14 Surgery Separation of the lower end of the fibula This is the most frequent accident to the ankle according to Prof. H’s experience Yet little has been said upon it A sensation of cracking and tearing attends the reception of the injury The foot is turned inwards, a little so are the toes there is some swelling in the outside & intense pain is felt upon pressing the fibula inwards. To be distinguished from fracture & from effusion into a bursa on the outside of the foot, in consequence of strains Extend the foot a little, turn the toes outwards & press in the lower part of the fibula Apply a very thick compress & bandage & splint and bandage high up the leg for the interosseous lig. may be torn for several inches Compound dislocations of the ankle are very serious accidents. Prof. H. has seen much mischief arise from short splints and tight bandaging Wounds of the Joints The pain is generally on the opposite side of the joint. Violent pain suddenly occurs if after a few days & is generally attributed to taking cold & the attendants attempt to sweat it out etc. Ultimately excessive suppuration occurs The wounds of the joint, communicating externally, are more dangerous by far than internal wounds, as from fractured bones As severe consequences may result from wounds of the superficial bursae, as for instance that on the external surface of the patella The prognosis may generally be a favorable one for the life of the patient but the joint is apt to be anchylosed Prophylactic treatment Draw the lips of the wound together with add. ph. apply a bandage & a splint & confine the pat. to his bed. In some cases, bleed etc. to prevent infl. Treat. of infl. Press out pus etc. if necessary probe the sac etc. In punctured wounds with excessive pain and swelling & violent const. sympt. envelope the whole joint in a blister which will give great relief Let large ulcerating cavities be thoroughly [pencilled] with lunar caustic The irritation will be very much [illegible] by it. Collections that occur about the joint, should, if they do not disperse be opened & corr. sub. be injected we may first try discut. lot. & blist. And in general, keep the joint wet with disc. lot. If inject. of sol. of corr. sub. fail put a little moistened upon the point of a probe & introduce it down to the bottom of the sore. The older surgeons used red precipitate and an almost saturated solution of sul. cup. Be careful that the limb anchyloses in a proper position if knee, straight if elbow, crooked Dislocations of the Tarsal bones When the astragalus in dislocated inwards it is partly turned over the external & under surface being above Prof. H. has known the os noviculare partially disloc. He kept it in its place by a plaister bandage Gun shot wounds A common ball is said to move 2000 ft. in a second more rapidly consequently than the passage of sound hence in a cannonade at night, the flashing is first seen, then the ball whizzes by & lastly is heard the report The contusion is so great that the parts in contact with the ball in its passings are completely killed The orifice at which a ball enters will have its edges depressed the opposite orifice will be ragged The course of a ball may be very circuitous case in which a ball struck the larynx and passed around the neck coming out near where it entered. Tendons may divert its course A ball may carry before it a silk handkerchief 7 be pulled out and lost when the handkerchief is Injuries formerly attributed to the wind of a ball (for when one leg is taken off by a ball, the other is not injured by the [illegible]) are now explained by the oblique stroke of the ball and the yielding nature of the skin. Bones may be comminuted and even the viscera injured, without braking the skin. Secondary hemorrhage rarely occurs (4 cases in 1000, Mr. [Illegible]) after gunshot wounds and primary hemorrhage is of course less common this sort of wounds than in others Baron Larrey mentioned to Dr Heerman that he had lost two pat. only, where a ball had passed directly through the body Compd fract & wounds of the joints are very dangerous Necrosis of a bone is apt to be produced in consequence of a gunshot wound Necrosis of the cranium may be produced 1st ind. is to suppress hem. 2d extract foreign bodies 3d to prevent inflammation 4 promote suppuration & separation of [ischous] 1st by pressure etc. by a tourniquet applied until ligature or amp. can be performed 2d If a ball is too deep to be felt, it should not be cut for. If it can be felt by the probe, let an assistant make the skin tense, and let the surgeon enlarge the wound & extract. If it is on the opposite side of the body, make the skin tense with the thumb and finger & cut down and squeezing it out. Another period for searching for and extracting balls & foreign bodies is that of suppuration & sloughing 2d The French still keep up the old practice of always enlarging the wound. The British surgeon have abandoned the practice. John Hunter originated the plan. The French speak much of debriding the wound by taking off the tension of the fasciae. They uniformly make incision Cold water is the principal discutient lotion of military surgeons With respect to dilating the wound the British surgeons say that the incision soon close unless kept open by tents. Of course for several days the wound looks very foul; the edges puff out & protrude (Hence Larrey speaks of debriding) Poultices & fermentations shd now be applied 3d As soon as suppuration takes place, poultices shd be discontinued & cerate applied Look out for hemor. when the sloughs are cast off. Direct the pat. & the nurses to apply a tourniquet immediately if hemor. commences When hem. takes place we can seldom depend on tying the artery at a distance It will generally be better to cut down at once Sometimes a complete division of the artery will answer In hem. from the popliteal artery, on account of the difficulty of finding the artery in the hem. the artery may be tied higher up The treatment shd be antiphlogistic strictly. Mr. [illegible] directs cal. & ant. at night If severe pain in the head and back occurs with high infl. in the wound, then bleed immediately. But when suppuration occurs we must give opium for irritation Dr Fuller of Columbia mentions that in the last war it was found necessary to bleed in the first place & then to give opium Neither would answer by itself It is now agreed upon that it is best if amputation is necessary to perform it immediately, as soon as the pat. has recovered from the shock & not to wait till the subsidence of the fever etc. Extraction of Foreign Bodies from gunshot & other wounds If they are suffered to remain a cyst forms around them We must take into consideration first the nature 2nd the situation of it 3d the length of time it has been in. For if this is short we had better not delay but if it has been long in & gives no inconvenience, it may be suffered to remain Great suppuration in some cases and in others excessive irritation may result from the retention. Even a needle may cause great irritation Amputation The best authority is now in favour of speedy amputation Baron Larrey does not hesitate to amputate even after bad symptoms have come on as the pat. will be apt to to die certainly without amputation Prof. H. has amputated successfully in cases of crushed limbs, 48 hours after the reception of the injury When a limb has been shot off you amputate of course. But in case of fingers Prof. H. frequently contents himself with picking out the fragments of bone & dressing the wound When the ball has lodged in a joint or when a bone is fractured it will generally be best to amputate When the bone of the arm or thigh has been broken, necrosis takes place, and if death does not supervene, the limb will be apt to be always useless, or with an artificial joint. Bar. Lar. amputates when the os humerus is struck and if struck near the end, he amputates at the joint Very extensive injury of the soft parts may make an amputation necessary or destruction of the principal arteries and nerves. Amputate above the knee, for injury of the upper part or the tibia Even after amputation death may result 1st from infl. of bloodvessels, both arteries & veins # 2d from metastasis [&] pus being found after death in the thorax, in the lips joint etc. Prof. H. would always let such pus out. In our climate & in. G.B. suppuration of the lungs takes place oftener than in warmer ones 3d by necrosis of the bones at a joint. If the amputation was not high enough at first it may be best to amput. again If necrosis occurs after amp. the end of the bone will be sharp and ragged instead of being rounded by the absorbents. If the main nerve is entirely destroyed paralysis occurs Tetanus is apt to occur from gun shot wounds especially in warm climates Bar. Lar. applied blisters & actual cautery often with success. # & that too whether the veins are tied or not Mr. [illegible] sometimes tied the [vein] for hem. without bad consequences Hospital Gangrene Vide [Hemmer’s] mil. surg. The wound will become painful hot, red, dark, finally livid & black in the mean time the fever increases and becomes more typhoid etc. etc. In hosp. gang. contrary to what is common in common gangrene the arteries are affected & hemorrhages take place. Vide John Bell also The disease is unlike any other but resembles most erysipela of cell. mem. etc. The dis. affects all the textures, spreads among the muscle effects the deep parts more especially Caused by bad air, and a crowded state of the hospital. The affected patients should be separated from the others. It may be communicated by the dressings Mr. [Hemmer] found bleeding give give great relief the patient would beg to be bled cath. also he applied arsenic to the sores and ultimately gave [illegible] etc. In all such cases something must be applied to destroy the surface of the sore White swelling [most] exquisite in the knee Divided into rheumatic & scrofulous the first aff. the leg & the second aff. the heads of the bones. S. Cooper denies however that the heads of the bones are enlarged. Mr. Brodie also makes one division in which the artic. cart. are aff. Prof. H. considers white swelling as always in the first place an inflam. of the synovial membranes & bursae We have pain, tumefaction a puffy swelling is seen, under the lig. of pat. wasting of the limb below 1st Acute form pain then swelling like the swell. of ac. rheum. tenderness on press. & [mot.] joint easier when bent headaches furred tongue anorexia pain in other parts of the limb perhaps edema below the joint We are cautioned against confounding this with dropsy of the joint so called which is merely eff. in to burs. muc. etc. To disting. this from acute rheu. it is only necessary to know that several joints have been aff. in succession for acute rheumatism in any one joint may exactly resemble wh. sw. Sometimes pus forms erodes the ligaments & points externally often taking a very circuitous rout 2nd Chron. form pain at first trifling tenderness or pressure puffy sw. beside the pat. wasting of the limb below or edema Often the pat. will be so well as to be encouraged to use the limb, & perhaps sprain it & have a severe case at once In the latter stage both forms are alike. After a while anchylosis forms & the limb is well. But anchylosis seldom takes place except after suppuration. When anchylosis is about to take place, keep a knee nearly (not quite) straight & an elbow bent. In some cases extensive suppuration comes on & hectic so that amputation must be performed in order to save the life of the patient Ind. 1st remove infl. & here we must consider the kind of infl. wheth. ac. or chron. When there is acute infl. of a large joint v.s. & afterwards cupping scarif. & leeches Mercurial cath. as in other infl. of serous memb. Opium for pain. If discut. lot. do not relieve apply blisters But children are sometimes thrown into convulsions by them. Savin cerate is recommended in order to keep blisters open but it is apt to produce spasmodic retraction of the limb at least in children. Boyer also directs for children foment. poultices, [linim.] etc. Let a blister heal up & apply mur. amm. then in a few days apply another blister If these fail, try corrosive sub. Cut a hole say as large as a bowl of a spoon in a plaister put this plaister on & then over this a plaister coated thickly with corr. sub. This creates considerable pain & irrit. & the disct. from it will last perhaps 3 or 4 weeks. Perhaps the gums will be affected a little. The benefit however is often very great the joint diminishing in size an inch perhaps. Issues are used made with caustic kali Bar. Lar. has introduced the moxa. Setons are used but then give children too much irrit. Apply then below generally When the joint is recovering and is very weak & relaxed much advantages may be derived from a plaister bandage Where the complaint is a sequel of acute rheum. merc. are very benef. no particular advant. is to be exp. [illegible] merc. oint. Give op & cal aa gr i Canth. camph & op. aa zj for a liniment Friction also is beneficial in the latter stages If suppurations occur, open immediately The dis. is apt to recur again from improper [exper.] & exertion & from accidental injuries Reaction of the bones has been practised successfully as a substitute for amp. but not in the knee White swelling of the wrist Hand & fingers both flexed Apply a splint & compress & brace the hand back. It will relieve the pain & give confidence in the use of the arm & great satisfaction Open ever so small a suppuration great relief will be given Nervous affections of the wrists of nervous & hysterical females No swelling but pain, soreness, & inability to use the wrist Blisters seem to do little good. Plaister bandages seemed to be of some service. A similar affection occurs in the ankle joint They get well perhaps after a while. A dangerous affection of the tarsal joints has been met with by Prof. H. Swellings (puffy swellings) like white swelling eventually suppuration perhaps a curdy matter issues little or no pain after suppuration Occurs in children & youth Surgical writers call the aff. a scrof. swelling & advise amputation. White swelling occurs however in the ankle but generally occurs in children, & in the chronic form. It is met with in the children of cotton mills. Prof. H. has treated them with cal. twice a week at first White swelling occurs also in the shoulder and in the elbow An enlargement of the bones at the joints of the fingers occurs in females It has been called gout but Prof. H. thinks it has no analogy. It has been attributed to hard labour but is often met with in others. The disease will commence with pain & swelling similar somewhat to white swelling & ends with permanent enlargement Prof. H. has generally prescribed principally to the constitution applying stimulating applications etc. Iodine has been lately used in white swelling, with advantage Hare Lip Once in a while it is said to occur in the lower lip. May be single or double may affect the bone. Varies from a small notch to a complete di Operation for hare lip first performed in [Winst.] cty by a mountebank Prof. H. at first delayed the operation until the child was some months old But now he operates as soon as called even if the child is but a few days old It seems to be the fact that children with enclosed harelip are more subject to bowel complaints Prof H operates with scissors Put in the lower pin first & push it first upwards & then (in the other half of the lip) downwards to prevent there being any notch in the edge of the lip. Two pins only for children. Wind the threads so as to cover the whole incision Apply over the whole long straps of adhesive plaister. Let the pins remain 3 or 4 days in children & 4 or 5 days in adults Take off the plaister very carefully first each end then the middle Then take out pin by a rotatory motion And afterwards reapply the straps. Double hare lips have a central piece which is not to be cut away but an incision is to be made in the shape of the letter M & then bring all together in one operation thrusting the pins through the whole Cancer of the lip May commence with a crack then a scab finally a hard tubercle which may continue for years, if not tampered with, without much inconvenience. The ulceration may commence in the centre of the tubercle Lancinating pains occur & eventually aff. of the lymphat. glands beneath the jaw etc. etc. Common canker of the lip may be cured by nit. sil. etc. & does not resemble this complaint much Occurs oftenest in middle aged men said to be caused by tobacc. improbable Prognosis favorable in general if the disease has not been tampered with, if the pat. is not intemperate & if the glands are not affected Prof. H. has seen cases of affection of the lip more resembling fungus haematodes than cancer Operate as for hare lip Bronchotomy The operation consists in making an opening into the traches Laryngotomy is an opening into the larynx Bronchtomy has succeeded in some cases of cynanche laryngea or extracting foreign bodies bronchotomy is to be preferred to laryngotomy It is the only certain mode of extricating them. Even if after some time the foreign body is coughed up, the pat. is apt to die of pulmonary consumption Often the substance will be coughed up. It may be necessary to keep the wound open for some time, in order to allow of the exit of fragments The foreign body may be above or below the opening. Irritate the trachea to produce coughing to bring up the body from below Push a body, above sometimes upwards through the rema glottidis, with a probe. If you do not find the body keep the wound open One physician, kept the edges of the wound apart with the blunt hooks Push a probe through the rima into the mouth etc. N.B. Enlarge the opening of the traches with a probe pointed bistoury Operation for fistula lachrymalis peformed Wounds of the throat Lately and English surgeon who happened to reach the pat. within 1 ½ min. after a wound of the carotid & saved the pat. Dr Horner also lately happened to be passing the courthouse when a prisoner cut the branches of the carotid he employed pressure & cut down & tied the trunk the pat. died Wounds of int. jug. vein are sometimes fatal from the rushing of air into the throat. Dr Warren in an operation upon hearing the rushing noise, immediately clapped his thumb on & stopped the operation pat. survived. Taking a full inspiration has been recommended. The int. jug. is much in the way in operations for the extirpation of tumours it bulges out like an intestine Transverse wounds of the traches require sutures though some object to them. Food is apt to come out of the wound use a tube The passage soon closes however Sometimes a fistulous orifice is left as in the case of Desta of Ky. a tube has to be worn for breathing Injuries of the Head 1st external injuries 2d concussion 3d compression 4th inflammation 1st Ext. inj. An incised wound of the scalp is to be treated on general principles It will not be necessary to tie every little artery compression with a dossil of lint will often answer Even if the scalp is extensively separated, the wound may heal by the first intention When there are uneven edges & angles, stitches (the interrupted suture) are useful. Sometimes it is convenient to braid the hair In wounds of the scalp erysipelas is apt to occur & prove troublesome. Treat it as for erys. in general ac. lead or if necessary, blister bleed, [illegible] etc. Delirium is apt to occur but soon subsides Contusions on the head are apt to cause alarm often there is a tumour caused by effusion & the edges being often higher a depression of the bone is imagined and a surgeon will be sent for to trephine 2nd Concussion may be with or without an external wound [illegible] come out of their insensibility without any thing done When first revived, vomiting is apt to occur & generally gives relief pat. breathing better pulse rising Abernethy calls vom. a favorable symptom. But the pat may grow worse afterwards Blood often appears and the attendants think it comes from the stomach but upon examination we shall find it to have come from the mouth, nose, or ears Symptoms generally similar to those of a shock q.v. surface excessively cold After the first symptoms you will generally find the pat. in a profound sleep with a soft pulse Stupor & insensibility more or less perfect In severe cases pupils dilated Delirium may come on incoherence etc. Pain in the head, intolerance of light & sound etc. Sometimes paralysis of one side occurs sometimes fatuity occurs & continue for months etc. etc. Treat by putting pat. in bed applying heat, frictions give hot drinks aromatics moderate quantities of alcohol. After the pulse returns bleed continue the bleeding as long as the pulse rises Dr Phys. restored the circulation by pouring cold water on the head afterwards he bled. Next excite the peristaltic action by calomel. When symptoms of infl. of the brain appear, we must bleed & give cath. Apply cold applications to the head & blisters to the back of the neck. if the unfavorable symptoms continue Dr Rush advised salivation in bad cases & the best surgery in England practise upon this plan, at the present time If languor debility & loss of memory remain long tonics may be required After death, lacerations of the brain are often discovered. Much [???usion] soon changes the symptoms into these which arise from compression of the brain Prof. T. believe the palsy from concussion of the brain to arise from infl. of the [brain] & effusion the palsy is always a secondary symptom never one of the first 3d Compression of brain Infants may not suffer from depositions of the cranium They are said to have depressions without fracture In adults fracture is necessary to compression Sympt. stupor slow depressed & irreg. pulse stertorous breathing dilated pupils. Pat. appears in profound sleep Breathing resembles that of a fatal apoplexy Pupils, perhaps irregularly shaped Paralysis of the opposite side often occurs. Sometimes vomiting which Mr. Ab. thinks a favorable symptom in concussion? It may continue a week at intervals until the depression is removed Whenever it is liable to occur upon raising the head we may consider it as indicating compression The second cause of compression is extravasation of blood which is generally between the cranium and dura mater but may be elsewhere This sort of compression may take place some time after the reception of the injury In concussion the symptoms take place immediately after the injury the pulse is soft equal slow, regular breathing soft pupils not dilated paralysis does not occur immediately & is partial & not hemiplegic. In compression one whole side is more or less affected if paralysis exists Compression may or may not accompany concussion Always examine very carefully for fracture, or depression, even if there is no wound of the scalp the pat. will generally wince when the fractured place is pressed on Bleeding is always proper in compression unless much blood has already been lost. Give cal. also No English or Am. surgeon hesitates to trephine. Yet Desault abandoned the operation because he found it always unsuccessful. This was probably owing to the crowded state of the Hotel Dieu All the symptoms are relieved by the operation the nausea goes off & the pulse rises perhaps 20 in a min. Prof. H. has seen fraction of the cranium in two places. Patient died Mr. Abernethy describes a case of fracture of the basis of the cranium, near the foramen magnum Caused by a fall on the top of the head Trephination was formerly not practiced in Connecticut and all the broken headed patients died. Afterwards it was the practice both in this country and in England to trephine in every case When the brain is wounded we are directed not to operate. Cases related by Prof. H. of benefit from extracting bone driven into the brain. He would make it a rule to extract foreign substance from the brain Inflammation may occur sometime after the operation [illegible] have been known to recover when a [illegible] pin or a bullet had lodged in the brain Oblique wounds, with depression are less dangerous than wounds with sharp instruments If the patients are going to get well you will find no bad symptoms. If you do find them you had better operate Inflammation of the brain does not arise till several days after the accident It may come on (after 4 or 5 days to 2 or 3 weeks) from injuries which produced nothing more than contusion, or concussion or after operation Wound of the arachnoid membrane dangerous Inflammation of serous membranes as of arachnoid memb. dangerous Inflammation of [illegible] Commences with pain in the head extending from pariet. to occip. in tolerance of light and sound delirium coma convulsions paralysis death Perhaps commences with a chill Eruptive diseases as measles are apt to bring on infl. of brain in such circumstances The lips of the wound become dry flabby & pale pus is not secreted Where there is no extern. wound there will often be a puffy tumour of the scalp caused by separation of the pericranium The bone beneath will be dry and dead (The pericranium appears to separate at the same time that the dura mater does) Where there is fracture of cran. without ext. wound, pus may collect under the scull and issue through the fracture, & perhaps (if not let out) make its way through the scalp Prof H. has in many instances seen a subacute form of this aff. takes place weeks or months after, the injury He has known cases of dropsy of the head, not only in children but in adults from injuries Treat by powerful bleedings by mercurial cath. & by blistering These means must be vigorously applied When we have reason to think that the infl. is kept up depressed bone we should operate Recapitulation. Trephination is to be performed 1st [from] compression from depressed bone 2nd for compress. from extrav. blood 3d for compress. from pus 1st Prof. H would trephine a person even if in good health without compression if sharp points of bone were sticking in. 2nd As soon as the circulation is restored [illegible] if compression continues make a incision down to the bone and if there is a fracture, operate If there is no fract. try bleeding etc. If infl. of brain is violet & cannot be remedied if we know exactly where the injury, [is] received, operate, to give a chance for life even if there is no fracture Do not operate for more concussion We are directed not to trephine at the lower part of the os [fronte] over the sinus etc. Mr. Abernethy relates a case in which the dura mater was opened by a surgeon a large quantity of extravasated blood was let out the patient was relieved and recovered Let the dressings remain on as long as you can until suppuration takes place or until the patient complains. Disturb the brain as little as possible Exuberant granulations rise from a wounded brain. We are obliged to resort to compression with sheet lead over lint. If necessary they shd be touched with nit. silv. Keep your pat. in a dark & quiet room head a little raised If symptoms of infl. come on bleed & purge Sometimes the [fungus] of the brain or hernia cerebri is very formidable Prof. H. thinks he has seen two varieties 1st a fleshy fungus 2nd a hernia of the substance of the brain Mr. Abernethy advises bleeding. Prof. H. has never seen a case which required it Where there is a true hernia of the brain the patient generally dies We are not to trephine whenever there is paralysis A subacute infl. may follow concussion & cause paralysis. Prof. H has known persons recover perfectly after pretty severe inflam. & paralysis Once there may be hemiplegia & infl. of the brain without compression. Cases related treated with bleeding and blistering etc. Considerable insanity may follow concussion Great advantage is derived from cal. & op in alterative doses cal. 3 grs op [illegible] gr. After compound fractures there will often be considerable exfoliation of bone an open ulcer may, in this way, be kept up for years, from necrosis. Perhaps this may be an additional reason for Wounds of the Thorax 1st those which do not penetrate the cavity 2nd those which penetrate, but do not wound the viscera 3d those which wound the viscera The first kind require no particular treatment The second give great distress for breath the air rushes in and the lung collapses. Close the wound immediately relief is immediately given by it. The air becomes absorbed by it The third sort, generally require a somewhat doubtful prognosis Bloody expectoration generally takes place. The main indication is to prevent or remove infl. If there is diff. breath coughing etc. bleed, purge & blister Emphysema may be enormous We are advised not to be in haste to discharge & extravasated blood. Place the patient in a proper posture for letting out the blood Where the accumulation of blood is considerable there may be an external ecchymosis which, if it occurs, will always indicate extravasation of blood In urgent cases paracentesis shd be performed for accumulation of air within the thorax Prof. A. has always found emphysema relieved by puncturing the cell. membrane. When an empyema occurs it commences with pain in the side & symptoms of fever (pleuritis or pneumonitis) A chill or more will come on about the time of the suppuration When the pus has collected, the pat. can lie only on this affected side, in order to relieve the other lung from pressure. Respiration is performed by the diaphragm & abdom muscles the abdomen is perhaps fuller perhaps there there is a fluctuation externally perhaps the heart will be pushed over to the other sides Percussion gives a dull sound Make the opening between the 6th or 7th ribs unless there is a tenderness [illegible] about the middle near the upper edge of the lower rib. Make an incision about 2 inches long in adults extend it about an inch & an half through them muscles let the opening be about ½ an inch through the pleura The air rushes in & perhaps the pus may not issue at first in this case turn the pat over keep the wound open with a slip of rag Dress with a compress & rag The discharge may continue for years It often happens that the pus does not occupy the white sac of the pleura being in a sac which is limited in extent by adhesions of the pleura Hence it is important to make the opening if possible at a tender spot or one where there is a protrusion The usual consequences of opening a large abscess result. The whole pleura inflames. There will generally be chills and fever. Small doses of ipecac and calomel do well but opium is the principal remedy. Sometimes a hectic supervenes. This may terminate fatally or may end in health. In one of Prof. H’s cases a pat. recovered after 2 ½ years discharge and a very severe hectic. Larrey says patients under 36 gr are more apt to recover because the cartilages are more flexible Prof H. has succeeded in more than half his cases and in many of them the operation was a month or 6 weeks too late After recovery that side of the chest is smaller. The pleura must adhere, if the pat. is to recover Sometimes lumps of matter were discharged Amputations Less frequent now than 40 years ago In the rev. war, many limbs were improperly amputated by surgeon’s mates Necessary from a variety of causes At the present day many compound fractures are cured which would formerly have been amputated Necrosis now rarely necessitates an amputation Great judgment and firmness are required. Some patients will get angry and send for another physician Amputation was first performed with a red hot knife. Then the surgeons cut directly down. Then Cheselden introduced the double incision Then the flap operation was invented Mr. Liston has lately proposed to transfix the limb. Ben Bell was the first to propose the healing by the first intention At length amputation at the joints was adopted and found to be very safe When patients are very low with chronic disease, it is apt to be supposed that the pat. will die of the operation. This however seldom happens In case of excessive shock from loss of a limb etc. amputation relieves the shock according to naval surgeons Case of Mr. Huskisson Prudence is required in communicating the necessity of amputation. It is very improper to bleed the matter beforehand about the neighborhood. Amputation of the joints of the hand performed N.B. The wrist joint makes a much better and more useful stump Wounds of the face and throat Introduction of a cannula for respiration? Wounds of the eye brow cause a ptosis of the upper eyelid A cicatrix may cause either the upper or the lower lid to retract Incised wounds dividing the supra orbitary nerve cause blindness Vie Coop. Surg. Dict. art. [illegible] Division of the parotid duct may cause a salivary fistula. Salivary fistulae may also result from an abscess or from operations for the extirpation of tumours Prof H has healed them by touching with nit. sil. and applying a dossil of lint and a [illegible] compress Cure by means of a trocar & a cannula etc. Desault’s method Another method & probably a better one Diseases of the antrum 1st Abscesses pain in the side of the face & soreness chills [illegible] with face pain may be in one or more molar teeth Discharge often into the nose but the orifice not being free the discharge continues, for sometime. Pus frequently very fetid yellowish green. Pain often so great in the teeth that the pat. has one extracted If this lays open the antrum a cure is effected The bone may be absorbed and the abscess open on the cheek or under the eye Distinguished from tic doloreux by the febrile state, by the tumefaction the soreness pain not in paroxysms general state and habit is different Cure by making a dependent opening. Extract the 1st or second of the true molar teeth unless one tooth is particularly affected. Make or enlarge the opening by a gimlet (say) Keep a bougie in to prevent the orifice from closing. Inject soap and water spirit and water etc. Let the pat. wear the bougie 2 or 3 weeks eventually use a probe & finally knitting needle When the discharge becomes serous we may conclude the membrane to be nearly sound. Even if the discharge has taken place into the nose or on the cheek if it does not soon cease make this dependent opening Sometimes the pointing of the abscess is into the mouth near the gums generally it will then be best to enlarge the opening use a bougie etc. 2nd Polypus of the antrum There is generally a polypus in the nose or a polyp. in the nose extends into the antrum. If it grows with antrum exclusively it must be extracted by opening the antrum externally through the cheek 3d Fungus of the antrum Affects adults and children Little or no pain until pressure is made by the humor on the bones The bones becomes absorbed or softened and a springy feel may be perceived It may project into the mouth externally or under the eye, protruding it The disease becomes horrible, the whole side of the face becomes affected. General health affected vomiting etc. Death Distinguished from abscess by its slow progress. abscess of pain at first want of pus etc. It is said that some cases have been cured. Probably many of the approach more to the character of polypus The bones become so soft that it may be easily cut with a knife Desault makes an opening just above the mouth or just inside of it scoops out the fungus and applies the actual cautery (through a cannula) thoroughly throughout the whole antrum and if the fungus grows again repeats the cauterising He says he has effected several cures Prof. Gibson describes some crooked knives which he has invented for the purpose of scooping out the antrum Polypus of the nose These tumours have no sensibility though they bleed 1st the soft kind with narrow neck & nearly the colour of a system reddish pale & shining 2nd with a broad base usually of a red colour 3d malignant as fungi etc. The first kind is enlarged in damp weather. The second kind resembles fungous flesh. The last kind is a true fungus haematoded accompanied with lancinating pains etc. they may produce fistula lachrymalis Mr. Abernethy cured some patients by prescribing for the disordered stomach Extirpation by the forceps is the only made of cure. A ligature cannot be applied Tear off repeatedly until you have got a great part of it away Introduce through a cone of paper some caustic kali. The polypus will disappear but will return again generally. Blood root snuff will do well after an operation When they extend into the throat apply a cannula (J. Bell) Prof. H. once extracted a polypus 4 in. long. It extended into the antrum It was contracted in the middle like a wasp These [illegible] or [illegible] kind are more dangerous apt to cause absorption of the bones. Rx savin leaves zi opium zj a good snuff. For polypus in the throat J. Bell passes a wire by a cannula, through the nostrils takes hold of it in the throat etc. Tumours on the gums Usually dark red, spongy [illegible] if suffered to grow they press upon and loosen the teeth. Extract the teeth, if dependent on them But they may appear on the outside on the inside, or between the teeth etc. Cut them away and cauterise immediately. The actual cautery is the only cure and they may reappear even after this is used They are covered by the internal membrane of the mouth, which must be lacerated. Prof. H. has known from an abscess a fistulous orifice through the gum continuing for years fungus may sprout up in them. Extract the tooth clip off the fungus cauterize Sulphuric ac. has been used also corr. sub Enlarged tonsils may obstruct the breathing Give cal. 2 or 3 times a week. Gargle with borax or with nit. sil. 3 or 4 gr. to oz. Or touch with nit sil. Removal has been proposed by ligature. The knife is better. Prof. H. severs the tonsil with a tenaculum and quickly slice off a part with a tenaculum Dr Hosack Jun. has an instrument. Great relief is rendered. A probe pointed knife is not necessary Diseases of the Eyelids 1st Infl. of lim. memb. red swollen hot, dry finally increased secretion of mucus (so that [rings], [hatos] etc. are seen) In the morning the lids will be glued together. May proceed to ulceration of the edges, with loss of lashes Caused and kept up by reading at night by smoke by drinking cider etc. Apply cold water frequently Sometimes bleed the recommendation is for cupping and leeches Prof. H. has known great benefit from v.s. Calomel is to be given. The best collyrium is nit. sil. dropped in twice a day. Apply an ointment if red precipitate about 30 gr. to 1 oz of lard at night let a little of it penetrate the eye If this gives too much irritation apply Turner’s cerate If there is much heat apply ac. pl. Vide Coop. Surg. Dict. art. ophth. for Dr Small’s method of curing ophthalmia by compression Granular conjunctiva Caused by the continuance of the preceding. Granular specks enlarged vessels sometimes a fringed fold like a cock’s comb just where the membrane passes off upon the ball of the eye sometimes warty excrescences Apply nit. sil. or sulph. cop. in substance to the granulations. Sulph. copper is most effectual Evert the lid apply the caustic then wash then return the lid. Pare off with a knife or clip off with scissors hard granulations Prof. H. has seen little advantage from scarifying If you can, clip off [illegible] veins with scissors this sort of bleeding is much more efficacious than scarifying Concretion of the lids Sometimes congenital oftener the result of opththalmia total or partial Divide with scissors Open the eyes frequently in a day or two touch with nit. sil. Ectropium Generally caused by cicatrizes from burns etc. A chronic inflammation is apt to come on in the eye Sir W. Adams cut out a piece S. Cooper cuts off a part of the thickened membrane That variety which occurs in old men may be cured by applying nit. sil. & then using compression. Wear goggles Trichiasis may be cured by wrong direction of the hairs or by turning in of the lid (entropium The eye may be destroyed by it Caused by cicatrices near the edge which causes the new hairs to grow wrong. Pull out the hairs and touch with aq. amm. or nit. sil. When resulting from relaxations apply adhesive plaister or cut out a piece with scissors or touch with strong sulphuric or nitric acid over an oval shaped part When there is a wrong direction of the edge cut out a slip of the lining membrane in order to allow the lid to turn out If all means fail of curing cut off the edges of the lids [illegible] of the upper lid Has been cured by adhesive straps; by nit. ac. as above by cutting out a slip [illegible] Hordeotum (stye) Ordinarily nothing to be done but to poultice. Sometimes the suppuration is imperfect especially in delicate females a tumour may thus be left behind and give great alarm, being mistaken for a wen or a cancer. There may be a granulation of the inner surface of the abscess just as in scrofulous abscesses. They are readily cured by touching with nit. sil. If they do not burst and the skin is whole over them so that they resemble a wen lay them thoroughly open and touch with nit. silv. Encysted tumours of the lid Commence without inflammation They are to be taken out either internally or externally when they do not adhere to the lining membrane of the eye, you may often succeed by splitting the tumour open and pulling out the cyst. Ophthalmia Inflammation of the eye May be considered in reference to the whole or a part of the eye but if one part is affected the rest are apt to become so Endemic in Egypt and Ohio burning sense of dryness copious hot scalding tears the eye is kept closed severe pain in head and face perhaps in the cheek or frontal sinus Redness and swelling of the eye. If the schoatica is affected the redness is of a darker colour (and apparently stationary) If the conjunctiva is the part in flamed the redness is brighter and the membrane is so much swollen that the cornea appears depressed Ultimately the cornea appears dusky a little. The aqueous tumour becomes somewhat opaque The cornea may eventually be cast off suppuration of the eye internally causing it to run out Caused by operations, by foreign bodies Amospheric influence Endemic influence etc. Prof. H. has known it alternate with intermittent The most powerful remedies shd be used First stand blood letting. The British surgeons in Egypt drew 60 ounces It is of no consequence from what part you bleed Prof. H. would bleed ad deliq. (in an upright posture) give [illegible] ca. followed by neutral salts afterwards apply ac. lead Collyquiums are forbidden but nit. sil. is dropped in with great advantages (3 or 4 or more grains to the pint more for chronic ophth.) If the pain etc. recurs repeat the bleeding & calomel. Antimony is much relied on in Europe. Prof. H has used it only as an adjuvant Use the nit. sil. 3 or 4 times a day not too strong just strong enough to create a little uneasiness at first If the eyelids stack together, by a discharge from the [illegible] apply a mild mercurial ointment Prof. H. never could see any advantage from bleeding from temp. art. or jug. vein Cupping and leeches may be used but shd not be relied on to the exclusion of general bleeding Letting out the aqueous humour has been practised with advantage. Vide S. C. surge. Dict. Blisters to the nape of the neck are beneficial When the disease becomes chronic a variety of remedies are used Nit. sil. continues to be beneficial It makes the surface of the eye feel smoother Vinous tinct. op. (Sydenhams laudanum) op. zii cinn. & cloves aa zi wine 1 pint digest a week This is often beneficial causing smarting at first but afterward relief Rx sulph zinc & ac. lead aa grs vi wat. oz ii we have ac. zinc. This is a good collyrium Scarification seems to be of little use Opium is useful. Dover’s powder is a good form. As soon as the pat. can bear this light accustom the eye gradually to the use of opium Tonics are seldom indicated. But in intermittent centuries Sul. quinine is highly useful. Bleeding etc. may be conjoined with sul. [illegible] (Vide the late periodicals) Cataract May originate from wounds & other causes Its commencement indicated by [halos] as observed around a candle & other such appearances To be distinguished from aneurism, by opacity, by some sensibility to light contraction and dilatation of pupils etc. It may be complicated with aneurism In aneurism flashes scintillations etc. are felt. Proceed to operate without debilitating the patient with low diet & a state of anxiety and apprehension It is customary now to dilate the pupil with belladonna or stramonium previous to the operation Apply it to the eye, eye lid etc. the night before [illegible] [illegible] hour before drop a little in the eye Enter the needle about a [line] & a half from the edge of the cornea the needle having its surfaces horizontal Pass the needle up to the top of the cataract turn the edges perpendicular press the edge down lacerate the capsule thoroughly then turn the needle horizontal again and carry the cataract directly downwards. If your needle horizontal again and carry the cataract directly downwards. If your needle is a crooked one turn the point first backwards in lacerating then downwards If the cataract proves to be a milky one lacerate a little and do the best you can After you have depressed, withdraw the needle partly and if the cataract rise depress again A caseous cataract must be cut to pieces and pushed through the pupil into the anterior chamber A secondary cataract must be pushed through also If the operation is to be repeated let an interval of at least two months intervene If both eyes are affected it is a good rule to operate upon one at a time. This is often safely disregarded with safety, however. Be very cautious about using the eye for some time. Wear a green shade at first. If there is much pain, bleed & give opium [Ceratonixis] or Laceration For a long time only tow operations vide extraction & depression. It was found however the congenital cataracts (which are generally membranes would be absorbed after laceration First established by [Saunders], at the eye infirmary in London