritation of administering the medicine may counteract the beneficial effects of the medicine. Prof. I. thinks a relaxation of the ventricles of the heart & of the sinuses of the head takes place owing to the violence of the cough Indicated 79 by resp. high count. bloated lips swollen & by a soft flowering & almost intermitting pulse In such cases give blood root 5 to 10 gr. in water alone or qualified Lead (acetate), also iodine, have been recommended. One year, the hoop. cough prevailed extensively in the spring but was Prussic ac. & arsenic occasionally cut the hoop. cough, short entirely The former is dangerous from want of uniformity of strength Fowler’s sol. is safe but does not answer so well in the first stages. It may leave the patient livid weak with swollen lips etc. which is to be cured by bark & other tonics 80 Gangrene in the mouth 81 Chilblains Exposure to extreme cold without freezing 82 Mesenteric fever tumefaction & pain of the bowels (distress rather than sharp pain) indigestion costiveness, loss of app. or [irreg.] app. Countenance pale except when flushed with fever sometimes a consequence of other fevers oftenest in scrofulous habits most common among the poor. It may become chronic. Indurated lump in the mesenteric glands Indications Act upon the bowels keeping up a peristaltic action evacuating the bow. changing the secretions & removing the obstructions of the lymphatic system. Give blue pill or calomel & chalk. In chronic cases friction once or twice a day will be beneficial Pill 4 parts blue pill 1 part ipecac or ½ part ipecac. Or 1 gr. ipecac in pill with a small quantity of opium Or tinct. rhubarb with aromatics & alkaline salts Burnt sponge is recommended perhaps it would be better to give iodine at once 83 in definite quantities Still the composition of articles existing in burnt sponge may be better [illegible] nodosus & vesiculosus (rockweed) are used Even the neutral salts with tonics have been useful Even as of camomile tea will relieve a paroxysm of pain Articles containing carbonic acid in a free state, sometimes with aromatics as ginger or spice, will be grateful and also useful From tinct muriate of iron martial flowers of iron or alkaline solution are used as tonics but iron is apt to irritate. Cold bath will invigorate the system Injections of mercury have been proposed Tepid bath will cleanse the skin etc. Muriate of lime with small doses of cal. or blue pill may be useful, but 84 is now generally superseded by iodine dissolve carb. lime in muriatic acid & give from 5 to 50 drops in water beginning with small doses, in case it may offend the stomach. Muriate of barytes might be used. Carb. barytes is used dose from 2 to 3 gr it being a powerful article The flesh brush thoroughly applied has a powerful effect A plaster of opium & diachylon or soap plaster, with an equal quantity of opium, applied to the abdomen has been very beneficial where opium did not agree. Or we may use 2 parts opium to 1 plaster. Diet dry toasted bread broiled meat use condiments farinaceous substances & sometimes the broth of lean meat Avoiding raw fruits potatoes corned beef etc. Take care 85 with wine Use farinaceous veg. well boiled not to interrupt digestion by distending the stomach with liquids The terebinthinates will benefit the mucous membrane of the ac. canal. The bests article is decoction of white pine bark which will be much milder than any preparation than any of the turpentine of the shops This disease may terminate in a peculiar hectic sometimes it commences with very considerable fever S. Cutting the fraenum. Very seldom practised now formerly thought to be almost always necessary. Complaints would be made that the child could not nurse on account of its being tongue tied. In such cases it was Dr Munson’s practice to apply the back of the knife, & thereby give very great satisfaction 86 Burns & scalds 87 Tympanitic abdomen a symptom in various diseases 88 Neuralgic affection of the lower limbs 1 Surgery Lecture 1st External injuries 1st Extensive injuries first produce a shock upon the system e.g. contusion upon the abdomen & frequently when a limb is carried off by a cannon ball the haemorrhage is slight & the patient dies of the shock Great difference in patients as to susceptibility of constitution. In the army it has hence been the custom to operate on some immediately and administer cordials & consolation to others State of the mind e.g. wounds after a defeat or after a victory. State of habit porter & gin drinkers in Soudan & debauchers in high life bad subjects The subsequent inflammation however is not in a direct proportion to the shock 2 1st of such injuries as prostrate the system beyond the point of reaction Coldness of surface faintness & prostration immediately follow large gun shot wounds The same effects follow the slight injury of important points e.g. punctures of the joints etc. These effects are through the medium of the nervous system The common people remark that extensive injuries of strike into the stomach This is merely part of the constitutional aff. Case of violent vomiting in a blacksmith whose eye was penetrated by a scale of iron & yet the eye recovered without difficulty Affected distress may be detected by the state of the pulse or respiration the ease with which the attention may be diverted. Sometimes die of the mortal inquietude even without internal haemorrhage Frequently difficult to test with respect to the propriety of amputation A navy 3 surgeon it has been said would probably have amputated Mr. [Huskisson’s] shattered thigh the constitutional irritation will be less after the operation The intellectual functions are suspended blindness sometimes continues for hours The food is not digested & the peristaltic motion suspended. Vomiting frequently favorable as marking a return of vital function. Case of a gentleman in a profound stupor from a fall from a horse no injury could be discovered Complaint of pain generally a favorable symptom particularly if an external part Infants frequently vomit etc. severely with paleness etc. & yet recover after a few hours sleep 1st indication restore warmth to the surface by frictions & the warm bath frictions should be dry, for moist cloths produce evaporation 4 warm blankets & may be applied especially by passing warm substances up & down the back 2nd indication restore the action of the pulse by brandy once an hour peppermint opium etc. [Discontinue] stimulants when reaction comes on as it may be excessive. 3d moderate pain & 4th const. irr. relieve pain by opium except (in Hubbard’s practice in cases of the head) One of the first things to be done is frequently to bleed which will be followed by a rise of the pulse It is a common practice in some places is to send immediately for a bleeder, who however in cases of a great shock is unable to obtain blood until after a surgeon has roused the vital powers Injections may be used. H. prefers among cathartics the mercurial in order to restore the peristaltic action These will answer the 4th indication also 5 We must be careful to examine for local injuries for frequently in cases of extreme prostration they are first mentioned by the patient after the return of consciousness Case of a man who was first unconscious next complained of his head after some hours of his knee & while he was recovering it was discovered that the orbit of the eye had splinters of pine in the flesh. Great caution frequently necessary in removing the sufferer for simple fractures are liable to be made compound. Cold is injurious The viscera are sometimes fractured in falls from great heights e.g. the liver Suppuration of the liver sometimes follows an external injury after a long interval The injury of a fall not necessarily proportioned the height. 8 or 10 drops of laudanum in gruel or starch by injection relied upon in Paris for the cure of traumatic delirium 6 apparently a trifling remedy recommended for trial relied upon implicitly by the French Mr. Travers is the only author who has treated regularly upon the subject of external injuries Inflammation Characterized by heat, pain, redness, tumefaction & soreness. When considerable or affecting important parts, it is [altered] with fever of constitutional irritation. This is different from the local fever which is called symptomatic. The pain usually precedes the heat & tumefaction The causes may be external or such as effect the system primarily. First of such as are caused by external injury or phlegmonous inflammation called also health inflammation This manner in which injury produces inflammation is not well understood 7 Phlegmonous infl. is characterised by a central spot & a circular outline Hunter speaks of healthy infl. considering it as a process set up by nature to accomplish a cure & believed that new vessels are formed An injury is generally followed by pain, which does not arise from inflammation for this has not yet come on, but from the separation of the parts. Great pain is produced by effused fluid as in sprains. After an injury there is pain etc. also there is a sense of distention & the action of the arteries in the neighborhood of the part is increased This extends to the whole arterial system, producing increased frequently fulness and even hardness of the pulse. The pain is caused by the nerves being affected. Mention should have been made of the cold stage which precedes extensive inflammation the cause of which seems to be unknown 8 Professor H. thinks fevers essentially different from inflammations, in opposition to the French physiologists. He thinks that at least at the commencement of infl. there is increased action of the vessels The pulse varies according to the part inflamed (vide below) Local causes of infl. may be heat, cold, mineral acids, acrid substances etc. the various sorts of external injuries Constitutional causes are fevers and various anomalous affections of the const. Prognosis Very violent inflammations are danger so also very extensive ones as burns. Infl. of important parts in the viscera is dangerous. In inf. of the bowels the pulse is quick small & tense & hard of the heart full The terminations are resolution suppuration adhesion & gangrene. Adhesive infl takes place in serous membranes & wounds that heal by the first intention Suppuration takes place when wounds 9 do not heal by the first intentions boils etc. Gangrene follows violent infl. which do not suppurate. It is the death of the part 1st indication is to remove the cause as splinters & in case of dislocation As much should be done by local remedies as possible. Reduce the temperature by cold or tepid lotions (according to