Two modes of operating the anterior & posterior First dilate the pupil and belladonna or stramonium Mr Saunders used the anterior mode & made an opening through the centre We are directed not to wound the iris; but some surgeons do not hesitate to do this Mr Saunders was frequently obliged to repeat his operation a number of times Extraction The advantages are that the operation in successful at once that a hard depressed cataract lies on the retina & irritates the eye etc. ON the other hand, secondary membranous cataract is said to recur sometimes after extraction the vitreous humour sometimes escapes. Prof. H. has always found a scar across the centre of the cornea, afterwards It is said that inflammation is more liable to occur. This is [denied] by others who say the extraction is the safest in this respect. Enter the knife at first perpendicularly then carry it horisontally Put the patient abed and keep him on his back. Both eyes must be kept closed for some days. The [illegible] humour flows for some time. When the eyes are first opened, if we find any of the iris protruding, we must endeavour to restore it. Extract of belladonna will perhaps assist this Iritis Redness dark caused by syphilis & mercury Terminate by [permanent] contraction & closure of pupil or by [illegible] pupil. May extend to crystalline loss of the cornea Treat by one full bleeding Never mind weakening your patient provided you save his eye Bring the system under the full influence of mercury as soon as possible Though the disease is sometimes caused by mercury yet this is proper for its cure. Conjoin opium say 1 gr. op. & 2 grs. cal. 2 or 3 times a day. Merc. oint. is rubbed into the eyebrow Along with these remedies are used to prevent permanent contraction of the pupil. Stramonium & belladonna Rx Red prec. 6 grs. op. 8 gr. lard z2 apply warm fomentations. Collyrium of corros. sub. & Sydenham’s laudanum is used Keep the patients eye in the dark Push the remedies if necessary Prolapsis of the iris May result from a wound or by suppuration A brownish tumor (or purple) size from a pin’s head to a pea, as large as a hazelnut Called staphyloma of the iris Exquisite pain is felt upon closing the eye Pupil on one side In recent cases the prolapsus must be returned and the eye kept at rest If this does not succeed the application of stramonium may draw it back In [older] cases where it is of long standing or where the protrusion follows upon ulceration then putting back with a probe will not answer we may touch this with nit. sil. pain follows at first but a leathery covering is formed which protects the part Collyrium of ac. or sulph. of zinc is also a good application. It may be necessary to draw out a portion with a hook & cut it off with scissors Prof. H has treated several cases caused by wounds with a pen knife with nit. sil. severed [illegible] successfully Inflammation of Cornea Mr. Travers questions the propriety of considering the cornea as subject to infl. Deposits of opaque matter however do form. An ulceration of the lining membrane may follow and discharge into the aqueous humour. Inflammation of the conjunction may If you perceive the cornea growing opaque redouble your exertions Ulcerations of Cornea 1st Irritable ulcers as [illegible] [illegible] like a of moss Eye very irritable feels as if sand was in the eye tears feel s scalding hot eye kept closed children hold their heads down Touch the ulcers with nit. sil. once in 2 or 3 days For young children we may inject a strong solution 6 to 10 gr. to the oz. The cicatrices from these ulcers generally wear away. 2nd Indolent, deep sloughing ulcers larger thicker slough may be ¼ to 1/3 of an inch in diameter. Use the caustic more freely When they change from their grayish to a pink colour, we may expect them to heal soon. Patients may in the latter stages need tonics much mischief is often done by injudicious purging Abscesses of the eye The pus settles down in the lower part of the anterior chamber & exhibits a half moon shape. Make a puncture with a spear pointed lancet. In one case Prof. H. found the cornea opaque the iris inflamed and the pupil about closing the puncture gave immediate relief Little vesicles may form & when they burst give rise to irritable ulcers Opacity of the cornea Mr Travers advises coll. of nit. sil. & alternately of corr. sub. (the latter 1 gr. or ½ gr. to the [illegible]. Divide the enlarged vessels with a hook & scissors this gives great relief it destroys the vessels Various substances are blown in e.g. levigated glass, calamine, white sugar The utility of these seems very doubtful Dupuytren advises 1st general v.s. or leeches 2d a seton in the back 3d Rx lap. cal. calm. & candied sugar equal weights in powder. He says that specks and commencing opacity may be relieved by the powder alone Mr Travers perseveres in a course of mercury Staphyloma Cornea projects to that the eye cannot be closed causing great irritation tears etc. The cornea is perfectly opaque & vision entirely lost First pass a ligature transversely through the cornea then pass a cataract keep through & finish the operation with scissors Fungous tumours of the cornea A small hook & scissors are the proper instruments Follow with nit. sil. Clip off enlarged bloodvessels Pterygium [illegible] of the [illegible] [illegible] A reddish triangular membrane the pupil growing from the internal angle of the eye. Sometimes it stops just at the cornea At others it passes over Sometimes but rarely, it arises from the external canthus It [causes] a proneness to infl. of the conjuctiva Dust lodges on the membrane & is not easily removed If combined with ulcers, these must be first cured Extirpate this elevate the membrane with forceps or a hook & clip off with scissors as far as the edge of the cornea It is unnecessary to remove it as far back as the canthus. Even if little points remain on the cornea they will be absorbed, if you interrupt the continuity Encanthus An excrescence growing from the [caruncula] lacyrymalis producing great irritation Cut off with scissors. Prof. H. has known a large one cured by touching repeatedly with nit. sil. Dropsy of the eye Generally proceed by external always by internal infl. Cornea always opaque Sometimes appeared confined to the anterior chamber The sclerotica becomes thin & bluish like a soft shelled egg irregular also. May be caused by a wound Tape the eye with a spear pointed lancet or a cornea knife Repeat the operation No infl. follows ultimately the cornea grows thicker and retracts. This is the mode for the anterior dropsy. Whether the dropsy of the whole ball can be cured in this way is not so clear S. Cooper directs a piece of the cornea to be cut out of the size of a pea Travers says all the humours cannot be evacuated except by cutting out a part of the iris Cancer of the eye When seated in the conjunctiva, there is a thickening of this membrane and perhaps the cornea is obscured. Eventually the whole eye is involved. Ulcer with hard edges. Extirpate with a straight edged scalpel Restrain haemorrhage by pinching a torsion of the arteries with forceps Prof H. would put neither lint nor sponge within the orbit. He would dress with comp. & laud. Fungus haematodes of eye Formerly called cancer In the first stage the pupil is dilated iris discoloured (dark green or amber) The fungus can be seen in the bottom of the eye like burnished iron. The schlerotic coat becomes knobby, bluish etc. Finally the cornea & sclerotica ulcerate Fungus finally protrudes dark red bleeds easily. Cancer begins externally & eats away it is a disease of advanced life. Fungus is a disease of childhood? Still these two diseases resemble each other more in the eye than elsewhere Prognostic after extirpation very doubtful. Amaurosis Function of the eye without any external appearance except want of contractility in the pupil. Dil. pupil said to be a symptom May be caused by infl. of the retina by tumours pressing on the nerve or the brain. Occurs after excessive use of the eye in viewing the minute objects Vision has been restored by proper remedies for infl of eye it begin early and pushed vigorously, when it arises from acute inflammation of the retina Acute infl. of retina destroys vision suddenly Chronic infl. destroys it gradually Corr. sub. has been preserved to cal. in this disease. On the continent of Eur. Antimony is celebrated for this complaint Cases caused by epilepsy, tumours of the brain etc. are of course hopeless Pretern. dilat. of pupil Seldom an idiopath. complaint Pret. contr. of pupil Myosis Constant rolling of the eye (just as in congenital cataract) Commonly caused by infl. may be attended by opaque lens or capsule or not. For recent cases apply belladonna Push remedies diligently if there is inflammation Closed pupils may be attended with opaque cornea or not opaque lens & capsuled or the eye may be full and prominent, or flattened and with a large [illegible] Ascertain carefully whether there is remaining any sensibility of the retina Three modes of operating 1st a simple incision 2d removing a piece of the iris 3d tearing the iris away from its attachment 1st Chelelden’s mode Another way is to make an incision with a knife & then with scissors make two incisions & shaped 2nd make an incision seize the iris & clip it off and if it does not retire push it back with a probe If the lens is opaque, extract it 3d Scarpe’s mode. Prof. H. has operated in this way. Introduce a couching needle as for coaching separate the upper edge ½ of an inch & depress it. In one case Prof. H. was interrupted by a sudden hemorrhage within the eye An irregular pupil of course is made Ranula A bluish tumour under the tongue Caused by obstruction of the duct (probably) Dupuytren introduced two connected buttons [illegible] Prof. H. opens thoroughly & touches thoroughly with nit. silver. Division of the frenum Prof. H. has had one case of a ligamentous frenum [binding] down the frenum Wounds of the tongue Stich it together use Physicks forceps Enlargement of the tongue Caused by mercury, which has sometimes made it so large that it would nearly be bitten in two by the incisor teeth Ulcer [illegible] & tumours of the tongue. Caused by irritation of the teeth by disorder of the digestive organs etc. Cancers may grown there. Encysted tumours may grow there. Use alum borax nit. sil. (nit. sil. 15 gr to 2 pt as a gargle). Ulcers of saliv. touch with nit. sil. Internal use of opium is the best remedy for salivation purgatives are injurious Solution of corr. sub. is a good garble for a number of minute ulcers. Extirpate cancers & tumours Mr. Coster cuts out a v. shaped piece when the tumor is on the tip of the tongue bringing the edges together with stitches Cauterise to stop hemorrhage Enlarged tonsils A curved bistoury is recommended Prof. H. uses an abscess lancet on a stick for an abscess. If no pus issues, no harm has been done the scarification will do goo Prof. H. has several times met with inflammations and an abscess on one side of the tongue near the roof very painful Open with great relief. [illegible] to [illegible] abscess of bursae mucosae. the abscess collects suddenly lined with a smooth membrane incline to close up, like bursae mucosae N.B. abscesses near the surface of mucous membranes are apt to be fetid the air apparently acting through the membrane Cut off enlarged [illegible] with scissors no fear about haemorrhage Osteosarcoma Formerly the patients were suffering to die Dr of Tennessee was the first to perform the operation In some cases the wound has not healed after the operation leaving the patient in a horrid state Dr Cogswell related case of this kind in a man living in Fairfield cty who had been operated on in Philadelphia. Prof. H. would prefer Mons. Costes mode of operating Sarcoma Cellulosum Bronchocele, goitre etc. Endemic in Derbyshire N. Hampshire Vermont western part of N.Y. etc. Occurs generally in young females Mr Wilmer was the first to publish an account of the treatment by burnt sponge. It was communicated to him with several useless additions to the remedy Prof. H. has met with sudden enlargements of the tumours accompanied with sore throat, pain in the head etc. He bled with advantage applied mur. amm. gave calomel etc. Wounds of Abdomen Wounds of the integuments require no particular treatment except to keep the muscles relaxed. Keep also a bandage over the parts in order to prevent hernia Penetrating wounds as by a stab require no particular treatment. Use the interrupted suture. Prof. H. has found no danger in carrying the stitches through the peritoneum. Let the patient avoid coughing laughing, straining at stool. Use a bed pan If intestines protrude with a warm and moist hand, return the viscera gradually return the omentum last. We must not be deterred from returning them by infl. or by a dark colour. Gangrene of the omentum may be distinguished by the blood’s not returning after pressure Gangrene of the intestine may be distinguished by an ash colour such shd not be returned. Larrey’s and others advise to cut off a gangrenous portion of intestine & return the remainder tying the vessels [using] a [leather] ligature] Close with interrupted suture using two needles for the same thread so as to carry the stitch from within outwards. It may be necessary to dilate the wound When an intestine is wounded the villous coat protrudes & turns out Sir A. C. in operating for strang. hernia found a small wound of intestines, he [illegible] it with his thumb & finger & tied a ligature around. The man did well Sew with the glover’s suture (over & over) It is found that a wounded intestine adheres by its peritoneal coat to the wall of the abdomen. The ligatures are cast off the cavity of the intestine & need not be kept out of the external wound Never enlarge a wound to search for a wound of the intestines. Larrey occasionally enlarged a wound in order to afford a freer passage for feces. His patients were eventually cured Vomiting is apt to occur V.S. will relieve it. Purgatives should not be given. Let your stitch, with the external wound remain as long as 8 days Wounds of the Bladder Urine issues In all cases except where the neck is wounded, keep a flexible catheter in the urethra. If there is extravasation of urine in the cell. memb. or scrotum make incisions to allow of its exit Laxatives are found to be very useful Castor oil & senna Passage of rake handles etc. into the anus etc. Prof. H. had one case in which a rake handle passed 22 inch. through the diaphragm. He died of affect. of the lungs spit blood etc. The thorax should have been opened. He has seen many cases of similar wounds of the vagina. In short has seen some odd things! falls on crowbars stumps of scrub oaks etc. all penetrating a greater or less number of inches. Bleed & starve. Blister the abdomen. Paracentesis of abdomen Do not perform the operation for less than a gallon of liquid. The operation is apt however to be delayed to long in cases of dropsy. Dr Fothergill advocated the practice of [illegible] early in dropsy Prof H. has noticed an increase of urine after the operation. He has known some cases of complete cure by tapping. Sometimes in encysted dropsy the accumulation remains stationary for years The fluid may be in one or more cysts or may be in the cavity of the peritoneum The former may come on with out much derangement of health. The latter is apt to be accompanied with a general hydropic diathesis When the fluid is in the peritoneal sac the tumour is general from the first In the early stages the fluid will be most at the lower part of the abdomen, when the patient is erect. The intestines float Ovarian dropsy is near the ilius the tumour shifts its place in different positions of the body at first At length however it enlarges and becomes adherent and a fluctuation is felt. When the accumulation is very large it can hardly be distinguished from ascites except by the history of the case. In one case the tumour burst from a fall The fluid was effused into the peritoneum, and the patient died in 20 hours Dropsy of the uterus must be exceedingly rare of course the os uteri must be closed by disease etc. Hydatids may be found in the uterus Mr [Rostan] says that in ascites a sound like that of tympanitis is given upon percussion at the upper part at the sides in encysted dropsy In ovarian dropsy the fluid may penetrate between the vagina & rectum & may be felt Encysted dropsy can scarcely be affected by medication Tapping must be resorted to. Put a broad bandage (from the ribs to the hips) around pin it behind Cut a hole in the bandage opposite the linea alba. If there is a hernia at the umbilicus if so, puncture there the walls being much thinner Let an assistant press the sides of the abdomen. Plunge in the trocar (If you push gradually the trocar will enter with difficulty) As the fluid flows, keep tightening the bandage. Towards the close press the abdomen in all directions Withdraw the canula if then the fluid continues to flow, let it run & be received on cloth. You may turn the patient over. Tap with the patient recumbent on the edges of the bed. When sitting the patient may faint. He may faint also if the bandage is not first applied. By means of the bandage we avoid all the danger of the operation After the operation dress with lint a compress & sticking plaister & bandage together Let a bandage be worn for months afterwards or even for years. It gives great relief The largest quantity which Prof. H. has drawn off was 32 gl yet in 23 days 23 quarts more accumulated. This case was caused by schirrhous liver which weighted about 13 pounds One patient was tapped in 13 places Another was tapped in 6 places at another in 6more finally in 6 others & the patient recovered One place where the operation was performed was between the vagina & rectum where two quarts were drawn off Occasionally the wound does not close. This is apt to be caused by the exhausted state of the constitution. It may arise from improper dressing. Stay by and watch whether the opening [illegible] If you cannot stay by and the orifice continues to flow and you cannot stay by use the twisted suture Diseased ovaria Prof. Smith operated to successfully Vide his memoirs Mr. [Losans] was generally unsuccessful. Prof. H has read all the accounts in the English language & thinks the operation scarcely advisable Hernia A protrusion of the peritoneum containing some of the viscera Sometimes hereditary Produced (especially if there is a predisposition) ty strains in lifting. Generally the causes are unknown 1st Inguinal 2d Femoral 3 Umbilica 4 Ventral 1st Inguinal 4 species. 1st oblique 2d direct 3d congenital along the spermatic cord 4th encysted hernial sac suspended in the tunica vaginalis The sac grows thicker as the hernia is [illegible] When it passes no further than the groin inguinal hernia is called bubonocele when it passes farther it is called scrotal 1st Oblique inguinal hernia Symptoms Distinguished from hydrocele by the latter’s not being affected by coughing by its transparency by the cord’s being felt Hydrocele of the cord is distinguished with more difficulty by coughing not affecting it Haematocele Hernia humoralis varicocele Mistaken are very often made and [illegible] applied to these diseases. Varic. happens twice as often as the [illegible] Hernia in the right [illegible] Hull’s truss is the best. It should be worn constantly day & night (A. Cooper) Dr Hull & Prof. H. think it sufficient to wear it during the day Many cases may be cured by a truss but let it be worn long after the hernia is cured. Dr. Hull denies that accidental protrusions will totally prevent the cure (as A. Coop. says) Children as they grow larger must have a new truss The use of the truss produces an adhesion of the neck of the sack Irreducible hernia Hernia may be irreducible from various causes from adhesions from a sudden protrusion of a large quantity of intestine The tumour (within) may be of a pear shape If the hernia cannot be reduced a bag truss should be worn. They are inconvenient and dangerous Sir A. C. has known a hernia supposed to be irreducible, finally reduced by ice applied 4 or 5 days. Prof. Smith distinguished between strangulated & incarcerated hernia. But the latter seems to be little more than an irreducible hernia Symptoms of strangulated hernia Pain constipation (though there may be tenesmus) [illegible] of [illegible] tumour very tender vomiting hiccup cold sweats etc. Omental hernia, when strangulated produces similar symptoms, but generally neither so violent or rapid Post mortem appearances exhibit infl. of the intestine perhaps over the whole peritoneal & in the latter case the death may be sudden within 48 hours In other cases operations have succeeded 1 or 2 weeks after the strangulation A small hernia exhibits more violent symptoms than a large To reduce place the patient on a bed his head & pelvis elevated thigh at right angles (bladder previously emptied) Embrace the tumour with both hands, as you would an elastic gum bottle. Prof. H. has practiced this mode for 20 years (It is Gohagan’s of Iceland) HE finds it better than A. Coopers of kneading. Gohagan advises to keep the pressure steadily for an hour changing the hand if fatigued Have a bowl of cold water at hand, and occasionally wet the hand Use ice also salt & water. Do not use violent pressure. If we fail with the [illegible] bleed to fainting & immediately try again with the [taxis] Bleeding lessens the tenderness & soreness It will also tend to prevent subsequent peritoneal infl. Warm bath may be tried Prof. H. has used tobacco injection zi to a pint half at a time a dangerous remedy however. It produces universal relaxation and then perhaps the tumour may be reduced Sir A. C. says calomel is often useful assisted by a [illegible3] of compd est. colocynth Strangulated hernia has often been mistaken for colic (perhaps the patient may be ignorant of the existence of a rupture or breach as they call it) Purgatives are dangerous apt to cause infl. After bleeding Prof. H. has used opium with advantage especially in old hernias of old men. Direct inguinal hernia Seldom large may be caused by a blow A rare species A truss is applied nearly in the same way as for oblique hern. Epigastric artery on the outside [illegible] muscle partly in front of the tumour An old large omental hernia may not be so soon fatal as a small & recent one Still all hernial (if [illegible]) are dangerous & when strangulated, an operation must not be too long delayed. Death may occur in a day or two in some few cases. Mr Hey lost many cases by operation too late. So with Desault. So with Prof. H. much mischief is often done, by violent and long continued handling It is the best rule to operate soon. Less pain is often felt in the operation than in the [previous] taxis Place the pat. on his back on a table feet in a chair set between the thighs If the hernia is small & the skin lax the surgeon & an assistant may pin it up the integument transversely [illegible] and [illegible] his knife through this gives less pain ‘ Do not carry the incision quite to the bottom of the tumour Divide each fascia with a director The sack when you get to it is usually known by its shining appearance though it may be purple etc. caused by a bloody fluid within Rub a fold of it between your finger & thumb so as to be certain that you have no intestine or omentum adhering to it. Pinch up a small fold with forceps and make a small incision then introduce a director and enlarge a little then introduce your finger as a director [illegible] reduce the intestine if you can If you cannot introduce your finger as a director carry the point of your knife along it arriving at the stricture depress the handle of your knife and divide gradually Divide freely enough to allow the entrance of your finger. It may be necessary after dividing a stricture at the external ring to divide another at the internal ring Divide upwards & outwards or perhaps better, always upwards Adhesions may always be broken up with the finger. Return the intestine first & then the omentum Prof. H. now passes his suture through the sac Sir F. Earle recommended this vide Hey and since he has adopted this practice has never had a case of a second protrusion. If more than 2 sutures are needed put the lower ones through the superficial integuments only Place the sutures about an inch apart Dress about the 4th or 5th day. If a stool does not come away in a few hours give castor oil or if this fails, calomel Dress with a T bandage etc. If the intestine is gangrenous (it is not so when merely purple & dark bloody) Sir A. C. says a gangrenous intestine will have a fetid smell Prof. H. has noticed this in incipient gangrene A gangrenous intestine is the strongest reason for operating If the intest. decidedly gangren. Prof. H. would not even divide the stricture, but make an incision into it and allow the feces to issue. Cut off mortified oment. with scissors Case in which the gut has burst Prof. H. did not do anything but leave the case to nature after opening the sac. After about a month the fever took their nat. course Dr Phys. in one case found two parts of intestine parallel [illegible] he made an incision into each in order to allow the fasc. to pass from one to the other The pat. dies from want of passage for feces Vide Travers After the operation if peritoneal infl. continues, treat by v.s. by cal. or by cal. & op. Diarrhoea sometimes takes place, both after the taxis and after the operation Treat with opium For direct ing. her. divide upw. & inwards Hernia of inguinal canal No distinct tumour exists except upon coughing May become strangulated & is often mistaken for peritoneal infl. Vide Sir A. C. for the operation Make the incision through the [tendon] of ext. oblique, very carefully etc. Oblique inguinal hernia in females. On coughing the tumour protrudes downwards this In femoral hernia the tumour protrudes upwards on coughing Operate as upon the male Congenital hernia Called [wind] ruptures by the nurses Tumour is within the tunica vaginalis Take care not to injure the testicle & leave the lower portions of the tunica vaginalis entire so as to contain the testis Encysted hernia of Mr. Hey The whole sac is protruded into the tunica vaginalis Open the tun. vag. & then search for the sac Femoral Hernia Prof. H. has cured one case in a male Prod or first a pain on suddenly stretching the limb. Finally a small swelling appears increases passes downwards inwards, forwards & the upwards over Poupart’s ligam. Sometimes passes downwards along the saphena vein Has been mistaken for [illegible] abscess or for an enlarged lymphat. Has been opened for an abscess Occurs oftenest in women who have borne many children Generally intestinal and small Often irreducible A truss does not cure so certainly. Women who wear a truss can dispense with it during pregnancy. Taxis often fails Strangulation causes severe symptoms We may try the taxis but should not use much force Delays are dangerous the hernia being small & the stricture sharp edged. Death has taken place in 17 hours. Patients will be apt to die about the 5th day Operation. Place pat. as before Carry your incision downwards beginning above the tumour. Sir A. C. advises another [illegible] transverse below Prof. H. has never made this. It is said that a superf. vein will be divided Prof. H. has often operated, and never met with this In his last operation not two teaspoonfuls of blood were lost N.B. we do not reduce the hernial sac only its contents Old sacs are generally adherent Divide the stricture upwards & a little inwards towards the umbilcal Divide freely enough to allow the introduction of the finger Endeavour to pull the neck of the sac out before dividing If the obturator artery surrounds its neck we can feel it with the finger Umbilical Hernia may become very large. Colicky pains flatus faintness at the stomach etc. In children called wind rupture also The superficial integuments will often be thinner in some places than in others appearing like an abscess Frequently than are two openings from within, into the sac. Occurs oftenest in females and in corpulent men Caused by ascites if so, then tap at that place Treat it in infants, with a conical piece of wood or ivory confined with adhesive straps Desault cured such cases by tying a tight ligature around the neck of the tumour after reducing the intestine Let older patients wear Hulls truss. If irreducible let a broad bandage be worn Sir A. c. advises to reduce without dividing the sac Prof. H. would be averse to attempting to operate without dividing the sac The hernial sac is apt to adhere to the skin so that the incision is [illegible] directly into the sac [?ntoal] Hernia Generally in the linea [similanaris] The stomach is sometimes included Symptoms of dyspepsia etc. may often be relieved by a truss Tobacco injections are very useful in this and the preceding species Irreducible hernias cause colic, constipations etc. requiring cath. sometimes there occurs pain and vomiting requiring perhaps v.s. and always opium in full doses When an irreducible hernia becomes inflamed there, less local soreness than when strangul. The pain is more universal and wandering over the abdomen. the abdomen is not swollen there is not hiccup etc. Give a large dose of opium Thyroidal hernia, occurs at the frama ovale. Pudendal hernia ix a variety of inguinal never requires an operation. Vaginal hernia occurs between the vag. & rect. use a pessary. A hernia occurs between the bladder and rectum in the male Hernia occurs (rarely) at the ischiotic sac. Prof. H. has seen one case of the latter in a boy. After all operations apply a truss when the pat. gets up Preternatural anus As the wound becomes smaller tighten the compresses and bandages When a little mucus is discharged from the rectum, solicit a natural passage with injections Finally tighten the dressings and touch with nit. sil. or sulph. cop. In permanent cases we have eversion of the villous coat etc. Desault introduced a roll of lining into the two ends, and kept thus the two in contact Dupuytren where there were two portions parallel punched the adjacent coat and caused a perforation for the feces (he continues a particular kind of forceps) the patient was cured Imperforate anus Make a crucial incision & keep in a bougie where there is no external anus When there is an anus, but the rectum terminates in a cul de sac the case is more difficult & they generally terminate fatally Stricture of the rectum Commences with difficulty of discharge [pellets] of matter imperfect evacuation pains in the hip, back etc. finally costiveness cathartics perhaps cause a liquid discharge, and often an apparent diarrhoea but the bowels remain full of hardened matter Colic flatulence acidity, dyspepsia. Reduced to liquid & bland food often the patients chew meat & spit it out swallowing the juice. Ill effects are generally felt, only sometime after the swallowing of food Hemorrhoids etc. may occur May be from hereditary malconformation. consider also by habitual costiveness Distinguished from hemorrhoids by the pure blood discharged from the latter & [illegible] the pellets of feces also by the apparent dysentery Structure of the colon is distinguished from it by absence of the straining freedom from dysentery seat of the pain also by the strictures being too high to be reached Always examine by the finger & if that will not reach by a bougie make bougies of dyachylon & wax 11 inches long for an adult Bear in mind the curved form of the rectum, when you introduce it Introduce by address not by force. To lessen the irritation, first inject 30 to 60 drops of laudanum Carry it as far as the sigmoid flexure when it has entered this, a little wind will issue Examine whether there are not more strictures than one Let the large end of the bougie pass up beyond the sphincter or the latter will be internally irritated. Let the loop hang out. Dr McClellan prefers the flexible metallic bougie The irritation may be excessive at the first application but it diminishes by use There may be a prolapsus of the colon through the stricture which must be pushed up by the bougie In this case also give cold injections to brace the parts bougies give great relief unless desperate cases Phlegmasis dolens Spergamosis puerperarum Dr Davis maintains that it is caused by an infl. of the iliac veins this is hypothetical Difficult to determine this as the disease is rarely fatal Origin very obscure. It seems to be preceded by increased fetor & abundance of the lochiae Occurs after all sorts of labours and in all sorts of patients. Said not to occur a second time but Prof. H. has met with instances. Occurs also in males after fevers Prof. H. thinks it probably Commences at an uncertain period after delivery by pain and swelling in the groin. The limbs swell rapidly Pain considerable pain in the groin also motion very painful. At this stage the surface does not put on pressure no serum issues upon puncture no coldness as in anasarca The constitutional shock is sometimes very great coldness, faintness The other thigh may be affected The swelling begins to go down, first in the groin and labia Prof. H. treats mainly by calomel which he says gives great relief. He follows with opium for the irritation He always applies bandages from the first This gives great relief. He wets the bandage with ac. lead or mur. amm. Apply a clean bandage every day Repeat the cal. frequently Dr Hosack treats as for a dropsy with ipecac and squills. After the relief of the disease a deep seated pain in the thigh. This Prof. H. has relieved by a large blister and this is the only case in which Prof H. has found blisters give relief Inflammation of the cell. memb. on the hips back etc. of puerperal women Often mistaken for phlegmasia dolens They suppurate and should be opened There will be redness instead of the general tumefaction and the white [shiny] appearance They may become gangrenous and terminate fatally i.e. the glands no suspicion of venereal disease Retention of Urine may be brought on in old persons by neglecting the calls of nature Suppression of urine belongs to the department of Theory & practice Retention caused 1st by paralysis of bladder 2d Inf. of neck of blad. 3d press if foreign bodies 4th press of gravid uterus 5th enlargement of the prostrate gland 6th strictures In the first place7th constant desire to pass pain thirst nausea of vomiting costiveness cathartics etc. not operate an injection pipe can scarcely be introduced The bladder may ulcerate into the peritoneum and the pat. die thus or he may die of const. irrit. and in the latter case he becomes comatose before death. These may be the symptoms of paralysis of the bladder 2nd infl. of neck of bladder may be caused by cantharides by ulcers in the perinaeum by infl. of vagina produced by instrument 3d Stones in the bladder scarcely cause complete retention 4th the gravid uterus may cause complete retention A retroversion the uterus will always cause retention Some think it is caused by retention 5th Enlargement of prostate gland will cause a difficulty of passing and the true nature of the affection will scarcely be suspected. Eventually a complete retention may come on and then when the catheter is introduced in large quantity will be drawn off at once Sometimes when the urine begins to dribble away the complaint is mistaken for diabetes Other causes have been named [Parturient] women have died from this cause The ultimate consequences are peritoneal infl. fever dry tongue delirium etc. Other diseases seen to be produced is phthisis pulmonalis etc. Introduce the catheter by drawing the penis [illegible] in the first place keep the end close under the os pubis Sometimes with drawing the stilette a little to increase the curve At other times withdraw the stilette wholly Diseased Prostate Begins with frequent & imperfect micturition ultimately the patient becomes costive pains are felt in the part also in the back & hips a constant necessity for cathartics and when a stool is obtained urine flows more freely. The patient often will not call on a surgeon until the latter stages of the disease Finally opium must be taken constantly and the patient wears out perhaps with pulmonay consumption Much has been said about repeatedly introducing the catheter or suffering it to remain in. Prof. H. in inclined to the former. It will at always be necessary to withdraw the catheter twice a week to clean off calcareous matter. Other remedies are proper for sudden attacks e.g. v.s. warm bath injections of laudanum etc. even in a last resort injections of tobacco For chronic cases tinct. mur. feri a highly recommended If a catheter cannot be introduced try a small bougie Generally the smallest catheters can be introduced as well as a bougie Read the remarks of different surgeons about introducing the catheter as J. Bell C. Bell S. Cooper etc. Such cases are better treated now than formerly less [illegible] is wasted now with diuretics Cases combined with stupor of the brain, are best remedied by tinct. cantharides. The cath. should however be used The French surgeons use a conical catheter and force a passage. This is not to be initiated If a young surgeon cannot introduce the catheter, let him send for an older one. If a catheter cannot be introduced. The bladder must be punctured Make an incision in the bria alba 1 or 3 inches long. Cut down to the bladder and introduce a large curved trocar piercing obliquely When the stilette is out push the canula further in Either leave the canula in or introduce through it a flexible catheter & keep it in Mr. Abernethy thought it better to separate the [pyrimalis] muscles For stricture of the urethra, in some cases, such a catheter or canula Hydrocele 1st take care the canula is in the tun. vag 2nd Place your patient against a wall keep the injection in 15 m. (Prof. H.) Take care to fill the tum. full Use 3 parts wine 1 water Make a large puncture 8th If you inject into the cell. mem. stop immediately Great pain is produced Sometimes faintness Hence have some one by to assist you in case of fainting After about 3 days the swelling begins to abate In a fortnight the may perhaps be cured Encysted hydrocele of the spermatic cord Haematocele Sarcocele Fungus haematodes of the testicle Schirrhus of testicle Hydrosarcocele Fungus of the testicle cured by caustics. Venereal enlargement of testicle Hydatids of the testicle may be very large and confounded with hydrocele Cure by castration. has been kept in 2 or 3 years Southern mode is to open into the rectum etc. Irritable testicle seems to be a neuralgic aff. Try v.s. cal & afterwards arsenic & conium. Use opium all the while iron and sulph. quin. are rec. & are useful. Put off castration if you can Suppuration of testicle Open the abscesses & keep in a little slip of [illegible] for a [illegible] membrane will close very speedily It may be necessary to introduce nit. sil. Or if you have not room for this you may dip your probe in nitric acid & thus form a little nit. silv. Circocele Begins gradually finally the veins feel like a bundle of earth worms Let the pat. be down and press at the abd. ring, and a circocele will be enlarged & thus it may be distinguished from hernia Apt to give alarm but not dangerous Cause obscure there may be in such cases a disposition to have varicose vein # Patients are often subject to paroxysms of pain. v.s. cal. & other laxatives Apply cold discutients. Quiet your pat. about the danger. Keep the parts constantly suspended. The spermatic art. has been taken up why it is difficult to determine. Generally by quieting the patient you will have little trouble. Much mischief has resulted from wearing trusses for them # perhaps caused by accumulated feces & by injuries Chimney sweeper’s cancer Caused in the scrotum by soot Perhaps the testicle may become affected It is said that the disease may be cured even after the lymphatic glands have become affected Probably a variety of cancerous tubercle of the skin Sarcomatous enlarge. of scrot. may weight 50 or more pounds Testicles not affected Penis disappears. Integuments of lower part of abdomen drawn down. Skin may be rough & scabby. Probably a variety of elephantiasis. Vide Larrey’s mem. of it in Egypt. Extirpate not dangerous is the operation Vide the case of a Chinese lately in London 60 or 70 pounds died immediately Gonorrhoea Infl. of muc. mem. of urethra sometimes extending to the glans Arises from impure [connexion] Whether the same or not, it is treated different from lues syphilis A milder disease now then formerly in London Vide Abernethy Cured more readily when it occurs immediately after connexion, then when it occurs after a week or more Different phys. treat it very differently probably because it often (as is said) cures itself & because it may be interrupted by various [illegible] Bals. cop. is very popular now formerly it was used only for gleet. Cubebs are said to be equally effectual. Give bals. cop. 1 teasp. 2 or 3 times a day If it purges giv e opium Rx bals. cop. & nit. eth zi aa. tinct. op. & tinct. camph aa zi t.sp. 3 or 4 times a day Apply cold lotions In France they give nit., pot. & sulph. sod. etc. Ac. pl. 14 gr. to ½ pt. or sulph zinc grs 10 or both together, for an inject. if the discharge continues Ultimately corr. sub. 1 gr. to 1 oz 1/2 pt or nit. silv. 3 or 4 grs. to 1 oz water Make inject. stronger [illegible] For gleet give bals. cop. & add tinct. canth. 20 or 30 drops Apply blisters to perinaeum if necessary Treat sympathetic buboes with discutients with blisters Treat chordee with opium dover’s powders etc. If urine is frequently passed & with pain use the catheter it giving [illegible] relief Opium is the best remedy for chronic aff. of bladder as a sequel Uva ursi is recom. also Whether the bladder or prostate is aff. use the cath. Hernia humoralis Infl. of testicle Caused by gonorrhoea by injuries by metastasis of hydrothorax etc. by metastasis from aff. of head mumps Not produced in the early stages of gonorrhoea but in the decline though to be brought on by stimulant injections Caused also by aff. of prostate & various urinary affections Flatulence borbogyna pain testicle swells when large flattened in bad cases a redness of the skin Pain & constitut. irrit. very great from the distention of the firm serous membrane Bleed cal. salts Horizontal posture suspensory bandage ac. plumbi Prof. H. troubles himself little about the running [illegible] the infl. of the testicle is cured generally the gonorrhoea ceases Where a serous effusion in the whole scrotum takes place, shave & blister the whole scrotum If a hardness remains (especially of the epidydimis) treat with camphorated mercurial ointment Pus should always be evacuated if it is not evacuated, a fungus will spring out nit. sil. Phymosis Congenital accidental generally goes off (when natural) at puberty if not we may be called on to remedy the complaint. In venereal diseases ulcers may be concealed, or ulcers may arise from the sebaceous glands may irritate The urine may irritate Sometimes the prepuce may be enormously distended. Sometimes infants are born without any orifice When there is an opening it is sufficient to slit up the prepuce. If now cut off the end When distended make an opening with a lancet. As to the size of the opening, calculate upon a retraction in [healing]. Use a sharp pointed knife upon a director If the [prepuce] is schirrhous in old men circumcise & you will do this more easily if you slit up first Everted urethra Case in an infant Mischief from tying a ligature around the penis by boys troubled in bed. Swelling may cause the string to disappear cases mistaken for phymosis etc. Paraphymosis When the prepuce cannot immediately be brought back, every moment increases the difficulty, as the glans continually swell. Gout swelling, infiltration etc. occurs. Apply cold water etc. & then the patient must submit to have the prepuce returned place him against the wall, & have him held Compress the glans a long time shifting your hands in order to keep them cold & when you have the glans sufficiently reduced, return the prepuce if you fail, try again It is not necessary to divide the stricture Le Franc, also always succeeded without division Stricture of urethra May exist to a slight extent Most commonly 6 or 7 inch from external orifice just behind the bulb next to this is 4 ½ in. frequently ‘ there are more than one & almost always one at 7 inch dist. (E. [illegible] May be on one side of the canal In old stricture we have an almost cartilaginous hardness Symptoms alteration in form or size of stream of urine may be forked Dose not tend to a spontaneous cure but to grow worse & worse Difficulty of passing urine increased by cold by drunkenness by hard exercise Ultimately irritation chills, fever, anasarca excessive pain anorexia aphthae etc. etc. A discharge may come on and be mistaken for gleet especially after gonorrhoea hernia haemorrhalis nocturnal emissions & semen thrown back into the bladder May be mistaken for gonorrhoea, gleet infl. & abscess of urethra or prostate calculi in bladder or urethra. Pain in passing urine greater in gonorrhoea Diseased prostate is generally in old men & admits the catheter for 7 ½ inch. & a catheter can generally be passed by skill in enlarged prostate enlarged prostate can be felt by the finger in the rectum. Caused after sometimes by gonorrhoea (as a remote consequence) By injury of the perinaeum by stone in the bladder by warm climates Treatment Ascertain the existence of a stricture by means of a bougie Warm & oil & [illegible] your bougie if you fail pass a smaller one. We may be obliged to desist from pain, irritation, shivering faintness etc. But the urethra becomes insensible after a time. Where a very small bougie is needed catgut is recommended it swells in the part When we have succeeded in passing a bougie the cure is in our power (S. Cooper) Eventually we can keep in the bougie for several hours When we cannot pass a bougie introduce caustic it lessens the irritability Prof. H. has lately preferred a small catheter with a piece of nit. sil. in the end. Some use the caustic kali Flexible metallic catheters are much used of late Bougies undoubtedly do goo besides their mechanical dilatation. They stimulate the parts Patience and perseverance are needed Retention of urine hemorrhage (when the slough separates) may occur Prof. S. laid open the stricture internally Fistula in perinaea Caused by strictures by calculi etc. Touch with nit. sil. Dr Physick passed a piece of tape laterally & tied it tight over the fistulous orifice Vide Dorsey’s Surg. In worse cases, pass a straight sound down to the stricture pass in a probe & feel its end. Cut down to the end of the sound Dr Stevens proposes to inject a coloured liquid into the cath. to assist in finding the urethra Always cure the stricture first Mr. Earle performed [a] [talication] operation Sir A. Cooper’s treatment of retention of urine remarks on Incontinence of urine 1st from paralysis of sphincter from general palsy from long continued peritoneal [illegible] from retention 2nd from injuries causing a communication by ulceration into the vagina or by a cancer 3d during sleep affect children under puberty 4th S. Cooper mentions an irritable state in which the pat. is constantly compelled to urinate. This is merely a symptom of hysteria hemorrhoids stone in the bladder etc. 1st When occurring from paralysis treat for the general aff. and introduce the catheter frequently. When from difficult labour introd. cath. freq. 2nd plans of cure by sutures 3d It has been lately supposed to be caused by lying on the back not so Prof. H. has cured by cantharides Sometimes connected with disorder of digestive organs great thirst etc. Imperforate vagina Sometimes the labia, wholly or partially adhere Separate sometimes with your thumb (vide Denman) When not discovered till the period of menstruation very troublesome Prof H. has had several cases. Sense of weight pain in the loins finally difficulty of passing urine in the first symptom noticed in some cases difficulty at stool swelling of abdomen nausea hiccup etc. Much variation in the nature of the closure sometimes membrane sometimes very thick Examine whether there be not more than an obstruction perhaps a ligamentous band Hemorrhoids Two kinds varicose & organized If the blood comes from the intestines above it will be black if not, florid? Prolapsus ani often often accompanies If very superficial and near the verge they may often be clipped off Prof. [illegible] [illegible] when from the intestine extirpates by a ligation Pass a needle through & tie each way Fistula in ano Prof. H. is convinced that it arises from infl. & suppuration of the bursa muc. behind the rectum Causes obscure perhaps hemorrhoids Begins with pain, fever etc. When the abscess bursts externally it is called external fistula when internally blind fist. when ext. & int. complete fistula Const. sympt. & pain very severe Open early & keep open with a bougie when external When blind pus on feces a tumour at [anus] very fetid, as is usual with abscesses in muc. memb. No plan of cure succeeds but laying open Pass your finger up the rectum & meet your finger with a probe pointed bistoury then cut down through the sphincter Introduce ling Be careful to distinguish from lumbar abscesses etc. pointing near this part. Cancer of the rectum. The extremity of the rectum has been extirpated. Distortions of the feet Club foot valgi & vari There is a malformation of the tarsal bones. Probably the affection is caused by some wrong position in the uterus Seeds to be more or less hereditary in some families. There is an institution in Paris for distortion s attended with great success When the foot turns directly upwards towards the tibia it is easily remedied by a roller an elastic splint and a bandage. Club feet are easily restored by the hand the difficulty is to keep it in its place. B. Bell’s mode by a [shoe] etc. [Machines] of wood carved out. Prof. H. has succeeded very well by a tin shoe with one side running up the leg He has succeeded well also with stiff saddler’s leather. But Smith’s splint in superior to all other modes. Apply to F. Gregory of Uxbridge Mass. The great object is to keep the sole of the foot, flat on the ground & turn the toes out as much as you can Palsy of the lower limb from diseased spine vide Pott. Generally affects children The child will be observed to stumble the toes point downwards, remarkably The limb looks remarkably smooth and tense, instead of flabby and wasted. Upon examination we shall find the [illegible] vertebrae, projecting Ultimately the bladder is affected with strangury perhaps there will be incontinence of urine. The patient may die of marasmus etc. Remote cause obscure Prognosis doubtful Caries and abscesses are often met with Mr. Pott invented the mode of treatment by issues, and was very successful in a number of cases Lateral distortions of the spine are said not to produce paralysis Paralysis appears to be caused only by this angular distortion. There will be also pains in the loins etc. Sensation is erroneous with respect to the heat of the limb Pat. thinking it hot when cold & v. versa Sometimes sensation remains, at other times the paralysis is complete. Sometimes the abdominal muscles are paralytic sometimes the urine & feces come away unconsciously. Large sores may be caused in the ischia & trochar [less] by lying in one position There is generally a permanent anchylosis after the cure Experience shows exercise to be injurious. Hence some propose to cure by rest Opium will almost always be needed. Ultimately sul. quin. Very probably iodine might be beneficial. Sometimes a seton has been substituted for an issue Once in 2 or 3 months an old issue should be suffered to dry up & a new one made Lateral distortions of verteb. We are generally first consulted for a projection of one shoulder blade Caused by long sitting in one posture etc. Darwin thinks position in bed to have some influence and directs those children who sleep together, to change sides occasionally. Mr. Casey’s machine has a staffed back. lifts pat. up by shoulders Carrying weight on the head proposed Depend principally upon exercise in the open air and sleep upon a hard mattress. Such a plan as this will make the distortion stationary, and restore the general health But Prof. H. has not known it permanently & effectually cures the distortion Give soda, iron, rhubarb etc. Setons and issues seem to do little good. Friction and sharpening are useful Mr. Harrison lays much stress upon manipulation on the back and this too for all kinds of vertebral distortion Diseases of the medulla spinalis, producing paralysis without aff. of vertebrae Affects mostly children from 2 or 6 mo. to 2 yrs old. Generally begins with a febrile affection, and soon a paralysyms & hemiplegia sometimes one side first one limb, then another Adults sometimes affected in a similar manner. Dentition has been thought a cause. This cannot always be the case. Scrofula has been considered the cause also but scrofula is uncommon in the country where nevertheless this aff. is met with. It is often attributed to the little calomel given in the commencing fever But many cases have received no medication at all Prof. H. considers the disease an inflammation of the serous membrane of the spinal marrow. Sometimes the disease is chronic and unattended with commending fever. Sometimes the brain may be affected thus; vide Amaurosis Prof. H. treats acute paraplegia and’ hemiplegia etc. first by v.s. mercurial & other cathartics and a succession of blisters. As has lately used more pinching up hard a small ball of cotton & [illegible] it dowm by the blow pipe Tart. emetic ointment etc. Prof. H. has often succeeded this for children but sometimes fails. Chronic cases he treats in a similar manner [Moxa] near the ear seems to have great influence upon paralysis of the face When the spinal marrow comes on during a fever Prof. H. has succeeded often in curing it Some cases seem to be caused by parturition The more acute the disease the easier cured. For chronic cases Disease of hip joint morbus [coxarious] [illegible] form 1t violent irritat. acute fev. etc. 2nd a chronic form coming on gradually counterfeits all diseases 1st begins with acute pain generally in the knee high irritative fever emaciation sallowness etc. Apt to be mistaken for aff. of the knee Not the slightest motion is allowed confined to one posture in bed limb elongated knees separated Eventually there will be shortened the [illegible] of the bone being on the dorsum of the ilium this shortening is ascertained by comparing thickness & ankles Prof. H. has known the length [illegible] in the first stage amount to 1 or 2 inches Supposed to be caused by scrofula this cannot always be so The disease is more rapid in children than in adults Distinguished from lumbar abscess by the history and appearance Sometimes after the spontaneous dislocation health will come on & nothing but lameness remains Generally there is some amendment when pus issues The prognostic is favorable if amendment follows evacuation if there is no hectic etc. In the chronic form we have first a slight lameness in walking pain is often exclusively at the knee sometimes at the hip over the [illegible] nerve This form is often caused by scrofula Seems often to arise from violence also from exposure to cold and sometimes no cause can be conjectured Many cases of sciatica are thought by Prof. H. & I. to be affections of hip joint Injuries will increase the disease as by nat. bonesetters Case related of this sort Treat. the acute form by v.s. & cal. apply ac lead (cold or warm) give opium freely from the first to relieve the pain better in the first place in form of dover powder. If the ain does not subsid. apply a blister Issues are too slow If the disease is attacked early it may generally be cured Treat the chronic form in a similar manner blisters seton is [illegible] & [illegible] Keep the limb absolutely at rest & secure this object by using Smith’s splint Make issues with caustic kali through a hole in a plaister & cover with another plaster In 6 or 8 hours it will have made a sore. Apply your issue generally back of the trochanter Prof. H. has succeed with them in the inside of the thigh near the knee. Setons are introduced on the anterior part of the joint Do not push your counterirritation too far with children Renew your setons and issues once in 6 w. or two mo. Prof. H. has applied tart. emet. Moxa now fashionable. Larrey does not wish for suppuration thinking the heat mainly beneficial The bowels are apt to be costive, from [illegible] to pass a stool manual assistance is sometimes necessary at stool The constitutional weakness and irritation are very great op. op. & cal conium etc. bark quinine Unopened abscesses are very dangerous Patients are apt to die suddenly with them Mr. Abernethy kept the pat. at rest at first (in the chronic) and gave the blue pill etc. for the constitution [the] prohibited motion for a long time etc. This practice not energetic enough for the acute form. Iodine now recommended We stand much in need of a better mode of treating this disease Considerable difficulty with parents often Venereal diseases formerly considered a unit. Mr. Hunter described the chancre But Mr. Hunter’s disease is now but rarely met with. Carmichael describes the true chancer & severe other sorts of sores on the penis A French writer has denied the existence of a specific syphilis Prof. H considers the inoculation of small pox and other poisons similar to the venereal contagion The first effects are entirely local 1st a little pimple or vesicle with serum or pus It degenerates into an ulcer of a foul & ragged appearance. Next the absorbents are affected Net an infl. of lymph. gland in the groin. Next ulcer in the throat or eruptions on the skin or both Net [nodes] tibia sternum fore arm perhaps ossa nasi It is now found that very many venereal sores may be cured without mercury. Such cases are now generally called syphiloid Many experiments have been made in the army more or less successful without mercury Mr. Hunter’s chancre has elevated edges & a hard base Prof H would pencil it thoroughly with nit. sil. afterwards wash with a saturated sol. of sulph. copper Then the black wash (cal. & lime water) Keep the pat. quiet in his room. If consulted early do nothing more If the chancre is early destroyed there will be no bubo When a bubo forms & suppurates, open and touch thoroughly with nit. sil. The ulcer in the throat looks very ill, yet gives less pain in swallowing then would be expected. The [pat.] will often deny its existence The eruption on the skin is quite singular looking like mallows cheeses Some prefer blue pill some corr. sub. others calomel others mercurial ointment. Sydenham gave 20 gr. doses of cal. Dr Carter of Natches has revised this practice procuring bilious discharges say 2 a week & salivation comes on Give corr. sub. in a bread pill 1/8 gr. Patients will scarcely bear more than ¾ gr. a day without a dysenteric aff. of the bowels Blue pill [5] gr. at night if this fails give it oftener Mercurial fumigation Mercl oint. rub in about a dram a day. We wish to avoid salivation Give large quantities of sarsaparilla. Conjoin guaicum etc. also Nodes will require no separate treatment Min. acids have been very famous. It does well after the system is reduced by mercury So sulph. quin. etc. when tonics are indicated [illegible] panacea has sometimes done well after a long mercurial course owing probably to its [minute] quantity of corr. sub. If a phlegmosis hide the chancre inject sil. cop. ac. lead or nit. sil. Inflammatory action will require v.s. & cal cathartics Sometimes life is threatened by a local hemorrhage The joints may become affected like rheumatism Partial blindness and deafness occurs If exfoliation comes on inside of the scull, generally the patient dies of paralysis etc. After long use of mercury the system becomes so susceptible that rubbing in a little merc. oint will affect the mouth in 15 min. In such cases Fowler’s solution has done well. Dr [Pardon] [Bowen] of Providence, relied very much on it. Give large quantities of sarsaparilla in the sequel The bones of the limbs sometimes becomes completely brittle Venereal infants mercury Calculus in the bladder May be produced upon a foreign body lodged in the bladder as a nucleus e.g. musket ball bits of a bougie etc. needles by hysterical women! More common in the western states and in Maine Symptoms very obscure pains in loins, vomiting, sediment in the urine sand passing away Nausea and vomiting with excessive pain are most apt to be cured by the passage of calculi along the ureters The pain will be sudden and violent not gradual and dull like that of psoas abscesses Retraction of testes, numbness etc. will also attend These passages through the ureters are commonly called attacks of gravel Passage of calculi through the urethra, gives rise to retention sense of tearing etc. perhap Symptoms of stone in the bladder pain at the extremity of the penis greatest when bladder is empty The pain comes on in paroxysms They are aggravated by walking or riding over a rough road. Pains in the neck of the bladder at stools. Yet these “fits of atone” may come on without any exciting cause. Patients pinch the glands Pass urine frequently have a frequent sense of inclination to go to stool. When the calculus is large there may be a sense of weight in the bladder. The urine becomes finally turbid perhaps bloody Children are said not to be subject to pain in the kidnies and ureters experiencing only stone in the bladder Finally micturition may be very frequent once in 15 min. A thickened and inflamed state of the bladder supervenes finally the patient dies of hectic. Prescribe remedies for irritation in general v.s. in extreme paroxysms Cal. opium as a matter of course It has been customary to cojoin alkalies & uva ursi these relieve though they do not dissolve the stone Prof. H. was for a long time afraid to blister for strangury but he now finds it very beneficial Operation Hippocrates swore his pupils not to perform it. The first mode was to pass the fingers up the rectum pull down the stone into the perinaeum & make an incision directly upon it. This was called the lesser operation or cutting by the gripe Next came the apparatus major so called in consequence of the large number of instruments A small opening was made to the forcibly dilated Next came the high operation above the pubis This has lately been attempted to be revived By this mode a large stone can be extracted without breaking Lately it has been proposed to operate through the rectum The present mode is called the lateral operation and is performed now as [Ches??da] formerly did. Some are inclined to substitute the knife for the gorget First sound perhaps a schirrhus may be sometimes mistake for a stone Prof. S. performed the operation for a calculus in the urethra. If the calculus drops down into the bottom of the bladder introduce your finger into the rectum Mr. Hey sometimes sounded with a silver cath. and felt the stone as the urine flowed. A flexible catheter without a stilette, has sometimes succeeded when other instruments have failed. Examine sitting standing, lying etc. Try repeatedly Administer over night a senna cathartic and an hour before the operation an injection Operation After it the urine flows out at the wound. Dr [Rhea] Barton keeps a flexible catheter in the bladder through the wound Some give opium immediately after the operation. Be guided by circumstances give opium if pat. has been in the habit of taking it Laxatives are very beneficial Children suffer very little But old people are apt to have chills, cold extremities etc. Treat as for shock q.v. Apply cloths, just as to a woman after delivery. Watch for hemorrhage When infl. comes on it is known by pain, chills etc. A very successful surgeon at the west, bleeds ad deliq. immediately after the commencement of delivery Fatal cases exhibit not gangrene but suppuration and abscesses The relief from the operation a very great pat. sleeping better the night after the oper. than for weeks previously Lithotomy in Women Case of a stone formed around a darning needle! extracted for Dr Cogswell The operation through the vagina is easy but the wound is apt not to close & [then] cause an incontinence of urine Sir A. C. introduced the plan by a sponge tent. Rx a sponge & dip it into melted beeswax moderately hot roll it into an oblong shape Introduce it the bees was melts out and the sponge dilates very powerfully often succeeding in a few hours When the stone is too large 1st cut [illegible] director to the left 2nd cut between Le France’s ode (invented by Costa) Place the pat. as for lith. a [illegible] is held by an assistant & depresses the urethra and vagina. Cut with a bistoury above the urethra and obliquely from the the symphisis pubis down close along [illegible] the ischium cut layer by layer until you arrive at the bladder Tumours of the bones Exostosis an increased growth of the body most frequently found in the [cran.] sternum clavicle ribs long bones Sometimes flat sometimes pointed sometimes pedunculated Sir A. C. makes two varieties one from the substance the other from the medulla Prof. H. makes cartilaginous (with bony parts interspersed) and fungoid or medullary Caused by external accidents as blows etc. scrofula syphilis etc. said to be the causes To be distinguished from [aster] sarcoma by its uniform hard [illegible] Seems not to affect the general health, unless the part is so large as to interrupt functions Most commonly the tumour stands out at an angle Sometimes they cease growing and remain stationary No treatment but extirpate is of use Use trepans [illegible] of various kinds, chisel & mallet etc. Operation not dangerous 2nd Osteosarcoma may be hard at the surface but will be soft (perhaps lardaceous!) in the centre (called fungus by Sir A.C.) base broad the whole substance of the bone is converted into it. Sometimes suppurations come on in the interior IT is fashionable to consider them all as fungus haematodes but they differ Fungus haematodes cause absorption of an adjacent bone. The general health is here affected Prof. H. considers internal remedies of little use. The disease is apt to return after extirpation. Boyer advises the actual cautery after extirpation. When on a limb amputate. May be of immense size as large as the body. Prof. H. has known on as large as a milkpail & two tablespoonfuls of laudanum at a dose necessary for the pain Caries soft black cloth stained dark perhaps honey combed from venereal etc. (may be caused perhaps by long unopened abscesses in some cases) Treat by caustics & especially actual cautery. Occurs most in the spongy bones Sometimes resection Caries of the hand penetrates the cranium Especially affects the mastoid process From syphilis We may touch only the mast. process with act. cautery. Remove carious portions Caries of sternum from syphilis Natural cure of caries is by necrosis terminations by depositions For superficial caries stimulating applications are generally sufficient e.g. nit. sil. sulph. copp. etc. Caries may occur on sacrum crest of ilium tubers of schium etc. from lying long on one [portion] Necrosis Death of bone Applied by Prof. S. to the specific disease called “fever sore” Bone first white then dirty yellow finally brown and black often surrounded on the edges by an elevated circle of granulations but finally the necrosed portion from being depressed well as it were rise up & be more elevated Commence with fever which is apt to be considered by the physician as an idiopathic fever followed by the fever sore. Occurs in the cylindrical bones principally oftenest in the tibia next in the os femoris External and internal periosteums dies & then the bone dies of course sometimes however the death is only in spots. Prof. H. is convinced that [illegible] incision often prevents the destruction of the periosteum vide [illegible] Commences with deep seated pain but often the pain is first in the joint & the disease is mistaken for rheumatism In a day or two fever comes on perhaps finally subsultus tendium and delirium Great pain on moving the limb. Pus first accumulates under the periosteum but in the thigh first in bursa under the tendons of the [ham.] In the spongy bones pus collects also in the cancellar structure Caused by cold contusions comminuted fractures caustics applied to ulcers most commonly in boys from excessive bathing in cold water many cases of this kind exposure to rain storms generally causes [illegible] sores unknown the joints near the part are apt to become much flexed Apply a splint pretty early Treatment. Bleeding cathartics blisters and opium Prof. H has found the subsequent irritation as much worse in the latter stages when the treatment was not commenced by evacuations The notion that evacuation shd not be used because the blood may y and bye be wanted. Prof. H. would pay little attention Besides at first we do not know certainly the nature of the affection in the first place in many cases we shall be told of an injury Blisters at the commencement are better than fomentations and poultices Pus will form however As soon as the disease is fully formed make an incision down to the bone through the periosteum we shall generally find pus If there is pus inside the bone bore into it with a nail gimlet It gives the greatest relief be careful not to split the bone Extracts from the notes taken by my friend T. H. Wadsworth of the Lectures on Surgery of Theodore H. Woodward Prefect Castleton Vt. Metastasis is another organ aff. sympath. & more so than the first Adhesion a vital process analogous to assimilation not an infl. for infl. hinders, as does coagulated blood, which has lost its vitality most successful where no heat or pain or mark of infl & then may take place in 18 h. The [illegible] lymph forms a bed for the vessels to ramify in The secretions of a part infl. gradually change to pus & then gradually back again, as in successful cures of clap. Prof. W. uses bandages to most acute infl. contrary to common practice they do good unless the irritability is very great or they are [illegible] fully applied they are particularly useful to deep seated infl. especially if chronic Mortification Prof. W. has seen all the muscles of the arm dissected clean from shoulder down & hanging but by their ends. A small strip of skin remained from wh. new skin was formed & covered then again. The case was caused by the bite of a hog When you bleed in cases where you expect extensive suppuration to come on, [illegible] on [illegible] you may want the vital power back again. You may temporarily relieve pain in any aff. whatever by v.s. you may if [illegible] wish produce syncope or death. In phlog. cases the best refrig. to follow v.s. in tart. ant. in nauseating doses it keeps the skin moist & affects the other secretions For superf. infl. cold is the main quality in external applic. Use spir. 1 pt to 4 water vinegar etc. etc. Somet. when all the [illegible] appear to indicate cold applic. they disagree & produce vomiting, spasm, or even convulsions. Here use fomentations which need not be medicated unless with narcotics which have considerable effect. Astringents added to washes do little good except for appearance. Lead, if very strong has some effect use a sat. sol. Lead applied too long to eye will produce palsy of it. For deep infl. use warmth cold is like water on outside of a blacksmith’s fire, making it hotter within. Use counterirritation Acute infl. term. in chron. is bad to manage & must be looked to it is apt to produce considerable irrit. of stomach. Commonly we want a moderate use of alteratives cal. & op. use bandages friction, liniments gradually change to a more generous diet. The best form of merc. in these chron. aff. is corr. sub. with op. bark may be [wanted] camph & carb. amm. good to allay irrit. & keep skin moist the position shd always be such as to favor the veins in this stage cool washes are not commonly good frict. with merc. oint. good. The const. treat shd be the same or nearly the same is if there was no local aff. The grade of action may be too low for suppuration in acute cases or it may be too high and gangrene or chronic weakness, effusion etc. may be the results Look to it After suppuration pat. somet. wants support, sometimes does as well without. When pus is in an important part, or under fasciae, do not wait but open After opening a large abscess of the chronic sort there is apt to be increase of pain, fever etc. It becomes aff. with acute infl. from the wound & perhaps from taking off the pressure suddenly Hence open them in the valvular manner, squeeze out the matter, bring the edges merely together, plaister & bandage with compression. By this process ac. infl. is prevented & adhesion of sac promoted we have to open several times but at each time there is less matter. Open common abscesses before the skin over them is diseased when it first begins to blush they heal much sooner bandage & compress. This is worth every thing else in the treat. of such tings Sudden stoppage of the secretion of pus is apt to affect important organs Ulcers Irritable ulcers limewater with mucilage good Rx zfs [illegible] hydrar. zfs cetacii zi opii Often they want calm. & op. say 5 gr. cal. at [illegible] & 1 gr. ope. 6 times a day. Prof. W. has cured many by moderate emet. of tur. min. repeated a few times wash of op. & bark sometimes. If you use bandaging it must be with care sometimes a good Sloughing ulcers no pus livid with [vesicle] constant pain granulations if any dark & often slough. Best applic. 50 drops nit. acid to 1 qt. water this more active than mur. acid charcoal as good as saw dust & no better Prof. W’s experience yeast poultice good. Port wine poultices good Stim. internally Most common in old drunkards Fungus ulcers (filled with proud flesh) are most common, changing sometimes to irritable & must be treated as such we must remove the lard edges before they will heal Cantharides in powder is often a good application to ulcers A simple roller if well applied is as good a way of bandaging as Boynton’s Ulcers with thick indurated inverted or everted edges must, in some way have these edges removed. When gangrene is commencing a poultice of yeast & flour etc. or a fomentation of brandy is good When not very deep seated & depending on local causes, a blister sometimes stops it Nitric zi to a pt. good turpentine ess. oils For [illegible] toes of old folks give tonics & stimulants For gangrene with considerable action remaining cold washes are best for others, hot. Diseases of Women The uterus has not quite so much to do with all dis of women as some think Some women regularly menstruate once in 35-45 60 even 90 days, yet are in perf. health & fit [for] business. Prof. W. has known many women have children at 52 Erythema anatomicum Best thing at first as to excite infl. in the part by caustics etc. Internally use stimulants etc. Anthrax Cut through the whole tumour both ways this relieves much, by taking of the stricture & the sloughs get out sooner Use anodyne fomentations etc. Scrofula Prof. W. has more faith in ext. & int. use of iodine then in any thing else known a large swelling much diminished in 18 m. & pat. become less evacuated & her health improves. Inflamed glands are often discussed in their early stages by blistering Wounds The sympt. fev. is commonly synochus but [illegible] with epid. disth. It is important to make arteries bleed if they will in first dressing & tying them Prof. W. prefers on the whole to let one and of lig. lie out where both are cut off, the part is always irritable Lacerated wounds are apt to bleed afterwards & it is best to secure them if possible In traumatic gang. no matter how soon you amputate if pat. has vigor enough unless the cause of the gang. is constitutional, & then though the gang. spread, you shd wait for the line of demarcation In gunshot wounds there is apt to come on deep seated pain from tension of fasciae etc. open & relieve The symptoms from large contused wounds are commonly those of atony & at any rate do not want dep. Second hem. is commonly from 7-12 d. Tetanus may be from injury of nerve but is generally (as Prof. W. thinks) from wound of a part of low vitality. Irritants to the wound are of use also to spine & stomach Give calom. ol. pin. op. etc. perhaps in some cases of considerable action v.s. to increase susceptibility to articles Wound of nerves Nerves unite as well as any part. The temperature of the part containing the divided nerve is colder but if it is covered with flannel it becomes warmer than the other corresponding part covered in the same way Sprains When the soreness is nearly gone, pouring water almost scalding hot, from a height has the best effect, with friction & bandaging often Sutures bandages, ligatures Prof. W. uses only the interrupted & twisted [sutures] An inexperienced hand had better enter the needle both ways from within in forming an interrupted [illegible] Old fashioned needles miserable things. Dr. Miller’s needle with a handle is good Flannel is more elastic & makes a better bandage for parts that are cold & edematous The only kinds of bandages of much use are strips single & double headed roller & 4 tailed Sometimes (not often) a T bandage Dentists silk makes the best ligature Spina Ventosa A bad name meaning internal caries of a long bone not easily known at first. The cavity of the bone increases in size? at first & fills with matter the outside also increases the shell is thin & there is an appearance of distention Oftenest affects the head of bones & is at first every way like white swelling except that the If even early evacuate the matter from the bone if you are certain what the disease is but if seen very early try general remedies & counterirritation as in white swell. In the latter stages the swelling bursts and often long tumors are formed, It will be attended with great pain irritation & discharge & the limb must be removed Ophthalmia In chronic stag nit. sil. & corr. sublimate better than mere astringents or cutting vessels but in some cases the vessels must be divided The applications are apt to be made too often twice a day will do Prof. W. has faith in local bleed. even when the syst. in general want tonics Great relief is afforded by applying at night a fomentation of cut tobacco, & binding on it may be dropped into the eye in cases not very irritable In many cases at the outset nit. sil. does well dropped into the eye, removing irrit. & vascularity. Do not continue warm app too long at least if infl proceeds to supp. use cold washes nit. sil. sub. zinc etc. In many cases Prof. W. has seen blisters near the eye cause irritation apply them to the neck Simple milk lachrymose ophth. may be cured by any mild stimulant Suppurative ophthalmia 4 sorts 1. epid. 2 metastatic (from clap or catarrh) often with a greenish secretion) 3 intermittent (from interm. causes) 4. infantum If the cornea fades & loses its lustre & its edge looks uneven it will certainly slough unless treated as gangrene by stim. ton. etc. Sclerotitis Straight vessels running to iris, well marked turgid & look as if painted florid color violent pain of eye, especially on motion there is apt to be effusion under the conjunctiva making the surface of the [sclerotic] coat unequal. It is apt to affect the choroid. Prof. W. does not know as there is a [chorditis] when chor is aff. there is dullness of function. the iris sluggishly contracting & limited in motion there is great irritability of the eye & division aching pain in forehead. Apt to aff. the iris. Treat as in other ophthalmitides but merch. ac. is especially useful in deep seated inflammations of the eye Rheumatic sclerotitis looks like the other, but aff. also the periosteum of the orbit & the pain is greatest then The pain is greatly aggravated at night sight always dim. iris acts sluggishly Apt to aff. the other coats. Eye dry & hot The pain often aff. half the head it is irregular & never entirely remitting. The fever is of the arthritic character with deranged secretions of the bowels. Prof. W. never saw bleed. do goos in any rheum. Calom & op. are better. Apply leeches & blisters. Keep the pupil dilated with belladonna. IN the last stage quinine arsenic is still better especially in chronic cases. In acute cases the best thing Prof. W. has seen has been actaea or colch. He never saw any local applic. but narcotics do good. There is no tending to chemosis Catarrh rheumatic aff. sclerot. & conjunct. both & has sympt. of both rheum. part goes off before the catarrhal It may terminate in opacities ulcerations of cornea, may ulcerate through. Digest apparatus much disturbed. Catarrhal or Epiderm. ophth. Prof. W. thinks the same as arythem. muco pur conjunctivitis It is apt to leave a villous look of the conjunctiva. Begins with stiffness of eyelids sense of pricking in the eye, especially about the lachrymal [caruncle] pat. cannot be persuaded that he has not sand in his eye & picks scratches & rubs. Conjunctiva of a mottled red, turgid. [Chemosis] commonly imperfect aff. only one side of the cornea (the chemosis is semitransparent & is evidently from serous effusion) Continues 6-8 days & there is a muco purulent secretion. Bad cases run on to the chronic stage, with ulcers of cornea, effusions, & spreading to other textures Prof. W. never saw sloughing in this It is epidemic & contagious General treat. same as for severe common ophth. Local applic. corr. sub. is best 1 gr. to 1 ounce nit. silv. good, but not equal to corr. sub. (common astring, generally irritate & do no good) Blisters In an early stage & even so late as the middle of the acute stage Prof. W. has cut it short by applying saturated solut. nit. oil, with internal use of arsenic quin. etc. Apply red prec. ointm. a piece as big as a pea between the eye lids & suffered to dissolve The pat. is very liable to subsequent attacks Chronic ophthalmias of all sorts are treated pretty much alike. Generally we must restore or change the secretions by merc. and corr. sub. is best. by other deobstruents in lower cases Narcotics & tonics When you apply red prec. ointm. 12 gr to zi is pretty strong Hydrocele Prof. W. prefers operating by seton of [illegible] thread, drawn through the tunica vaginalis & kept there till there is considerable infl. Causes of spasmodic cholera are not contusion & infection but those of wide spreading epidemics A board of 100 medical officers in India declare for non contagion So the medical board of Madras So also the 24 physicians constitution the medical boards of [Moscow] with only 3 dissentients. We sometimes have cases in this country precisely like those of India This is true of other diseases Diseases cannot be distinguished in their ataxic form this is true even of fever & ague which has destroyed patients in the second paroxysm Pneumonia typhodes has exhibited cases among as precisely resembling those of cholera spasmodica Physicians have differed more in their treatment than in regard to its causes large doses of calomel & opium diaphoretic treatment severe pain at stomach & bowels vomiting & purging great thirst coldness extremities cold to a bystander pulse at first languid or small & throbbing & in bad cases quick small & intermitting cold & clammy sweats death like coldness of extremities hiccup etc. etc. death sometimes with us in 24 hours distinguished from dysentery by watery stools & spasmodic griping pains from colic by stools allied to bilious fever yellow fever etc. produced by the same unknown causes, modified in their action it is to bilious fever what a tornado is to a settled stom. Spasmodic cholera of India has prevailed in 1774 & 1787 & in 18- Prevailed extensively in Sydenham’s time The present epidemic commenced in 1817 Said to have originated from bad rice Dr F. thinks that there may have been a predisposition then the disease first broke out in consequence of bad food & afterwards fear & anxiety would be sufficient exciting causes Anecdote of the plague in the French army Anecdote of a small pox case in Fairfield cty [30,000] reduced to 8000 in [Toflia] 17000 in 8 days at Astraca [6000000] in Asia up to 1830 4000 out of 8000 died in [illegible] Cholera called cholera morbus to distinguish that of [illegible] from chol infantum Copious discharge from stom & bow with painful spasmodic action Sometimes defined as the vomiting & purging of bilious matter this is incorrect bile is not vomited healthy bile could be vomited only in [illegible] cases The liver is diseased in connection with the stomach Affects hot climates & the hot seasons of temperate climates July to Sept. Affects the exhalents & absorbent vessels of the stomach the liver & pancreas There is a translation of action from the surface to the intestinal canal & its attendant glands In ataxic forms there [illegible] be no secretion Causes Sudden check of perspiration especially after great heat By unripe fruits large quantities of acids wild grasses, peaches & milk in short any thing which suspends the action of the stomach in case there is a predisposition. When it is epidemic very slight causes will bring it on & hence contagion is alleged Chills languor drowsiness [distention] [pressure] at [prae] [cordia] 14 Surgery Separation of the lower end of the fibula This is the most frequent accident to the ankle according to Prof. H’s experience Yet little has been said upon it A sensation of cracking and tearing attends the reception of the injury The foot is turned inwards, a little so are the toes there is some swelling in the outside & intense pain is felt upon pressing the fibula inwards. To be distinguished from fracture & from effusion into a bursa on the outside of the foot, in consequence of strains Extend the foot a little, turn the toes outwards & press in the lower part of the fibula Apply a very thick compress & bandage & splint and bandage high up the leg for the interosseous lig. may be torn for several inches Compound dislocations of the ankle are very serious accidents. Prof. H. has seen much mischief arise from short splints and tight bandaging Wounds of the Joints The pain is generally on the opposite side of the joint. Violent pain suddenly occurs if after a few days & is generally attributed to taking cold & the attendants attempt to sweat it out etc. Ultimately excessive suppuration occurs The wounds of the joint, communicating externally, are more dangerous by far than internal wounds, as from fractured bones As severe consequences may result from wounds of the superficial bursae, as for instance that on the external surface of the patella The prognosis may generally be a favorable one for the life of the patient but the joint is apt to be anchylosed Prophylactic treatment Draw the lips of the wound together with add. ph. apply a bandage & a splint & confine the pat. to his bed. In some cases, bleed etc. to prevent infl. Treat. of infl. Press out pus etc. if necessary probe the sac etc. In punctured wounds with excessive pain and swelling & violent const. sympt. envelope the whole joint in a blister which will give great relief Let large ulcerating cavities be thoroughly [pencilled] with lunar caustic The irritation will be very much [illegible] by it. Collections that occur about the joint, should, if they do not disperse be opened & corr. sub. be injected we may first try discut. lot. & blist. And in general, keep the joint wet with disc. lot. If inject. of sol. of corr. sub. fail put a little moistened upon the point of a probe & introduce it down to the bottom of the sore. The older surgeons used red precipitate and an almost saturated solution of sul. cup. Be careful that the limb anchyloses in a proper position if knee, straight if elbow, crooked Dislocations of the Tarsal bones When the astragalus in dislocated inwards it is partly turned over the external & under surface being above Prof. H. has known the os noviculare partially disloc. He kept it in its place by a plaister bandage Gun shot wounds A common ball is said to move 2000 ft. in a second more rapidly consequently than the passage of sound hence in a cannonade at night, the flashing is first seen, then the ball whizzes by & lastly is heard the report The contusion is so great that the parts in contact with the ball in its passings are completely killed The orifice at which a ball enters will have its edges depressed the opposite orifice will be ragged The course of a ball may be very circuitous case in which a ball struck the larynx and passed around the neck coming out near where it entered. Tendons may divert its course A ball may carry before it a silk handkerchief 7 be pulled out and lost when the handkerchief is Injuries formerly attributed to the wind of a ball (for when one leg is taken off by a ball, the other is not injured by the [illegible]) are now explained by the oblique stroke of the ball and the yielding nature of the skin. Bones may be comminuted and even the viscera injured, without braking the skin. Secondary hemorrhage rarely occurs (4 cases in 1000, Mr. [Illegible]) after gunshot wounds and primary hemorrhage is of course less common this sort of wounds than in others Baron Larrey mentioned to Dr Heerman that he had lost two pat. only, where a ball had passed directly through the body Compd fract & wounds of the joints are very dangerous Necrosis of a bone is apt to be produced in consequence of a gunshot wound Necrosis of the cranium may be produced 1st ind. is to suppress hem. 2d extract foreign bodies 3d to prevent inflammation 4 promote suppuration & separation of [ischous] 1st by pressure etc. by a tourniquet applied until ligature or amp. can be performed 2d If a ball is too deep to be felt, it should not be cut for. If it can be felt by the probe, let an assistant make the skin tense, and let the surgeon enlarge the wound & extract. If it is on the opposite side of the body, make the skin tense with the thumb and finger & cut down and squeezing it out. Another period for searching for and extracting balls & foreign bodies is that of suppuration & sloughing 2d The French still keep up the old practice of always enlarging the wound. The British surgeon have abandoned the practice. John Hunter originated the plan. The French speak much of debriding the wound by taking off the tension of the fasciae. They uniformly make incision Cold water is the principal discutient lotion of military surgeons With respect to dilating the wound the British surgeons say that the incision soon close unless kept open by tents. Of course for several days the wound looks very foul; the edges puff out & protrude (Hence Larrey speaks of debriding) Poultices & fermentations shd now be applied 3d As soon as suppuration takes place, poultices shd be discontinued & cerate applied Look out for hemor. when the sloughs are cast off. Direct the pat. & the nurses to apply a tourniquet immediately if hemor. commences When hem. takes place we can seldom depend on tying the artery at a distance It will generally be better to cut down at once Sometimes a complete division of the artery will answer In hem. from the popliteal artery, on account of the difficulty of finding the artery in the hem. the artery may be tied higher up The treatment shd be antiphlogistic strictly. Mr. [illegible] directs cal. & ant. at night If severe pain in the head and back occurs with high infl. in the wound, then bleed immediately. But when suppuration occurs we must give opium for irritation Dr Fuller of Columbia mentions that in the last war it was found necessary to bleed in the first place & then to give opium Neither would answer by itself It is now agreed upon that it is best if amputation is necessary to perform it immediately, as soon as the pat. has recovered from the shock & not to wait till the subsidence of the fever etc. Extraction of Foreign Bodies from gunshot & other wounds If