the sensations of the patient) sometimes fomentations or poultices give more relief than any other mode of applying warmth especially in pelvic infl. & by the French in thoracic. The warm bath is frequently useful especially to children. In case of fomentations permanent moisture should be kept up. Warm applications may be made to reduce the heat of the part by evaporation if not too warm. The same thing may be accomplished by spirit. Acetate of lead sulphate of zinc vinegar and cold water 10 are used Perhaps the latter is generally as good as any of the patient will be satisfied with it. Narcotics sometimes are used externally but their utility is doubtful. Blisters are used especially in infl. of the joints & deep seated parts in general The first general remedy and the most powerful is bleeding it would seem to be one of the best arguments for it that those of opposites [illegible] recommend it viz. those who believe action to be increased & those who believe it to be diminished Of course not always necessary, as in trifling cases, & delicate habits, No rules can be given as to the extent to which it may be carried. The modes are venesection [arteriotones] leeches & cupping Venesection is the most common and most convenient. In children the veins of the hand or foot or the external jugular may be more convenient than those of the arm It is a good rule to draw blood until pain is relieved or faintness is produced provided the patient is in an erect position 11 There is no doubt of the propriety of taking a large amount of blood at once rather than by several small bleedings. The buffy coat not to be relied on Prof. H. thinks the heat of the extracted blood of more consequence Blood letting has been objected to in case of old persons. Prof. H. has often practised it with advantages. So of delicate constitutions if the patient is kept in a horizontal posture Arteriotomy from the temporal artery has apparently no advantages over venesection Prof. H. sees no advantage in the use of leeches in preference to venesection except in chronic inflammation Cupping seems to combine the advantages of depletion and counterirritation & is highly spoken of. Prof. H. has not used it much Cathartics are used next. also antimonials especially in the Italian way of beginning with small doses frequently repeated until the quantity which may be taken without nausea is very great 12 Narcotics are used for the same purpose Soreness is relieved by quiet etc. Pain may be diminished by elevating the part. Diet should be antiphlogistic, but generally the patient has not much appetite. Great difference is produced by the constitution and habits of the patient e.g. intemperate patients will not bear some things N.B. they do not bear bleeding well Frequently cordials and tonics are useful at the close of the cure. The best work on inflammation is Thompson on inflammation. Erysipelas an inflammation of the skin sometimes extending to the cellular membrane Distinguished by leaving a white spot after pressure by the finger & by being terminated by a definite [line] It has a tendency to spread sometimes leaving one part & spreading to another. Occasionally affecting various parts at the same time 13 When caused by a wound it frequently affects distant instead of adjacent parts colour dark & yellowish little swelling leathery feel. More yellowness towards the decline of the disease. This disease is liable to affect the mucous memb. of the mouth, & is said to affect int. parts It is accompanied with chills fever etc. & in erysip. of the head with delirium Sometimes the fever precedes. The fever is also followed by a bitter taste in the mouth Case of an old woman attacked with feverish symptoms, which, as was expected were soon followed by erysipelas. Various divisions have been made as phlegmonous bilious etc. Prof. H. divides into that affecting the skin & that extending to the cell. mem. 1st of the skin. it terminates by scales & affects the young It however may term. by sup. & also affects all ages The second is attended with more tumefaction & terminates in sloughing suppuration & in gangrene. It sometimes extends to the fascia & tendons so that they will slough. This kind of erysipelas 14 is oftenest met with with in old and intemperate persons as in cases of chronic sore leg Erysipelas is distinguished from phlegmonic infl. by the latter having a central spot its circumference being less defined, & its pus collected into a central cavity The nervous irritation of erysipelas is greater producing delirium etc. The heart & arteries are more irritated producing a sharp and quick pulse which is very weak when the infl. tends to gangrene. The al. can. is generally affected, producing sometimes dysenteric symptoms. The exciting causes are wounds contusions irritations of the skin by acrid substances by alterations of temperature etc. 15 The predisposing cause is in the constitution & is unknown from the yellowness of the skin some have ascribed it to the liver We know not why some wounds should be followed by phlegmonous & some by erysipelatous inflammation except that at the time the patient was not in good health. This may be caused by malaria, the bad air of hospitals etc. Case of Pomfret when the meadows were drained. From its prevailing in hospitals some have thought it contagious This not probable Though depending upon the state of constitution, yet the extent of the constitutional is proportioned that of the local affection. It sometimes seems to alternate with other diseases 16 Prognosis varies according to the age & habits of the patient & the extent of the infl. The most dangerous cases are those of the head which are frequently attended with delirium & coma. Coma is however a common symptom in ole people Indications 1st to promote a resolution 1st by topical 2nd by general remedies Some are opposed to topical application Prof. H. finds no danger in them. The best Is acetate of lead. Cold water, milk & water Also 2 dr. mur. amm. in a gill of water or corros. sublimate 10 or [illegible] sometimes a drachm of opium to a pint of water or of the solution of acetate of lead Mercurial ointments are best in the decline of the disease The lard by itself is good especially when the [branny] scales are abundant. To this is ascribed by come all the benefit of the mercurial ointment. One of the most common applications is dry wheat flour. Yet it is one of the worst 17 2nd General remedies. They should be always used to prevent the affection from being driven in & then returning 1st venesection Strongly urged & strongly opposed Prof. H. approves of it in case of strong constitutional affection but not when there is extensive suppuration & when the pulse is weak & small 2nd purgatives they have been universally used. The indication has by many been drawn from the yellowness etc. The mercurial cathartics are best Calomel may be combined with a little opium in case of great irritation Neutral salts sulphur & magnesia have been recommended Antimonials are much used, especially in the Italian mode of beginning’ with say 1/6 gr. & doubling the dose (of tartar em.) until even 4 gr. are given 3d Tonics their use is strongly urged upon the supposition of erys. being 18 an atonic disease In cases of malaria and gangrenous tendency bark is undoubtedly proper. Opium & Dovers powder are proper in one of great irritation & opium is given by some as a stimulant. The most common preventive remedy among the people is neutral salts. They generally do much injury. Even low diet is generally injurious when practised with this view Infants are frequently affected with this disease. Sometimes their pudenda are badly affected with it Treatment calomel internally acetate of lead externally etc. A new remedy is nitrate of silver externally applied by moistening & touching. Prof. H. has tried this and found it useful but not deserving so very high commendation as it has received Prof. H has found blisters very as have Dr. Rush & others 19 especially in violent cases & in those which affect the cell. mem. An old mode has been lately revived viz that of making long & deep incisions even to the extent of 6 or 9 inches. This is efficacious in violent cases especially when suppuration is suspected. This disease requires great care and attention. Sometimes the disease may without our knowledge attack another part hence the old patients affected with stupor & infants should be examined every day Abscesses When phlegmonous infl. does not terminate by resolution it does by suppuration. So of erysipelatous. The signs of suppuration are diminution of the pain & chills (the patient will say he has caught cold) in external phlegm. infl. a softness will be felt. This will increase & frequently be surrounded by a hard rim sometimes there is a sharp [illegible] or [illegible] pain Pus is discovered by its fluctuation. We must press 20 alternately with the fingers or better with the the thumbs. IN muscular parts we may be deceived by the fluctuation of the muscles under the fascia, if we press transversely. We nay be deceived by fungous tumours Tumours of the viscera are apt to be mistaken for a collection of pus Great mischief is done by opening fungous tumours. In a gland suppuration never takes place until after the skin has adhered to the gland. Prof H. know of no remedies for promoting suppuration but poultices & similar applications. On pus. It is a secretion. A French surgeon maintains that it is secreted by a membrane lining the internal surface of the abscess. (Delbecke) It is of very little consequence of what poultices are made. Fomentations, as by wringing out woollen cloths dipped in hot water & then applying them to the part. Venesection & evacuant remedies are contraindicated. The bowels should be 21 kept free. Tonics are not generally needed Opium may sometimes be used according to circumstances. Prof’s Smith & Hubbard approved of opening abscesses immediately & not waiting for them to burst In erysipelatous infl. the pus is diffused & not in a cavity of a circular form Abscesses tend towards the surface unless prevented by strong fasciae etc. The opening need not be very large but should allow of a free passage to the pus There are inflammations of the cellular membrane where there is no erysipelas of the skin. The inflamed part is hard & is sometimes very extensive The constitutional symptoms are very severe & resemble those of erysipelas The suppuration has a peculiar [illegible] irregular feel. [illegible] this kid very dangerous generally arising in bad habits Indications moderate the const. affect. by calomel opium etc. The best external 22 remedy is blistering