they are suffered to remain a cyst forms around them We must take into consideration first the nature 2nd the situation of it 3d the length of time it has been in. For if this is short we had better not delay but if it has been long in & gives no inconvenience, it may be suffered to remain Great suppuration in some cases and in others excessive irritation may result from the retention. Even a needle may cause great irritation Amputation The best authority is now in favour of speedy amputation Baron Larrey does not hesitate to amputate even after bad symptoms have come on as the pat. will be apt to to die certainly without amputation Prof. H. has amputated successfully in cases of crushed limbs, 48 hours after the reception of the injury When a limb has been shot off you amputate of course. But in case of fingers Prof. H. frequently contents himself with picking out the fragments of bone & dressing the wound When the ball has lodged in a joint or when a bone is fractured it will generally be best to amputate When the bone of the arm or thigh has been broken, necrosis takes place, and if death does not supervene, the limb will be apt to be always useless, or with an artificial joint. Bar. Lar. amputates when the os humerus is struck and if struck near the end, he amputates at the joint Very extensive injury of the soft parts may make an amputation necessary or destruction of the principal arteries and nerves. Amputate above the knee, for injury of the upper part or the tibia Even after amputation death may result 1st from infl. of bloodvessels, both arteries & veins # 2d from metastasis [&] pus being found after death in the thorax, in the lips joint etc. Prof. H. would always let such pus out. In our climate & in. G.B. suppuration of the lungs takes place oftener than in warmer ones 3d by necrosis of the bones at a joint. If the amputation was not high enough at first it may be best to amput. again If necrosis occurs after amp. the end of the bone will be sharp and ragged instead of being rounded by the absorbents. If the main nerve is entirely destroyed paralysis occurs Tetanus is apt to occur from gun shot wounds especially in warm climates Bar. Lar. applied blisters & actual cautery often with success. # & that too whether the veins are tied or not Mr. [illegible] sometimes tied the [vein] for hem. without bad consequences Hospital Gangrene Vide [Hemmer’s] mil. surg. The wound will become painful hot, red, dark, finally livid & black in the mean time the fever increases and becomes more typhoid etc. etc. In hosp. gang. contrary to what is common in common gangrene the arteries are affected & hemorrhages take place. Vide John Bell also The disease is unlike any other but resembles most erysipela of cell. mem. etc. The dis. affects all the textures, spreads among the muscle effects the deep parts more especially Caused by bad air, and a crowded state of the hospital. The affected patients should be separated from the others. It may be communicated by the dressings Mr. [Hemmer] found bleeding give give great relief the patient would beg to be bled cath. also he applied arsenic to the sores and ultimately gave [illegible] etc. In all such cases something must be applied to destroy the surface of the sore White swelling [most] exquisite in the knee Divided into rheumatic & scrofulous the first aff. the leg & the second aff. the heads of the bones. S. Cooper denies however that the heads of the bones are enlarged. Mr. Brodie also makes one division in which the artic. cart. are aff. Prof. H. considers white swelling as always in the first place an inflam. of the synovial membranes & bursae We have pain, tumefaction a puffy swelling is seen, under the lig. of pat. wasting of the limb below 1st Acute form pain then swelling like the swell. of ac. rheum. tenderness on press. & [mot.] joint easier when bent headaches furred tongue anorexia pain in other parts of the limb perhaps edema below the joint We are cautioned against confounding this with dropsy of the joint so called which is merely eff. in to burs. muc. etc. To disting. this from acute rheu. it is only necessary to know that several joints have been aff. in succession for acute rheumatism in any one joint may exactly resemble wh. sw. Sometimes pus forms erodes the ligaments & points externally often taking a very circuitous rout 2nd Chron. form pain at first trifling tenderness or pressure puffy sw. beside the pat. wasting of the limb below or edema Often the pat. will be so well as to be encouraged to use the limb, & perhaps sprain it & have a severe case at once In the latter stage both forms are alike. After a while anchylosis forms & the limb is well. But anchylosis seldom takes place except after suppuration. When anchylosis is about to take place, keep a knee nearly (not quite) straight & an elbow bent. In some cases extensive suppuration comes on & hectic so that amputation must be performed in order to save the life of the patient Ind. 1st remove infl. & here we must consider the kind of infl. wheth. ac. or chron. When there is acute infl. of a large joint v.s. & afterwards cupping scarif. & leeches Mercurial cath. as in other infl. of serous memb. Opium for pain. If discut. lot. do not relieve apply blisters But children are sometimes thrown into convulsions by them. Savin cerate is recommended in order to keep blisters open but it is apt to produce spasmodic retraction of the limb at least in children. Boyer also directs for children foment. poultices, [linim.] etc. Let a blister heal up & apply mur. amm. then in a few days apply another blister If these fail, try corrosive sub. Cut a hole say as large as a bowl of a spoon in a plaister put this plaister on & then over this a plaister coated thickly with corr. sub. This creates considerable pain & irrit. & the disct. from it will last perhaps 3 or 4 weeks. Perhaps the gums will be affected a little. The benefit however is often very great the joint diminishing in size an inch perhaps. Issues are used made with caustic kali Bar. Lar. has introduced the moxa. Setons are used but then give children too much irrit. Apply then below generally When the joint is recovering and is very weak & relaxed much advantages may be derived from a plaister bandage Where the complaint is a sequel of acute rheum. merc. are very benef. no particular advant. is to be exp. [illegible] merc. oint. Give op & cal aa gr i Canth. camph & op. aa zj for a liniment Friction also is beneficial in the latter stages If suppurations occur, open immediately The dis. is apt to recur again from improper [exper.] & exertion & from accidental injuries Reaction of the bones has been practised successfully as a substitute for amp. but not in the knee White swelling of the wrist Hand & fingers both flexed Apply a splint & compress & brace the hand back. It will relieve the pain & give confidence in the use of the arm & great satisfaction Open ever so small a suppuration great relief will be given Nervous affections of the wrists of nervous & hysterical females No swelling but pain, soreness, & inability to use the wrist Blisters seem to do little good. Plaister bandages seemed to be of some service. A similar affection occurs in the ankle joint They get well perhaps after a while. A dangerous affection of the tarsal joints has been met with by Prof. H. Swellings (puffy swellings) like white swelling eventually suppuration perhaps a curdy matter issues little or no pain after suppuration Occurs in children & youth Surgical writers call the aff. a scrof. swelling & advise amputation. White swelling occurs however in the ankle but generally occurs in children, & in the chronic form. It is met with in the children of cotton mills. Prof. H. has treated them with cal. twice a week at first White swelling occurs also in the shoulder and in the elbow An enlargement of the bones at the joints of the fingers occurs in females It has been called gout but Prof. H. thinks it has no analogy. It has been attributed to hard labour but is often met with in others. The disease will commence with pain & swelling similar somewhat to white swelling & ends with permanent enlargement Prof. H. has generally prescribed principally to the constitution applying stimulating applications etc. Iodine has been lately used in white swelling, with advantage Hare Lip Once in a while it is said to occur in the lower lip. May be single or double may affect the bone. Varies from a small notch to a complete di Operation for hare lip first performed in [Winst.] cty by a mountebank Prof. H. at first delayed the operation until the child was some months old But now he operates as soon as called even if the child is but a few days old It seems to be the fact that children with enclosed harelip are more subject to bowel complaints Prof H operates with scissors Put in the lower pin first & push it first upwards & then (in the other half of the lip) downwards to prevent there being any notch in the edge of the lip. Two pins only for children. Wind the threads so as to cover the whole incision Apply over the whole long straps of adhesive plaister. Let the pins remain 3 or 4 days in children & 4 or 5 days in adults Take off the plaister very carefully first each end then the middle Then take out pin by a rotatory motion And afterwards reapply the straps. Double hare lips have a central piece which is not to be cut away but an incision is to be made in the shape of the letter M & then bring all together in one operation thrusting the pins through the whole Cancer of the lip May commence with a crack then a scab finally a hard tubercle which may continue for years, if not tampered with, without much inconvenience. The ulceration may commence in the centre of the tubercle Lancinating pains occur & eventually aff. of the lymphat. glands beneath the jaw etc. etc. Common canker of the lip may be cured by nit. sil. etc. & does not resemble this complaint much Occurs oftenest in middle aged men said to be caused by tobacc. improbable Prognosis favorable in general if the disease has not been tampered with, if the pat. is not intemperate & if the glands are not affected Prof. H. has seen cases of affection of the lip more resembling fungus haematodes than cancer Operate as for hare lip Bronchotomy The operation consists in making an opening into the traches Laryngotomy is an opening into the larynx Bronchtomy has succeeded in some cases of cynanche laryngea or extracting foreign bodies bronchotomy is to be preferred to laryngotomy It is the only certain mode of extricating them. Even if after some time the foreign body is coughed up, the pat. is apt to die of pulmonary consumption Often the substance will be coughed up. It may be necessary to keep the wound open for some time, in order to allow of the exit of fragments The foreign body may be above or below the opening. Irritate the trachea to produce coughing to bring up the body from below Push a body, above sometimes upwards through the rema glottidis, with a probe. If you do not find the body keep the wound open One physician, kept the edges of the wound apart with the blunt hooks Push a probe through the rima into the mouth etc. N.B. Enlarge the opening of the traches with a probe pointed bistoury Operation for fistula lachrymalis peformed Wounds of the throat Lately and English surgeon who happened to reach the pat. within 1 ½ min. after a wound of the carotid & saved the pat. Dr Horner also lately happened to be passing the courthouse when a prisoner cut the branches of the carotid he employed pressure & cut down & tied the trunk the pat. died Wounds of int. jug. vein are sometimes fatal from the rushing of air into the throat. Dr Warren in an operation upon hearing the rushing noise, immediately clapped his thumb on & stopped the operation pat. survived. Taking a full inspiration has been recommended. The int. jug. is much in the way in operations for the extirpation of tumours it bulges out like an intestine Transverse wounds of the traches require sutures though some object to them. Food is apt to come out of the wound use a tube The passage soon closes however Sometimes a fistulous orifice is left as in the case of Desta of Ky. a tube has to be worn for breathing Injuries of the Head 1st external injuries 2d concussion 3d compression 4th inflammation 1st Ext. inj. An incised wound of the scalp is to be treated on general principles It will not be necessary to tie every little artery compression with a dossil of lint will often answer Even if the scalp is extensively separated, the wound may heal by the first intention When there are uneven edges & angles, stitches (the interrupted suture) are useful. Sometimes it is convenient to braid the hair In wounds of the scalp erysipelas is apt to occur & prove troublesome. Treat it as for erys. in general ac. lead or if necessary, blister bleed, [illegible] etc. Delirium is apt to occur but soon subsides Contusions on the head are apt to cause alarm often there is a tumour caused by effusion & the edges being often higher a depression of the bone is imagined and a surgeon will be sent for to trephine 2nd Concussion may be with or without an external wound [illegible] come out of their insensibility without any thing done When first revived, vomiting is apt to occur & generally gives relief pat. breathing better pulse rising Abernethy calls vom. a favorable symptom. But the pat may grow worse afterwards Blood often appears and the attendants think it comes from the stomach but upon examination we shall find it to have come from the mouth, nose, or ears Symptoms generally similar to those of a shock q.v. surface excessively cold After the first symptoms you will generally find the pat. in a profound sleep with a soft pulse Stupor & insensibility more or less perfect In severe cases pupils dilated Delirium may come on incoherence etc. Pain in the head, intolerance of light & sound etc. Sometimes paralysis of one side occurs sometimes fatuity occurs & continue for months etc. etc. Treat by putting pat. in bed applying heat, frictions give hot drinks aromatics moderate quantities of alcohol. After the pulse returns bleed continue the bleeding as long as the pulse rises Dr Phys. restored the circulation by pouring cold water on the head afterwards he bled. Next excite the peristaltic action by calomel. When symptoms of infl. of the brain appear, we must bleed & give cath. Apply cold applications to the head & blisters to the back of the neck. if the unfavorable symptoms continue Dr Rush advised salivation in bad cases & the best surgery in England practise upon this plan, at the present time If languor debility & loss of memory remain long tonics may be required After death, lacerations of the brain are often discovered. Much [???usion] soon changes the symptoms into these which arise from compression of the brain Prof. T. believe the palsy from concussion of the brain to arise from infl. of the [brain] & effusion the palsy is always a secondary symptom never one of the first 3d Compression of brain Infants may not suffer from depositions of the cranium They are said to have depressions without fracture In adults fracture is necessary to compression Sympt. stupor slow depressed & irreg. pulse stertorous breathing dilated pupils. Pat. appears in profound sleep Breathing resembles that of a fatal apoplexy Pupils, perhaps irregularly shaped Paralysis of the opposite side often occurs. Sometimes vomiting which Mr. Ab. thinks a favorable symptom in concussion? It may continue a week at intervals until the depression is removed Whenever it is liable to occur upon raising the head we may consider it as indicating compression The second cause of compression is extravasation of blood which is generally between the cranium and dura mater but may be elsewhere This sort of compression may take place some time after the reception of the injury In concussion the symptoms take place immediately after the injury the pulse is soft equal slow, regular breathing soft pupils not dilated paralysis does not occur immediately & is partial & not hemiplegic. In compression one whole side is more or less affected if paralysis exists Compression may or may not accompany concussion Always examine very carefully for fracture, or depression, even if there is no wound of the scalp the pat. will generally wince when the fractured place is pressed on Bleeding is always proper in compression unless much blood has already been lost. Give cal. also No English or Am. surgeon hesitates to trephine. Yet Desault abandoned the operation because he found it always unsuccessful. This was probably owing to the crowded state of the Hotel Dieu All the symptoms are relieved by the operation the nausea goes off & the pulse rises perhaps 20 in a min. Prof. H. has seen fraction of the cranium in two places. Patient died Mr. Abernethy describes a case of fracture of the basis of the cranium, near the foramen magnum Caused by a fall on the top of the head Trephination was formerly not practiced in Connecticut and all the broken headed patients died. Afterwards it was the practice both in this country and in England to trephine in every case When the brain is wounded we are directed not to operate. Cases related by Prof. H. of benefit from extracting bone driven into the brain. He would make it a rule to extract foreign substance from the brain Inflammation may occur sometime after the operation [illegible] have been known to recover when a [illegible] pin or a bullet had lodged in the brain Oblique wounds, with depression are less dangerous than wounds with sharp instruments If the patients are going to get well you will find no bad symptoms. If you do find them you had better operate Inflammation of the brain does not arise till several days after the accident It may come on (after 4 or 5 days to 2 or 3 weeks) from injuries which produced nothing more than contusion, or concussion or after operation Wound of the arachnoid membrane dangerous Inflammation of serous membranes as of arachnoid memb. dangerous Inflammation of [illegible] Commences with pain in the head extending from pariet. to occip. in tolerance of light and sound delirium coma convulsions paralysis death Perhaps commences with a chill Eruptive diseases as measles are apt to bring on infl. of brain in such circumstances The lips of the wound become dry flabby & pale pus is not secreted Where there is no extern. wound there will often be a puffy tumour of the scalp caused by separation of the pericranium The bone beneath will be dry and dead (The pericranium appears to separate at the same time that the dura mater does) Where there is fracture of cran. without ext. wound, pus may collect under the scull and issue through the fracture, & perhaps (if not let out) make its way through the scalp Prof H. has in many instances seen a subacute form of this aff. takes place weeks or months after, the injury He has known cases of dropsy of the head, not only in children but in adults from injuries Treat by powerful bleedings by mercurial cath. & by blistering These means must be vigorously applied When we have reason to think that the infl. is kept up depressed bone we should operate Recapitulation. Trephination is to be performed 1st [from] compression from depressed bone 2nd for compress. from extrav. blood 3d for compress. from pus 1st Prof. H would trephine a person even if in good health without compression if sharp points of bone were sticking in. 2nd As soon as the circulation is restored [illegible] if compression continues make a incision down to the bone and if there is a fracture, operate If there is no fract. try bleeding etc. If infl. of brain is violet & cannot be remedied if we know exactly where the injury, [is] received, operate, to give a chance for life even if there is no fracture Do not operate for more concussion We are directed not to trephine at the lower part of the os [fronte] over the sinus etc. Mr. Abernethy relates a case in which the dura mater was opened by a surgeon a large quantity of extravasated blood was let out the patient was relieved and recovered Let the dressings remain on as long as you can until suppuration takes place or until the patient complains. Disturb the brain as little as possible Exuberant granulations rise from a wounded brain. We are obliged to resort to compression with sheet lead over lint. If necessary they shd be touched with nit. silv. Keep your pat. in a dark & quiet room head a little raised If symptoms of infl. come on bleed & purge Sometimes the [fungus] of the brain or hernia cerebri is very formidable Prof. H. thinks he has seen two varieties 1st a fleshy fungus 2nd a hernia of the substance of the brain Mr. Abernethy advises bleeding. Prof. H. has never seen a case which required it Where there is a true hernia of the brain the patient generally dies We are not to trephine whenever there is paralysis A subacute infl. may follow concussion & cause paralysis. Prof. H has known persons recover perfectly after pretty severe inflam. & paralysis Once there may be hemiplegia & infl. of the brain without compression. Cases related treated with bleeding and blistering etc. Considerable insanity may follow concussion Great advantage is derived from cal. & op in alterative doses cal. 3 grs op [illegible] gr. After compound fractures there will often be considerable exfoliation of bone an open ulcer may, in this way, be kept up for years, from necrosis. Perhaps this may be an additional reason for Wounds of the Thorax 1st those which do not penetrate the cavity 2nd those which penetrate, but do not wound the viscera 3d those which wound the viscera The first kind require no particular treatment The second give great distress for breath the air rushes in and the lung collapses. Close the wound immediately relief is immediately given by it. The air becomes absorbed by it The third sort, generally require a somewhat doubtful prognosis Bloody expectoration generally takes place. The main indication is to prevent or remove infl. If there is diff. breath coughing etc. bleed, purge & blister Emphysema may be enormous We are advised not to be in haste to discharge & extravasated blood. Place the patient in a proper posture for letting out the blood Where the accumulation of blood is considerable there may be an external ecchymosis which, if it occurs, will always indicate extravasation of blood In urgent cases paracentesis shd be performed for accumulation of air within the thorax Prof. A. has always found emphysema relieved by puncturing the cell. membrane. When an empyema occurs it commences with pain in the side & symptoms of fever (pleuritis or pneumonitis) A chill or more will come on about the time of the suppuration When the pus has collected, the pat. can lie only on this affected side, in order to relieve the other lung from pressure. Respiration is performed by the diaphragm & abdom muscles the abdomen is perhaps fuller perhaps there there is a fluctuation externally perhaps the heart will be pushed over to the other sides Percussion gives a dull sound Make the opening between the 6th or 7th ribs unless there is a tenderness [illegible] about the middle near the upper edge of the lower rib. Make an incision about 2 inches long in adults extend it about an inch & an half through them muscles let the opening be about ½ an inch through the pleura The air rushes in & perhaps the pus may not issue at first in this case turn the pat over keep the wound open with a slip of rag Dress with a compress & rag The discharge may continue for years It often happens that the pus does not occupy the white sac of the pleura being in a sac which is limited in extent by adhesions of the pleura Hence it is important to make the opening if possible at a tender spot or one where there is a protrusion The usual consequences of opening a large abscess result. The whole pleura inflames. There will generally be chills and fever. Small doses of ipecac and calomel do well but opium is the principal remedy. Sometimes a hectic supervenes. This may terminate fatally or may end in health. In one of Prof. H’s cases a pat. recovered after 2 ½ years discharge and a very severe hectic. Larrey says patients under 36 gr are more apt to recover because the cartilages are more flexible Prof H. has succeeded in more than half his cases and in many of them the operation was a month or 6 weeks too late After recovery that side of the chest is smaller. The pleura must adhere, if the pat. is to recover Sometimes lumps of matter were discharged Amputations Less frequent now than 40 years ago In the rev. war, many limbs were improperly amputated by surgeon’s mates Necessary from a variety of causes At the present day many compound fractures are cured which would formerly have been amputated Necrosis now rarely necessitates an amputation Great judgment and firmness are required. Some patients will get angry and send for another physician Amputation was first performed with a red hot knife. Then the surgeons cut directly down. Then Cheselden introduced the double incision Then the flap operation was invented Mr. Liston has lately proposed to transfix the limb. Ben Bell was the first to propose the healing by the first intention At length amputation at the joints was adopted and found to be very safe When patients are very low with chronic disease, it is apt to be supposed that the pat. will die of the operation. This however seldom happens In case of excessive shock from loss of a limb etc. amputation relieves the shock according to naval surgeons Case of Mr. Huskisson Prudence is required in communicating the necessity of amputation. It is very improper to bleed the matter beforehand about the neighborhood. Amputation of the joints of the hand performed N.B. The wrist joint makes a much better and more useful stump Wounds of the face and throat Introduction of a cannula for respiration? Wounds of the eye brow cause a ptosis of the upper eyelid A cicatrix may cause either the upper or the lower lid to retract Incised wounds dividing the supra orbitary nerve cause blindness Vie Coop. Surg. Dict. art. [illegible] Division of the parotid duct may cause a salivary fistula. Salivary fistulae may also result from an abscess or from operations for the extirpation of tumours Prof H has healed them by touching with nit. sil. and applying a dossil of lint and a [illegible] compress Cure by means of a trocar & a cannula etc. Desault’s method Another method & probably a better one Diseases of the antrum 1st Abscesses pain in the side of the face & soreness chills [illegible] with face pain may be in one or more molar teeth Discharge often into the nose but the orifice not being free the discharge continues, for sometime. Pus frequently very fetid yellowish green. Pain often so great in the teeth that the pat. has one extracted If this lays open the antrum a cure is effected The bone may be absorbed and the abscess open on the cheek or under the eye Distinguished from tic doloreux by the febrile state, by the tumefaction the soreness pain not in paroxysms general state and habit is different Cure by making a dependent opening. Extract the 1st or second of the true molar teeth unless one tooth is particularly affected. Make or enlarge the opening by a gimlet (say) Keep a bougie in to prevent the orifice from closing. Inject soap and water spirit and water etc. Let the pat. wear the bougie 2 or 3 weeks eventually use a probe & finally knitting needle When the discharge becomes serous we may conclude the membrane to be nearly sound. Even if the discharge has taken place into the nose or on the cheek if it does not soon cease make this dependent opening Sometimes the pointing of the abscess is into the mouth near the gums generally it will then be best to enlarge the opening use a bougie etc. 2nd Polypus of the antrum There is generally a polypus in the nose or a polyp. in the nose extends into the antrum. If it grows with antrum exclusively it must be extracted by opening the antrum externally through the cheek 3d Fungus of the antrum Affects adults and children Little or no pain until pressure is made by the humor on the bones The bones becomes absorbed or softened and a springy feel may be perceived It may project into the mouth externally or under the eye, protruding it The disease becomes horrible, the whole side of the face becomes affected. General health affected vomiting etc. Death Distinguished from abscess by its slow progress. abscess of pain at first want of pus etc. It is said that some cases have been cured. Probably many of the approach more to the character of polypus The bones become so soft that it may be easily cut with a knife Desault makes an opening just above the mouth or just inside of it scoops out the fungus and applies the actual cautery (through a cannula) thoroughly throughout the whole antrum and if the fungus grows again repeats the cauterising He says he has effected several cures Prof. Gibson describes some crooked knives which he has invented for the purpose of scooping out the antrum Polypus of the nose These tumours have no sensibility though they bleed 1st the soft kind with narrow neck & nearly the colour of a system reddish pale & shining 2nd with a broad base usually of a red colour 3d malignant as fungi etc. The first kind is enlarged in damp weather. The second kind resembles fungous flesh. The last kind is a true fungus haematoded accompanied with lancinating pains etc. they may produce fistula lachrymalis Mr. Abernethy cured some patients by prescribing for the disordered stomach Extirpation by the forceps is the only made of cure. A ligature cannot be applied Tear off repeatedly until you have got a great part of it away Introduce through a cone of paper some caustic kali. The polypus will disappear but will return again generally. Blood root snuff will do well after an operation When they extend into the throat apply a cannula (J. Bell) Prof. H. once extracted a polypus 4 in. long. It extended into the antrum It was contracted in the middle like a wasp These [illegible] or [illegible] kind are more dangerous apt to cause absorption of the bones. Rx savin leaves zi opium zj a good snuff. For polypus in the throat J. Bell passes a wire by a cannula, through the nostrils takes hold of it in the throat etc. Tumours on the gums Usually dark red, spongy [illegible] if suffered to grow they press upon and loosen the teeth. Extract the teeth, if dependent on them But they may appear on the outside on the inside, or between the teeth etc. Cut them away and cauterise immediately. The actual cautery is the only cure and they may reappear even after this is used They are covered by the internal membrane of the mouth, which must be lacerated. Prof. H. has known from an abscess a fistulous orifice through the gum continuing for years fungus may sprout up in them. Extract the tooth clip off the fungus cauterize Sulphuric ac. has been used also corr. sub Enlarged tonsils may obstruct the breathing Give cal. 2 or 3 times a week. Gargle with borax or with nit. sil. 3 or 4 gr. to oz. Or touch with nit sil. Removal has been proposed by ligature. The knife is better. Prof. H. severs the tonsil with a tenaculum and quickly slice off a part with a tenaculum Dr Hosack Jun. has an instrument. Great relief is rendered. A probe pointed knife is not necessary Diseases of the Eyelids 1st Infl. of lim. memb. red swollen hot, dry finally increased secretion of mucus (so that [rings], [hatos] etc. are seen) In the morning the lids will be glued together. May proceed to ulceration of the edges, with loss of lashes Caused and kept up by reading at night by smoke by drinking cider etc. Apply cold water frequently Sometimes bleed the recommendation is for cupping and leeches Prof. H. has known great benefit from v.s. Calomel is to be given. The best collyrium is nit. sil. dropped in twice a day. Apply an ointment if red precipitate about 30 gr. to 1 oz of lard at night let a little of it penetrate the eye If this gives too much irritation apply Turner’s cerate If there is much heat apply ac. pl. Vide Coop. Surg. Dict. art. ophth. for Dr Small’s method of curing ophthalmia by compression Granular conjunctiva Caused by the continuance of the preceding. Granular specks enlarged vessels sometimes a fringed fold like a cock’s comb just where the membrane passes off upon the ball of the eye sometimes warty excrescences Apply nit. sil. or sulph. cop. in substance to the granulations. Sulph. copper is most effectual Evert the lid apply the caustic then wash then return the lid. Pare off with a knife or clip off with scissors hard granulations Prof. H. has seen little advantage from scarifying If you can, clip off [illegible] veins with scissors this sort of bleeding is much more efficacious than scarifying Concretion of the lids Sometimes congenital oftener the result of opththalmia total or partial Divide with scissors Open the eyes frequently in a day or two touch with nit. sil. Ectropium Generally caused by cicatrizes from burns etc. A chronic inflammation is apt to come on in the eye Sir W. Adams cut out a piece S. Cooper cuts off a part of the thickened membrane That variety which occurs in old men may be cured by applying nit. sil. & then using compression. Wear goggles Trichiasis may be cured by wrong direction of the hairs or by turning in of the lid (entropium The eye may be destroyed by it Caused by cicatrices near the edge which causes the new hairs to grow wrong. Pull out the hairs and touch with aq. amm. or nit. sil. When resulting from relaxations apply adhesive plaister or cut out a piece with scissors or touch with strong sulphuric or nitric acid over an oval shaped part When there is a wrong direction of the edge cut out a slip of the lining membrane in order to allow the lid to turn out If all means fail of curing cut off the edges of the lids [illegible] of the upper lid Has been cured by adhesive straps; by nit. ac. as above by cutting out a slip [illegible] Hordeotum (stye) Ordinarily nothing to be done but to poultice. Sometimes the suppuration is imperfect especially in delicate females a tumour may thus be left behind and give great alarm, being mistaken for a wen or a cancer. There may be a granulation of the inner surface of the abscess just as in scrofulous abscesses. They are readily cured by touching with nit. sil. If they do not burst and the skin is whole over them so that they resemble a wen lay them thoroughly open and touch with nit. silv. Encysted tumours of the lid Commence without inflammation They are to be taken out either internally or externally when they do not adhere to the lining membrane of the eye, you may often succeed by splitting the tumour open and pulling out the cyst. Ophthalmia Inflammation of the eye May be considered in reference to the whole or a part of the eye but if one part is affected the rest are apt to become so Endemic in Egypt and Ohio burning sense of dryness copious hot scalding tears the eye is kept closed severe pain in head and face perhaps in the cheek or frontal sinus Redness and swelling of the eye. If the schoatica is affected the redness is of a darker colour (and apparently stationary) If the conjunctiva is the part in flamed the redness is brighter and the membrane is so much swollen that the cornea appears depressed Ultimately the cornea appears dusky a little. The aqueous tumour becomes somewhat opaque The cornea may eventually be cast off suppuration of the eye internally causing it to run out Caused by operations, by foreign bodies Amospheric influence Endemic influence etc. Prof. H. has known it alternate with intermittent The most powerful remedies shd be used First stand blood letting. The British surgeons in Egypt drew 60 ounces It is of no consequence from what part you bleed Prof. H. would bleed ad deliq. (in an upright posture) give [illegible] ca. followed by neutral salts afterwards apply ac. lead Collyquiums are forbidden but nit. sil. is dropped in with great advantages (3 or 4 or more grains to the pint more for chronic ophth.) If the pain etc. recurs repeat the bleeding & calomel. Antimony is much relied on in Europe. Prof. H has used it only as an adjuvant Use the nit. sil. 3 or 4 times a day not too strong just strong enough to create a little uneasiness at first If the eyelids stack together, by a discharge from the [illegible] apply a mild mercurial ointment Prof. H. never could see any advantage from bleeding from temp. art. or jug. vein Cupping and leeches may be used but shd not be relied on to the exclusion of general bleeding Letting out the aqueous humour has been practised with advantage. Vide S. C. surge. Dict. Blisters to the nape of the neck are beneficial When the disease becomes chronic a variety of remedies are used Nit. sil. continues to be beneficial It makes the surface of the eye feel smoother Vinous tinct. op. (Sydenhams laudanum) op. zii cinn. & cloves aa zi wine 1 pint digest a week This is often beneficial causing smarting at first but afterward relief Rx sulph zinc & ac. lead aa grs vi wat. oz ii we have ac. zinc. This is a good collyrium Scarification seems to be of little use Opium is useful. Dover’s powder is a good form. As soon as the pat. can bear this light accustom the eye gradually to the use of opium Tonics are seldom indicated. But in intermittent centuries Sul. quinine is highly useful. Bleeding etc. may be conjoined with sul. [illegible] (Vide the late periodicals) Cataract May originate from wounds & other causes Its commencement indicated by [halos] as observed around a candle & other such appearances To be distinguished from aneurism, by opacity, by some sensibility to light contraction and dilatation of pupils etc. It may be complicated with aneurism In aneurism flashes scintillations etc. are felt. Proceed to operate without debilitating the patient with low diet & a state of anxiety and apprehension It is customary now to dilate the pupil with belladonna or stramonium previous to the operation Apply it to the eye, eye lid etc. the night before [illegible] [illegible] hour before drop a little in the eye Enter the needle about a [line] & a half from the edge of the cornea the needle having its surfaces horizontal Pass the needle up to the top of the cataract turn the edges perpendicular press the edge down lacerate the capsule thoroughly then turn the needle horizontal again and carry the cataract directly downwards. If your needle horizontal again and carry the cataract directly downwards. If your needle is a crooked one turn the point first backwards in lacerating then downwards If the cataract proves to be a milky one lacerate a little and do the best you can After you have depressed, withdraw the needle partly and if the cataract rise depress again A caseous cataract must be cut to pieces and pushed through the pupil into the anterior chamber A secondary cataract must be pushed through also If the operation is to be repeated let an interval of at least two months intervene If both eyes are affected it is a good rule to operate upon one at a time. This is often safely disregarded with safety, however. Be very cautious about using the eye for some time. Wear a green shade at first. If there is much pain, bleed & give opium [Ceratonixis] or Laceration For a long time only tow operations vide extraction & depression. It was found however the congenital cataracts (which are generally membranes would be absorbed after laceration First established by [Saunders], at the eye infirmary in London Two modes of operating the anterior & posterior First dilate the pupil and belladonna or stramonium Mr Saunders used the anterior mode & made an opening through the centre We are directed not to wound the iris; but some surgeons do not hesitate to do this Mr Saunders was frequently obliged to repeat his operation a number of times Extraction The advantages are that the operation in successful at once that a hard depressed cataract lies on the retina & irritates the eye etc. ON the other hand, secondary membranous cataract is said to recur sometimes after extraction the vitreous humour sometimes escapes. Prof. H. has always found a scar across the centre of the cornea, afterwards It is said that inflammation is more liable to occur. This is [denied] by others who say the extraction is the safest in this respect. Enter the knife at first perpendicularly then carry it horisontally Put the patient abed and keep him on his back. Both eyes must be kept closed for some days. The [illegible] humour flows for some time. When the eyes are first opened, if we find any of the iris protruding, we must endeavour to restore it. Extract of belladonna will perhaps assist this Iritis Redness dark caused by syphilis & mercury Terminate by [permanent] contraction & closure of pupil or by [illegible] pupil. May extend to crystalline loss of the cornea Treat by one full bleeding Never mind weakening your patient provided you save his eye Bring the system under the full influence of mercury as soon as possible Though the disease is sometimes caused by mercury yet this is proper for its cure. Conjoin opium say 1 gr. op. & 2 grs. cal. 2 or 3 times a day. Merc. oint. is rubbed into the eyebrow Along with these remedies are used to prevent permanent contraction of the pupil. Stramonium & belladonna Rx Red prec. 6 grs. op. 8 gr. lard z2 apply warm fomentations. Collyrium of corros. sub. & Sydenham’s laudanum is used Keep the patients eye in the dark Push the remedies if necessary Prolapsis of the iris May result from a wound or by suppuration A brownish tumor (or purple) size from a pin’s head to a pea, as large as a hazelnut Called staphyloma of the iris Exquisite pain is felt upon closing the eye Pupil on one side In recent cases the prolapsus must be returned and the eye kept at rest If this does not succeed the application of stramonium may draw it back In [older] cases where it is of long standing or where the protrusion follows upon ulceration then putting back with a probe will not answer we may touch this with nit. sil. pain follows at first but a leathery covering is formed which protects the part Collyrium of ac. or sulph. of zinc is also a good application. It may be necessary to draw out a portion with a hook & cut it off with scissors Prof. H has treated several cases caused by wounds with a pen knife with nit. sil. severed [illegible] successfully Inflammation of Cornea Mr. Travers questions the propriety of considering the cornea as subject to infl. Deposits of opaque matter however do form. An ulceration of the lining membrane may follow and discharge into the aqueous humour. Inflammation of the conjunction may If you perceive the cornea growing opaque redouble your exertions Ulcerations of Cornea 1st Irritable ulcers as [illegible] [illegible] like a of moss Eye very irritable feels as if sand was in the eye tears feel s scalding hot eye kept closed children hold their heads down Touch the ulcers with nit. sil. once in 2 or 3 days For young children we may inject a strong solution 6 to 10 gr. to the oz. The cicatrices from these ulcers generally wear away. 2nd Indolent, deep sloughing ulcers larger thicker slough may be ¼ to 1/3 of an inch in diameter. Use the caustic more freely When they change from their grayish to a pink colour, we may expect them to heal soon. Patients may in the latter stages need tonics much mischief is often done by injudicious purging Abscesses of the eye The pus settles down in the lower part of the anterior chamber & exhibits a half moon shape. Make a puncture with a spear pointed lancet. In one case Prof. H. found the cornea opaque the iris inflamed and the pupil about closing the puncture gave immediate relief Little vesicles may form & when they burst give rise to irritable ulcers Opacity of the cornea Mr Travers advises coll. of nit. sil. & alternately of corr. sub. (the latter 1 gr. or ½ gr. to the [illegible]. Divide the enlarged vessels with a hook & scissors this gives great relief it destroys the vessels Various substances are blown in e.g. levigated glass, calamine, white sugar The utility of these seems very doubtful Dupuytren advises 1st general v.s. or leeches 2d a seton in the back 3d Rx lap. cal. calm. & candied sugar equal weights in powder. He says that specks and commencing opacity may be relieved by the powder alone Mr Travers perseveres in a course of mercury Staphyloma Cornea projects to that the eye cannot be closed causing great irritation tears etc. The cornea is perfectly opaque & vision entirely lost First pass a ligature transversely through the cornea then pass a cataract keep through & finish the operation with scissors Fungous tumours of the cornea A small hook & scissors are the proper instruments Follow with nit. sil. Clip off enlarged bloodvessels Pterygium [illegible] of the [illegible] [illegible] A reddish triangular membrane the pupil growing from the internal angle of the eye. Sometimes it stops just at the cornea At others it passes over Sometimes but rarely, it arises from the external canthus It [causes] a proneness to infl. of the conjuctiva Dust lodges on the membrane & is not easily removed If combined with ulcers, these must be first cured Extirpate this elevate the membrane with forceps or a hook & clip off with scissors as far as the edge of the cornea It is unnecessary to remove it as far back as the canthus. Even if little points remain on the cornea they will be absorbed, if you interrupt the continuity Encanthus An excrescence growing from the [caruncula] lacyrymalis producing great irritation Cut off with scissors. Prof. H. has known a large one cured by touching repeatedly with nit. sil. Dropsy of the eye Generally proceed by external always by internal infl. Cornea always opaque Sometimes appeared confined to the anterior chamber The sclerotica becomes thin & bluish like a soft shelled egg irregular also. May be caused by a wound Tape the eye with a spear pointed lancet or a cornea knife Repeat the operation No infl. follows ultimately the cornea grows thicker and retracts. This is the mode for the anterior dropsy. Whether the dropsy of the whole ball can be cured in