extensively afterwards using external lotions etc. This kind of inflammation frequently follows wounds of dissection Case of a man who lay down under a haystack & fell asleep. Infl. in the thigh, leg, shoulder & knees confined to the cellular membrane & yielding quarts & pints of matter when opened finally recovered. Another upon whom numerous similar abscesses were opened on succession finally there was an effusion in the thorax & the man died. The two last kinds of inf. & much more dangerous than phlegmonous. Frequently they arise from a very slight cause as a scratch in the old & intemperate. In the latter, delirium tremens is frequently caused by such inflammations. Prof. H. does not open with caustic He does not call the furunculus a proper phlegmonic inflam. The core of a boil is a dead portion of 23 cell memb. There are no better remedies than poultices etc. After opening an abscess we may use pressure to expel the matter but too great violence must not be used. Then a plug of lint may sometimes be advantageously introduced & finally the sides of the abscess should be brought together by a bandage if possible Frequently by a skilfull application of bandages around the opening, pus may be expelled which could not otherwise be obtained When it is wished to make a second opening into an abscess near the first, instead of lifting up the skin upon a probe & then cutting down to the probe, it is better to close up the first opening & suffer the pus to accumulate so as to cause a protrusion an incision may then be made with ease 24 Anthrax Begins with a small pimple a vesicle filled with lymph. The burning heat and pain very great. The const. irr. very great. The redness is of a darker colour than in the furunculus There is an areola somewhat resembling that of [illegible] pox. This will be surrounded with small pimples, which become small holes filled with a yellow matter The swelling extends & with it the holes Sometimes a considerable portion of skin sloughs off Eventually a considerable portion of cell. memb. sloughs off with a copious discharge of pus & the patient recovers In fatal cases extensive gangrene takes place without suppuration. Sometimes before the cure large portions of cell memb. (rotten) may be extracted with the [illegible]. Const. aff. very great tongue white & eventually yellow 25 When the anthrax is near the head delirium & coma are produced The infl. seems to be more erysipelatous than phlegmonous. Some persons of broken const. are liable to be [illegible] Prognosis depends 1st on the situation & extent of the anthrax Apt to be fatal if on the head face & neck especially if nothing but serum is discharged. If upon the limbs & back with suppuration they are there it is dangerous 2nd the const. sympt. Violent pain severe fever old age & intemperance especially the latter are bad symptoms One of the best local applications is an extensive blister plaster followed by cerate & if there is much heat & inflammation apply over the cerate ac. plumbi or in bad cases, emollient poultices The sooner the pus is formed and discharged the better. It relieves the irrit. 26 Frequently pus may be felt through the sloughing skin. Caustics are used by some but Prof. H. prefers blistering & if the first application does not relieve the pain & irritation apply a second. Frequently a slight incision is necessary to evacuate the pus Const. remedies 1st Venes. in rigorous habits, and early in the disease Mercurial purges are always proper unless there is great exhaustion Opium when there is great irritation and towards the close when the patient is weak give bark. Give dov. powd. at first & afterwards opium alone. Farther remarks on abscesses. Sometimes after opening an abscess lunar caustic or a solution of cor. sub. must be introduced to promote the healing of the sides of the abscess Sometimes the pus is collected in the bursae mucosae, as on the olecranon 27 process. The thumb the knees. The serous membranes of the bursae are liable to inflammation followed by a rapid collection of pus, & violent const. irr. It is especially important to open abscess of this kind, near the joints. Acute inflammation of the joints sometimes occurs, essentially different from chronic infl. It occurs oftenest in the hip Sometimes it is fatal in a few days Caused occasionally by injuries. The mode of cure is to cut boldly into the joint, to save life. The female mammae are especially liable to abscesses. Sore breasts & broken breasts are not all the same disease 1st superficial phlegmonic abscess. There is infl. of the gland The skin adheres. Venesection purging & antimony may be used. Tartar emetic has been lately recommended very strongly The usual external remedies may be used 28 It is decidedly advisable to open these abscesses though there is a prejudice against the practice. Erysipelas of the breasts is common & treated as other erys. infl. Infl. in the bur. muc. which lies between the mammary gland & the pectoral muscles Sometimes the pus makes its way out between the two breasts. We must open with an abscess lancet & then promote the healing by injections of cor. sub. etc. If this fails, introduce a seton of several threads & extract one thread at a time (vide Dorsey) Chronic inflammation. Sometimes a sequel of acute infl. That which follow acute phlegmonous infl. will be circumscribed It will not be of the skin but of the cell memb. Glandular parts are those which generally run into chronic infl. e.g. testis mammary glands the lymphatics (scrofula) These last are frequently subjects of surgical treatment, they are occasionally 29 inflamed from wounds The joints are peculiarly liable to it. The constitutional symptoms are less severe, resembling hectic generally without sweat & chills. The tongue is commonly coated sometimes [illegible] appetite capricious emaciation restlessness Coagulable infl. is effused & causes rigidity & tumefact. Indications, lessen the action of the vessels & promote absorption Bleeding must be practised with caution. Cupping & leeches are most commonly used. Prof. H. has found occasional bleeding serviceable promoting absorption. Cathartics must be used moderately The mercurial most valuable & the stimulant as aloes Narcotics, opium, hyoscyamus conium to allay irritation. Frequently the mineral acids as tonics Iron & arsenic & other mineral tonics seem 30 to cease irritation Iodine is used. Blistering is the best local application Case of its application to infl. mammary Tartar em ointment setons moxa compression is valuable when practicable, especially in infl. of cell. mem. It may be alternated with blisters mur. amm. etc. If the limbs are inflamed, exercise is useful Stimulating liniments, opodeldoc etc. are applied Chronic abscess. One which has either not been preceded by violent symptoms or in which they have [illegible] off. The patients account will often be that at some previous time he had a fever etc. followed by a swelling The fever did not leave him well etc. Sometimes the chronic abscess will be found in a different part [from] that in which the pain was formerly felt. 31 Prof H. has never known a fair case of perfect absorption of pus Though the evacuations may have taken place only after years of continuance. The prognosis is difficult The French open by caustic. Prof H. has not tried it. Lumbar abscess, as an example of chronic abscesses in general. Arises from scrofula, from injury or from no apparent cause The lameness at first often is ascribed to rheumatism The patient bends forward & towards the part affected. A soreness may be felt Finally a collection & a tumour pointing to the top of the thigh or even down the leg The pus is contained in the bur. muc. which protrudes under [illegible] lig. This may be mistaken for hernia & even for aneurism of ext iliac. It sometimes bursts in the groin 32 By proper examination in a standing posture the fluctuation may be discovered. Open by placing the pat. on his side, making pressure & inserting an abscess lancet making the orifice of the cyst as large as that of the skin by a turn of the point of the lancet. The pus discharges better in a [standing] posture of the patient when the tumour points downwards. When the pus is all out apply a compressing bandage & heal the orifice by the first intention. Afterwards open the abscess again & so continue. Keep the bandage on to diminish the secretion of pus After three or four openings, the orifice will generally ulcerate, if the abscess is not healed Sometimes a seton must be used This practice is a great improvement of Abernethy’s. Various remedies were formerly tried to promote the absorption of pus. Prof. H. has never known the cure. Sudden deaths arise from unopened chronic 33 as well as acute abscesses. After great operations, abscesses of the lung frequently come on Hectic fever following the permanent opening of chronic lumbar abscesses Chills, heat feebleness, irritation soreness confinement to the bed nausea vomiting loss of appetite. This is frequently mistaken for a new disease John Hunter was the first to deny the doctrine that hectic fever is produced by the absorption of pus. James Rose’s son 13 or 14 yrs. of age Injured his back by lifting. Became lame, was treated for rheumatism. Became more lame, emaciation & sallowness Prof. H. found a coll. of pus extending half way down the thigh. By Abernethy’s mode, about 3 pts of pus came out. The attending physician did not pursue the same mode but kept the orifice open. Hectic fever confinement to bed 34 died miserably in about a year. Instead of being better, they may find themselves worse immediately after the opening Oxygen has been supposed to be the cause. Cold air likewise has been brought [illegible] 10 gr. corr. sub. to 1 pt. water is the best injection when a lumb. abscess remains open. If no benefit results after a few weeks it must be abandoned. Limewater has been recommended as an injection. Calomel is the best treatment for the symptomatic fever, except when the patient is exhausted Irritation may be relieved by Dov. powder, quietness etc. The cavity should be carefully cleaned out every day Slight ptyalism may follow the corr. sub. Prof. Smith was in the habit of using this injection immediately after opening Prognosis Some have ascribed lumb. abs. to an aff. of vertebrae Very probably this affection of the vertebrae may be an affect instead of a 35 cause Small chronic (as scrofulous) abscesses may be treated like acute abscesses In scrofula the abscesses will not be regular & round like phlegmon They should be opened as soon a pus is formed In abscesses of this kind granulations are frequently found which must be removed by caustic. Sometimes the skin must be cut away to get at them Case related to illustrate the danger of opening [chronic] abscesses by large incisions & keeping the orifice open. Died in a week Quality of the discharge Commonly mild & inodorous thick (sometimes curdy) before the healing, it becomes thin & whey like. Acute abscesses frequently furnish this thin discharge, especially if’ erysipelatous Hectic fever Blood drawn will generally exhibit the buffy coat, before the opening of the abscess. Afterwards 36 we have hectic fever Pulse quick (sometimes not in old persons) generally 2 paroxysms in a day the nightly one attended with profuse sweats frequently with diarrhoea sometimes pains in various parts which exhausts the patient less of app. & nausea & vomiting occasionally aphthae (sometimes also as well as night sweats, before openings) may come on so also dropsical effusion of cellular membrane. The degree depends 1st on the nature of the part according to its power of restoration 2nd on the extent of the abscess e.g. occasionally it following the suppuration of an extensive burn 3d on the constitution of patient frequently mental causes have great effect [illegible] modifies hectic the old have less sweat & loss of appetite, but more diarrhoea Sometimes we are surprised to see so little constitutional affection. Such persons are generally very tranquil in mind. It is perhaps impossible to cure hectic 37 while the cause remains Some patients are exceeding by restless irritable & troublesome & [illegible] Prognosis this depends on our success in removing the cause. We may however moderate it by tonics e.g. sulph quinine, wine, opium This last invaluable, promoting sweats relieving [illegible] & supporting the vit. powers Keep the bowels free. Inflammation of the lymphatic vessels Causes may be ext. or internal 1st wounds acrid substances etc. Wounds have been given in bleeding Symptoms swelling, redness, hardness, a core may be felt a discharge of lymph, a swelling of the lymphatics in the axilla. Cured by touching by with caustic Sometimes a very small puncture will cause an inflammation extending upwards in the direction of the 38 lymphatics, indicated by red lines swelling soreness etc. frequently very troublesome sometimes an erysipelatous infl. & abscesses It may be occasioned by erysipelas Touch the small orifice (apparently in considerable) of the wound with caustic & apply adhesive plaster if this does not cure, blister the whole inflamed part, use compression etc. Open abscesses if there are any. Sometimes the inflammation extends from the heart instead of towards it in the course of the vessels. It appears in the throat in scarlatina. It may be caused by [sore lips] Frequently this disease comes on from an affection of a distant part is phlegmasia doleus from the uterus It may appear in the legs from consumption. Phlebitis infl. of the veins First pointed out by J. Hunter. It may be caused by venesection & by a ligature Vein appears like an inflamed cord Sometimes pus is found around the vein. Constitutional symptoms like those of erysipelas & very violent, accompanied with fainting palpitation 39 of the heart anxiety etc. Treatment venesection (some say ad deliquum) calomel & opium blisters Mr [Lizars] advises to destroy the vein above the part by caustic. Inflam of the arteries Not much is known respecting it. Ossification of the arteries, appears to a frequent result Mortification. The death of the part A cold ash coloured mass becoming black Gangrene is considered under this head Two kinds, acute & chronic hospital gangrene is a case The affected part from red becomes pale & cold the vessels filled not with watery but bloody serum. Pulse quick weak intermittent occasionally, sweat, singultus. Symptoms vary 1st according to the extent of the mortification. 2d acc. to the [illegible] of the part & 3d acc. to constitution 40 Chronic mortification frequently comes on as in the toes of old persons without pervious acute inflammation preceded by pains & heat. There comes on first a dark purple spot. Liable to be confounded at first view with shingles a skin disease. There first appears a redness then vesication, lastly mortification Two circumstances will always distinguish mort. 1st the coagulated state of the vessels, yielding no fluid 2nd no sensation being present in the part Causes external injury, a sudden cessation of vascular action in the limb!! bits of rattlesnakes wounds from dissection compression of bloodvessels from ligatures strang hernia etc. Inflammation more especially erysipelas & anthrax. Occurs oftenest in the old Ossification of the arteries is either a cause or after [illegible] There may such a degree of tumefaction or distention of vessels in violent infl. Case in which the skin was to much stretched as to cause mortif. Fire & frost bite after an operation for cancer of the breast as to cause mort. cause mortification IT has been attributed to the use of bad rye flour that which contained ergot. 41 Prognosis, difficult. All mort. is dangerous. Chronic mort. always dangerous Sometimes patients die when apparently almost recovered especially if old & when fasciae & tendons remain to be cast off. Sometimes patients are carried off by a new accession of erysipelatous infl. or a translation to an internal part It is a good symptom for the patient to go gently to sleep Treatment The attempt to imitate nature by endeavouring to excite an infl around the mort. part & so produce a line of demarcation & eventually the sloughing of the part, is to be considered Ind. 1st Venesection may be useful to moderate the violence of action Calomel for the disordered secretions in alterative doses Bark was formerly supposed to be a specific It is now discountenanced Acetate of lead & mur. amm. externally applied cold, as being more agreeable Emollient poultices, yest poultices will 42 correct fetor. Chlorate of lime & soda Bark was formerly used in poultice 2nd diminish irritation extract foreign bodies if there are any, open abscesses remove mortified sloughs. Calomel opium even with venesection, & especially when purgatives are required Emollient poultices 2d prevent the spreading of the mortification which spreads sometimes in the cellular membrane very rapidly. Bark may be useful but blisters are the great remedy. They should be extensive & on a limb, should extend above the part mortified except in case of mortified toes. Nitric acid (100 to 300-400 drops to 1 pt. water) may be used as a caustic application 4th support the patient by opium, bark wine ale porter, indulgence in nutritious diet. Keep the bowels in order, attend to the secretions etc. etc. After treatment of the part Keep on the external application etc. Clear away 43 the sloughs Case which terminated favorably related in which the whole gastro [illegible] muscle was lost. Near the close of the cure the following preparation may be used as a mild cerate. 2 drachms acetate of lead ½ oz. sulph. sodae, 2 ½ oz. simple cerate Mortification continued It may prove fatal from const. irritation either gradually or suddenly Case related of an old man who first had apparently an anthrax on the bottom of his foot There came on a phlebitis of the vena saphena. Mortif. affecting a whole limb will [rarely] be cured. Generally amputation is the best remedy. The const. irr. will be surprisingly relieved. Hiccup is generally a fatal symptom As to the propriety of amputation It must be done when the injury 44 has destroyed the principal blood vessels & limbs. Also in mortification of the toes extending over the foot for all such cases cannot be cured without too extensive a suppuration to be borne by the constitution As to the time of amputation. It is now settled that we are not to want for the mort. to stop spreading & for the mortified part to be sloughed off. The mortified toes of old people should not be taken off. If amputation is to be performed, it should be of the leg, or if this beings to be affected, of the thigh. Case of mortif. of finger of an intemperate shoemaker. When amputation is performed we almost always find the arteries ossified In compd fract. burns, frost bites etc. if the parts are likely to be dead, then operate immediately. Sometimes mort. extends along the cell. memb. under the skin, giving rise to a crackling feel & a sort of eymphyema. 45 Wounds in general. Solution of continuity in a part. They are of six kinds incised punctured lacerated poisoned contused & gunshot wounds. Extensive wounds may affect the system more or less according to various circumstances, one of which is the degree of confinement, e.g. wounds of the lower limbs affect the system more. The symptomatic fever will vary from a slight heat, to a high fever; sometimes we have chills sometimes erysipelatous inflammation The first indication respects the hemorrhage. This if slight may be stopped by cold air cold water, lint etc. If an artery is wounded, a ligature must be used, except that sometimes a small artery may be stopped by a total division of the vessel. Case of a man who had wounded the art. [illegible] 46 There came on a very troublesome & frequently recurring haem. Cured by opening the wound & totally dividing [the] partially divided artery. The temporal art. may, in this way, be totally divided & then stopped by compression Ligatures may be of silk, thread, or better of leather, rolled. Mr Lawrence has lately recommended a small silk lig. with the ends cut very close it is said they will come out by a small [pustule] Leather is absorbed. It is now [illegible] inadvisable to cut the internal coat of the artery by the ligature Mode od dressing. Bring the edges accurately together, apply adhesive plaster and a compress Leave the wound in this cond. for 4 to 5 days. The interrupted suture is used. 47 The sticking plasters may be used in addition to these, a strip between each two stitches In case of much heat & inflammation Prof. H. keeps up the practice of wetting the dressings even with ac. plumbi. Punctured wounds; of by a bayonet or similar instrument, they partake of the nature of others Considered dangerous yet often heal by the first intention. If pus collects at the bottom treat as in other cases of suppuration. Haemorrhage from wounds. The artery retracts when cut, the internal coat adheres & the [illegible] extends as far as the next collateral branch. This first led to the practice of using small round ligatures. Sometimes the needle & ligature is used when it is impracticable to use the tenaculum or forceps especially in punctured wounds, to avoid the necessity 48 of extensive incisions. We must be cautious about tying arteries in old wounds lest the tied part slough off & we have haemorrhage again to avoid this make a new incision. Be cautious about leaving any substance in the wound Sutures should be generally be left 4 or 6 days A proper posture is of importance. Horizontal for the lower limbs flexed if upon the back side of them. Union of parts totally divided as noses & fingers has not succeeded in Prof. H’s practice. When a little skin is left they do very well unless suppuration comes on Rest & simple diet are of importance. Rest is especially [so] in case of wounds of the lower limbs Contused & lacerated wounds may be treated under one head. The haem. is generally small. Do not hesitate to draw the edges of the wound 49 together instead of treating with fomentation & poultices to promote suppuration Poisoned wounds where a poisoned substance is applied to a puncture as stings and bites. It is difficult to say whether the effect is upon the nerves or the poison is absorbed The effects are very analogous to erysipelatous inflammation Excision should be performed as a prophylactic. Cupping has been practised. Caustics Among the French caustic acids are favorite applications If acetate of lead etc. fails Prof. H. would try blisters. For the general remedies use vol. alk. opium, alcohol camphor a variety if necessary of stimulants If violent inflammation comes on use venesection mercurials etc. If suppuration or gangrene ensue treat as usual for them. Case related in which 8 gr of arsenic were given in 4 hours cured. 