this way is not so clear S. Cooper directs a piece of the cornea to be cut out of the size of a pea Travers says all the humours cannot be evacuated except by cutting out a part of the iris Cancer of the eye When seated in the conjunctiva, there is a thickening of this membrane and perhaps the cornea is obscured. Eventually the whole eye is involved. Ulcer with hard edges. Extirpate with a straight edged scalpel Restrain haemorrhage by pinching a torsion of the arteries with forceps Prof H. would put neither lint nor sponge within the orbit. He would dress with comp. & laud. Fungus haematodes of eye Formerly called cancer In the first stage the pupil is dilated iris discoloured (dark green or amber) The fungus can be seen in the bottom of the eye like burnished iron. The schlerotic coat becomes knobby, bluish etc. Finally the cornea & sclerotica ulcerate Fungus finally protrudes dark red bleeds easily. Cancer begins externally & eats away it is a disease of advanced life. Fungus is a disease of childhood? Still these two diseases resemble each other more in the eye than elsewhere Prognostic after extirpation very doubtful. Amaurosis Function of the eye without any external appearance except want of contractility in the pupil. Dil. pupil said to be a symptom May be caused by infl. of the retina by tumours pressing on the nerve or the brain. Occurs after excessive use of the eye in viewing the minute objects Vision has been restored by proper remedies for infl of eye it begin early and pushed vigorously, when it arises from acute inflammation of the retina Acute infl. of retina destroys vision suddenly Chronic infl. destroys it gradually Corr. sub. has been preserved to cal. in this disease. On the continent of Eur. Antimony is celebrated for this complaint Cases caused by epilepsy, tumours of the brain etc. are of course hopeless Pretern. dilat. of pupil Seldom an idiopath. complaint Pret. contr. of pupil Myosis Constant rolling of the eye (just as in congenital cataract) Commonly caused by infl. may be attended by opaque lens or capsule or not. For recent cases apply belladonna Push remedies diligently if there is inflammation Closed pupils may be attended with opaque cornea or not opaque lens & capsuled or the eye may be full and prominent, or flattened and with a large [illegible] Ascertain carefully whether there is remaining any sensibility of the retina Three modes of operating 1st a simple incision 2d removing a piece of the iris 3d tearing the iris away from its attachment 1st Chelelden’s mode Another way is to make an incision with a knife & then with scissors make two incisions & shaped 2nd make an incision seize the iris & clip it off and if it does not retire push it back with a probe If the lens is opaque, extract it 3d Scarpe’s mode. Prof. H. has operated in this way. Introduce a couching needle as for coaching separate the upper edge ½ of an inch & depress it. In one case Prof. H. was interrupted by a sudden hemorrhage within the eye An irregular pupil of course is made Ranula A bluish tumour under the tongue Caused by obstruction of the duct (probably) Dupuytren introduced two connected buttons [illegible] Prof. H. opens thoroughly & touches thoroughly with nit. silver. Division of the frenum Prof. H. has had one case of a ligamentous frenum [binding] down the frenum Wounds of the tongue Stich it together use Physicks forceps Enlargement of the tongue Caused by mercury, which has sometimes made it so large that it would nearly be bitten in two by the incisor teeth Ulcer [illegible] & tumours of the tongue. Caused by irritation of the teeth by disorder of the digestive organs etc. Cancers may grown there. Encysted tumours may grow there. Use alum borax nit. sil. (nit. sil. 15 gr to 2 pt as a gargle). Ulcers of saliv. touch with nit. sil. Internal use of opium is the best remedy for salivation purgatives are injurious Solution of corr. sub. is a good garble for a number of minute ulcers. Extirpate cancers & tumours Mr. Coster cuts out a v. shaped piece when the tumor is on the tip of the tongue bringing the edges together with stitches Cauterise to stop hemorrhage Enlarged tonsils A curved bistoury is recommended Prof. H. uses an abscess lancet on a stick for an abscess. If no pus issues, no harm has been done the scarification will do goo Prof. H. has several times met with inflammations and an abscess on one side of the tongue near the roof very painful Open with great relief. [illegible] to [illegible] abscess of bursae mucosae. the abscess collects suddenly lined with a smooth membrane incline to close up, like bursae mucosae N.B. abscesses near the surface of mucous membranes are apt to be fetid the air apparently acting through the membrane Cut off enlarged [illegible] with scissors no fear about haemorrhage Osteosarcoma Formerly the patients were suffering to die Dr of Tennessee was the first to perform the operation In some cases the wound has not healed after the operation leaving the patient in a horrid state Dr Cogswell related case of this kind in a man living in Fairfield cty who had been operated on in Philadelphia. Prof. H. would prefer Mons. Costes mode of operating Sarcoma Cellulosum Bronchocele, goitre etc. Endemic in Derbyshire N. Hampshire Vermont western part of N.Y. etc. Occurs generally in young females Mr Wilmer was the first to publish an account of the treatment by burnt sponge. It was communicated to him with several useless additions to the remedy Prof. H. has met with sudden enlargements of the tumours accompanied with sore throat, pain in the head etc. He bled with advantage applied mur. amm. gave calomel etc. Wounds of Abdomen Wounds of the integuments require no particular treatment except to keep the muscles relaxed. Keep also a bandage over the parts in order to prevent hernia Penetrating wounds as by a stab require no particular treatment. Use the interrupted suture. Prof. H. has found no danger in carrying the stitches through the peritoneum. Let the patient avoid coughing laughing, straining at stool. Use a bed pan If intestines protrude with a warm and moist hand, return the viscera gradually return the omentum last. We must not be deterred from returning them by infl. or by a dark colour. Gangrene of the omentum may be distinguished by the blood’s not returning after pressure Gangrene of the intestine may be distinguished by an ash colour such shd not be returned. Larrey’s and others advise to cut off a gangrenous portion of intestine & return the remainder tying the vessels [using] a [leather] ligature] Close with interrupted suture using two needles for the same thread so as to carry the stitch from within outwards. It may be necessary to dilate the wound When an intestine is wounded the villous coat protrudes & turns out Sir A. C. in operating for strang. hernia found a small wound of intestines, he [illegible] it with his thumb & finger & tied a ligature around. The man did well Sew with the glover’s suture (over & over) It is found that a wounded intestine adheres by its peritoneal coat to the wall of the abdomen. The ligatures are cast off the cavity of the intestine & need not be kept out of the external wound Never enlarge a wound to search for a wound of the intestines. Larrey occasionally enlarged a wound in order to afford a freer passage for feces. His patients were eventually cured Vomiting is apt to occur V.S. will relieve it. Purgatives should not be given. Let your stitch, with the external wound remain as long as 8 days Wounds of the Bladder Urine issues In all cases except where the neck is wounded, keep a flexible catheter in the urethra. If there is extravasation of urine in the cell. memb. or scrotum make incisions to allow of its exit Laxatives are found to be very useful Castor oil & senna Passage of rake handles etc. into the anus etc. Prof. H. had one case in which a rake handle passed 22 inch. through the diaphragm. He died of affect. of the lungs spit blood etc. The thorax should have been opened. He has seen many cases of similar wounds of the vagina. In short has seen some odd things! falls on crowbars stumps of scrub oaks etc. all penetrating a greater or less number of inches. Bleed & starve. Blister the abdomen. Paracentesis of abdomen Do not perform the operation for less than a gallon of liquid. The operation is apt however to be delayed to long in cases of dropsy. Dr Fothergill advocated the practice of [illegible] early in dropsy Prof H. has noticed an increase of urine after the operation. He has known some cases of complete cure by tapping. Sometimes in encysted dropsy the accumulation remains stationary for years The fluid may be in one or more cysts or may be in the cavity of the peritoneum The former may come on with out much derangement of health. The latter is apt to be accompanied with a general hydropic diathesis When the fluid is in the peritoneal sac the tumour is general from the first In the early stages the fluid will be most at the lower part of the abdomen, when the patient is erect. The intestines float Ovarian dropsy is near the ilius the tumour shifts its place in different positions of the body at first At length however it enlarges and becomes adherent and a fluctuation is felt. When the accumulation is very large it can hardly be distinguished from ascites except by the history of the case. In one case the tumour burst from a fall The fluid was effused into the peritoneum, and the patient died in 20 hours Dropsy of the uterus must be exceedingly rare of course the os uteri must be closed by disease etc. Hydatids may be found in the uterus Mr [Rostan] says that in ascites a sound like that of tympanitis is given upon percussion at the upper part at the sides in encysted dropsy In ovarian dropsy the fluid may penetrate between the vagina & rectum & may be felt Encysted dropsy can scarcely be affected by medication Tapping must be resorted to. Put a broad bandage (from the ribs to the hips) around pin it behind Cut a hole in the bandage opposite the linea alba. If there is a hernia at the umbilicus if so, puncture there the walls being much thinner Let an assistant press the sides of the abdomen. Plunge in the trocar (If you push gradually the trocar will enter with difficulty) As the fluid flows, keep tightening the bandage. Towards the close press the abdomen in all directions Withdraw the canula if then the fluid continues to flow, let it run & be received on cloth. You may turn the patient over. Tap with the patient recumbent on the edges of the bed. When sitting the patient may faint. He may faint also if the bandage is not first applied. By means of the bandage we avoid all the danger of the operation After the operation dress with lint a compress & sticking plaister & bandage together Let a bandage be worn for months afterwards or even for years. It gives great relief The largest quantity which Prof. H. has drawn off was 32 gl yet in 23 days 23 quarts more accumulated. This case was caused by schirrhous liver which weighted about 13 pounds One patient was tapped in 13 places Another was tapped in 6 places at another in 6more finally in 6 others & the patient recovered One place where the operation was performed was between the vagina & rectum where two quarts were drawn off Occasionally the wound does not close. This is apt to be caused by the exhausted state of the constitution. It may arise from improper dressing. Stay by and watch whether the opening [illegible] If you cannot stay by and the orifice continues to flow and you cannot stay by use the twisted suture Diseased ovaria Prof. Smith operated to successfully Vide his memoirs Mr. [Losans] was generally unsuccessful. Prof. H has read all the accounts in the English language & thinks the operation scarcely advisable Hernia A protrusion of the peritoneum containing some of the viscera Sometimes hereditary Produced (especially if there is a predisposition) ty strains in lifting. Generally the causes are unknown 1st Inguinal 2d Femoral 3 Umbilica 4 Ventral 1st Inguinal 4 species. 1st oblique 2d direct 3d congenital along the spermatic cord 4th encysted hernial sac suspended in the tunica vaginalis The sac grows thicker as the hernia is [illegible] When it passes no further than the groin inguinal hernia is called bubonocele when it passes farther it is called scrotal 1st Oblique inguinal hernia Symptoms Distinguished from hydrocele by the latter’s not being affected by coughing by its transparency by the cord’s being felt Hydrocele of the cord is distinguished with more difficulty by coughing not affecting it Haematocele Hernia humoralis varicocele Mistaken are very often made and [illegible] applied to these diseases. Varic. happens twice as often as the [illegible] Hernia in the right [illegible] Hull’s truss is the best. It should be worn constantly day & night (A. Cooper) Dr Hull & Prof. H. think it sufficient to wear it during the day Many cases may be cured by a truss but let it be worn long after the hernia is cured. Dr. Hull denies that accidental protrusions will totally prevent the cure (as A. Coop. says) Children as they grow larger must have a new truss The use of the truss produces an adhesion of the neck of the sack Irreducible hernia Hernia may be irreducible from various causes from adhesions from a sudden protrusion of a large quantity of intestine The tumour (within) may be of a pear shape If the hernia cannot be reduced a bag truss should be worn. They are inconvenient and dangerous Sir A. C. has known a hernia supposed to be irreducible, finally reduced by ice applied 4 or 5 days. Prof. Smith distinguished between strangulated & incarcerated hernia. But the latter seems to be little more than an irreducible hernia Symptoms of strangulated hernia Pain constipation (though there may be tenesmus) [illegible] of [illegible] tumour very tender vomiting hiccup cold sweats etc. Omental hernia, when strangulated produces similar symptoms, but generally neither so violent or rapid Post mortem appearances exhibit infl. of the intestine perhaps over the whole peritoneal & in the latter case the death may be sudden within 48 hours In other cases operations have succeeded 1 or 2 weeks after the strangulation A small hernia exhibits more violent symptoms than a large To reduce place the patient on a bed his head & pelvis elevated thigh at right angles (bladder previously emptied) Embrace the tumour with both hands, as you would an elastic gum bottle. Prof. H. has practiced this mode for 20 years (It is Gohagan’s of Iceland) HE finds it better than A. Coopers of kneading. Gohagan advises to keep the pressure steadily for an hour changing the hand if fatigued Have a bowl of cold water at hand, and occasionally wet the hand Use ice also salt & water. Do not use violent pressure. If we fail with the [illegible] bleed to fainting & immediately try again with the [taxis] Bleeding lessens the tenderness & soreness It will also tend to prevent subsequent peritoneal infl. Warm bath may be tried Prof. H. has used tobacco injection zi to a pint half at a time a dangerous remedy however. It produces universal relaxation and then perhaps the tumour may be reduced Sir A. C. says calomel is often useful assisted by a [illegible3] of compd est. colocynth Strangulated hernia has often been mistaken for colic (perhaps the patient may be ignorant of the existence of a rupture or breach as they call it) Purgatives are dangerous apt to cause infl. After bleeding Prof. H. has used opium with advantage especially in old hernias of old men. Direct inguinal hernia Seldom large may be caused by a blow A rare species A truss is applied nearly in the same way as for oblique hern. Epigastric artery on the outside [illegible] muscle partly in front of the tumour An old large omental hernia may not be so soon fatal as a small & recent one Still all hernial (if [illegible]) are dangerous & when strangulated, an operation must not be too long delayed. Death may occur in a day or two in some few cases. Mr Hey lost many cases by operation too late. So with Desault. So with Prof. H. much mischief is often done, by violent and long continued handling It is the best rule to operate soon. Less pain is often felt in the operation than in the [previous] taxis Place the pat. on his back on a table feet in a chair set between the thighs If the hernia is small & the skin lax the surgeon & an assistant may pin it up the integument transversely [illegible] and [illegible] his knife through this gives less pain ‘ Do not carry the incision quite to the bottom of the tumour Divide each fascia with a director The sack when you get to it is usually known by its shining appearance though it may be purple etc. caused by a bloody fluid within Rub a fold of it between your finger & thumb so as to be certain that you have no intestine or omentum adhering to it. Pinch up a small fold with forceps and make a small incision then introduce a director and enlarge a little then introduce your finger as a director [illegible] reduce the intestine if you can If you cannot introduce your finger as a director carry the point of your knife along it arriving at the stricture depress the handle of your knife and divide gradually Divide freely enough to allow the entrance of your finger. It may be necessary after dividing a stricture at the external ring to divide another at the internal ring Divide upwards & outwards or perhaps better, always upwards Adhesions may always be broken up with the finger. Return the intestine first & then the omentum Prof. H. now passes his suture through the sac Sir F. Earle recommended this vide Hey and since he has adopted this practice has never had a case of a second protrusion. If more than 2 sutures are needed put the lower ones through the superficial integuments only Place the sutures about an inch apart Dress about the 4th or 5th day. If a stool does not come away in a few hours give castor oil or if this fails, calomel Dress with a T bandage etc. If the intestine is gangrenous (it is not so when merely purple & dark bloody) Sir A. C. says a gangrenous intestine will have a fetid smell Prof. H. has noticed this in incipient gangrene A gangrenous intestine is the strongest reason for operating If the intest. decidedly gangren. Prof. H. would not even divide the stricture, but make an incision into it and allow the feces to issue. Cut off mortified oment. with scissors Case in which the gut has burst Prof. H. did not do anything but leave the case to nature after opening the sac. After about a month the fever took their nat. course Dr Phys. in one case found two parts of intestine parallel [illegible] he made an incision into each in order to allow the fasc. to pass from one to the other The pat. dies from want of passage for feces Vide Travers After the operation if peritoneal infl. continues, treat by v.s. by cal. or by cal. & op. Diarrhoea sometimes takes place, both after the taxis and after the operation Treat with opium For direct ing. her. divide upw. & inwards Hernia of inguinal canal No distinct tumour exists except upon coughing May become strangulated & is often mistaken for peritoneal infl. Vide Sir A. C. for the operation Make the incision through the [tendon] of ext. oblique, very carefully etc. Oblique inguinal hernia in females. On coughing the tumour protrudes downwards this In femoral hernia the tumour protrudes upwards on coughing Operate as upon the male Congenital hernia Called [wind] ruptures by the nurses Tumour is within the tunica vaginalis Take care not to injure the testicle & leave the lower portions of the tunica vaginalis entire so as to contain the testis Encysted hernia of Mr. Hey The whole sac is protruded into the tunica vaginalis Open the tun. vag. & then search for the sac Femoral Hernia Prof. H. has cured one case in a male Prod or first a pain on suddenly stretching the limb. Finally a small swelling appears increases passes downwards inwards, forwards & the upwards over Poupart’s ligam. Sometimes passes downwards along the saphena vein Has been mistaken for [illegible] abscess or for an enlarged lymphat. Has been opened for an abscess Occurs oftenest in women who have borne many children Generally intestinal and small Often irreducible A truss does not cure so certainly. Women who wear a truss can dispense with it during pregnancy. Taxis often fails Strangulation causes severe symptoms We may try the taxis but should not use much force Delays are dangerous the hernia being small & the stricture sharp edged. Death has taken place in 17 hours. Patients will be apt to die about the 5th day Operation. Place pat. as before Carry your incision downwards beginning above the tumour. Sir A. C. advises another [illegible] transverse below Prof. H. has never made this. It is said that a superf. vein will be divided Prof. H. has often operated, and never met with this In his last operation not two teaspoonfuls of blood were lost N.B. we do not reduce the hernial sac only its contents Old sacs are generally adherent Divide the stricture upwards & a little inwards towards the umbilcal Divide freely enough to allow the introduction of the finger Endeavour to pull the neck of the sac out before dividing If the obturator artery surrounds its neck we can feel it with the finger Umbilical Hernia may become very large. Colicky pains flatus faintness at the stomach etc. In children called wind rupture also The superficial integuments will often be thinner in some places than in others appearing like an abscess Frequently than are two openings from within, into the sac. Occurs oftenest in females and in corpulent men Caused by ascites if so, then tap at that place Treat it in infants, with a conical piece of wood or ivory confined with adhesive straps Desault cured such cases by tying a tight ligature around the neck of the tumour after reducing the intestine Let older patients wear Hulls truss. If irreducible let a broad bandage be worn Sir A. c. advises to reduce without dividing the sac Prof. H. would be averse to attempting to operate without dividing the sac The hernial sac is apt to adhere to the skin so that the incision is [illegible] directly into the sac [?ntoal] Hernia Generally in the linea [similanaris] The stomach is sometimes included Symptoms of dyspepsia etc. may often be relieved by a truss Tobacco injections are very useful in this and the preceding species Irreducible hernias cause colic, constipations etc. requiring cath. sometimes there occurs pain and vomiting requiring perhaps v.s. and always opium in full doses When an irreducible hernia becomes inflamed there, less local soreness than when strangul. The pain is more universal and wandering over the abdomen. the abdomen is not swollen there is not hiccup etc. Give a large dose of opium Thyroidal hernia, occurs at the frama ovale. Pudendal hernia ix a variety of inguinal never requires an operation. Vaginal hernia occurs between the vag. & rect. use a pessary. A hernia occurs between the bladder and rectum in the male Hernia occurs (rarely) at the ischiotic sac. Prof. H. has seen one case of the latter in a boy. After all operations apply a truss when the pat. gets up Preternatural anus As the wound becomes smaller tighten the compresses and bandages When a little mucus is discharged from the rectum, solicit a natural passage with injections Finally tighten the dressings and touch with nit. sil. or sulph. cop. In permanent cases we have eversion of the villous coat etc. Desault introduced a roll of lining into the two ends, and kept thus the two in contact Dupuytren where there were two portions parallel punched the adjacent coat and caused a perforation for the feces (he continues a particular kind of forceps) the patient was cured Imperforate anus Make a crucial incision & keep in a bougie where there is no external anus When there is an anus, but the rectum terminates in a cul de sac the case is more difficult & they generally terminate fatally Stricture of the rectum Commences with difficulty of discharge [pellets] of matter imperfect evacuation pains in the hip, back etc. finally costiveness cathartics perhaps cause a liquid discharge, and often an apparent diarrhoea but the bowels remain full of hardened matter Colic flatulence acidity, dyspepsia. Reduced to liquid & bland food often the patients chew meat & spit it out swallowing the juice. Ill effects are generally felt, only sometime after the swallowing of food Hemorrhoids etc. may occur May be from hereditary malconformation. consider also by habitual costiveness Distinguished from hemorrhoids by the pure blood discharged from the latter & [illegible] the pellets of feces also by the apparent dysentery Structure of the colon is distinguished from it by absence of the straining freedom from dysentery seat of the pain also by the strictures being too high to be reached Always examine by the finger & if that will not reach by a bougie make bougies of dyachylon & wax 11 inches long for an adult Bear in mind the curved form of the rectum, when you introduce it Introduce by address not by force. To lessen the irritation, first inject 30 to 60 drops of laudanum Carry it as far as the sigmoid flexure when it has entered this, a little wind will issue Examine whether there are not more strictures than one Let the large end of the bougie pass up beyond the sphincter or the latter will be internally irritated. Let the loop hang out. Dr McClellan prefers the flexible metallic bougie The irritation may be excessive at the first application but it diminishes by use There may be a prolapsus of the colon through the stricture which must be pushed up by the bougie In this case also give cold injections to brace the parts bougies give great relief unless desperate cases Phlegmasis dolens Spergamosis puerperarum Dr Davis maintains that it is caused by an infl. of the iliac veins this is hypothetical Difficult to determine this as the disease is rarely fatal Origin very obscure. It seems to be preceded by increased fetor & abundance of the lochiae Occurs after all sorts of labours and in all sorts of patients. Said not to occur a second time but Prof. H. has met with instances. Occurs also in males after fevers Prof. H. thinks it probably Commences at an uncertain period after delivery by pain and swelling in the groin. The limbs swell rapidly Pain considerable pain in the groin also motion very painful. At this stage the surface does not put on pressure no serum issues upon puncture no coldness as in anasarca The constitutional shock is sometimes very great coldness, faintness The other thigh may be affected The swelling begins to go down, first in the groin and labia Prof. H. treats mainly by calomel which he says gives great relief. He follows with opium for the irritation He always applies bandages from the first This gives great relief. He wets the bandage with ac. lead or mur. amm. Apply a clean bandage every day Repeat the cal. frequently Dr Hosack treats as for a dropsy with ipecac and squills. After the relief of the disease a deep seated pain in the thigh. This Prof. H. has relieved by a large blister and this is the only case in which Prof H. has found blisters give relief Inflammation of the cell. memb. on the hips back etc. of puerperal women Often mistaken for phlegmasia dolens They suppurate and should be opened There will be redness instead of the general tumefaction and the white [shiny] appearance They may become gangrenous and terminate fatally i.e. the glands no suspicion of venereal disease Retention of Urine may be brought on in old persons by neglecting the calls of nature Suppression of urine belongs to the department of Theory & practice Retention caused 1st by paralysis of bladder 2d Inf. of neck of blad. 3d press if foreign bodies 4th press of gravid uterus 5th enlargement of the prostrate gland 6th strictures In the first place7th constant desire to pass pain thirst nausea of vomiting costiveness cathartics etc. not operate an injection pipe can scarcely be introduced The bladder may ulcerate into the peritoneum and the pat. die thus or he may die of const. irrit. and in the latter case he becomes comatose before death. These may be the symptoms of paralysis of the bladder 2nd infl. of neck of bladder may be caused by cantharides by ulcers in the perinaeum by infl. of vagina produced by instrument 3d Stones in the bladder scarcely cause complete retention 4th the gravid uterus may cause complete retention A retroversion the uterus will always cause retention Some think it is caused by retention 5th Enlargement of prostate gland will cause a difficulty of passing and the true nature of the affection will scarcely be suspected. Eventually a complete retention may come on and then when the catheter is introduced in large quantity will be drawn off at once Sometimes when the urine begins to dribble away the complaint is mistaken for diabetes Other causes have been named [Parturient] women have died from this cause The ultimate consequences are peritoneal infl. fever dry tongue delirium etc. Other diseases seen to be produced is phthisis pulmonalis etc. Introduce the catheter by drawing the penis [illegible] in the first place keep the end close under the os pubis Sometimes with drawing the stilette a little to increase the curve At other times withdraw the stilette wholly Diseased Prostate Begins with frequent & imperfect micturition ultimately the patient becomes costive pains are felt in the part also in the back & hips a constant necessity for cathartics and when a stool is obtained urine flows more freely. The patient often will not call on a surgeon until the latter stages of the disease Finally opium must be taken constantly and the patient wears out perhaps with pulmonay consumption Much has been said about repeatedly introducing the catheter or suffering it to remain in. Prof. H. in inclined to the former. It will at always be necessary to withdraw the catheter twice a week to clean off calcareous matter. Other remedies are proper for sudden attacks e.g. v.s. warm bath injections of laudanum etc. even in a last resort injections of tobacco For chronic cases tinct. mur. feri a highly recommended If a catheter cannot be introduced try a small bougie Generally the smallest catheters can be introduced as well as a bougie Read the remarks of different surgeons about introducing the catheter as J. Bell C. Bell S. Cooper etc. Such cases are better treated now than formerly less [illegible] is wasted now with diuretics Cases combined with stupor of the brain, are best remedied by tinct. cantharides. The cath. should however be used The French surgeons use a conical catheter and force a passage. This is not to be initiated If a young surgeon cannot introduce the catheter, let him send for an older one. If a catheter cannot be introduced. The bladder must be punctured Make an incision in the bria alba 1 or 3 inches long. Cut down to the bladder and introduce a large curved trocar piercing obliquely When the stilette is out push the canula further in Either leave the canula in or introduce through it a flexible catheter & keep it in Mr. Abernethy thought it better to separate the [pyrimalis] muscles For stricture of the urethra, in some cases, such a catheter or canula Hydrocele 1st take care the canula is in the tun. vag 2nd Place your patient against a wall keep the injection in 15 m. (Prof. H.) Take care to fill the tum. full Use 3 parts wine 1 water Make a large puncture 8th If you inject into the cell. mem. stop immediately Great pain is produced Sometimes faintness Hence have some one by to assist you in case of fainting After about 3 days the swelling begins to abate In a fortnight the may perhaps be cured Encysted hydrocele of the spermatic cord Haematocele Sarcocele Fungus haematodes of the testicle Schirrhus of testicle Hydrosarcocele Fungus of the testicle cured by caustics. Venereal enlargement of testicle Hydatids of the testicle may be very large and confounded with hydrocele Cure by castration. has been kept in 2 or 3 years Southern mode is to open into the rectum etc. Irritable testicle seems to be a neuralgic aff. Try v.s. cal & afterwards arsenic & conium. Use opium all the while iron and sulph. quin. are rec. & are useful. Put off castration if you can Suppuration of testicle Open the abscesses & keep in a little slip of [illegible] for a [illegible] membrane will close very speedily It may be necessary to introduce nit. sil. Or if you have not room for this you may dip your probe in nitric acid & thus form a little nit. silv. Circocele Begins gradually finally the veins feel like a bundle of earth worms Let the pat. be down and press at the abd. ring, and a circocele will be enlarged & thus it may be distinguished from hernia Apt to give alarm but not dangerous Cause obscure there may be in such cases a disposition to have varicose vein # Patients are often subject to paroxysms of pain. v.s. cal. & other laxatives Apply cold discutients. Quiet your pat. about the danger. Keep the parts constantly suspended. The spermatic art. has been taken up why it is difficult to determine. Generally by quieting the patient you will have little trouble. Much mischief has resulted from wearing trusses for them # perhaps caused by accumulated feces & by injuries Chimney sweeper’s cancer Caused in the scrotum by soot Perhaps the testicle may become affected It is said that the disease may be cured even after the lymphatic glands have become affected Probably a variety of cancerous tubercle of the skin Sarcomatous enlarge. of scrot. may weight 50 or more pounds Testicles not affected Penis disappears. Integuments of lower part of abdomen drawn down. Skin may be rough & scabby. Probably a variety of elephantiasis. Vide Larrey’s mem. of it in Egypt. Extirpate not dangerous is the operation Vide the case of a Chinese lately in London 60 or 70 pounds died immediately Gonorrhoea Infl. of muc. mem. of urethra sometimes extending to the glans Arises from impure [connexion] Whether the same or not, it is treated different from lues syphilis A milder disease now then formerly in London Vide Abernethy Cured more readily when it occurs immediately after connexion, then when it occurs after a week or more Different phys. treat it very differently probably because it often (as is said) cures itself & because it may be interrupted by various [illegible] Bals. cop. is very popular now formerly it was used only for gleet. Cubebs are said to be equally effectual. Give bals. cop. 1 teasp. 2 or 3 times a day If it purges giv e opium Rx bals. cop. & nit. eth zi aa. tinct. op. & tinct. camph aa zi t.sp. 3 or 4 times a day Apply cold lotions In France they give nit., pot. & sulph. sod. etc. Ac. pl. 14 gr. to ½ pt. or sulph zinc grs 10 or both together, for an inject. if the discharge continues Ultimately corr. sub. 1 gr. to 1 oz 1/2 pt or nit. silv. 3 or 4 grs. to 1 oz water Make inject. stronger [illegible] For gleet give bals. cop. & add tinct. canth. 20 or 30 drops Apply blisters to perinaeum if necessary Treat sympathetic buboes with discutients with blisters Treat chordee with opium dover’s powders etc. If urine is frequently passed & with pain use the catheter it giving [illegible] relief Opium is the best remedy for chronic aff. of bladder as a sequel Uva ursi is recom. also Whether the bladder or prostate is aff. use the cath. Hernia humoralis Infl. of testicle Caused by gonorrhoea by injuries by metastasis of hydrothorax etc. by metastasis from aff. of head mumps Not produced in the early stages of gonorrhoea but in the decline though to be brought on by stimulant injections Caused also by aff. of prostate & various urinary affections Flatulence borbogyna pain testicle swells when large flattened in bad cases a redness of the skin Pain & constitut. irrit. very great from the distention of the firm serous membrane Bleed cal. salts Horizontal posture suspensory bandage ac. plumbi Prof. H. troubles himself little about the running [illegible] the infl. of the testicle is cured generally the gonorrhoea ceases Where a serous effusion in the whole scrotum takes place, shave & blister the whole scrotum If a hardness remains (especially of the epidydimis) treat with camphorated mercurial ointment Pus should always be evacuated if it is not evacuated, a fungus will spring out nit. sil. Phymosis Congenital accidental generally goes off (when natural) at puberty if not we may be called on to remedy the complaint. In venereal diseases ulcers may be concealed, or ulcers may arise from the sebaceous glands may irritate The urine may irritate Sometimes the prepuce may be enormously distended. Sometimes infants are born without any orifice When there is an opening it is sufficient to slit up the prepuce. If now cut off the end When distended make an opening with a lancet. As to the size of the opening, calculate upon a retraction in [healing]. Use a sharp pointed knife upon a director If the [prepuce] is schirrhous in old men circumcise & you will do this more easily if you slit up first Everted urethra Case in an infant Mischief from tying a ligature around the penis by boys troubled in bed. Swelling may cause the string to disappear cases mistaken for phymosis etc. Paraphymosis When the prepuce cannot immediately be brought back, every moment increases the difficulty, as the glans continually swell. Gout swelling, infiltration etc. occurs. Apply cold water etc. & then the patient must submit to have the prepuce returned place him against the wall, & have him held Compress the glans a long time shifting your hands in order to keep them cold & when you have the glans sufficiently reduced, return the prepuce if you fail, try again It is not necessary to divide the stricture Le Franc, also always succeeded without division Stricture of urethra May exist to a slight extent Most commonly 6 or 7 inch from external orifice just behind the bulb next to this is 4 ½ in. frequently ‘ there are more than one & almost always one at 7 inch dist. (E. [illegible] May be on one side of the canal In old stricture we have an almost cartilaginous hardness Symptoms alteration in form or size of stream of urine may be forked Dose not tend to a spontaneous cure but to grow worse & worse Difficulty of passing urine increased by cold by drunkenness by hard exercise Ultimately irritation chills, fever, anasarca excessive pain anorexia aphthae etc. etc. A discharge may come on and be mistaken for gleet especially after gonorrhoea hernia haemorrhalis nocturnal emissions & semen thrown back into the bladder May be mistaken for gonorrhoea, gleet infl. & abscess of urethra or prostate calculi in bladder or urethra. Pain in passing urine greater in gonorrhoea Diseased prostate is generally in old men & admits the catheter for 7 ½ inch. & a catheter can generally be passed by skill in enlarged prostate enlarged prostate can be felt by the finger in the rectum. Caused after sometimes by gonorrhoea (as a remote consequence) By injury of the perinaeum by stone in the bladder by warm climates Treatment Ascertain the existence of a stricture by means of a bougie Warm & oil & [illegible] your bougie if you fail pass a smaller one. We may be obliged to desist from pain, irritation, shivering faintness etc. But the urethra becomes insensible after a time. Where a very small bougie is needed catgut is recommended it swells in the part When we have succeeded in passing a bougie the cure is in our power (S. Cooper) Eventually we can keep in the bougie for several hours When we cannot pass a bougie introduce caustic it lessens the irritability Prof. H. has lately preferred a small catheter with a piece of nit. sil. in the end. Some use the caustic kali Flexible metallic catheters are much used of late Bougies undoubtedly do goo besides their mechanical dilatation. They stimulate the parts Patience and perseverance are needed Retention of urine hemorrhage (when the slough separates) may occur Prof. S. laid open the stricture internally Fistula in perinaea Caused by strictures by calculi etc. Touch with nit. sil. Dr Physick passed a piece of tape laterally & tied it tight over the fistulous orifice Vide Dorsey’s Surg. In worse cases, pass a straight sound down to the stricture pass in a probe & feel its end. Cut down to the end of the sound Dr Stevens proposes to inject a coloured liquid into the cath. to assist in finding the urethra Always cure the stricture first Mr. Earle performed [a] [talication] operation Sir A. Cooper’s treatment of retention of urine remarks on Incontinence of urine 1st from paralysis of sphincter from general palsy from long continued peritoneal [illegible] from retention 2nd from injuries causing a communication by ulceration into the vagina or by a cancer 3d during sleep affect children under puberty 4th S. Cooper mentions an irritable state in which the pat. is constantly compelled to urinate. This is merely a symptom of hysteria hemorrhoids stone in the bladder etc. 1st When occurring from paralysis treat for the general aff. and introduce the catheter frequently. When from difficult labour introd. cath. freq. 2nd plans of cure by sutures 3d It has been lately supposed to be caused by lying on the back not so Prof. H. has cured by cantharides Sometimes connected with disorder of digestive organs great thirst etc. Imperforate vagina Sometimes the labia, wholly or partially adhere Separate sometimes with your thumb (vide Denman) When not discovered till the period of menstruation very troublesome Prof H. has had several cases. Sense of weight pain in the loins finally difficulty of passing urine in the first symptom noticed in some cases difficulty at stool swelling of abdomen nausea hiccup etc. Much variation in the nature of the closure sometimes membrane sometimes very thick Examine whether there be not more than an obstruction perhaps a ligamentous band Hemorrhoids Two kinds varicose & organized If the blood comes from the intestines above it will be black if not, florid? Prolapsus ani often often accompanies If very superficial and near the verge they may often be clipped off Prof. [illegible] [illegible] when from the intestine extirpates by a ligation Pass a needle through & tie each way Fistula in ano Prof. H. is convinced that it arises from infl. & suppuration of the bursa muc. behind the rectum Causes obscure perhaps hemorrhoids Begins with pain, fever etc. When the abscess bursts externally it is called external fistula when internally blind fist. when ext. & int. complete fistula Const. sympt. & pain very severe Open early & keep open with a bougie when external When blind pus on feces a tumour at [anus] very fetid, as is usual with abscesses in muc. memb. No plan of cure succeeds but laying open Pass your finger up the rectum & meet your finger with a probe pointed bistoury then cut down through the sphincter Introduce ling Be careful to distinguish from lumbar abscesses etc. pointing near this part. Cancer of the rectum. The extremity of the rectum has been extirpated. Distortions of the feet Club foot valgi & vari There is a malformation of the tarsal bones. Probably the affection is caused by some wrong position in the uterus Seeds to be more or less hereditary in some families. There is an institution in Paris for distortion s attended with great success When the foot turns directly upwards towards the tibia it is easily remedied by a roller an elastic splint and a bandage. Club feet are easily restored by the hand the difficulty is to keep it in its place. B. Bell’s mode by a [shoe] etc. [Machines] of wood carved out. Prof. H. has succeeded very well by a tin shoe with one side running up the leg He has succeeded well also with stiff saddler’s leather. But Smith’s splint in superior to all other modes. Apply to F. Gregory of Uxbridge Mass. The great object is to keep the sole of the foot, flat on the ground & turn the toes out as much as you can Palsy of the lower limb from diseased spine vide Pott. Generally affects children The child will be observed to stumble the toes point downwards, remarkably The limb looks remarkably smooth and tense, instead of flabby and wasted. Upon examination we shall find the [illegible] vertebrae, projecting Ultimately the bladder is affected with strangury perhaps there will be incontinence of urine. The patient may die of marasmus etc. Remote cause obscure Prognosis doubtful Caries and abscesses are often met with Mr. Pott invented the mode of treatment by issues, and was very successful in a number of cases Lateral distortions of the spine are said not to produce paralysis Paralysis appears to be caused only by this angular distortion. There will be also pains in the loins etc. Sensation is erroneous with respect to the heat of the limb Pat. thinking it hot when cold & v. versa Sometimes sensation remains, at other times the paralysis is complete. Sometimes the abdominal muscles are paralytic sometimes the urine & feces come away unconsciously. Large sores may be caused in the ischia & trochar [less] by lying in one position There is generally a permanent anchylosis after the cure Experience shows exercise to be injurious. Hence some propose to cure by rest Opium will almost always be needed. Ultimately sul. quin. Very probably iodine might be beneficial. Sometimes a seton has been substituted for an issue Once in 2 or 3 months an old issue should be suffered to dry up & a new one made Lateral distortions of verteb. We are generally first consulted for a projection of one shoulder blade Caused by long sitting in one posture etc. Darwin thinks position in bed to have some influence and directs those children who sleep together, to change sides occasionally. Mr. Casey’s machine has a staffed back. lifts pat. up by shoulders Carrying weight on the head proposed Depend principally upon exercise in the open air and sleep upon a hard mattress. Such a plan as this will make the distortion stationary, and restore the general health But Prof. H. has not known it permanently & effectually cures the distortion Give soda, iron, rhubarb etc. Setons and issues seem to do little good. Friction and sharpening are useful Mr. Harrison lays much stress upon manipulation on the back and this too for all kinds of vertebral distortion Diseases of the medulla spinalis, producing paralysis without aff. of vertebrae Affects mostly children from 2 or 6 mo. to 2 yrs old. Generally begins with a febrile affection, and soon a paralysyms & hemiplegia sometimes one side first one limb, then another Adults sometimes affected in a similar manner. Dentition has been thought a cause. This cannot always be the case. Scrofula has been considered the cause also but scrofula is uncommon in the country where nevertheless this aff. is met with. It is often attributed to the little calomel given in the commencing fever But many cases have received no medication at all Prof. H. considers the disease an inflammation of the serous membrane of the spinal marrow. Sometimes the disease is chronic and unattended with commending fever. Sometimes the brain may be affected thus; vide Amaurosis Prof. H. treats acute paraplegia and’ hemiplegia etc. first by v.s. mercurial & other cathartics and a succession of blisters. As has lately used more pinching up hard a small ball of cotton & [illegible] it dowm by the blow pipe Tart. emetic ointment etc. Prof. H. has often succeeded this for children but sometimes fails. Chronic cases he treats in a similar manner [Moxa] near the ear seems to have great influence upon paralysis of the face When the spinal marrow comes on during a fever Prof. H. has succeeded often in curing it Some cases seem to be caused by parturition The more acute the disease the easier cured. For chronic cases Disease of hip joint morbus [coxarious] [illegible] form 1t violent irritat. acute fev. etc. 2nd a chronic form coming on gradually counterfeits all diseases 1st begins with acute pain generally in the knee high irritative fever emaciation sallowness etc. Apt to be mistaken for aff. of the knee Not the slightest motion is allowed confined to one posture in bed limb elongated knees separated Eventually there will be shortened the [illegible] of the bone being on the dorsum of the ilium this shortening is ascertained by comparing thickness & ankles Prof. H. has known the length [illegible] in the first stage amount to 1 or 2 inches Supposed to be caused by scrofula this cannot always be so The disease is more rapid in children than in adults Distinguished from lumbar abscess by the history and appearance Sometimes after the spontaneous dislocation health will come on & nothing but lameness remains Generally there is some amendment when pus issues The prognostic is favorable if amendment follows evacuation if there is no hectic etc. In the chronic form we have first a slight lameness in walking pain is often exclusively at the knee sometimes at the hip over the [illegible] nerve This form is often caused by scrofula Seems often to arise from violence also from exposure to cold and sometimes no cause can be conjectured Many cases of sciatica are thought by Prof. H. & I. to be affections of hip joint Injuries will increase the disease as by nat. bonesetters Case related of this sort Treat. the acute form by v.s. & cal. apply ac lead (cold or warm) give opium freely from the first to relieve the pain better in the first place in form of dover powder. If the ain does not subsid. apply a blister Issues are too slow If the disease is attacked early it may generally be cured Treat the chronic form in a similar manner blisters seton is [illegible] & [illegible] Keep the limb absolutely at rest & secure this object by using Smith’s splint Make issues with caustic kali through a hole in a plaister & cover with another plaster In 6 or 8 hours it will have made a sore. Apply your issue generally back of the trochanter Prof. H. has succeed with them in the inside of the thigh near the knee. Setons are introduced on the anterior part of the joint Do not push your counterirritation too far with children Renew your setons and issues once in 6 w. or two mo. Prof. H. has applied tart. emet. Moxa now fashionable. Larrey does not wish for suppuration thinking the heat mainly beneficial The bowels are apt to be costive, from [illegible] to pass a stool manual assistance is sometimes necessary at stool The constitutional weakness and irritation are very great op. op. & cal conium etc. bark quinine Unopened abscesses are very dangerous Patients are apt to die suddenly with them Mr. Abernethy kept the pat. at rest at first (in the chronic) and gave the blue pill etc. for the constitution [the] prohibited motion for a long time etc. This practice not energetic enough for the acute form. Iodine now recommended We stand much in need of a better mode of treating this disease Considerable difficulty with parents often Venereal diseases formerly considered a unit. Mr. Hunter described the chancre But Mr. Hunter’s disease is now but rarely met with. Carmichael describes the true chancer & severe other sorts of sores on the penis A French writer has denied the existence of a specific syphilis Prof. H considers the inoculation of small pox and other poisons similar to the venereal contagion The first effects are entirely local 1st a little pimple or vesicle with serum or pus It degenerates into an ulcer of a foul & ragged appearance. Next the absorbents are affected Net an infl. of lymph. gland in the groin. Next ulcer in the throat or eruptions on the skin or both Net [nodes] tibia sternum fore arm perhaps ossa nasi It is now found that very many venereal sores may be cured without mercury. Such cases are now generally called syphiloid Many experiments have been made in the army more or less successful without mercury Mr. Hunter’s chancre has elevated edges & a hard base Prof H would pencil it thoroughly with nit. sil. afterwards wash with a saturated sol. of sulph. copper Then the black wash (cal. & lime water) Keep the pat. quiet in his room. If consulted early do nothing more If the chancre is early destroyed there will be no bubo When a bubo forms & suppurates, open and touch thoroughly with nit. sil. The ulcer in the throat looks very ill, yet gives less pain in swallowing then would be expected. The [pat.] will often deny its existence The eruption on the skin is quite singular looking like mallows cheeses Some prefer blue pill some corr. sub. others calomel others mercurial ointment. Sydenham gave 20 gr. doses of cal. Dr Carter of Natches has revised this practice procuring bilious discharges say 2 a week & salivation comes on Give corr. sub. in a bread pill 1/8 gr. Patients will scarcely bear more than ¾ gr. a day without a dysenteric aff. of the bowels Blue pill [5] gr. at night if this fails give it oftener Mercurial fumigation Mercl oint. rub in about a dram a day. We wish to avoid salivation Give large quantities of sarsaparilla. Conjoin guaicum etc. also Nodes will require no separate treatment Min. acids have been very famous. It does well after the system is reduced by mercury So sulph. quin. etc. when tonics are indicated [illegible] panacea has sometimes done well after a long mercurial course owing probably to its [minute] quantity of corr. sub. If a phlegmosis hide the chancre inject sil. cop. ac. lead or nit. sil. Inflammatory action will require v.s. & cal cathartics Sometimes life is threatened by a local hemorrhage The joints may become affected like rheumatism Partial blindness and deafness occurs If exfoliation comes on inside of the scull, generally the patient dies of paralysis etc. After long use of mercury the system becomes so susceptible that rubbing in a little merc. oint will affect the mouth in 15 min. In such cases Fowler’s solution has done well. Dr [Pardon] [Bowen] of Providence, relied very much on it. Give large quantities of sarsaparilla in the sequel The bones of the limbs sometimes becomes completely brittle Venereal infants mercury Calculus in the bladder May be produced upon a foreign body lodged in the bladder as a nucleus e.g. musket ball bits of a bougie etc. needles by hysterical women! More common in the western states and in Maine Symptoms very obscure pains in loins, vomiting, sediment in the urine sand passing away Nausea and vomiting with excessive pain are most apt to be cured by the passage of calculi along the ureters The pain will be sudden and violent not gradual and dull like that of psoas abscesses Retraction of testes, numbness etc. will also attend These passages through the ureters are commonly called attacks of gravel Passage of calculi through the urethra, gives rise to retention sense of tearing etc. perhap Symptoms of stone in the bladder pain at the extremity of the penis greatest when bladder is empty The pain comes on in paroxysms They are aggravated by walking or riding over a rough road. Pains in the neck of the bladder at stools. Yet these “fits of atone” may come on without any exciting cause. Patients pinch the glands Pass urine frequently have a frequent sense of inclination to go to stool. When the calculus is large there may be a sense of weight in the bladder. The urine becomes finally turbid perhaps bloody Children are said not to be subject to pain in the kidnies and ureters experiencing only stone in the bladder Finally micturition may be very frequent once in 15 min. A thickened and inflamed state of the bladder supervenes finally the patient dies of hectic. Prescribe remedies for irritation in general v.s. in extreme paroxysms Cal. opium as a matter of course It has been customary to cojoin alkalies & uva ursi these relieve though they do not dissolve the stone Prof. H. was for a long time afraid to blister for strangury but he now finds it very beneficial Operation Hippocrates swore his pupils not to perform it. The first mode was to pass the fingers up the rectum pull down the stone into the perinaeum & make an incision directly upon it. This was called the lesser operation or cutting by the gripe Next came the apparatus major so called in consequence of the large number of instruments A small opening was made to the forcibly dilated Next came the high operation above the pubis This has lately been attempted to be revived By this mode a large stone can be extracted without breaking Lately it has been proposed to operate through the rectum The present mode is called the lateral operation and is performed now as [Ches??da] formerly did. Some are inclined to substitute the knife for the gorget First sound perhaps a schirrhus may be sometimes mistake for a stone Prof. S. performed the operation for a calculus in the urethra. If the calculus drops down into the bottom of the bladder introduce your finger into the rectum Mr. Hey sometimes sounded with a silver cath. and felt the stone as the urine flowed. A flexible catheter without a stilette, has sometimes succeeded when other instruments have failed. Examine sitting standing, lying etc. Try repeatedly Administer over night a senna cathartic and an hour before the operation an injection Operation After it the urine flows out at the wound. Dr [Rhea] Barton keeps a flexible catheter in the bladder through the wound Some give opium immediately after the operation. Be guided by circumstances give opium if pat. has been in the habit of taking it Laxatives are very beneficial Children suffer very little But old people are apt to have chills, cold extremities etc. Treat as for shock q.v. Apply cloths, just as to a woman after delivery. Watch for hemorrhage When infl. comes on it is known by pain, chills etc. A very successful surgeon at the west, bleeds ad deliq. immediately after the commencement of delivery Fatal cases exhibit not gangrene but suppuration and abscesses The relief from the operation a very great pat. sleeping better the night after the oper. than for weeks previously Lithotomy in Women Case of a stone formed around a darning needle! extracted for Dr Cogswell The operation through the vagina is easy but the wound is apt not to close & [then] cause an incontinence of urine Sir A. C. introduced the plan by a sponge tent. Rx a sponge & dip it into melted beeswax moderately hot roll it into an oblong shape Introduce it the bees was melts out and the sponge dilates very powerfully often succeeding in a few hours When the stone is too large 1st cut [illegible] director to the left 2nd cut between Le France’s ode (invented by Costa) Place the pat. as for lith. a [illegible] is held by an assistant & depresses the urethra and vagina. Cut with a bistoury above the urethra and obliquely from the the symphisis pubis down close along [illegible] the ischium cut layer by layer until you arrive at the bladder Tumours of the bones Exostosis an increased growth of the body most frequently found in the [cran.] sternum clavicle ribs long bones Sometimes flat sometimes pointed sometimes pedunculated Sir A. C. makes two varieties one from the substance the other from the medulla Prof. H. makes cartilaginous (with bony parts interspersed) and fungoid or medullary Caused by external accidents as blows etc. scrofula syphilis etc. said to be the causes To be distinguished from [aster] sarcoma by its uniform hard [illegible] Seems not to affect the general health, unless the part is so large as to interrupt functions Most commonly the tumour stands out at an angle Sometimes they cease growing and remain stationary No treatment but extirpate is of use Use trepans [illegible] of various kinds, chisel & mallet etc. Operation not dangerous 2nd Osteosarcoma may be hard at the surface but will be soft (perhaps lardaceous!) in the centre (called fungus by Sir A.C.) base broad the whole substance of the bone is converted into it. Sometimes suppurations come on in the interior IT is fashionable to consider them all as fungus haematodes but they differ Fungus haematodes cause absorption of an adjacent bone. The general health is here affected Prof. H. considers internal remedies of little use. The disease is apt to return after extirpation. Boyer advises the actual cautery after extirpation. When on a limb amputate. May be of immense size as large as the body. Prof. H. has known on as large as a milkpail & two tablespoonfuls of laudanum at a dose necessary for the pain Caries soft black cloth stained dark perhaps honey combed from venereal etc. (may be caused perhaps by long unopened abscesses in some cases) Treat by caustics & especially actual cautery. Occurs most in the spongy bones Sometimes resection Caries of the hand penetrates the cranium Especially affects the mastoid process From syphilis We may touch only the mast. process with act. cautery. Remove carious portions Caries of sternum from syphilis Natural cure of caries is by necrosis terminations by depositions For superficial caries stimulating applications are generally sufficient e.g. nit. sil. sulph. copp. etc. Caries may occur on sacrum crest of ilium tubers of schium etc. from lying long on one [portion] Necrosis Death of bone Applied by Prof. S. to the specific disease called “fever sore” Bone first white then dirty yellow finally brown and black often surrounded on the edges by an elevated circle of granulations but finally the necrosed portion from being depressed well as it were rise up & be more elevated Commence with fever which is apt to be considered by the physician as an idiopathic fever followed by the fever sore. Occurs in the cylindrical bones principally oftenest in the tibia next in the os femoris External and internal periosteums dies & then the bone dies of course sometimes however the death is only in spots. Prof. H. is convinced that [illegible] incision often prevents the destruction of the periosteum vide [illegible] Commences with deep seated pain but often the pain is first in the joint & the disease is mistaken for rheumatism In a day or two fever comes on perhaps finally subsultus tendium and delirium Great pain on moving the limb. Pus first accumulates under the periosteum but in the thigh first in bursa under the tendons of the [ham.] In the spongy bones pus collects also in the cancellar structure Caused by cold contusions comminuted fractures caustics applied to ulcers most commonly in boys from excessive bathing in cold water many cases of this kind exposure to rain storms generally causes [illegible] sores unknown the joints near the part are apt to become much flexed Apply a splint pretty early Treatment. Bleeding cathartics blisters and opium Prof. H has found the subsequent irritation as much worse in the latter stages when the treatment was not commenced by evacuations The notion that evacuation shd not be used because the blood may y and bye be wanted. Prof. H. would pay little attention Besides at first we do not know certainly the nature of the affection in the first place in many cases we shall be told of an injury Blisters at the commencement are better than fomentations and poultices Pus will form however As soon as the disease is fully formed make an incision down to the bone through the periosteum we shall generally find pus If there is pus inside the bone bore into it with a nail gimlet It gives the greatest relief be careful not to split the bone Extracts from the notes taken by my friend T. H. Wadsworth of the Lectures on Surgery of Theodore H. Woodward Prefect Castleton Vt. Metastasis is another organ aff. sympath. & more so than the first Adhesion a vital process analogous to assimilation not an infl. for infl. hinders, as does coagulated blood, which has lost its vitality most successful where no heat or pain or mark of infl & then may take place in 18 h. The [illegible] lymph forms a bed for the vessels to ramify in The secretions of a part infl. gradually change to pus & then gradually back again, as in successful cures of clap. Prof. W. uses bandages to most acute infl. contrary to common practice they do good unless the irritability is very great or they are [illegible] fully applied they are particularly useful to deep seated infl. especially if chronic Mortification Prof. W. has seen all the muscles of the arm dissected clean from shoulder down & hanging but by their ends. A small strip of skin remained from wh. new skin was formed & covered then again. The case was caused by the bite of a hog When you bleed in cases where you expect extensive suppuration to come on, [illegible] on [illegible] you may want the vital power back again. You may temporarily relieve pain in any aff. whatever by v.s. you may if [illegible] wish produce syncope or death. In phlog. cases the best refrig. to follow v.s. in tart. ant. in nauseating doses it keeps the skin moist & affects the other secretions For superf. infl. cold is the main quality in external applic. Use spir. 1 pt to 4 water vinegar etc. etc. Somet. when all the [illegible] appear to indicate cold applic. they disagree & produce vomiting, spasm, or even convulsions. Here use fomentations which need not be medicated unless with narcotics which have considerable effect. Astringents added to washes do little good except for appearance. Lead, if very strong has some effect use a sat. sol. Lead applied too long to eye will produce palsy of it. For deep infl. use warmth cold is like water on outside of a blacksmith’s fire, making it hotter within. Use counterirritation Acute infl. term. in chron. is bad to manage & must be looked to it is apt to produce considerable irrit. of stomach. Commonly we want a moderate use of alteratives cal. & op. use bandages friction, liniments gradually change to a more generous diet. The best form of merc. in these chron. aff. is corr. sub. with op. bark may be [wanted] camph & carb. amm. good to allay irrit. & keep skin moist the position shd always be such as to favor the veins in this stage cool washes are not commonly good frict. with merc. oint. good. The const. treat shd be the same or nearly the same is if there was no local aff. The grade of action may be too low for suppuration in acute cases or it may be too high and gangrene or chronic weakness, effusion etc. may be the results Look to it After suppuration pat. somet. wants support, sometimes does as well without. When pus is in an important part, or under fasciae, do not wait but open After opening a large abscess of the chronic sort there is apt to be increase of pain, fever etc. It becomes aff. with acute infl. from the wound & perhaps from taking off the pressure suddenly Hence open them in the valvular manner, squeeze out the matter, bring the edges merely together, plaister & bandage with compression. By this process ac. infl. is prevented & adhesion of sac promoted we have to open several times but at each time there is less matter. Open common abscesses before the skin over them is diseased when it first begins to blush they heal much sooner bandage & compress. This is worth every thing else in the treat. of such tings Sudden stoppage of the secretion of pus is apt to affect important organs Ulcers Irritable ulcers limewater with mucilage good Rx zfs [illegible] hydrar. zfs cetacii zi opii Often they want calm. & op. say 5 gr. cal. at [illegible] & 1 gr. ope. 6 times a day. Prof. W. has cured many by moderate emet. of tur. min. repeated a few times wash of op. & bark sometimes. If you use bandaging it must be with care sometimes a good Sloughing ulcers no pus livid with [vesicle] constant pain granulations if any dark & often slough. Best applic. 50 drops nit. acid to 1 qt. water this more active than mur. acid charcoal as good as saw dust & no better Prof. W’s experience yeast poultice good. Port wine poultices good Stim. internally Most common in old drunkards Fungus ulcers (filled with proud flesh) are most common, changing sometimes to irritable & must be treated as such we must remove the lard edges before they will heal Cantharides in powder is often a good application to ulcers A simple roller if well applied is as good a way of bandaging as Boynton’s Ulcers with thick indurated inverted or everted edges must, in some way have these edges removed. When gangrene is commencing a poultice of yeast & flour etc. or a fomentation of brandy is good When not very deep seated & depending on local causes, a blister sometimes stops it Nitric zi to a pt. good turpentine ess. oils For [illegible] toes of old folks give tonics & stimulants For gangrene with considerable action remaining cold washes are best for others, hot. Diseases of Women The uterus has not quite so much to do with all dis of women as some think Some women regularly menstruate once in 35-45 60 even 90 days, yet are in perf. health & fit [for] business. Prof. W. has known many women have children at 52 Erythema anatomicum Best thing at first as to excite infl. in the part by caustics etc. Internally use stimulants etc. Anthrax Cut through the whole tumour both ways this relieves much, by taking of the stricture & the sloughs get out sooner Use anodyne fomentations etc. Scrofula Prof. W. has more faith in ext. & int. use of iodine then in any thing else known a large swelling much diminished in 18 m. & pat. become less evacuated & her health improves. Inflamed glands are often discussed in their early stages by blistering Wounds The sympt. fev. is commonly synochus but [illegible] with epid. disth. It is important to make arteries bleed if they will in first dressing & tying them Prof. W. prefers on the whole to let one and of lig. lie out where both are cut off, the part is always irritable Lacerated wounds are apt to bleed afterwards & it is best to secure them if possible In traumatic gang. no matter how soon you amputate if pat. has vigor enough unless the cause of the gang. is constitutional, & then though the gang. spread, you shd wait for the line of demarcation In gunshot wounds there is apt to come on deep seated pain from tension of fasciae etc. open & relieve The symptoms from large contused wounds are commonly those of atony & at any rate do not want dep. Second hem. is commonly from 7-12 d. Tetanus may be from injury of nerve but is generally (as Prof. W. thinks) from wound of a part of low vitality. Irritants to the wound are of use also to spine & stomach Give calom. ol. pin. op. etc. perhaps in some cases of considerable action v.s. to increase susceptibility to articles Wound of nerves Nerves unite as well as any part. The temperature of the part containing the divided nerve is colder but if it is covered with flannel it becomes warmer than the other corresponding part covered in the same way Sprains When the soreness is nearly gone, pouring water almost scalding hot, from a height has the best effect, with friction & bandaging often Sutures bandages, ligatures Prof. W. uses only the interrupted & twisted [sutures] An inexperienced hand had better enter the needle both ways from within in forming an interrupted [illegible] Old fashioned needles miserable things. Dr. Miller’s needle with a handle is good Flannel is more elastic & makes a better bandage for parts that are cold & edematous The only kinds of bandages of much use are strips single & double headed roller & 4 tailed Sometimes (not often) a T bandage Dentists silk makes the best ligature Spina Ventosa A bad name meaning internal caries of a long bone not easily known at first. The cavity of the bone increases in size? at first & fills with matter the outside also increases the shell is thin & there is an appearance of distention Oftenest affects the head of bones & is at first every way like white swelling except that the If even early evacuate the matter from the bone if you are certain what the disease is but if seen very early try general remedies & counterirritation as in white swell. In the latter stages the swelling bursts and often long tumors are formed, It will be attended with great pain irritation & discharge & the limb must be removed Ophthalmia In chronic stag nit. sil. & corr. sublimate better than mere astringents or cutting vessels but in some cases the vessels must be divided The applications are apt to be made too often twice a day will do Prof. W. has faith in local bleed. even when the syst. in general want tonics Great relief is afforded by applying at night a fomentation of cut tobacco, & binding on it may be dropped into the eye in cases not very irritable In many cases at the outset nit. sil. does well dropped into the eye, removing irrit. & vascularity. Do not continue warm app too long at least if infl proceeds to supp. use cold washes nit. sil. sub. zinc etc. In many cases Prof. W. has seen blisters near the eye cause irritation apply them to the neck Simple milk lachrymose ophth. may be cured by any mild stimulant Suppurative ophthalmia 4 sorts 1. epid. 2 metastatic (from clap or catarrh) often with a greenish secretion) 3 intermittent (from interm. causes) 4. infantum If the cornea fades & loses its lustre & its edge looks uneven it will certainly slough unless treated as gangrene by stim. ton. etc. Sclerotitis Straight vessels running to iris, well marked turgid & look as if painted florid color violent pain of eye, especially on motion there is apt to be effusion under the conjunctiva making the surface of the [sclerotic] coat unequal. It is apt to affect the choroid. Prof. W. does not know as there is a [chorditis] when chor is aff. there is dullness of function. the iris sluggishly contracting & limited in motion there is great irritability of the eye & division aching pain in forehead. Apt to aff. the iris. Treat as in other ophthalmitides but merch. ac. is especially useful in deep seated inflammations of the eye Rheumatic sclerotitis looks like the other, but aff. also the periosteum of the orbit & the pain is greatest then The pain is greatly aggravated at night sight always dim. iris acts sluggishly Apt to aff. the other coats. Eye dry & hot The pain often aff. half the head it is irregular & never entirely remitting. The fever is of the arthritic character with deranged secretions of the bowels. Prof. W. never saw bleed. do goos in any rheum. Calom & op. are better. Apply leeches & blisters. Keep the pupil dilated with belladonna. IN the last stage quinine arsenic is still better especially in chronic cases. In acute cases the best thing Prof. W. has seen has been actaea or colch. He never saw any local applic. but narcotics do good. There is no tending to chemosis Catarrh rheumatic aff. sclerot. & conjunct. both & has sympt. of both rheum. part goes off before the catarrhal It may terminate in opacities ulcerations of cornea, may ulcerate through. Digest apparatus much disturbed. Catarrhal or Epiderm. ophth. Prof. W. thinks the same as arythem. muco pur conjunctivitis It is apt to leave a villous look of the conjunctiva. Begins with stiffness of eyelids sense of pricking in the eye, especially about the lachrymal [caruncle] pat. cannot be persuaded that he has not sand in his eye & picks scratches & rubs. Conjunctiva of a mottled red, turgid. [Chemosis] commonly imperfect aff. only one side of the cornea (the chemosis is semitransparent & is evidently from serous effusion) Continues 6-8 days & there is a muco purulent secretion. Bad cases run on to the chronic stage, with ulcers of cornea, effusions, & spreading to other textures Prof. W. never saw sloughing in this It is epidemic & contagious General treat. same as for severe common ophth. Local applic. corr. sub. is best 1 gr. to 1 ounce nit. silv. good, but not equal to corr. sub. (common astring, generally irritate & do no good) Blisters In an early stage & even so late as the middle of the acute stage Prof. W. has cut it short by applying saturated solut. nit. oil, with internal use of arsenic quin. etc. Apply red prec. ointm. a piece as big as a pea between the eye lids & suffered to dissolve The pat. is very liable to subsequent attacks Chronic ophthalmias of all sorts are treated pretty much alike. Generally we must restore or change the secretions by merc. and corr. sub. is best. by other deobstruents in lower cases Narcotics & tonics When you apply red prec. ointm. 12 gr to zi is pretty strong Hydrocele Prof. W. prefers operating by seton of [illegible] thread, drawn through the tunica vaginalis & kept there till there is considerable infl. Causes of spasmodic cholera are not contusion & infection but those of wide spreading epidemics A board of 100 medical officers in India declare for non contagion So the medical board of Madras So also the 24 physicians constitution the medical boards of [Moscow] with only 3 dissentients. We sometimes have cases in this country precisely like those of India This is true of other diseases Diseases cannot be distinguished in their ataxic form this is true even of fever & ague which has destroyed patients in the second paroxysm Pneumonia typhodes has exhibited cases among as precisely resembling those of cholera spasmodica Physicians have differed more in their treatment than in regard to its causes large doses of calomel & opium diaphoretic treatment severe pain at stomach & bowels vomiting & purging great thirst coldness extremities cold to a bystander pulse at first languid or small & throbbing & in bad cases quick small & intermitting cold & clammy sweats death like coldness of extremities hiccup etc. etc. death sometimes with us in 24 hours distinguished from dysentery by watery stools & spasmodic griping pains from colic by stools allied to bilious fever yellow fever etc. produced by the same unknown causes, modified in their action it is to bilious fever what a tornado is to a settled stom. Spasmodic cholera of India has prevailed in 1774 & 1787 & in 18- Prevailed extensively in Sydenham’s time The present epidemic commenced in 1817 Said to have originated from bad rice Dr F. thinks that there may have been a predisposition then the disease first broke out in consequence of bad food & afterwards fear & anxiety would be sufficient exciting causes Anecdote of the plague in the French army Anecdote of a small pox case in Fairfield cty [30,000] reduced to 8000 in [Toflia] 17000 in 8 days at Astraca [6000000] in Asia up to 1830 4000 out of 8000 died in [illegible] Cholera called cholera morbus to distinguish that of [illegible] from chol infantum Copious discharge from stom & bow with painful spasmodic action Sometimes defined as the vomiting & purging of bilious matter this is incorrect bile is not vomited healthy bile could be vomited only in [illegible] cases The liver is diseased in connection with the stomach Affects hot climates & the hot seasons of temperate climates July to Sept. Affects the exhalents & absorbent vessels of the stomach the liver & pancreas There is a translation of action from the surface to the intestinal canal & its attendant glands In ataxic forms there [illegible] be no secretion Causes Sudden check of perspiration especially after great heat By unripe fruits large quantities of acids wild grasses, peaches & milk in short any thing which suspends the action of the stomach in case there is a predisposition. When it is epidemic very slight causes will bring it on & hence contagion is alleged Chills languor drowsiness [distention] [pressure] at [prae] [cordia] 14 Surgery Separation of the lower end of the fibula This is the most frequent accident to the ankle according to Prof. H’s experience Yet little has been said upon it A sensation of cracking and tearing attends the reception of the injury The foot is turned inwards, a little so are the toes there is some swelling in the outside & intense pain is felt upon pressing the fibula inwards. To be distinguished from fracture & from effusion into a bursa on the outside of the foot, in consequence of strains Extend the foot a little, turn the toes outwards & press in the lower part of the fibula Apply a very thick compress & bandage & splint and bandage high up the leg for the interosseous lig. may be torn for several inches Compound dislocations of the ankle are very serious accidents. Prof. H. has seen much mischief arise from short splints and tight bandaging Wounds of the Joints The pain is generally on the opposite side of the joint. Violent pain suddenly occurs if after a few days & is generally attributed to taking cold & the attendants attempt to sweat it out etc. Ultimately excessive suppuration occurs The wounds of the joint, communicating externally, are more dangerous by far than internal wounds, as from fractured bones As severe consequences may result from wounds of the superficial bursae, as for instance that on the external surface of the patella The prognosis may generally be a favorable one for the life of the patient but the joint is apt to be anchylosed Prophylactic treatment Draw the lips of the wound together with add. ph. apply a bandage & a splint & confine the pat. to his bed. In some cases, bleed etc. to prevent infl. Treat. of infl. Press out pus etc. if necessary probe the sac etc. In punctured wounds with excessive pain and swelling & violent const. sympt. envelope the whole joint in a blister which will give great relief Let large ulcerating cavities be thoroughly [pencilled] with lunar caustic The irritation will be very much [illegible] by it. Collections that occur about the joint, should, if they do not disperse be opened & corr. sub. be injected we may first try discut. lot. & blist. And in general, keep the joint wet with disc. lot. If inject. of sol. of corr. sub. fail put a little moistened upon the point of a probe & introduce it down to the bottom of the sore. The older surgeons used red precipitate and an almost saturated solution of sul. cup. Be careful that the limb anchyloses in a proper position if knee, straight if elbow, crooked Dislocations of the Tarsal bones When the astragalus in dislocated inwards it is partly turned over the external & under surface being above Prof. H. has known the os noviculare partially disloc. He kept it in its place by a plaister bandage Gun shot wounds A common ball is said to move 2000 ft. in a second more rapidly consequently than the passage of sound hence in a cannonade at night, the flashing is first seen, then the ball whizzes by & lastly is heard the report The contusion is so great that the parts in contact with the ball in its passings are completely killed The orifice at which a ball enters will have its edges depressed the opposite orifice will be ragged The course of a ball may be very circuitous case in which a ball struck the larynx and passed around the neck coming out near where it entered. Tendons may divert its course A ball may carry before it a silk handkerchief 7 be pulled out and lost when the handkerchief is Injuries formerly attributed to the wind of a ball (for when one leg is taken off by a ball, the other is not injured by the [illegible]) are now explained by the oblique stroke of the ball and the yielding nature of the skin. Bones may be comminuted and even the viscera injured, without braking the skin. Secondary hemorrhage rarely occurs (4 cases in 1000, Mr. [Illegible]) after gunshot wounds and primary hemorrhage is of course less common this sort of wounds than in others Baron Larrey mentioned to Dr Heerman that he had lost two pat. only, where a ball had passed directly through the body Compd fract & wounds of the joints are very dangerous Necrosis of a bone is apt to be produced in consequence of a gunshot wound Necrosis of the cranium may be produced 1st ind. is to suppress hem. 2d extract foreign bodies 3d to prevent inflammation 4 promote suppuration & separation of [ischous] 1st by pressure etc. by a tourniquet applied until ligature or amp. can be performed 2d If a ball is too deep to be felt, it should not be cut for. If it can be felt by the probe, let an assistant make the skin tense, and let the surgeon enlarge the wound & extract. If it is on the opposite side of the body, make the skin tense with the thumb and finger & cut down and squeezing it out. Another period for searching for and extracting balls & foreign bodies is that of suppuration & sloughing 2d The French still keep up the old practice of always enlarging the wound. The British surgeon have abandoned the practice. John Hunter originated the plan. The French speak much of debriding the wound by taking off the tension of the fasciae. They uniformly make incision Cold water is the principal discutient lotion of military surgeons With respect to dilating the wound the British surgeons say that the incision soon close unless kept open by tents. Of course for several days the wound looks very foul; the edges puff out & protrude (Hence Larrey speaks of debriding) Poultices & fermentations shd now be applied 3d As soon as suppuration takes place, poultices shd be discontinued & cerate applied Look out for hemor. when the sloughs are cast off. Direct the pat. & the nurses to apply a tourniquet immediately if hemor. commences When hem. takes place we can seldom depend on tying the artery at a distance It will generally be better to cut down at once Sometimes a complete division of the artery will answer In hem. from the popliteal artery, on account of the difficulty of finding the artery in the hem. the artery may be tied higher up The treatment shd be antiphlogistic strictly. Mr. [illegible] directs cal. & ant. at night If severe pain in the head and back occurs with high infl. in the wound, then bleed immediately. But when suppuration occurs we must give opium for irritation Dr Fuller of Columbia mentions that in the last war it was found necessary to bleed in the first place & then to give opium Neither would answer by itself It is now agreed upon that it is best if amputation is necessary to perform it immediately, as soon as the pat. has recovered from the shock & not to wait till the subsidence of the fever etc. Extraction of Foreign Bodies from gunshot & other wounds If they are suffered to remain a cyst forms around them We must take into consideration first the nature 2nd the situation of it 3d the length of time it has been in. For if this is short we had better not delay but if it has been long in & gives no inconvenience, it may be suffered to remain Great suppuration in some cases and in others excessive irritation may result from the retention. Even a needle may cause great irritation Amputation The best authority is now in favour of speedy amputation Baron Larrey does not hesitate to amputate even after bad symptoms have come on as the pat. will be apt to to die certainly without amputation Prof. H. has amputated successfully in cases of crushed limbs, 48 hours after the reception of the injury When a limb has been shot off you amputate of course. But in case of fingers Prof. H. frequently contents himself with picking out the fragments of bone & dressing the wound When the ball has lodged in a joint or when a bone is fractured it will generally be best to amputate When the bone of the arm or thigh has been broken, necrosis takes place, and if death does not supervene, the limb will be apt to be always useless, or with an artificial joint. Bar. Lar. amputates when the os humerus is struck and if struck near the end, he amputates at the joint Very extensive injury of the soft parts may make an amputation necessary or destruction of the principal arteries and nerves. Amputate above the knee, for injury of the upper part or the tibia Even after amputation death may result 1st from infl. of bloodvessels, both arteries & veins # 2d from metastasis [&] pus being found after death in the thorax, in the lips joint etc. Prof. H. would always let such pus out. In our climate & in. G.B. suppuration of the lungs takes place oftener than in warmer ones 3d by necrosis of the bones at a joint. If the amputation was not high enough at first it may be best to amput. again If necrosis occurs after amp. the end of the bone will be sharp and ragged instead of being rounded by the absorbents. If the main nerve is entirely destroyed paralysis occurs Tetanus is apt to occur from gun shot wounds especially in warm climates Bar. Lar. applied blisters & actual cautery often with success. # & that too whether the veins are tied or not Mr. [illegible] sometimes tied the [vein] for hem. without bad consequences Hospital Gangrene Vide [Hemmer’s] mil. surg. The wound will become painful hot, red, dark, finally livid & black in the mean time the fever increases and becomes more typhoid etc. etc. In hosp. gang. contrary to what is common in common gangrene the arteries are affected & hemorrhages take place. Vide John Bell also The disease is unlike any other but resembles most erysipela of cell. mem. etc. The dis. affects all the textures, spreads among the muscle effects the deep parts more especially Caused by bad air, and a crowded state of the hospital. The affected patients should be separated from the others. It may be communicated by the dressings Mr. [Hemmer] found bleeding give give great relief the patient would beg to be bled cath. also he applied arsenic to the sores and ultimately gave [illegible] etc. In all such cases something must be applied to destroy the surface of the sore White swelling [most] exquisite in the knee Divided into rheumatic & scrofulous the first aff. the leg & the second aff. the heads of the bones. S. Cooper denies however that the heads of the bones are enlarged. Mr. Brodie also makes one division in which the artic. cart. are aff. Prof. H. considers white swelling as always in the first place an inflam. of the synovial membranes & bursae We have pain, tumefaction a puffy swelling is seen, under the lig. of pat. wasting of the limb below 1st Acute form pain then swelling like the swell. of ac. rheum. tenderness on press. & [mot.] joint easier when bent headaches furred tongue anorexia pain in other parts of the limb perhaps edema below the joint We are cautioned against confounding this with dropsy of the joint so called which is merely eff. in to burs. muc. etc. To disting. this from acute rheu. it is only necessary to know that several joints have been aff. in succession for acute rheumatism in any one joint may exactly resemble wh. sw. Sometimes pus forms erodes the ligaments & points externally often taking a very circuitous rout 2nd Chron. form pain at first trifling tenderness or pressure puffy sw. beside the pat. wasting of the limb below or edema Often the pat. will be so well as to be encouraged to use the limb, & perhaps sprain it & have a severe case at once In the latter stage both forms are alike. After a while anchylosis forms & the limb is well. But anchylosis seldom takes place except after suppuration. When anchylosis is about to take place, keep a knee nearly (not quite) straight & an elbow bent. In some cases extensive suppuration comes on & hectic so that amputation must be performed in order to save the life of the patient Ind. 1st remove infl. & here we must consider the kind of infl. wheth. ac. or chron. When there is acute infl. of a large joint v.s. & afterwards cupping scarif. & leeches Mercurial cath. as in other infl. of serous memb. Opium for pain. If discut. lot. do not relieve apply blisters But children are sometimes thrown into convulsions by them. Savin cerate is recommended in order to keep blisters open but it is apt to produce spasmodic retraction of the limb at least in children. Boyer also directs for children foment. poultices, [linim.] etc. Let a blister heal up & apply mur. amm. then in a few days apply another blister If these fail, try corrosive sub. Cut a hole say as large as a bowl of a spoon in a plaister put this plaister on & then over this a plaister coated thickly with corr. sub. This creates considerable pain & irrit. & the disct. from it will last perhaps 3 or 4 weeks. Perhaps the gums will be affected a little. The benefit however is often very great the joint diminishing in size an inch perhaps. Issues are used made with caustic kali Bar. Lar. has introduced the moxa. Setons are used but then give children too much irrit. Apply then below generally When the joint is recovering and is very weak & relaxed much advantages may be derived from a plaister bandage Where the complaint is a sequel of acute rheum. merc. are very benef. no particular advant. is to be exp. [illegible] merc. oint. Give op & cal aa gr i Canth. camph & op. aa zj for a liniment Friction also is beneficial in the latter stages If suppurations occur, open immediately The dis. is apt to recur again from improper [exper.] & exertion & from accidental injuries Reaction of the