50 Apparently phlebitis has been occasioned by bites of serpents Indian remedies are of little consequence. Stings of wasps & bees Bad case of a sting near the eye relieved by laudanum next day fever relieved by bleed. & mercurials Young woman in Toll. cty. stung in the leg by a wasp fainting & anxiety died in 15 or 20 m. Dissection wounds A wound seems to be necessary. Prof. H. does not think they can be explained by the predisposing causes of late hours, study etc. Symptoms finger very sore & painful soreness extends up the arm pain in the head & back, chills & fever. Swelling of the part up the arm in the axilla pus under the pectoral muscle & in the chest death. If the pus collects in the finger alone the case is less dangerous. Prof H. has known similar effects follow a puncture without morbid matter. Case of a boy wounded in the heel with a fish spear. red streaks abscesses in the foot & leg 51 suppuration under the pectoral muscle under the pleura death Very bad sores upon the fingers often have arisen from dressing ulcers. Prognosis varies upon the situation etc. Touching the wound with nit. silver has not always been successful Suppuration in the lungs following operations compd fractures etc. The treatment is the same as in other inflammations of the pleura bleeding etc. In two cases Prof. H. made an opening into the sac of the pleura one of them was fatal, the other recovered. Gunshot wounds The contusion must be very great. A spent ball will produce contusion merely. It was formerly supposed that the ball burned the parts judging from the appearance of the [illegible. This is a mistake Often the shock to the system is very great, but with some it is trifling The entering orifice will be smaller than the issuing The latter will have 52 ragged and projecting edges. Sometimes a ball may be pulled back by taking hold of a piece of silk, which was carried in before it. Its course may be very circuitous, being diverted by tendon sometimes as well as by bone. Abscesses and also cysts are formed around it. The effect formerly acribed to the wind of a ball are explained by the oblique stroke; the skin yielding & being unlacerated, while even the bones within are broken. That the wind does not produce the effect is proved by the fact of one leg’s being carried off without injury to the other, when both are in contact The contusion destroys the life of the adjacent parts. The hemorrhage is generally slight Balls may pass through the body without penetrating cavities, as of the chest. Baron Larrey told Dr [Heerman] that he had lost but two patients whose bodies had been perforated by a ball. 53 Necrosis is generally produced by a ball’s striking a long bone in other bones caries. Wounds of the lungs will often be followed by haemor. from the mouth of the bowels by feces issuing from the orifice. Wounds of the joints are dangerous Indications 1st suppress hemorrhage Do this by the tourniquet if possible Tie arteries as soon as possible, unless amputation is to be performed 2nd extract foreign bodies unless they are out of sight & of the reach of the finger or probe When the ball has passed nearly through cut down on the other side, while squeezing with the finger & thumb. Thread etc. will come out by suppuration A foreign body lodged in a bone is very dangerous. In a superf. bone trephine 3d prevent or remove irritation The French make incisions to take of the stricture & debridling the part. This is now discountenanced by the British In case of a fleshy wound, apply 54 merely lint and simple cerate. Many keep a moistened compress upon the orifice This is [illegible] cold water is generally the best application. For some days the wound will look ugly, with swelling & frequently a watery discharge. If suppuration comes on slowly, poultice but do not continue them after suppuration’ is fairly established, but absorb the pus with dry lint. The separation of the slough is another critical period if secondary hemor. then comes on apply a compress immediately. The plan of tying the artery at a distance has generally failed In an old wound we must make a new one. General treatment should be antiphlogistic Prof. H. uses calomel as a cathartic & the British surgeons are adopting the practice. If there is pain in the head fullness of the veins etc. bleed & purge In the latter stages opium is invaluable 55 to allay irritation Sometimes also in the first shock & then according to some bleeding must be conjoined. Amputation 1st as to the time 2nd as to the particular case. The unanimous testimony is now in favour of immediate amputation waiting however for recovery from a violent shock & administering a mouthful of wine & also consolation & encouragement. Baron Larrey & Prof H. prefer immed. amp. even when bad symptoms have come on 2nd the different cases 1st amp. is necessary when a limb has been shot off for a clean incised wound is made the patient will be more comfortable & mortif. less likely In fingers the injured phalanx only need be removed, at the joint. 2nd when a ball has passed through or lodged in a joint. 3d in some cases where a bone is fractured according to the degree of injury to the bone & also to the soft parts Even if the patient recovers, the limb will often be not so good as a wooden one Necrosis often comes on. The suffering will be great Often a bone will be fractured & split into the condyle 4th by extensive destruction of soft parts, to prevent gangrene, or extensive supp. & hectic & where the muscles are torn off the limb will be stiff. If the upper part of the femoris or os humeri is fractured amp. is necessary (at hip joint?) Consecutive amp. may be necessary The destruction of large arteries sometimes the skin will be unbroken in the meantime often indicates amputation Good accommodations for the wounded may enable us to save patients without amputation Be careful to amputate entirely above the fracture Mr. [illegible] says that after amp. death takes place 1st from infl of bloodvessels 2d [metastasis] to some important internal part most commonly to the thorax in our climate 3d from disease of the bone or joint 1st the veins may perhaps be tied 3nd pus has been found in the sac of the pleura 3d the hip joint Prof. H. would evacuate Suppuration of the liver more freq. take place in hot climates After amp. the end of the bone becomes round if the cure is favourable Paralysis is a frequent consequence of extensive gunshot wounds cured by moxa according to Bar. Lar. Tetanus Failure of success almost universal in acute tetanus more common in warm climates Bar. Lar. has had most success. It may be occasioned by tying up a nerve with an artery by exposure to night ari by suppression of suppuration acc. to Bar. Lar. Actual cautery has succeeded Amp. has generally failed Canthar. often fail It occurs oftenest in the young & in wounds of a [ginglim???] joint acc. to Bar. Lar.’ Emprosthotonas will follow an anterior wound & opisth. is a posterior & tetanus where there equal injury before & behind acc. to Bar. Lar. Warm & cold bathing have been much used Case of a young man wounded in the foot by a piece of glass. Bled. blister to the healed wound calomel opium cured was stiff for a year. Case 2d blacksmith hot iron upon foot corr. sub. into the wound blister over the foot calomel & opium the latter followed up cured. Make a powerful impression. A red hot ploughshare has been passed along the spine. Bite of mad dog Excise deeply it has never failed in Prof. H’s practice A finger may be cut off. He has cut out 6 days afterwards with success. Dr Physick says at any time before the [accession] of the symptom Contusions without breach of the skin It is an injury causing a rupture of vessels & effusion of their contents under the skin 1st swelling owing to extravasation next echymosis or discoloration which frequently extends some distance especially in the direction of gravity e.g. black eye from contusion on the forehead finger discol. after an injury of the arm very easily produced in old people. Commonly a considerable degree of soreness. The powers of absorption greater in the young Indications 1st prevent further effusion 2d reduce infl. 3d promote absorption 1st by wet lotions of water [mar.] [illegible] etc. 2d if much fever bleeding & cathartics & fiunally if necessary opium 3d Use warm applications (these also may be for the first indication after a while) Add to these bandages & compression. Also we can apply camphorated spirits opodeldoc etc. In many cases an incision must be made to let out the effused blood (called bloody abscesses by the French) We should however generally defer [illegible] One reason for which is that the vessels may continue to bleed. If the blood is coagulated a snapping will sometimes be felt as of something breaking & slipping away. [illegible] in this state it is though more likely to be absorbed. Before incision try remedies and [observe] if you appear to be gaining ground. Sometimes the effusion is in a bursa mucosa Case of it in the knee So [much] a [illegible] Make the incision on the outside of the tendon of the rectus musc Prof H has several times been obliged to open these bursae e.g. at the elbow. Upon the back he has had to make an incision & let out a quart of fluid tarlike blood. If the vitality of the skin is destroyed an incision will be advisable. We shall have a sloughing sore in either case. There is a bursa directly on the olecranon which is liable to be filled with effused blood Often there will be a second eff. when the orifice must be opened & the cavity injected with corr. sub as in [illegible] Contusions of abdomen. Death has been occasioned by blows on the epigastrium apparently caused by the shock alone Often the peristaltic motion suspended which denoted by swelling of the abdomen vomiting want of sup. anxiety of countenance etc. Sometimes blood is vomited It is generally best to avoid stimulants Case young man kicked by a [illegible] vomiting of blood 1 great pain & excessive thirst to stop the flow of blood cold wet cloths were applied to the abdomen bled ad deliq. pain ceased pain & vom. returned bled again calomel finally injections The bleeding relieved the pain the vom. & the thirst. cured in 2 or 3 days Venesection is the most important indication, the next is purgatives continued for some [time] Sprains not much treated of It is an unnatural extension of ligaments of a joint sometimes accompanied by dialysis or rupture. Joints most commonly affected are those which are not strongly defended & admit of little motion. They are the knee ankle wrist & hand. At first motion is free but it is soon hindered by effusion & swelling frequently there is effusion into bursae mucosa There is an effusion into a bursae of the foot which is often [illegible] for dislocation. It is apparently set by pressing & breaking the sac. Prognosis Some families are particularly liable to them Scrofula gives a tendency. In some constitutions a slight sprain will cause [hemorr.] for months Treatment Rest is more necessary than in contusions. Cold lotions to prevent infl. cold water or ac. plumb. A bandage is always proper moistened at first. In case of much pain use warm fomentations best by wringing out a cloth dipped in hot water, applying it & covering it with flannels to keep in the steam. Poultices may be used In case of stiffness apply opodeldoc & other stimulant applications friction passive & active exercise. Lameness is often caused by want of exercise. The violent wrenching of the natural bonesetters has some good in this way. Burns. Inflammation caused by heat The practice has been exceedingly empirical No advantage in dividing them into species Superficial burns of sufficiently extensive are of the highest consequence Case of a child blistered by cantharides over the whole body died in great agony. The British East India surgeons sometimes used hot water for blistering The [illegible] indication is to shut out the external air. Treatment like that for a blister Deep burns are generally [illegible] by a suppurative inflammation which is generally ascribed by the patient to taking cold. Sometimes flame is inhaled the viscera are affected, under the external injury, in some patients Consequences of extensive burns if the pat. survives the first shock, are fever, extensive [illegible] etc. This last is frequently fatal, hence the end of three weeks is a critical period Children are sometimes affected with convulsions When we find apparently comfort application already made, we should be careful about interfering with them Treatment has been opposite & empirical Cold water on one hand & spts turpentine on the other. Antiphlogistic & powerful internal stimulation For simple external burns anything that keeps out the external air perhaps as good as any is simple cerate. If there are vesicles [illegible] them Equal parts of basilicon (or common cerate) & spts turpentine is the best application in case of extensive sloughing & suppuration Prof H. has tried cold application & poultices, but does not like them [illegible] is the necessity frequent exposure to the air in dressing. The above cerate seems to promote a quick suppuration & so prevent gangrene. It must be laid aside (causing smarting etc.) as soon as suppuration is free, when simp. cerate should be dressing not oftener than once in 24 hours having the dressing ready for immediate application the cold air. Then granulations come on use Turners cerate Finally use ac. lead 1 oz beeswax & sulph. sod. 2 oz. This is called saturnine cerate. Turner’s cerate above is made of oxide of zinc. Often near the close of the cure adhesive straps & bandages are useful to keep the sides of the ulcer together Constitutional treatment. The shock is often very great. In children there is either violent distress with screeching [or a comatose] state with deadly coldness which indicates alcohol camphor ammonia etc. Opium also though Prof. H is afraid of it in coma. Next comes on fever treated by venesection cathartics etc. to be discontinued when suppuration comes on. In children it will be sufficient to keep the bowels open & bleed only incase of convulsions In adults the bleeding should not be copious. Bark [seems] to be irritative Opium is the principal remedy on account of the pain etc. Cotton seems to be advantageous only by keeping out the external air & keeping the parts warm & by being easily applied & kept on Case of a man who fell into a kettle of boiling potatoes Took a large quantity of spirits Was dressed with the turpentine cerate then with simple cerate opium [was given] the bowels kept free about the [2?] day there was a critical period his mouth was treated with borax & other means were adopted which cured him. If an extremity is burnt off then amputate the stump immediately Sometimes the bones come off themselves. Deformities from burns The fingers are liable to adhere This is to be prevented by dressing. Splints are to be used to keep parts in their place preventing [illegible] flexion of fingers etc. When the joints are affected they should [illegible] straight & when the sore is healed, practice flexing them. Case of a young man who scalded his legs Deformities following burns Case of a burn at 7 yrs. of age upon the back of the thigh troublesome with sores etc. at 47 yrs had been of latter years much troubled with a horny excretion which was softened with [poultices] & shave off [At] 47 yrs of age the limb was amputated IT was an old practice to cut across the cicatrix & stretch the parts in case of deformity caused by contraction The new practice is to cut out the scar entirely sometimes adding the taliacotian operation Case of a young man with a large & sore scar on his foot. A good foot was made Frost bites A degree of torpor is produced by severe & long continued cold amounting to drowsiness & irresistible inclination to rest. Case of Prof. H’s preceptor, an army surgeon Not suddenly to be brought into a warm room nor to be too free with cordials Immerse frozen limbs in cold water gradually warming the water after a little while. A limb thoroughly frozen cannot be restored to vitality, however The contrary treatment totally destroys the frozen part. The effects of frost are similar to a burn superficial redness mortification which commences with a purple & terminates with an ash colour in case of thoroughly frozen limbs In frost bites apply ac. plumbi etc. poultices, cerate in case of suppurations which may have liquid applications over them. Cold and warm applications are both used. In case of mortified extremities amputate without hesitation as soon as the line of mortification is distinct else we shall have suppurations abscesses etc. Case of Capt P. of Brooklyn was overturned, & [stunned], in extreme cold weather lay all night was put int a very warm room. The phys. attempted to bleed him no blood followed there was a wound on the eyebrow knee the other knee dislocated right hand frozen. Prof. H. bled him, & gave a dose of cal. & jal. Afterwards he grew more insensible & eventually comatose for several hours. An erysipelatous inflam. with delirium supervened. He was bled & treated on general principles. Eventually recovered The fingers & thumb of the right hand were amputated after about a fortnight This amputation was however too late as was proved by suppuration & abscesses taking place on the hand & arm. The patient was partially sensible & able to tell his name when he was first discovered by the road side. The effect of the warm room was to bring on complete insensibility & finally coma A foot or hand frostbitten if applied to the fire is followed often by violent infl. & mortification which when superficial merely will cause nothing more than the loss of nails skin & so on Tumors Varieties numerous 1st Encysted 2d sarcomatous 3d medullary Also malignant & non malignant the last however may become malignant We know little of their origin. Mr. Aber. attributes them to extravasated blood. Their progress is often similar to that of chronic inflammation The nature of the tumor will often be inflamed by that of the parts where they are situated e.g. they may contain hair when upon the scalp. The growth seems to depend upon the size of the bloodvessels of the part. They increase, in general, in geometrical progression They should be extirpated before they have arrived at any considerable size. 1st Encysted tumors contained in a cyst of more or less density, which encloses [stertomatous], or [illegible] mellitus, or is an [illegible], curdy matter being contained There is a kind affecting the red part of the lip having a think sac & contents resembling the white of an egg not larger than a musket ball. There is a tumour composed of adipose matter disposed in cells called sarcomatous Various discutient remedies, have been recommended. As far as they are effectual at all, they do injury. If the cyst is penetrated, a very troublesome sore follows & sometimes cancer Caustics instead of knife have been successful Cancer quacks cure small tumors in this way and call them cancers. In case of large tumors caustics often fail & the knife is always preferable. It was formerly advised to extract without opening the cyst this not always practicable without great difficulty. Sir A. Coop. opens the cyst presses out the contents & pulls out the cyst by inversion. If any portion of the cyst remains the tum. will be renewed. Sometimes a small tumour may be removed by caustic alkali upon lint introduced into the cyst. external injuries freq. cause these tumors Sarcomatous tum. In these the cyst is not strong enough to be pulled out. If the skin adheres firmly, make two semilunar incisions & take out a piece of skin Then separate the tumour from adjacent parts by the fingers as much as possible Membranous connecting bands