bones has been practised successfully as a substitute for amp. but not in the knee White swelling of the wrist Hand & fingers both flexed Apply a splint & compress & brace the hand back. It will relieve the pain & give confidence in the use of the arm & great satisfaction Open ever so small a suppuration great relief will be given Nervous affections of the wrists of nervous & hysterical females No swelling but pain, soreness, & inability to use the wrist Blisters seem to do little good. Plaister bandages seemed to be of some service. A similar affection occurs in the ankle joint They get well perhaps after a while. A dangerous affection of the tarsal joints has been met with by Prof. H. Swellings (puffy swellings) like white swelling eventually suppuration perhaps a curdy matter issues little or no pain after suppuration Occurs in children & youth Surgical writers call the aff. a scrof. swelling & advise amputation. White swelling occurs however in the ankle but generally occurs in children, & in the chronic form. It is met with in the children of cotton mills. Prof. H. has treated them with cal. twice a week at first White swelling occurs also in the shoulder and in the elbow An enlargement of the bones at the joints of the fingers occurs in females It has been called gout but Prof. H. thinks it has no analogy. It has been attributed to hard labour but is often met with in others. The disease will commence with pain & swelling similar somewhat to white swelling & ends with permanent enlargement Prof. H. has generally prescribed principally to the constitution applying stimulating applications etc. Iodine has been lately used in white swelling, with advantage Hare Lip Once in a while it is said to occur in the lower lip. May be single or double may affect the bone. Varies from a small notch to a complete di Operation for hare lip first performed in [Winst.] cty by a mountebank Prof. H. at first delayed the operation until the child was some months old But now he operates as soon as called even if the child is but a few days old It seems to be the fact that children with enclosed harelip are more subject to bowel complaints Prof H operates with scissors Put in the lower pin first & push it first upwards & then (in the other half of the lip) downwards to prevent there being any notch in the edge of the lip. Two pins only for children. Wind the threads so as to cover the whole incision Apply over the whole long straps of adhesive plaister. Let the pins remain 3 or 4 days in children & 4 or 5 days in adults Take off the plaister very carefully first each end then the middle Then take out pin by a rotatory motion And afterwards reapply the straps. Double hare lips have a central piece which is not to be cut away but an incision is to be made in the shape of the letter M & then bring all together in one operation thrusting the pins through the whole Cancer of the lip May commence with a crack then a scab finally a hard tubercle which may continue for years, if not tampered with, without much inconvenience. The ulceration may commence in the centre of the tubercle Lancinating pains occur & eventually aff. of the lymphat. glands beneath the jaw etc. etc. Common canker of the lip may be cured by nit. sil. etc. & does not resemble this complaint much Occurs oftenest in middle aged men said to be caused by tobacc. improbable Prognosis favorable in general if the disease has not been tampered with, if the pat. is not intemperate & if the glands are not affected Prof. H. has seen cases of affection of the lip more resembling fungus haematodes than cancer Operate as for hare lip Bronchotomy The operation consists in making an opening into the traches Laryngotomy is an opening into the larynx Bronchtomy has succeeded in some cases of cynanche laryngea or extracting foreign bodies bronchotomy is to be preferred to laryngotomy It is the only certain mode of extricating them. Even if after some time the foreign body is coughed up, the pat. is apt to die of pulmonary consumption Often the substance will be coughed up. It may be necessary to keep the wound open for some time, in order to allow of the exit of fragments The foreign body may be above or below the opening. Irritate the trachea to produce coughing to bring up the body from below Push a body, above sometimes upwards through the rema glottidis, with a probe. If you do not find the body keep the wound open One physician, kept the edges of the wound apart with the blunt hooks Push a probe through the rima into the mouth etc. N.B. Enlarge the opening of the traches with a probe pointed bistoury Operation for fistula lachrymalis peformed Wounds of the throat Lately and English surgeon who happened to reach the pat. within 1 ½ min. after a wound of the carotid & saved the pat. Dr Horner also lately happened to be passing the courthouse when a prisoner cut the branches of the carotid he employed pressure & cut down & tied the trunk the pat. died Wounds of int. jug. vein are sometimes fatal from the rushing of air into the throat. Dr Warren in an operation upon hearing the rushing noise, immediately clapped his thumb on & stopped the operation pat. survived. Taking a full inspiration has been recommended. The int. jug. is much in the way in operations for the extirpation of tumours it bulges out like an intestine Transverse wounds of the traches require sutures though some object to them. Food is apt to come out of the wound use a tube The passage soon closes however Sometimes a fistulous orifice is left as in the case of Desta of Ky. a tube has to be worn for breathing Injuries of the Head 1st external injuries 2d concussion 3d compression 4th inflammation 1st Ext. inj. An incised wound of the scalp is to be treated on general principles It will not be necessary to tie every little artery compression with a dossil of lint will often answer Even if the scalp is extensively separated, the wound may heal by the first intention When there are uneven edges & angles, stitches (the interrupted suture) are useful. Sometimes it is convenient to braid the hair In wounds of the scalp erysipelas is apt to occur & prove troublesome. Treat it as for erys. in general ac. lead or if necessary, blister bleed, [illegible] etc. Delirium is apt to occur but soon subsides Contusions on the head are apt to cause alarm often there is a tumour caused by effusion & the edges being often higher a depression of the bone is imagined and a surgeon will be sent for to trephine 2nd Concussion may be with or without an external wound [illegible] come out of their insensibility without any thing done When first revived, vomiting is apt to occur & generally gives relief pat. breathing better pulse rising Abernethy calls vom. a favorable symptom. But the pat may grow worse afterwards Blood often appears and the attendants think it comes from the stomach but upon examination we shall find it to have come from the mouth, nose, or ears Symptoms generally similar to those of a shock q.v. surface excessively cold After the first symptoms you will generally find the pat. in a profound sleep with a soft pulse Stupor & insensibility more or less perfect In severe cases pupils dilated Delirium may come on incoherence etc. Pain in the head, intolerance of light & sound etc. Sometimes paralysis of one side occurs sometimes fatuity occurs & continue for months etc. etc. Treat by putting pat. in bed applying heat, frictions give hot drinks aromatics moderate quantities of alcohol. After the pulse returns bleed continue the bleeding as long as the pulse rises Dr Phys. restored the circulation by pouring cold water on the head afterwards he bled. Next excite the peristaltic action by calomel. When symptoms of infl. of the brain appear, we must bleed & give cath. Apply cold applications to the head & blisters to the back of the neck. if the unfavorable symptoms continue Dr Rush advised salivation in bad cases & the best surgery in England practise upon this plan, at the present time If languor debility & loss of memory remain long tonics may be required After death, lacerations of the brain are often discovered. Much [???usion] soon changes the symptoms into these which arise from compression of the brain Prof. T. believe the palsy from concussion of the brain to arise from infl. of the [brain] & effusion the palsy is always a secondary symptom never one of the first 3d Compression of brain Infants may not suffer from depositions of the cranium They are said to have depressions without fracture In adults fracture is necessary to compression Sympt. stupor slow depressed & irreg. pulse stertorous breathing dilated pupils. Pat. appears in profound sleep Breathing resembles that of a fatal apoplexy Pupils, perhaps irregularly shaped Paralysis of the opposite side often occurs. Sometimes vomiting which Mr. Ab. thinks a favorable symptom in concussion? It may continue a week at intervals until the depression is removed Whenever it is liable to occur upon raising the head we may consider it as indicating compression The second cause of compression is extravasation of blood which is generally between the cranium and dura mater but may be elsewhere This sort of compression may take place some time after the reception of the injury In concussion the symptoms take place immediately after the injury the pulse is soft equal slow, regular breathing soft pupils not dilated paralysis does not occur immediately & is partial & not hemiplegic. In compression one whole side is more or less affected if paralysis exists Compression may or may not accompany concussion Always examine very carefully for fracture, or depression, even if there is no wound of the scalp the pat. will generally wince when the fractured place is pressed on Bleeding is always proper in compression unless much blood has already been lost. Give cal. also No English or Am. surgeon hesitates to trephine. Yet Desault abandoned the operation because he found it always unsuccessful. This was probably owing to the crowded state of the Hotel Dieu All the symptoms are relieved by the operation the nausea goes off & the pulse rises perhaps 20 in a min. Prof. H. has seen fraction of the cranium in two places. Patient died Mr. Abernethy describes a case of fracture of the basis of the cranium, near the foramen magnum Caused by a fall on the top of the head Trephination was formerly not practiced in Connecticut and all the broken headed patients died. Afterwards it was the practice both in this country and in England to trephine in every case When the brain is wounded we are directed not to operate. Cases related by Prof. H. of benefit from extracting bone driven into the brain. He would make it a rule to extract foreign substance from the brain Inflammation may occur sometime after the operation [illegible] have been known to recover when a [illegible] pin or a bullet had lodged in the brain Oblique wounds, with depression are less dangerous than wounds with sharp instruments If the patients are going to get well you will find no bad symptoms. If you do find them you had better operate Inflammation of the brain does not arise till several days after the accident It may come on (after 4 or 5 days to 2 or 3 weeks) from injuries which produced nothing more than contusion, or concussion or after operation Wound of the arachnoid membrane dangerous Inflammation of serous membranes as of arachnoid memb. dangerous Inflammation of [illegible] Commences with pain in the head extending from pariet. to occip. in tolerance of light and sound delirium coma convulsions paralysis death Perhaps commences with a chill Eruptive diseases as measles are apt to bring on infl. of brain in such circumstances The lips of the wound become dry flabby & pale pus is not secreted Where there is no extern. wound there will often be a puffy tumour of the scalp caused by separation of the pericranium The bone beneath will be dry and dead (The pericranium appears to separate at the same time that the dura mater does) Where there is fracture of cran. without ext. wound, pus may collect under the scull and issue through the fracture, & perhaps (if not let out) make its way through the scalp Prof H. has in many instances seen a subacute form of this aff. takes place weeks or months after, the injury He has known cases of dropsy of the head, not only in children but in adults from injuries Treat by powerful bleedings by mercurial cath. & by blistering These means must be vigorously applied When we have reason to think that the infl. is kept up depressed bone we should operate Recapitulation. Trephination is to be performed 1st [from] compression from depressed bone 2nd for compress. from extrav. blood 3d for compress. from pus 1st Prof. H would trephine a person even if in good health without compression if sharp points of bone were sticking in. 2nd As soon as the circulation is restored [illegible] if compression continues make a incision down to the bone and if there is a fracture, operate If there is no fract. try bleeding etc. If infl. of brain is violet & cannot be remedied if we know exactly where the injury, [is] received, operate, to give a chance for life even if there is no fracture Do not operate for more concussion We are directed not to trephine at the lower part of the os [fronte] over the sinus etc. Mr. Abernethy relates a case in which the dura mater was opened by a surgeon a large quantity of extravasated blood was let out the patient was relieved and recovered Let the dressings remain on as long as you can until suppuration takes place or until the patient complains. Disturb the brain as little as possible Exuberant granulations rise from a wounded brain. We are obliged to resort to compression with sheet lead over lint. If necessary they shd be touched with nit. silv. Keep your pat. in a dark & quiet room head a little raised If symptoms of infl. come on bleed & purge Sometimes the [fungus] of the brain or hernia cerebri is very formidable Prof. H. thinks he has seen two varieties 1st a fleshy fungus 2nd a hernia of the substance of the brain Mr. Abernethy advises bleeding. Prof. H. has never seen a case which required it Where there is a true hernia of the brain the patient generally dies We are not to trephine whenever there is paralysis A subacute infl. may follow concussion & cause paralysis. Prof. H has known persons recover perfectly after pretty severe inflam. & paralysis Once there may be hemiplegia & infl. of the brain without compression. Cases related treated with bleeding and blistering etc. Considerable insanity may follow concussion Great advantage is derived from cal. & op in alterative doses cal. 3 grs op [illegible] gr. After compound fractures there will often be considerable exfoliation of bone an open ulcer may, in this way, be kept up for years, from necrosis. Perhaps this may be an additional reason for Wounds of the Thorax 1st those which do not penetrate the cavity 2nd those which penetrate, but do not wound the viscera 3d those which wound the viscera The first kind require no particular treatment The second give great distress for breath the air rushes in and the lung collapses. Close the wound immediately relief is immediately given by it. The air becomes absorbed by it The third sort, generally require a somewhat doubtful prognosis Bloody expectoration generally takes place. The main indication is to prevent or remove infl. If there is diff. breath coughing etc. bleed, purge & blister Emphysema may be enormous We are advised not to be in haste to discharge & extravasated blood. Place the patient in a proper posture for letting out the blood Where the accumulation of blood is considerable there may be an external ecchymosis which, if it occurs, will always indicate extravasation of blood In urgent cases paracentesis shd be performed for accumulation of air within the thorax Prof. A. has always found emphysema relieved by puncturing the cell. membrane. When an empyema occurs it commences with pain in the side & symptoms of fever (pleuritis or pneumonitis) A chill or more will come on about the time of the suppuration When the pus has collected, the pat. can lie only on this affected side, in order to relieve the other lung from pressure. Respiration is performed by the diaphragm & abdom muscles the abdomen is perhaps fuller perhaps there there is a fluctuation externally perhaps the heart will be pushed over to the other sides Percussion gives a dull sound Make the opening between the 6th or 7th ribs unless there is a tenderness [illegible] about the middle near the upper edge of the lower rib. Make an incision about 2 inches long in adults extend it about an inch & an half through them muscles let the opening be about ½ an inch through the pleura The air rushes in & perhaps the pus may not issue at first in this case turn the pat over keep the wound open with a slip of rag Dress with a compress & rag The discharge may continue for years It often happens that the pus does not occupy the white sac of the pleura being in a sac which is limited in extent by adhesions of the pleura Hence it is important to make the opening if possible at a tender spot or one where there is a protrusion The usual consequences of opening a large abscess result. The whole pleura inflames. There will generally be chills and fever. Small doses of ipecac and calomel do well but opium is the principal remedy. Sometimes a hectic supervenes. This may terminate fatally or may end in health. In one of Prof. H’s cases a pat. recovered after 2 ½ years discharge and a very severe hectic. Larrey says patients under 36 gr are more apt to recover because the cartilages are more flexible Prof H. has succeeded in more than half his cases and in many of them the operation was a month or 6 weeks too late After recovery that side of the chest is smaller. The pleura must adhere, if the pat. is to recover Sometimes lumps of matter were discharged Amputations Less frequent now than 40 years ago In the rev. war, many limbs were improperly amputated by surgeon’s mates Necessary from a variety of causes At the present day many compound fractures are cured which would formerly have been amputated Necrosis now rarely necessitates an amputation Great judgment and firmness are required. Some patients will get angry and send for another physician Amputation was first performed with a red hot knife. Then the surgeons cut directly down. Then Cheselden introduced the double incision Then the flap operation was invented Mr. Liston has lately proposed to transfix the limb. Ben Bell was the first to propose the healing by the first intention At length amputation at the joints was adopted and found to be very safe When patients are very low with chronic disease, it is apt to be supposed that the pat. will die of the operation. This however seldom happens In case of excessive shock from loss of a limb etc. amputation relieves the shock according to naval surgeons Case of Mr. Huskisson Prudence is required in communicating the necessity of amputation. It is very improper to bleed the matter beforehand about the neighborhood. Amputation of the joints of the hand performed N.B. The wrist joint makes a much better and more useful stump Wounds of the face and throat Introduction of a cannula for respiration? Wounds of the eye brow cause a ptosis of the upper eyelid A cicatrix may cause either the upper or the lower lid to retract Incised wounds dividing the supra orbitary nerve cause blindness Vie Coop. Surg. Dict. art. [illegible] Division of the parotid duct may cause a salivary fistula. Salivary fistulae may also result from an abscess or from operations for the extirpation of tumours Prof H has healed them by touching with nit. sil. and applying a dossil of lint and a [illegible] compress Cure by means of a trocar & a cannula etc. Desault’s method Another method & probably a better one Diseases of the antrum 1st Abscesses pain in the side of the face & soreness chills [illegible] with face pain may be in one or more molar teeth Discharge often into the nose but the orifice not being free the discharge continues, for sometime. Pus frequently very fetid yellowish green. Pain often so great in the teeth that the pat. has one extracted If this lays open the antrum a cure is effected The bone may be absorbed and the abscess open on the cheek or under the eye Distinguished from tic doloreux by the febrile state, by the tumefaction the soreness pain not in paroxysms general state and habit is different Cure by making a dependent opening. Extract the 1st or second of the true molar teeth unless one tooth is particularly affected. Make or enlarge the opening by a gimlet (say) Keep a bougie in to prevent the orifice from closing. Inject soap and water spirit and water etc. Let the pat. wear the bougie 2 or 3 weeks eventually use a probe & finally knitting needle When the discharge becomes serous we may conclude the membrane to be nearly sound. Even if the discharge has taken place into the nose or on the cheek if it does not soon cease make this dependent opening Sometimes the pointing of the abscess is into the mouth near the gums generally it will then be best to enlarge the opening use a bougie etc. 2nd Polypus of the antrum There is generally a polypus in the nose or a polyp. in the nose extends into the antrum. If it grows with antrum exclusively it must be extracted by opening the antrum externally through the cheek 3d Fungus of the antrum Affects adults and children Little or no pain until pressure is made by the humor on the bones The bones becomes absorbed or softened and a springy feel may be perceived It may project into the mouth externally or under the eye, protruding it The disease becomes horrible, the whole side of the face becomes affected. General health affected vomiting etc. Death Distinguished from abscess by its slow progress. abscess of pain at first want of pus etc. It is said that some cases have been cured. Probably many of the approach more to the character of polypus The bones become so soft that it may be easily cut with a knife Desault makes an opening just above the mouth or just inside of it scoops out the fungus and applies the actual cautery (through a cannula) thoroughly throughout the whole antrum and if the fungus grows again repeats the cauterising He says he has effected several cures Prof. Gibson describes some crooked knives which he has invented for the purpose of scooping out the antrum Polypus of the nose These tumours have no sensibility though they bleed 1st the soft kind with narrow neck & nearly the colour of a system reddish pale & shining 2nd with a broad base usually of a red colour 3d malignant as fungi etc. The first kind is enlarged in damp weather. The second kind resembles fungous flesh. The last kind is a true fungus haematoded accompanied with lancinating pains etc. they may produce fistula lachrymalis Mr. Abernethy cured some patients by prescribing for the disordered stomach Extirpation by the forceps is the only made of cure. A ligature cannot be applied Tear off repeatedly until you have got a great part of it away Introduce through a cone of paper some caustic kali. The polypus will disappear but will return again generally. Blood root snuff will do well after an operation When they extend into the throat apply a cannula (J. Bell) Prof. H. once extracted a polypus 4 in. long. It extended into the antrum It was contracted in the middle like a wasp These [illegible] or [illegible] kind are more dangerous apt to cause absorption of the bones. Rx savin leaves zi opium zj a good snuff. For polypus in the throat J. Bell passes a wire by a cannula, through the nostrils takes hold of it in the throat etc. Tumours on the gums Usually dark red, spongy [illegible] if suffered to grow they press upon and loosen the teeth. Extract the teeth, if dependent on them But they may appear on the outside on the inside, or between the teeth etc. Cut them away and cauterise immediately. The actual cautery is the only cure and they may reappear even after this is used They are covered by the internal membrane of the mouth, which must be lacerated. Prof. H. has known from an abscess a fistulous orifice through the gum continuing for years fungus may sprout up in them. Extract the tooth clip off the fungus cauterize Sulphuric ac. has been used also corr. sub Enlarged tonsils may obstruct the breathing Give cal. 2 or 3 times a week. Gargle with borax or with nit. sil. 3 or 4 gr. to oz. Or touch with nit sil. Removal has been proposed by ligature. The knife is better. Prof. H. severs the tonsil with a tenaculum and quickly slice off a part with a tenaculum Dr Hosack Jun. has an instrument. Great relief is rendered. A probe pointed knife is not necessary Diseases of the Eyelids 1st Infl. of lim. memb. red swollen hot, dry finally increased secretion of mucus (so that [rings], [hatos] etc. are seen) In the morning the lids will be glued together. May proceed to ulceration of the edges, with loss of lashes Caused and kept up by reading at night by smoke by drinking cider etc. Apply cold water frequently Sometimes bleed the recommendation is for cupping and leeches Prof. H. has known great benefit from v.s. Calomel is to be given. The best collyrium is nit. sil. dropped in twice a day. Apply an ointment if red precipitate about 30 gr. to 1 oz of lard at night let a little of it penetrate the eye If this gives too much irritation apply Turner’s cerate If there is much heat apply ac. pl. Vide Coop. Surg. Dict. art. ophth. for Dr Small’s method of curing ophthalmia by compression Granular conjunctiva Caused by the continuance of the preceding. Granular specks enlarged vessels sometimes a fringed fold like a cock’s comb just where the membrane passes off upon the ball of the eye sometimes warty excrescences Apply nit. sil. or sulph. cop. in substance to the granulations. Sulph. copper is most effectual Evert the lid apply the caustic then wash then return the lid. Pare off with a knife or clip off with scissors hard granulations Prof. H. has seen little advantage from scarifying If you can, clip off [illegible] veins with scissors this sort of bleeding is much more efficacious than scarifying Concretion of the lids Sometimes congenital oftener the result of opththalmia total or partial Divide with scissors Open the eyes frequently in a day or two touch with nit. sil. Ectropium Generally caused by cicatrizes from burns etc. A chronic inflammation is apt to come on in the eye Sir W. Adams cut out a piece S. Cooper cuts off a part of the thickened membrane That variety which occurs in old men may be cured by applying nit. sil. & then using compression. Wear goggles Trichiasis may be cured by wrong direction of the hairs or by turning in of the lid (entropium The eye may be destroyed by it Caused by cicatrices near the edge which causes the new hairs to grow wrong. Pull out the hairs and touch with aq. amm. or nit. sil. When resulting from relaxations apply adhesive plaister or cut out a piece with scissors or touch with strong sulphuric or nitric acid over an oval shaped part When there is a wrong direction of the edge cut out a slip of the lining membrane in order to allow the lid to turn out If all means fail of curing cut off the edges of the lids [illegible] of the upper lid Has been cured by adhesive straps; by nit. ac. as above by cutting out a slip [illegible] Hordeotum (stye) Ordinarily nothing to be done but to poultice. Sometimes the suppuration is imperfect especially in delicate females a tumour may thus be left behind and give great alarm, being mistaken for a wen or a cancer. There may be a granulation of the inner surface of the abscess just as in scrofulous abscesses. They are readily cured by touching with nit. sil. If they do not burst and the skin is whole over them so that they resemble a wen lay them thoroughly open and touch with nit. silv. Encysted tumours of the lid Commence without inflammation They are to be taken out either internally or externally when they do not adhere to the lining membrane of the eye, you may often succeed by splitting the tumour open and pulling out the cyst. Ophthalmia Inflammation of the eye May be considered in reference to the whole or a part of the eye but if one part is affected the rest are apt to become so Endemic in Egypt and Ohio burning sense of dryness copious hot scalding tears the eye is kept closed severe pain in head and face perhaps in the cheek or frontal sinus Redness and swelling of the eye. If the schoatica is affected the redness is of a darker colour (and apparently stationary) If the conjunctiva is the part in flamed the redness is brighter and the membrane is so much swollen that the cornea appears depressed Ultimately the cornea appears dusky a little. The aqueous tumour becomes somewhat opaque The cornea may eventually be cast off suppuration of the eye internally causing it to run out Caused by operations, by foreign bodies Amospheric influence Endemic influence etc. Prof. H. has known it alternate with intermittent The most powerful remedies shd be used First stand blood letting. The British surgeons in Egypt drew 60 ounces It is of no consequence from what part you bleed Prof. H. would bleed ad deliq. (in an upright posture) give [illegible] ca. followed by neutral salts afterwards apply ac. lead Collyquiums are forbidden but nit. sil. is dropped in with great advantages (3 or 4 or more grains to the pint more for chronic ophth.) If the pain etc. recurs repeat the bleeding & calomel. Antimony is much relied on in Europe. Prof. H has used it only as an adjuvant Use the nit. sil. 3 or 4 times a day not too strong just strong enough to create a little uneasiness at first If the eyelids stack together, by a discharge from the [illegible] apply a mild mercurial ointment Prof. H. never could see any advantage from bleeding from temp. art. or jug. vein Cupping and leeches may be used but shd not be relied on to the exclusion of general bleeding Letting out the aqueous humour has been practised with advantage. Vide S. C. surge. Dict. Blisters to the nape of the neck are beneficial When the disease becomes chronic a variety of remedies are used Nit. sil. continues to be beneficial It makes the surface of the eye feel smoother Vinous tinct. op. (Sydenhams laudanum) op. zii cinn. & cloves aa zi wine 1 pint digest a week This is often beneficial causing smarting at first but afterward relief Rx sulph zinc & ac. lead aa grs vi wat. oz ii we have ac. zinc. This is a good collyrium Scarification seems to be of little use Opium is useful. Dover’s powder is a good form. As soon as the pat. can bear this light accustom the eye gradually to the use of opium Tonics are seldom indicated. But in intermittent centuries Sul. quinine is highly useful. Bleeding etc. may be conjoined with sul. [illegible] (Vide the late periodicals) Cataract May originate from wounds & other causes Its commencement indicated by [halos] as observed around a candle & other such appearances To be distinguished from aneurism, by opacity, by some sensibility to light contraction and dilatation of pupils etc. It may be complicated with aneurism In aneurism flashes scintillations etc. are felt. Proceed to operate without debilitating the patient with low diet & a state of anxiety and apprehension It is customary now to dilate the pupil with belladonna or stramonium previous to the operation Apply it to the eye, eye lid etc. the night before [illegible] [illegible] hour before drop a little in the eye Enter the needle about a [line] & a half from the edge of the cornea the needle having its surfaces horizontal Pass the needle up to the top of the cataract turn the edges perpendicular press the edge down lacerate the capsule thoroughly then turn the needle horizontal again and carry the cataract directly downwards. If your needle horizontal again and carry the cataract directly downwards. If your needle is a crooked one turn the point first backwards in lacerating then downwards If the cataract proves to be a milky one lacerate a little and do the best you can After you have depressed, withdraw the needle partly and if the cataract rise depress again A caseous cataract must be cut to pieces and pushed through the pupil into the anterior chamber A secondary cataract must be pushed through also If the operation is to be repeated let an interval of at least two months intervene If both eyes are affected it is a good rule to operate upon one at a time. This is often safely disregarded with safety, however. Be very cautious about using the eye for some time. Wear a green shade at first. If there is much pain, bleed & give opium [Ceratonixis] or Laceration For a long time only tow operations vide extraction & depression. It was found however the congenital cataracts (which are generally membranes would be absorbed after laceration First established by [Saunders], at the eye infirmary in London Two modes of operating the anterior & posterior First dilate the pupil and belladonna or stramonium Mr Saunders used the anterior mode & made an opening through the centre We are directed not to wound the iris; but some surgeons do not hesitate to do this Mr Saunders was frequently obliged to repeat his operation a number of times Extraction The advantages are that the operation in successful at once that a hard depressed cataract lies on the retina & irritates the eye etc. ON the other hand, secondary membranous cataract is said to recur sometimes after extraction the vitreous humour sometimes escapes. Prof. H. has always found a scar across the centre of the cornea, afterwards It is said that inflammation is more liable to occur. This is [denied] by others who say the extraction is the safest in this respect. Enter the knife at first perpendicularly then carry it horisontally Put the patient abed and keep him on his back. Both eyes must be kept closed for some days. The [illegible] humour flows for some time. When the eyes are first opened, if we find any of the iris protruding, we must endeavour to restore it. Extract of belladonna will perhaps assist this Iritis Redness dark caused by syphilis & mercury Terminate by [permanent] contraction & closure of pupil or by [illegible] pupil. May extend to crystalline loss of the cornea Treat by one full bleeding Never mind weakening your patient provided you save his eye Bring the system under the full influence of mercury as soon as possible Though the disease is sometimes caused by mercury yet this is proper for its cure. Conjoin opium say 1 gr. op. & 2 grs. cal. 2 or 3 times a day. Merc. oint. is rubbed into the eyebrow Along with these remedies are used to prevent permanent contraction of the pupil. Stramonium & belladonna Rx Red prec. 6 grs. op. 8 gr. lard z2 apply warm fomentations. Collyrium of corros. sub. & Sydenham’s laudanum is used Keep the patients eye in the dark Push the remedies if necessary Prolapsis of the iris May result from a wound or by suppuration A brownish tumor (or purple) size from a pin’s head to a pea, as large as a hazelnut Called staphyloma of the iris Exquisite pain is felt upon closing the eye Pupil on one side In recent cases the prolapsus must be returned and the eye kept at rest If this does not succeed the application of stramonium may draw it back In [older] cases where it is of long standing or where the protrusion follows upon ulceration then putting back with a probe will not answer we may touch this with nit. sil. pain follows at first but a leathery covering is formed which protects the part Collyrium of ac. or sulph. of zinc is also a good application. It may be necessary to draw out a portion with a hook & cut it off with scissors Prof. H has treated several cases caused by wounds with a pen knife with nit. sil. severed [illegible] successfully Inflammation of Cornea Mr. Travers questions the propriety of considering the cornea as subject to infl. Deposits of opaque matter however do form. An ulceration of the lining membrane may follow and discharge into the aqueous humour. Inflammation of the conjunction may If you perceive the cornea growing opaque redouble your exertions Ulcerations of Cornea 1st Irritable ulcers as [illegible] [illegible] like a of moss Eye very irritable feels as if sand was in the eye tears feel s scalding hot eye kept closed children hold their heads down Touch the ulcers with nit. sil. once in 2 or 3 days For young children we may inject a strong solution 6 to 10 gr. to the oz. The cicatrices from these ulcers generally wear away. 2nd Indolent, deep sloughing ulcers larger thicker slough may be ¼ to 1/3 of an inch in diameter. Use the caustic more freely When they change from their grayish to a pink colour, we may expect them to heal soon. Patients may in the latter stages need tonics much mischief is often done by injudicious purging Abscesses of the eye The pus settles down in the lower part of the anterior chamber & exhibits a half moon shape. Make a puncture with a spear pointed lancet. In one case Prof. H. found the cornea opaque the iris inflamed and the pupil about closing the puncture gave immediate relief Little vesicles may form & when they burst give rise to irritable ulcers Opacity of the cornea Mr Travers advises coll. of nit. sil. & alternately of corr. sub. (the latter 1 gr. or ½ gr. to the [illegible]. Divide the enlarged vessels with a hook & scissors this gives great relief it destroys the vessels Various substances are blown in e.g. levigated glass, calamine, white sugar The utility of these seems very doubtful Dupuytren advises 1st general v.s. or leeches 2d a seton in the back 3d Rx lap. cal. calm. & candied sugar equal weights in powder. He says that specks and commencing opacity may be relieved by the powder alone Mr Travers perseveres in a course of mercury Staphyloma Cornea projects to that the eye cannot be closed causing great irritation tears etc. The cornea is perfectly opaque & vision entirely lost First pass a ligature transversely through the cornea then pass a cataract keep through & finish the operation with scissors Fungous tumours of the cornea A small hook & scissors are the proper instruments Follow with nit. sil. Clip off enlarged bloodvessels Pterygium [illegible] of the [illegible] [illegible] A reddish triangular membrane the pupil growing from the internal angle of the eye. Sometimes it stops just at the cornea At others it passes over Sometimes but rarely, it arises from the external canthus It [causes] a proneness to infl. of the conjuctiva Dust lodges on the membrane & is not easily removed If combined with ulcers, these must be first cured Extirpate this elevate the membrane with forceps or a hook & clip off with scissors as far as the edge of the cornea It is unnecessary to remove it as far back as the canthus. Even if little points remain on the cornea they will be absorbed, if you interrupt the continuity Encanthus An excrescence growing from the [caruncula] lacyrymalis producing great irritation Cut off with scissors. Prof. H. has known a large one cured by touching repeatedly with nit. sil. Dropsy of the eye Generally proceed by external always by internal infl. Cornea always opaque Sometimes appeared confined to the anterior chamber The sclerotica becomes thin & bluish like a soft shelled egg irregular also. May be caused by a wound Tape the eye with a spear pointed lancet or a cornea knife Repeat the operation No infl. follows ultimately the cornea grows thicker and retracts. This is the mode for the anterior dropsy. Whether the dropsy of the whole ball can be cured in this way is not so clear S. Cooper directs a piece of the cornea to be cut out of the size of a pea Travers says all the humours cannot be evacuated except by cutting out a part of the iris Cancer of the eye When seated in the conjunctiva, there is a thickening of this membrane and perhaps the cornea is obscured. Eventually the whole eye is involved. Ulcer with hard edges. Extirpate with a straight edged scalpel Restrain haemorrhage by pinching a torsion of the arteries with forceps Prof H. would put neither lint nor sponge within the orbit. He would dress with comp. & laud. Fungus haematodes of eye Formerly called cancer In the first stage the pupil is dilated iris discoloured (dark green or amber) The fungus can be seen in the bottom of the eye like burnished iron. The schlerotic coat becomes knobby, bluish etc. Finally the cornea & sclerotica ulcerate Fungus finally protrudes dark red bleeds easily. Cancer begins externally & eats away it is a disease of advanced life. Fungus is a disease of childhood? Still these two diseases resemble each other more in the eye than elsewhere Prognostic after extirpation very doubtful. Amaurosis Function of the eye without any external appearance except want of contractility in the pupil. Dil. pupil said to be a symptom May be caused by infl. of the retina by tumours pressing on the nerve or the brain. Occurs after excessive use of the eye in viewing the minute objects Vision has been restored by proper remedies for infl of eye it begin early and pushed vigorously, when it arises from acute inflammation of the retina Acute infl. of retina destroys vision suddenly Chronic infl. destroys it gradually Corr. sub. has been preserved to cal. in this disease. On the continent of Eur. Antimony is celebrated for this complaint Cases caused by epilepsy, tumours of the brain etc. are of course hopeless Pretern. dilat. of pupil Seldom an idiopath. complaint Pret. contr. of pupil Myosis Constant rolling of the eye (just as in congenital cataract) Commonly caused by infl. may be attended by opaque lens or capsule or not. For recent cases apply belladonna Push remedies diligently if there is inflammation Closed pupils may be attended with opaque cornea or not opaque lens & capsuled or the eye may be full and prominent, or flattened and with a large [illegible] Ascertain carefully whether there is remaining any sensibility of the retina Three modes of operating 1st a simple incision 2d removing a piece of the iris 3d tearing the iris away from its attachment 1st Chelelden’s mode Another way is to make an incision with a knife & then with scissors make two incisions & shaped 2nd make an incision seize the iris & clip it off and if it does not retire push it back with a probe If the lens is opaque, extract it 3d Scarpe’s mode. Prof. H. has operated in this way. Introduce a couching needle as for coaching separate the upper edge ½ of an inch & depress it. In one case Prof. H. was interrupted by a sudden hemorrhage within the eye An irregular pupil of course is made Ranula A bluish tumour under the tongue Caused by obstruction of the duct (probably) Dupuytren introduced two connected buttons [illegible] Prof. H. opens thoroughly & touches thoroughly with nit. silver. Division of the frenum Prof. H. has had one case of a ligamentous frenum [binding] down the frenum Wounds of the tongue Stich it together use Physicks forceps Enlargement of the tongue Caused by mercury, which has sometimes made it so large that it would nearly be bitten in two by the incisor teeth Ulcer [illegible] & tumours of the tongue. Caused by irritation of the teeth by disorder of the digestive organs etc. Cancers may grown there. Encysted tumours may grow there. Use alum borax nit. sil. (nit. sil. 15 gr to 2 pt as a gargle). Ulcers of saliv. touch with nit. sil. Internal use of opium is the best remedy for salivation purgatives are injurious Solution of corr. sub. is a good garble for a number of minute ulcers. Extirpate cancers & tumours Mr. Coster cuts out a v. shaped piece when the tumor is on the tip of the tongue bringing the edges together with stitches Cauterise to stop hemorrhage Enlarged tonsils A curved bistoury is recommended Prof. H. uses an abscess lancet on a stick for an abscess. If no pus issues, no harm has been done the scarification will do goo Prof. H. has several times met with inflammations and an abscess on one side of the tongue near the roof very painful Open with great relief. [illegible] to [illegible] abscess of bursae mucosae. the abscess collects suddenly lined with a smooth membrane incline to close up, like bursae mucosae N.B. abscesses near the surface of mucous membranes are apt to be fetid the air apparently acting through the membrane Cut off enlarged [illegible] with scissors no fear about haemorrhage Osteosarcoma Formerly the patients were suffering to die Dr of Tennessee was the first to perform the operation In some cases the wound has not healed after the operation leaving the patient in a horrid state Dr Cogswell related case of this kind in a man living in Fairfield cty who had been operated on in Philadelphia. Prof. H. would prefer Mons. Costes mode of operating Sarcoma Cellulosum Bronchocele, goitre etc. Endemic in Derbyshire N. Hampshire Vermont western part of N.Y. etc. Occurs generally in young females Mr Wilmer was the first to publish an account of the treatment by burnt sponge. It was communicated to him with several useless additions to the remedy Prof. H. has met with sudden enlargements of the tumours accompanied with sore throat, pain in the head etc. He bled with advantage applied mur. amm. gave calomel etc. Wounds of Abdomen Wounds of the integuments require no particular treatment except to keep the muscles relaxed. Keep also a bandage over the parts in order to prevent hernia Penetrating wounds as by a stab require no particular treatment. Use the interrupted suture. Prof. H. has found no danger in carrying the stitches through the peritoneum. Let the patient avoid coughing laughing, straining at stool. Use a bed pan If intestines protrude with a warm and moist hand, return the viscera gradually return the omentum last. We must not be deterred from returning them by infl. or by a dark colour. Gangrene of the omentum may be distinguished by the blood’s not returning after pressure Gangrene of the intestine may be distinguished by an ash colour such shd not be returned. Larrey’s and others advise to cut off a gangrenous portion of intestine & return the remainder tying the vessels [using] a [leather] ligature] Close with interrupted suture using two needles for the same thread so as to carry the stitch from within outwards. It may be necessary to dilate the wound When an intestine is wounded the villous coat protrudes & turns out Sir A. C. in operating for strang. hernia found a small wound of intestines, he [illegible] it with his thumb & finger & tied a ligature around. The man did well Sew with the glover’s suture (over & over) It is found that a wounded intestine adheres by its peritoneal coat to the wall of the abdomen. The ligatures are cast off the cavity of the intestine & need not be kept out of the external wound Never enlarge a wound to search for a wound of the intestines. Larrey occasionally enlarged a wound in order to afford a freer passage for feces. His patients were eventually cured Vomiting is apt to occur V.S. will relieve it. Purgatives should not be given. Let your stitch, with the external wound remain as long as 8 days Wounds of the Bladder Urine issues In all cases except where the neck is wounded, keep a flexible catheter in the urethra. If there is extravasation of urine in the cell. memb. or scrotum make incisions to allow of its exit Laxatives are found to be very useful Castor oil & senna Passage of rake handles etc. into the anus etc. Prof. H. had one case in which a rake handle passed 22 inch. through the diaphragm. He died of affect. of the lungs spit blood etc. The thorax should have been opened. He has seen many cases of similar wounds of the vagina. In short has seen some odd things! falls on crowbars stumps of scrub oaks etc. all penetrating a greater or less number of inches. Bleed & starve. Blister the abdomen. Paracentesis of abdomen Do not perform the operation for less than a gallon of liquid. The operation is apt however to be delayed to long in cases of dropsy. Dr Fothergill advocated the practice of [illegible] early in dropsy Prof H. has noticed an increase of urine after the operation. He has known some cases of complete cure by tapping. Sometimes in encysted dropsy the accumulation remains stationary for years The fluid may be in one or more cysts or may be in the cavity of the peritoneum The former may come on with out much derangement of health. The latter is apt to be accompanied with a general hydropic diathesis When the fluid is in the peritoneal sac the tumour is general from the first In the early stages the fluid will be most at the lower part of the abdomen, when the patient is erect. The intestines float Ovarian dropsy is near the ilius the tumour shifts its place in different positions of the body at first At length however it enlarges and becomes adherent and a fluctuation is felt. When the accumulation is very large it can hardly be distinguished from ascites except by the history of the case. In one case the tumour burst from a fall The fluid was effused into the peritoneum, and the patient died in 20 hours Dropsy of the uterus must be exceedingly rare of course the os uteri must be closed by disease etc. Hydatids may be found in the uterus Mr [Rostan] says that in ascites a sound like that of tympanitis is given upon percussion at the upper part at the sides in encysted dropsy In ovarian dropsy the fluid may penetrate between the vagina & rectum & may be felt Encysted dropsy can scarcely be affected by medication Tapping must be resorted to. Put a broad bandage (from the ribs to the hips) around pin it behind Cut a hole in the bandage opposite the linea alba. If there is a hernia at the umbilicus if so, puncture there the walls being much thinner Let an assistant press the sides of the abdomen. Plunge in the trocar (If you push gradually the trocar will enter with difficulty) As the fluid flows, keep tightening the bandage. Towards the close press the abdomen in all directions Withdraw the canula if then the fluid continues to flow, let it run & be received on cloth. You may turn the patient over. Tap with the patient recumbent on the edges of the bed. When sitting the patient may faint. He may faint also if the bandage is not first applied. By means of the bandage we avoid all the danger of the operation After the operation dress with lint a compress & sticking plaister & bandage together Let a bandage be worn for months afterwards or even for years. It gives great relief The largest quantity which Prof. H. has drawn off was 32 gl yet in 23 days 23 quarts more accumulated. This case was caused by schirrhous liver which weighted about 13 pounds One patient was tapped in 13 places Another was tapped in 6 places at another in 6more finally in 6 others & the patient recovered One place where the operation was performed was between the vagina & rectum where two quarts were drawn off Occasionally the wound does not close. This is apt to be caused by the exhausted state of the constitution. It may arise from improper dressing. Stay by and watch whether the opening [illegible] If you cannot stay by and the orifice continues to flow and you cannot stay by use the twisted suture Diseased ovaria Prof. Smith operated to successfully Vide his memoirs Mr. [Losans] was generally unsuccessful. Prof. H has read all the accounts in the English language & thinks the operation scarcely advisable Hernia A protrusion of the peritoneum containing some of the viscera Sometimes hereditary Produced (especially if there is a predisposition) ty strains in lifting. Generally the causes are unknown 1st Inguinal 2d Femoral 3 Umbilica 4 Ventral 1st Inguinal 4 species. 