often have to be divided. These tumors are troublesome from their size, from impeding motion etc. when pendulous, the skin is frequently affected with an erysipelatous infl. Cases of old woman & an old gentleman extirpated with safety. The arteries are usually very small in these fatty tumors sometimes however they give a troublesome haemorrhage They are divided into various kinds by Mr. Abernethy. All the kinds may become malignant Fungus haematode medullary tumors malignant from the commencement & liable to return even if thoroughly extirpated. Hence a portion of undiseased parts should be cut away After extirpation treat as for a simple wound. The largest [tumors] are the fatty even 40-50 pounds They feel like a bag filled with cotton Sometimes there is a puckering of the skin (caused by imperfect adhesions of the skin) under the fingers. This is a pathognomic symptom These adipose tumors must not be confounded with the steatomatous encysted tumors. It is a question whether the whole parotid gland has been extirpated. They will prove fatal (many of them) eventually & hence should be extirpated while small. The testicle & the fem. mam. are enlarged frequently & sometimes will become small again Medullary tumour or fungus haematodes the substance of them resembles that of the brain but is redder & harder found in every part of the body even in the bones & then called osteosarcoma There is at first an elastic feel caused by the binding down of fasciae Growth is very rapid, causing absorption of adjacent parts as bones Most common are they in the young they were all formerly called varieties of cancer In the testicle most taken for hydrocele It is found about the eye Prof H. has met with them oftenest about the hip. Case of mortification & death in three days in consequence of opening one, in search of pus. Case in which a small point was left, which grew in spite of caustics & proved fatal. Case in which it returned three times & was then left We must hence cut away sound parts also. If the bone is affected amputate. Prognosis is generally bad though the wound heals well enough. They may return in internal parts. They are not always pulsative nor generally painful except by pressure upon surrounding parts & by a general [illegible] of health loss of app. sallowness of continence etc. pain when a nerve is pressed on Diagnosis of medullary tumors Abscesses begin deep & are not painful and are circumscribed by a hard edge. fungous tumours have an elastic feel. The colour of the skin over a fungous tumour will be dark red, but not tender like that of an abscess, nor surrounded with a hard rim. We must also inquire into the previous symptoms fungous tum. begin without infl & pain & are indolent. Spots will be found in the neighborhood which if opened largely will prove fatal. Case of a fung. haem. of test. mistake for hydrocele. Though we have no remedy for this disease yet extirpation should be performed if possible cutting into the sound parts. Case of Dr Wood. of [Cast.] cutting out one of the thigh every few months the man able to labour. Case in which the most powerful caustics failed in killing the tumour, fast as it grew. Ulcers A solut. of cont. in soft parts with a discharge of fluid. The absorbent vessels remove the parts faster than the nutrient vessels renew them hence the opposite to healing Differs from mortif. by the dead parts remaining in the latter case Various classes of them Causes wounds abscesses external injuries (local) The constitutional causes are syphilis scrophula scurvy etc. also in some families from a predisposition e.g. hereditary sore legs An oedematous affection predisposes e.g. dropsy phlegmasia dolens 1st simple 2nd irritable 3d indolent 4th varicose 5th specific ulcers 1st simple discharge of mild inodorous pus small round granulations filling up the cavity finally a bluish skin (cuticle only) which makes cicatrization Formerly 3 stages were always expected in the healing of a wound viz. ulceration, granulation (restoration) & cicatrization. Much benefit arises in a simple ulcer from adhesive straps, as in a wound, to promote cicatrization. The bandage will keep the parts together & also prevent proud flesh (a luxuriant gran. protruding beyond the skin) which should by nit. sil. or if that fails by sul. cop., be reduced Irritable ulcers painful sore irregular shape (sometimes round when small) gran. irregular do not bear bandaging well. The irritability may generally be abated by touching with nit. sil. or by wash of corr. sub. or by 1 scr. corr. sub. to 1 pt water (called yellow wash) or sprinkle with calomel, or apply the black wash of cal. & lime water or wash with [illegible] op to 1 pt water 1 dr. ac. lad to 1 pt. mucilage will be cooling & lenient. Warm fomentations are apt to soften too much We frequently change our application Indolent discharge serous& curdy bottom smooth edges swollen surrounding cell mem. thickened often very large as large as a hand [illegible] patients will suffer little, and continue to labour. A farrago of remedies in popular use Nitr. ac. & nit. sil. & other caustics are used. The best rem. is MR. [Berts] plaster bandage, surrounding the limb. above & below with this bandage applying a compress wetting the whole with cold water. Sometimes leave a little vacancy for the discharge of matter The plaster may be common adhesive pl. or diachylon, or rosin pl. or [litharge] pl. sometimes in case of irritation from Soap plaster of the [illegible] is used rosin softening this last with tallow one half Dress once in 2 or 3 days only Sometimes an erysipelatous infl. & sloughing comes on Guard against this by diet etc. Improper to make a class of sloughing ulcers Indolent ulcers may be cured much sooner by confinement, as is practised in the hospitals. 3d Varicose ulcers. The veins will be found varicose. Some are irritable more commonly they are indolent. Treatment of the varicose veins is the particular indication. Proper bandages with confinement of the patient is always proper. However the cure will be more sure of being permanent when it is effected without Diet is of the highest importance The patients are generally plethoric more or less; hence use venesection or purgatives (mercurial). Where erysipelatous infl. come on treat as usual by ac. plum. blistering etc. Some patients are feeble with low pulse cold skin & pain in the affected limb. In this case give cal. [illegible] cal 1 ½ gr. op. 1 gr. also Dov. pow. bark & opium etc. Nitrate of silver relieves irritable [illegible] sloughing etc. better than any thing touching with it once in a few days. There is generally little hazard to life from sore legs. Cases in which by the continual application of caustics & irritatives caused enormous ulcerations cancers & affections of the bone which required the operation for necrosis, or amputation It has been proposed to be the vena saphema Sir A Coop. objects. Cutting across the vein is thought better by some also cutting with the convex cutting edge of a bistoury, so as not to wound the skin also cutting out a part of the vein & then bringing the edges of the wound together, as is practised with success in the Pennsylvania hospital. This latter mode probably the best. It has been supposed that the drain from old ulcers is very beneficial this opinion is probably derived from the fact of the stopping of the discarge in an acute disease as fever There is no danger in curing them Hence the old opinion, which is still the popular one, is to be entirely disregarded Plethora had better be relieved by venesection & cathartics than by ulcers. Specific ulcers e.g. venereal, noli metangere cancers etc. Anomalous ulcers Sore on the instep somewhat like elephantiasis. Benefitted by powdering with calomel. Nitrate silv. saturnine cerate acetate of lead & calomel with lard may be tried also. There is a thin watery discharge redness hardness thickening extending over the whole upper [surface] of the foot. Sometimes stopping in one direction & extending in another Fungous ulcers [ment.] by Sir. A. Coop. principally on the calf of the leg resembling a scrofulous affection of the metatarsal bones generally in young & corpulent women Apply bandages wet in case of heat when the fungous protrudes through the skin apply nit. sil. Also wash with ac. of lead etc. & prescribe for constitutional symptoms. Ulcers following scrofulous abscesses Fungous flesh overhanging, thin, dark purple skin they are oblong Apply nit. sil. in pencil under the skin if necessary that is if this first application does not cure then cut off the diseased skin & lay open the whole sore. Sometimes where the orifice is small, a director must be introduced & a long incision made it will not in this case be necessary to clip away the skin. These like other ulcers are often called cancers Schirrhus or cancer. A hard tumour without ulceration is called schirrous cancer, when ulceration comes on Schirrus may be fatal without running on to external ulceration Lower limbs & testes in males breasts & uterus most often affected When affecting the skin they begin with a blood war, or with a discoloration & tumour of the skin to be treated of afterwards. Scrofulous tum. are less hard, seldom single, oftener in young people, they are smooth, and attended with scrofulous habit. Young women are often affected with an induration of the mammary gland which is mistaken for schirrus. The latter is almost always found in adults. Cancer of the breast [Commences] with a painfulness When first examined there is found a hard tumor. An inflammation of the skin takes place. The nipple retracts & disappears eventually the hollow will discharge an ichorrous fluid. Or the cancer may commence with a small vesicle which breaks, discharges, & finally becomes an irregular knobby cancerous ulcer Cancers however, do appear to commence sometimes internally. The lymphatic glands & sometimes the lymph vessels, are affected when the ulcer opens. Sometimes the skin adheres to these inflamed lymphatic vessels Finally the manna adheres to the pectoral muscle & even to the periosteum of the ribs & sternum even attacking the other mamma with the same symptoms The lymphatic glands of the axilla are more affected & the arm sometimes is so oedematous as to require puncturation Great difficulty of respiration occurs The disease is fatal from hydrothorax or other affections of the thorax, as well as from hectic Sometimes without much ulceration the whole mammae are bound down at death with schirrhus. Sometimes the bones of the extremities become singularly brittle. Sometimes a paralysis of the limbs takes place The whole spinal narrow has been affected. Very numerous & various symptoms may come on in the sequel. Difference of opinion as to whether this disease is constitutional or local. For sometimes the disease returns in the same or another part & sometimes not Prognosis doubtful The more speedy the access the mor probable the return Sometimes in very old people from their slow progress & insensibility they give very little trouble. Their cure has been attempted by bleedings & low diet also by salivation No dependance can be placed on these remedies. So of the internal use of arsenic and of conium also. Iron internally & externally seems to have failed Pressure has been much tried, but fails The hard cartilaginous nature of the tumour would lead us to despair or resolving them by internal or external remedies Caustics have been successful in very small cancers, but generally they give so much irritation as to increase the disease making a loathsome sore Iodine has been proposed There are no accounts however of perfect cures by it. Prof Smith stated he never knew a woman survive the application of caustics to the mamma more than a year The sooner the knife is used the [better] Use the knife also even after ulceration has come on. We must not expect the infl. of the lymph gland to subside of itself, this tumour also must be cut out. Reexterpation Should be performed as often as the disease returns provided the patient can bear the operation Case of 4 times in a year & the patient is now well. Various remedies, or issues, have been tried to prevent the return of the cancer It is of no use to prescribe any thing except for the general health In other parts of the body cancer may begin in a manner similar to those of the breast In the lip, we may have first a crack in the lip ulceration the lymphatic glands of the neck are affected the gums are affected the cheek the bones the whole mouth consumed & sometimes the patient dies of starvation. Mode of extirpation take out a piece in the shape of the letter v. bringing the parts together. If the skin is not affected, we may cut away down to the skin, leaving the latter Mr [Richaraud] cuts away the whole with scissors instead of the knife Prof. H. has extirpated the diseased glands under the inferior maxillary but generally without success where the disease has proceeded so far. We must not be too solicitous to save skin, cutting away all that adheres for the disease may return in the skin. Even when the disease returns it is not generally so rapid & fatal as at first. We must be very careful not to confound cancer with other diseases of female mammae Hydatid or incysted tumour of the breast of Sir A. Cooper 1st an enlargement then a tumour which yields serum when punctured then returns again and may attain to the size of several pounds. When of this size it is found after extirpation to be composed of one or of several cysts & may be of other forms. Case of a woman who had one opened a second time the opening kept open by [illegible] died of extensive suppuration & const. irritation Another case was extirpated at the first time. The tumor was the enlarged mammary gland with a cyst in the centre. Diagnosis absence of pain If opened the fluid perfectly limpid Indication immediate extirpation Simple chronic tumour of the breast of Sir A. Cooper. Rather upon the breast, than in it moveable Not generally painful & does not affect the constitution It grows very slowly but may arrive at a large size. There is no difficulty in cutting off the tumour & it does not appear to be liable to return It may be either before or behind the mam. gland These tumours are composed of several cells resembling sweet bread a glistening & glandular appearance. The cause is unknown. The patients sometimes suppose them to be caused by the pressure of dress Caustics may have cured them. Adipose tumors sometimes many pounds in weight may be either before or behind the gland. They are to be extirpated Irritable tumours of the breast for 15 to 30 yrs. lobe of the breast swollen & painful the arm is affected, more painful during menstruation especially during difficult menstruation great irritability etc. If patient is plethoric, bleed, & purge apply spirit & water or a plaster the best external application is soft fur or cotton batting. Give opium Sir A. C. speaks of an ossific tumor of a cartilaginous nature to be extirpated Lacteal tumor after delivery a swelling, which when opened yield milk Caused by an obstruction in the duct of the gland. Treatment, open & let out the milk wean the child & so stop the secretion of milk. If the orifice does not heal, touch with nit. silv. Some women are very liable to small abscesses of breast during suckling If they continue to succeed one another the child must be weaned. Breast large & pendulous It may be diminished by bearing & nursing children also by suspension Sometimes there is an enlargement & inflammation of the breasts during pregnancy which often require opening to evacuate pus With the exception of the small chronic tumors upon the breast, the whole glandular portion of the breast should be removed. Mode of operation. Instruments 2 or 3 round edged scalpels tenaculums needles & ligatures adhesive straps from 1 ft. to 9 in. long & 1 inch wide Bandage by a broad band passed around the breast & crossed over the shoulder stitching down in front. Have also lint & compress. Cordials & cold water for fainting. This last is best remedied by dashing on cold water Place patient on a table, with feet in a chair arm extended sitting in a chair is apt to occasion fainting Make the first incision in the direction of the greatest length of the tumor Or make it in an oblique direction in that of the pectoral muscles. If the skin is affected semilunar incisions are necessary. Stretch the skin with your left hand & by that of an assistant Use a drawing stroke, from heel to point of the scalpel. Make your incisions long enough at first Use considerable force & repeat the stroke also until the incision is deep enough If two incisions are made, make the lower one first. Observe this rule also in your following dissections. If an artery bleeds, stop & tye it or have an assistant keep his finger on it. Be careful to examine the bottom of the wound & also the under surface of the tumour. Cutting away little additional portions does not give very great pain. Then proceed to take out the tumour from the axilla Sometimes the same incision will answer for both. They may sometimes be torn out by the fingers being imbedded in the cell. mem. merely we can generally get the fingers behind them When there is a diseased chord in the in the cell. membrane, take it out with the tumour in the axilla Spunge the wound out well & tie every bleeding artery wait sometime in order to prevent secondary hemorrhage The French direct us to wait ¾ of an hour Wipe dry & bring parts together with adhesive plaster, beginning at the top & leaving a small space for ligatures to come out, unless they be made of leather then apply lint & a compress, & bandages It has been the practice of some surgeons to tie the carotid previously to the operation There is no necessity for this Other tumours. Cutaneous tubercles of Mr Lawrence. Prof. H. has seen it often. Frequently beginning about the face especially of elderly people upon the eyelids, nose, & upon the generative organs of both sexes. It becomes ulcerative & resembles cancer. Sometimes resembles a wart & sometimes a vaccine vesicle, at the first Always reddish & without inflammation of the skin. Sometimes it grows very slowly & gives but little trouble. At other times, especially if irritated, its growth is rapid. Finally they ulcerate without any disposition to heal & indeed become cancers; they are covered with scabs. Menstruating females are liable to periodical evacuations from the uterus, intestines (hemorrhoids), lungs etc. produced by these tumours This disease is different from noli metanges Treatment. Extirpation is the only mode of cure, & appears to be effectual the disease apparently not liable to recur The health of females with periodical hemorrhages, will be much improved. Mode make two semilunar incisions & be careful to cut into the healthy skin They do not extend inward Subcutaneous tumor Vide Cheselden’s Anatomy & Mr. Wood in Ed. Med & Sur. Jour. A hard tumor surrounded & covered with emaciated & discolored skin excessively painful growing very slowly & continuing quite small, notwithstanding their painfulness They are of a cartilaginous hardness. They do not appear to tend to ulceration more painful during menstruation & pregnancy Extirpate without delay or hesitation [Naevus] materna called marks apparently composed almost wholly of enlarged blood vessels they may be red or purple, or brown sometimes without any elevation of the surface They are sometimes troublesome in after life the swelling increasing suddenly the tumour becoming pulsative swelling & pulsating when the child cries in this latter case however, there will generally be no trouble in after life from the [naeva] Sometimes they become aneurisms from anastomosis sometimes affecting the whole & sometimes only a part of the naeva sometimes ulcerating at the principal point the ulcer may also very extensive attended with frequent haemorrhage. Aneurisms from anastomosis may come on without being preceded by naevus they may be made almost to disappear by pressure they pulsate violently they are tumours composed of cell. sub. & blood vessels. They should be extirpated after extirpation they of course shrink to a very small size. They may ulcerate extensively & the ulcers are very difficult to cure (They pulsate upon exercise) They may grow to a very large size & are then liable to be confounded with fungus haematodes They may be distinguished by their origin, situation progress, pulsation etc. As ulceration sometimes cures these aneurisms, caustics have been recommended for their cure Extirpate the haemorrhage will be troublesome, hence cut around & avoid cutting into the tumour as much as possible, also cut quickly, stopping the arteries by the fingers of assistants If practicable, the better way is to surround the (small) tumour with a double ligature. A new way is by passing 2 or 3 times through them a white hot needle apparently successful in case of small ones Case in which a naevus on the head was cured by Prof. H. by ac. lead bandages & compression Inoculation with vaccine matter has succeeded, apparently caustic would be better however as a means of promoting ulceration Tying the principal artery leading to the tumour, has been practised when on the head the carotid has been tied apparently without success.