1st oblique 2d direct 3d congenital along the spermatic cord 4th encysted hernial sac suspended in the tunica vaginalis The sac grows thicker as the hernia is [illegible] When it passes no further than the groin inguinal hernia is called bubonocele when it passes farther it is called scrotal 1st Oblique inguinal hernia Symptoms Distinguished from hydrocele by the latter’s not being affected by coughing by its transparency by the cord’s being felt Hydrocele of the cord is distinguished with more difficulty by coughing not affecting it Haematocele Hernia humoralis varicocele Mistaken are very often made and [illegible] applied to these diseases. Varic. happens twice as often as the [illegible] Hernia in the right [illegible] Hull’s truss is the best. It should be worn constantly day & night (A. Cooper) Dr Hull & Prof. H. think it sufficient to wear it during the day Many cases may be cured by a truss but let it be worn long after the hernia is cured. Dr. Hull denies that accidental protrusions will totally prevent the cure (as A. Coop. says) Children as they grow larger must have a new truss The use of the truss produces an adhesion of the neck of the sack Irreducible hernia Hernia may be irreducible from various causes from adhesions from a sudden protrusion of a large quantity of intestine The tumour (within) may be of a pear shape If the hernia cannot be reduced a bag truss should be worn. They are inconvenient and dangerous Sir A. C. has known a hernia supposed to be irreducible, finally reduced by ice applied 4 or 5 days. Prof. Smith distinguished between strangulated & incarcerated hernia. But the latter seems to be little more than an irreducible hernia Symptoms of strangulated hernia Pain constipation (though there may be tenesmus) [illegible] of [illegible] tumour very tender vomiting hiccup cold sweats etc. Omental hernia, when strangulated produces similar symptoms, but generally neither so violent or rapid Post mortem appearances exhibit infl. of the intestine perhaps over the whole peritoneal & in the latter case the death may be sudden within 48 hours In other cases operations have succeeded 1 or 2 weeks after the strangulation A small hernia exhibits more violent symptoms than a large To reduce place the patient on a bed his head & pelvis elevated thigh at right angles (bladder previously emptied) Embrace the tumour with both hands, as you would an elastic gum bottle. Prof. H. has practiced this mode for 20 years (It is Gohagan’s of Iceland) HE finds it better than A. Coopers of kneading. Gohagan advises to keep the pressure steadily for an hour changing the hand if fatigued Have a bowl of cold water at hand, and occasionally wet the hand Use ice also salt & water. Do not use violent pressure. If we fail with the [illegible] bleed to fainting & immediately try again with the [taxis] Bleeding lessens the tenderness & soreness It will also tend to prevent subsequent peritoneal infl. Warm bath may be tried Prof. H. has used tobacco injection zi to a pint half at a time a dangerous remedy however. It produces universal relaxation and then perhaps the tumour may be reduced Sir A. C. says calomel is often useful assisted by a [illegible3] of compd est. colocynth Strangulated hernia has often been mistaken for colic (perhaps the patient may be ignorant of the existence of a rupture or breach as they call it) Purgatives are dangerous apt to cause infl. After bleeding Prof. H. has used opium with advantage especially in old hernias of old men. Direct inguinal hernia Seldom large may be caused by a blow A rare species A truss is applied nearly in the same way as for oblique hern. Epigastric artery on the outside [illegible] muscle partly in front of the tumour An old large omental hernia may not be so soon fatal as a small & recent one Still all hernial (if [illegible]) are dangerous & when strangulated, an operation must not be too long delayed. Death may occur in a day or two in some few cases. Mr Hey lost many cases by operation too late. So with Desault. So with Prof. H. much mischief is often done, by violent and long continued handling It is the best rule to operate soon. Less pain is often felt in the operation than in the [previous] taxis Place the pat. on his back on a table feet in a chair set between the thighs If the hernia is small & the skin lax the surgeon & an assistant may pin it up the integument transversely [illegible] and [illegible] his knife through this gives less pain ‘ Do not carry the incision quite to the bottom of the tumour Divide each fascia with a director The sack when you get to it is usually known by its shining appearance though it may be purple etc. caused by a bloody fluid within Rub a fold of it between your finger & thumb so as to be certain that you have no intestine or omentum adhering to it. Pinch up a small fold with forceps and make a small incision then introduce a director and enlarge a little then introduce your finger as a director [illegible] reduce the intestine if you can If you cannot introduce your finger as a director carry the point of your knife along it arriving at the stricture depress the handle of your knife and divide gradually Divide freely enough to allow the entrance of your finger. It may be necessary after dividing a stricture at the external ring to divide another at the internal ring Divide upwards & outwards or perhaps better, always upwards Adhesions may always be broken up with the finger. Return the intestine first & then the omentum Prof. H. now passes his suture through the sac Sir F. Earle recommended this vide Hey and since he has adopted this practice has never had a case of a second protrusion. If more than 2 sutures are needed put the lower ones through the superficial integuments only Place the sutures about an inch apart Dress about the 4th or 5th day. If a stool does not come away in a few hours give castor oil or if this fails, calomel Dress with a T bandage etc. If the intestine is gangrenous (it is not so when merely purple & dark bloody) Sir A. C. says a gangrenous intestine will have a fetid smell Prof. H. has noticed this in incipient gangrene A gangrenous intestine is the strongest reason for operating If the intest. decidedly gangren. Prof. H. would not even divide the stricture, but make an incision into it and allow the feces to issue. Cut off mortified oment. with scissors Case in which the gut has burst Prof. H. did not do anything but leave the case to nature after opening the sac. After about a month the fever took their nat. course Dr Phys. in one case found two parts of intestine parallel [illegible] he made an incision into each in order to allow the fasc. to pass from one to the other The pat. dies from want of passage for feces Vide Travers After the operation if peritoneal infl. continues, treat by v.s. by cal. or by cal. & op. Diarrhoea sometimes takes place, both after the taxis and after the operation Treat with opium For direct ing. her. divide upw. & inwards Hernia of inguinal canal No distinct tumour exists except upon coughing May become strangulated & is often mistaken for peritoneal infl. Vide Sir A. C. for the operation Make the incision through the [tendon] of ext. oblique, very carefully etc. Oblique inguinal hernia in females. On coughing the tumour protrudes downwards this In femoral hernia the tumour protrudes upwards on coughing Operate as upon the male Congenital hernia Called [wind] ruptures by the nurses Tumour is within the tunica vaginalis Take care not to injure the testicle & leave the lower portions of the tunica vaginalis entire so as to contain the testis Encysted hernia of Mr. Hey The whole sac is protruded into the tunica vaginalis Open the tun. vag. & then search for the sac Femoral Hernia Prof. H. has cured one case in a male Prod or first a pain on suddenly stretching the limb. Finally a small swelling appears increases passes downwards inwards, forwards & the upwards over Poupart’s ligam. Sometimes passes downwards along the saphena vein Has been mistaken for [illegible] abscess or for an enlarged lymphat. Has been opened for an abscess Occurs oftenest in women who have borne many children Generally intestinal and small Often irreducible A truss does not cure so certainly. Women who wear a truss can dispense with it during pregnancy. Taxis often fails Strangulation causes severe symptoms We may try the taxis but should not use much force Delays are dangerous the hernia being small & the stricture sharp edged. Death has taken place in 17 hours. Patients will be apt to die about the 5th day Operation. Place pat. as before Carry your incision downwards beginning above the tumour. Sir A. C. advises another [illegible] transverse below Prof. H. has never made this. It is said that a superf. vein will be divided Prof. H. has often operated, and never met with this In his last operation not two teaspoonfuls of blood were lost N.B. we do not reduce the hernial sac only its contents Old sacs are generally adherent Divide the stricture upwards & a little inwards towards the umbilcal Divide freely enough to allow the introduction of the finger Endeavour to pull the neck of the sac out before dividing If the obturator artery surrounds its neck we can feel it with the finger Umbilical Hernia may become very large. Colicky pains flatus faintness at the stomach etc. In children called wind rupture also The superficial integuments will often be thinner in some places than in others appearing like an abscess Frequently than are two openings from within, into the sac. Occurs oftenest in females and in corpulent men Caused by ascites if so, then tap at that place Treat it in infants, with a conical piece of wood or ivory confined with adhesive straps Desault cured such cases by tying a tight ligature around the neck of the tumour after reducing the intestine Let older patients wear Hulls truss. If irreducible let a broad bandage be worn Sir A. c. advises to reduce without dividing the sac Prof. H. would be averse to attempting to operate without dividing the sac The hernial sac is apt to adhere to the skin so that the incision is [illegible] directly into the sac [?ntoal] Hernia Generally in the linea [similanaris] The stomach is sometimes included Symptoms of dyspepsia etc. may often be relieved by a truss Tobacco injections are very useful in this and the preceding species Irreducible hernias cause colic, constipations etc. requiring cath. sometimes there occurs pain and vomiting requiring perhaps v.s. and always opium in full doses When an irreducible hernia becomes inflamed there, less local soreness than when strangul. The pain is more universal and wandering over the abdomen. the abdomen is not swollen there is not hiccup etc. Give a large dose of opium Thyroidal hernia, occurs at the frama ovale. Pudendal hernia ix a variety of inguinal never requires an operation. Vaginal hernia occurs between the vag. & rect. use a pessary. A hernia occurs between the bladder and rectum in the male Hernia occurs (rarely) at the ischiotic sac. Prof. H. has seen one case of the latter in a boy. After all operations apply a truss when the pat. gets up Preternatural anus As the wound becomes smaller tighten the compresses and bandages When a little mucus is discharged from the rectum, solicit a natural passage with injections Finally tighten the dressings and touch with nit. sil. or sulph. cop. In permanent cases we have eversion of the villous coat etc. Desault introduced a roll of lining into the two ends, and kept thus the two in contact Dupuytren where there were two portions parallel punched the adjacent coat and caused a perforation for the feces (he continues a particular kind of forceps) the patient was cured Imperforate anus Make a crucial incision & keep in a bougie where there is no external anus When there is an anus, but the rectum terminates in a cul de sac the case is more difficult & they generally terminate fatally Stricture of the rectum Commences with difficulty of discharge [pellets] of matter imperfect evacuation pains in the hip, back etc. finally costiveness cathartics perhaps cause a liquid discharge, and often an apparent diarrhoea but the bowels remain full of hardened matter Colic flatulence acidity, dyspepsia. Reduced to liquid & bland food often the patients chew meat & spit it out swallowing the juice. Ill effects are generally felt, only sometime after the swallowing of food Hemorrhoids etc. may occur May be from hereditary malconformation. consider also by habitual costiveness Distinguished from hemorrhoids by the pure blood discharged from the latter & [illegible] the pellets of feces also by the apparent dysentery Structure of the colon is distinguished from it by absence of the straining freedom from dysentery seat of the pain also by the strictures being too high to be reached Always examine by the finger & if that will not reach by a bougie make bougies of dyachylon & wax 11 inches long for an adult Bear in mind the curved form of the rectum, when you introduce it Introduce by address not by force. To lessen the irritation, first inject 30 to 60 drops of laudanum Carry it as far as the sigmoid flexure when it has entered this, a little wind will issue Examine whether there are not more strictures than one Let the large end of the bougie pass up beyond the sphincter or the latter will be internally irritated. Let the loop hang out. Dr McClellan prefers the flexible metallic bougie The irritation may be excessive at the first application but it diminishes by use There may be a prolapsus of the colon through the stricture which must be pushed up by the bougie In this case also give cold injections to brace the parts bougies give great relief unless desperate cases Phlegmasis dolens Spergamosis puerperarum Dr Davis maintains that it is caused by an infl. of the iliac veins this is hypothetical Difficult to determine this as the disease is rarely fatal Origin very obscure. It seems to be preceded by increased fetor & abundance of the lochiae Occurs after all sorts of labours and in all sorts of patients. Said not to occur a second time but Prof. H. has met with instances. Occurs also in males after fevers Prof. H. thinks it probably Commences at an uncertain period after delivery by pain and swelling in the groin. The limbs swell rapidly Pain considerable pain in the groin also motion very painful. At this stage the surface does not put on pressure no serum issues upon puncture no coldness as in anasarca The constitutional shock is sometimes very great coldness, faintness The other thigh may be affected The swelling begins to go down, first in the groin and labia Prof. H. treats mainly by calomel which he says gives great relief. He follows with opium for the irritation He always applies bandages from the first This gives great relief. He wets the bandage with ac. lead or mur. amm. Apply a clean bandage every day Repeat the cal. frequently Dr Hosack treats as for a dropsy with ipecac and squills. After the relief of the disease a deep seated pain in the thigh. This Prof. H. has relieved by a large blister and this is the only case in which Prof H. has found blisters give relief Inflammation of the cell. memb. on the hips back etc. of puerperal women Often mistaken for phlegmasia dolens They suppurate and should be opened There will be redness instead of the general tumefaction and the white [shiny] appearance They may become gangrenous and terminate fatally i.e. the glands no suspicion of venereal disease Retention of Urine may be brought on in old persons by neglecting the calls of nature Suppression of urine belongs to the department of Theory & practice Retention caused 1st by paralysis of bladder 2d Inf. of neck of blad. 3d press if foreign bodies 4th press of gravid uterus 5th enlargement of the prostrate gland 6th strictures In the first place7th constant desire to pass pain thirst nausea of vomiting costiveness cathartics etc. not operate an injection pipe can scarcely be introduced The bladder may ulcerate into the peritoneum and the pat. die thus or he may die of const. irrit. and in the latter case he becomes comatose before death. These may be the symptoms of paralysis of the bladder 2nd infl. of neck of bladder may be caused by cantharides by ulcers in the perinaeum by infl. of vagina produced by instrument 3d Stones in the bladder scarcely cause complete retention 4th the gravid uterus may cause complete retention A retroversion the uterus will always cause retention Some think it is caused by retention 5th Enlargement of prostate gland will cause a difficulty of passing and the true nature of the affection will scarcely be suspected. Eventually a complete retention may come on and then when the catheter is introduced in large quantity will be drawn off at once Sometimes when the urine begins to dribble away the complaint is mistaken for diabetes Other causes have been named [Parturient] women have died from this cause The ultimate consequences are peritoneal infl. fever dry tongue delirium etc. Other diseases seen to be produced is phthisis pulmonalis etc. Introduce the catheter by drawing the penis [illegible] in the first place keep the end close under the os pubis Sometimes with drawing the stilette a little to increase the curve At other times withdraw the stilette wholly Diseased Prostate Begins with frequent & imperfect micturition ultimately the patient becomes costive pains are felt in the part also in the back & hips a constant necessity for cathartics and when a stool is obtained urine flows more freely. The patient often will not call on a surgeon until the latter stages of the disease Finally opium must be taken constantly and the patient wears out perhaps with pulmonay consumption Much has been said about repeatedly introducing the catheter or suffering it to remain in. Prof. H. in inclined to the former. It will at always be necessary to withdraw the catheter twice a week to clean off calcareous matter. Other remedies are proper for sudden attacks e.g. v.s. warm bath injections of laudanum etc. even in a last resort injections of tobacco For chronic cases tinct. mur. feri a highly recommended If a catheter cannot be introduced try a small bougie Generally the smallest catheters can be introduced as well as a bougie Read the remarks of different surgeons about introducing the catheter as J. Bell C. Bell S. Cooper etc. Such cases are better treated now than formerly less [illegible] is wasted now with diuretics Cases combined with stupor of the brain, are best remedied by tinct. cantharides. The cath. should however be used The French surgeons use a conical catheter and force a passage. This is not to be initiated If a young surgeon cannot introduce the catheter, let him send for an older one. If a catheter cannot be introduced. The bladder must be punctured Make an incision in the bria alba 1 or 3 inches long. Cut down to the bladder and introduce a large curved trocar piercing obliquely When the stilette is out push the canula further in Either leave the canula in or introduce through it a flexible catheter & keep it in Mr. Abernethy thought it better to separate the [pyrimalis] muscles For stricture of the urethra, in some cases, such a catheter or canula Hydrocele 1st take care the canula is in the tun. vag 2nd Place your patient against a wall keep the injection in 15 m. (Prof. H.) Take care to fill the tum. full Use 3 parts wine 1 water Make a large puncture 8th If you inject into the cell. mem. stop immediately Great pain is produced Sometimes faintness Hence have some one by to assist you in case of fainting After about 3 days the swelling begins to abate In a fortnight the may perhaps be cured Encysted hydrocele of the spermatic cord Haematocele Sarcocele Fungus haematodes of the testicle Schirrhus of testicle Hydrosarcocele Fungus of the testicle cured by caustics. Venereal enlargement of testicle Hydatids of the testicle may be very large and confounded with hydrocele Cure by castration. has been kept in 2 or 3 years Southern mode is to open into the rectum etc. Irritable testicle seems to be a neuralgic aff. Try v.s. cal & afterwards arsenic & conium. Use opium all the while iron and sulph. quin. are rec. & are useful. Put off castration if you can Suppuration of testicle Open the abscesses & keep in a little slip of [illegible] for a [illegible] membrane will close very speedily It may be necessary to introduce nit. sil. Or if you have not room for this you may dip your probe in nitric acid & thus form a little nit. silv. Circocele Begins gradually finally the veins feel like a bundle of earth worms Let the pat. be down and press at the abd. ring, and a circocele will be enlarged & thus it may be distinguished from hernia Apt to give alarm but not dangerous Cause obscure there may be in such cases a disposition to have varicose vein # Patients are often subject to paroxysms of pain. v.s. cal. & other laxatives Apply cold discutients. Quiet your pat. about the danger. Keep the parts constantly suspended. The spermatic art. has been taken up why it is difficult to determine. Generally by quieting the patient you will have little trouble. Much mischief has resulted from wearing trusses for them # perhaps caused by accumulated feces & by injuries Chimney sweeper’s cancer Caused in the scrotum by soot Perhaps the testicle may become affected It is said that the disease may be cured even after the lymphatic glands have become affected Probably a variety of cancerous tubercle of the skin Sarcomatous enlarge. of scrot. may weight 50 or more pounds Testicles not affected Penis disappears. Integuments of lower part of abdomen drawn down. Skin may be rough & scabby. Probably a variety of elephantiasis. Vide Larrey’s mem. of it in Egypt. Extirpate not dangerous is the operation Vide the case of a Chinese lately in London 60 or 70 pounds died immediately Gonorrhoea Infl. of muc. mem. of urethra sometimes extending to the glans Arises from impure [connexion] Whether the same or not, it is treated different from lues syphilis A milder disease now then formerly in London Vide Abernethy Cured more readily when it occurs immediately after connexion, then when it occurs after a week or more Different phys. treat it very differently probably because it often (as is said) cures itself & because it may be interrupted by various [illegible] Bals. cop. is very popular now formerly it was used only for gleet. Cubebs are said to be equally effectual. Give bals. cop. 1 teasp. 2 or 3 times a day If it purges giv e opium Rx bals. cop. & nit. eth zi aa. tinct. op. & tinct. camph aa zi t.sp. 3 or 4 times a day Apply cold lotions In France they give nit., pot. & sulph. sod. etc. Ac. pl. 14 gr. to ½ pt. or sulph zinc grs 10 or both together, for an inject. if the discharge continues Ultimately corr. sub. 1 gr. to 1 oz 1/2 pt or nit. silv. 3 or 4 grs. to 1 oz water Make inject. stronger [illegible] For gleet give bals. cop. & add tinct. canth. 20 or 30 drops Apply blisters to perinaeum if necessary Treat sympathetic buboes with discutients with blisters Treat chordee with opium dover’s powders etc. If urine is frequently passed & with pain use the catheter it giving [illegible] relief Opium is the best remedy for chronic aff. of bladder as a sequel Uva ursi is recom. also Whether the bladder or prostate is aff. use the cath. Hernia humoralis Infl. of testicle Caused by gonorrhoea by injuries by metastasis of hydrothorax etc. by metastasis from aff. of head mumps Not produced in the early stages of gonorrhoea but in the decline though to be brought on by stimulant injections Caused also by aff. of prostate & various urinary affections Flatulence borbogyna pain testicle swells when large flattened in bad cases a redness of the skin Pain & constitut. irrit. very great from the distention of the firm serous membrane Bleed cal. salts Horizontal posture suspensory bandage ac. plumbi Prof. H. troubles himself little about the running [illegible] the infl. of the testicle is cured generally the gonorrhoea ceases Where a serous effusion in the whole scrotum takes place, shave & blister the whole scrotum If a hardness remains (especially of the epidydimis) treat with camphorated mercurial ointment Pus should always be evacuated if it is not evacuated, a fungus will spring out nit. sil. Phymosis Congenital accidental generally goes off (when natural) at puberty if not we may be called on to remedy the complaint. In venereal diseases ulcers may be concealed, or ulcers may arise from the sebaceous glands may irritate The urine may irritate Sometimes the prepuce may be enormously distended. Sometimes infants are born without any orifice When there is an opening it is sufficient to slit up the prepuce. If now cut off the end When distended make an opening with a lancet. As to the size of the opening, calculate upon a retraction in [healing]. Use a sharp pointed knife upon a director If the [prepuce] is schirrhous in old men circumcise & you will do this more easily if you slit up first Everted urethra Case in an infant Mischief from tying a ligature around the penis by boys troubled in bed. Swelling may cause the string to disappear cases mistaken for phymosis etc. Paraphymosis When the prepuce cannot immediately be brought back, every moment increases the difficulty, as the glans continually swell. Gout swelling, infiltration etc. occurs. Apply cold water etc. & then the patient must submit to have the prepuce returned place him against the wall, & have him held Compress the glans a long time shifting your hands in order to keep them cold & when you have the glans sufficiently reduced, return the prepuce if you fail, try again It is not necessary to divide the stricture Le Franc, also always succeeded without division Stricture of urethra May exist to a slight extent Most commonly 6 or 7 inch from external orifice just behind the bulb next to this is 4 ½ in. frequently ‘ there are more than one & almost always one at 7 inch dist. (E. [illegible] May be on one side of the canal In old stricture we have an almost cartilaginous hardness Symptoms alteration in form or size of stream of urine may be forked Dose not tend to a spontaneous cure but to grow worse & worse Difficulty of passing urine increased by cold by drunkenness by hard exercise Ultimately irritation chills, fever, anasarca excessive pain anorexia aphthae etc. etc. A discharge may come on and be mistaken for gleet especially after gonorrhoea hernia haemorrhalis nocturnal emissions & semen thrown back into the bladder May be mistaken for gonorrhoea, gleet infl. & abscess of urethra or prostate calculi in bladder or urethra. Pain in passing urine greater in gonorrhoea Diseased prostate is generally in old men & admits the catheter for 7 ½ inch. & a catheter can generally be passed by skill in enlarged prostate enlarged prostate can be felt by the finger in the rectum. Caused after sometimes by gonorrhoea (as a remote consequence) By injury of the perinaeum by stone in the bladder by warm climates Treatment Ascertain the existence of a stricture by means of a bougie Warm & oil & [illegible] your bougie if you fail pass a smaller one. We may be obliged to desist from pain, irritation, shivering faintness etc. But the urethra becomes insensible after a time. Where a very small bougie is needed catgut is recommended it swells in the part When we have succeeded in passing a bougie the cure is in our power (S. Cooper) Eventually we can keep in the bougie for several hours When we cannot pass a bougie introduce caustic it lessens the irritability Prof. H. has lately preferred a small catheter with a piece of nit. sil. in the end. Some use the caustic kali Flexible metallic catheters are much used of late Bougies undoubtedly do goo besides their mechanical dilatation. They stimulate the parts Patience and perseverance are needed Retention of urine hemorrhage (when the slough separates) may occur Prof. S. laid open the stricture internally Fistula in perinaea Caused by strictures by calculi etc. Touch with nit. sil. Dr Physick passed a piece of tape laterally & tied it tight over the fistulous orifice Vide Dorsey’s Surg. In worse cases, pass a straight sound down to the stricture pass in a probe & feel its end. Cut down to the end of the sound Dr Stevens proposes to inject a coloured liquid into the cath. to assist in finding the urethra Always cure the stricture first Mr. Earle performed [a] [talication] operation Sir A. Cooper’s treatment of retention of urine remarks on Incontinence of urine 1st from paralysis of sphincter from general palsy from long continued peritoneal [illegible] from retention 2nd from injuries causing a communication by ulceration into the vagina or by a cancer 3d during sleep affect children under puberty 4th S. Cooper mentions an irritable state in which the pat. is constantly compelled to urinate. This is merely a symptom of hysteria hemorrhoids stone in the bladder etc. 1st When occurring from paralysis treat for the general aff. and introduce the catheter frequently. When from difficult labour introd. cath. freq. 2nd plans of cure by sutures 3d It has been lately supposed to be caused by lying on the back not so Prof. H. has cured by cantharides Sometimes connected with disorder of digestive organs great thirst etc. Imperforate vagina Sometimes the labia, wholly or partially adhere Separate sometimes with your thumb (vide Denman) When not discovered till the period of menstruation very troublesome Prof H. has had several cases. Sense of weight pain in the loins finally difficulty of passing urine in the first symptom noticed in some cases difficulty at stool swelling of abdomen nausea hiccup etc. Much variation in the nature of the closure sometimes membrane sometimes very thick Examine whether there be not more than an obstruction perhaps a ligamentous band Hemorrhoids Two kinds varicose & organized If the blood comes from the intestines above it will be black if not, florid? Prolapsus ani often often accompanies If very superficial and near the verge they may often be clipped off Prof. [illegible] [illegible] when from the intestine extirpates by a ligation Pass a needle through & tie each way Fistula in ano Prof. H. is convinced that it arises from infl. & suppuration of the bursa muc. behind the rectum Causes obscure perhaps hemorrhoids Begins with pain, fever etc. When the abscess bursts externally it is called external fistula when internally blind fist. when ext. & int. complete fistula Const. sympt. & pain very severe Open early & keep open with a bougie when external When blind pus on feces a tumour at [anus] very fetid, as is usual with abscesses in muc. memb. No plan of cure succeeds but laying open Pass your finger up the rectum & meet your finger with a probe pointed bistoury then cut down through the sphincter Introduce ling Be careful to distinguish from lumbar abscesses etc. pointing near this part. Cancer of the rectum. The extremity of the rectum has been extirpated. Distortions of the feet Club foot valgi & vari There is a malformation of the tarsal bones. Probably the affection is caused by some wrong position in the uterus Seeds to be more or less hereditary in some families. There is an institution in Paris for distortion s attended with great success When the foot turns directly upwards towards the tibia it is easily remedied by a roller an elastic splint and a bandage. Club feet are easily restored by the hand the difficulty is to keep it in its place. B. Bell’s mode by a [shoe] etc. [Machines] of wood carved out. Prof. H. has succeeded very well by a tin shoe with one side running up the leg He has succeeded well also with stiff saddler’s leather. But Smith’s splint in superior to all other modes. Apply to F. Gregory of Uxbridge Mass. The great object is to keep the sole of the foot, flat on the ground & turn the toes out as much as you can Palsy of the lower limb from diseased spine vide Pott. Generally affects children The child will be observed to stumble the toes point downwards, remarkably The limb looks remarkably smooth and tense, instead of flabby and wasted. Upon examination we shall find the [illegible] vertebrae, projecting Ultimately the bladder is affected with strangury perhaps there will be incontinence of urine. The patient may die of marasmus etc. Remote cause obscure Prognosis doubtful Caries and abscesses are often met with Mr. Pott invented the mode of treatment by issues, and was very successful in a number of cases Lateral distortions of the spine are said not to produce paralysis Paralysis appears to be caused only by this angular distortion. There will be also pains in the loins etc. Sensation is erroneous with respect to the heat of the limb Pat. thinking it hot when cold & v. versa Sometimes sensation remains, at other times the paralysis is complete. Sometimes the abdominal muscles are paralytic sometimes the urine & feces come away unconsciously. Large sores may be caused in the ischia & trochar [less] by lying in one position There is generally a permanent anchylosis after the cure Experience shows exercise to be injurious. Hence some propose to cure by rest Opium will almost always be needed. Ultimately sul. quin. Very probably iodine might be beneficial. Sometimes a seton has been substituted for an issue Once in 2 or 3 months an old issue should be suffered to dry up & a new one made Lateral distortions of verteb. We are generally first consulted for a projection of one shoulder blade Caused by long sitting in one posture etc. Darwin thinks position in bed to have some influence and directs those children who sleep together, to change sides occasionally. Mr. Casey’s machine has a staffed back. lifts pat. up by shoulders Carrying weight on the head proposed Depend principally upon exercise in the open air and sleep upon a hard mattress. Such a plan as this will make the distortion stationary, and restore the general health But Prof. H. has not known it permanently & effectually cures the distortion Give soda, iron, rhubarb etc. Setons and issues seem to do little good. Friction and sharpening are useful Mr. Harrison lays much stress upon manipulation on the back and this too for all kinds of vertebral distortion Diseases of the medulla spinalis, producing paralysis without aff. of vertebrae Affects mostly children from 2 or 6 mo. to 2 yrs old. Generally begins with a febrile affection, and soon a paralysyms & hemiplegia sometimes one side first one limb, then another Adults sometimes affected in a similar manner. Dentition has been thought a cause. This cannot always be the case. Scrofula has been considered the cause also but scrofula is uncommon in the country where nevertheless this aff. is met with. It is often attributed to the little calomel given in the commencing fever But many cases have received no medication at all Prof. H. considers the disease an inflammation of the serous membrane of the spinal marrow. Sometimes the disease is chronic and unattended with commending fever. Sometimes the brain may be affected thus; vide Amaurosis Prof. H. treats acute paraplegia and’ hemiplegia etc. first by v.s. mercurial & other cathartics and a succession of blisters. As has lately used more pinching up hard a small ball of cotton & [illegible] it dowm by the blow pipe Tart. emetic ointment etc. Prof. H. has often succeeded this for children but sometimes fails. Chronic cases he treats in a similar manner [Moxa] near the ear seems to have great influence upon paralysis of the face When the spinal marrow comes on during a fever Prof. H. has succeeded often in curing it Some cases seem to be caused by parturition The more acute the disease the easier cured. For chronic cases Disease of hip joint morbus [coxarious] [illegible] form 1t violent irritat. acute fev. etc. 2nd a chronic form coming on gradually counterfeits all diseases 1st begins with acute pain generally in the knee high irritative fever emaciation sallowness etc. Apt to be mistaken for aff. of the knee Not the slightest motion is allowed confined to one posture in bed limb elongated knees separated Eventually there will be shortened the [illegible] of the bone being on the dorsum of the ilium this shortening is ascertained by comparing thickness & ankles Prof. H. has known the length [illegible] in the first stage amount to 1 or 2 inches Supposed to be caused by scrofula this cannot always be so The disease is more rapid in children than in adults Distinguished from lumbar abscess by the history and appearance Sometimes after the spontaneous dislocation health will come on & nothing but lameness remains Generally there is some amendment when pus issues The prognostic is favorable if amendment follows evacuation if there is no hectic etc. In the chronic form we have first a slight lameness in walking pain is often exclusively at the knee sometimes at the hip over the [illegible] nerve This form is often caused by scrofula Seems often to arise from violence also from exposure to cold and sometimes no cause can be conjectured Many cases of sciatica are thought by Prof. H. & I. to be affections of hip joint Injuries will increase the disease as by nat. bonesetters Case related of this sort Treat. the acute form by v.s. & cal. apply ac lead (cold or warm) give opium freely from the first to relieve the pain better in the first place in form of dover powder. If the ain does not subsid. apply a blister Issues are too slow If the disease is attacked early it may generally be cured Treat the chronic form in a similar manner blisters seton is [illegible] & [illegible] Keep the limb absolutely at rest & secure this object by using Smith’s splint Make issues with caustic kali through a hole in a plaister & cover with another plaster In 6 or 8 hours it will have made a sore. Apply your issue generally back of the trochanter Prof. H. has succeed with them in the inside of the thigh near the knee. Setons are introduced on the anterior part of the joint Do not push your counterirritation too far with children Renew your setons and issues once in 6 w. or two mo. Prof. H. has applied tart. emet. Moxa now fashionable. Larrey does not wish for suppuration thinking the heat mainly beneficial The bowels are apt to be costive, from [illegible] to pass a stool manual assistance is sometimes necessary at stool The constitutional weakness and irritation are very great op. op. & cal conium etc. bark quinine Unopened abscesses are very dangerous Patients are apt to die suddenly with them Mr. Abernethy kept the pat. at rest at first (in the chronic) and gave the blue pill etc. for the constitution [the] prohibited motion for a long time etc. This practice not energetic enough for the acute form. Iodine now recommended We stand much in need of a better mode of treating this disease Considerable difficulty with parents often Venereal diseases formerly considered a unit. Mr. Hunter described the chancre But Mr. Hunter’s disease is now but rarely met with. Carmichael describes the true chancer & severe other sorts of sores on the penis A French writer has denied the existence of a specific syphilis Prof. H considers the inoculation of small pox and other poisons similar to the venereal contagion The first effects are entirely local 1st a little pimple or vesicle with serum or pus It degenerates into an ulcer of a foul & ragged appearance. Next the absorbents are affected Net an infl. of lymph. gland in the groin. Next ulcer in the throat or eruptions on the skin or both Net [nodes] tibia sternum fore arm perhaps ossa nasi It is now found that very many venereal sores may be cured without mercury. Such cases are now generally called syphiloid Many experiments have been made in the army more or less successful without mercury Mr. Hunter’s chancre has elevated edges & a hard base Prof H would pencil it thoroughly with nit. sil. afterwards wash with a saturated sol. of sulph. copper Then the black wash (cal. & lime water) Keep the pat. quiet in his room. If consulted early do nothing more If the chancre is early destroyed there will be no bubo When a bubo forms & suppurates, open and touch thoroughly with nit. sil. The ulcer in the throat looks very ill, yet gives less pain in swallowing then would be expected. The [pat.] will often deny its existence The eruption on the skin is quite singular looking like mallows cheeses Some prefer blue pill some corr. sub. others calomel others mercurial ointment. Sydenham gave 20 gr. doses of cal. Dr Carter of Natches has revised this practice procuring bilious discharges say 2 a week & salivation comes on Give corr. sub. in a bread pill 1/8 gr. Patients will scarcely bear more than ¾ gr. a day without a dysenteric aff. of the bowels Blue pill [5] gr. at night if this fails give it oftener Mercurial fumigation Mercl oint. rub in about a dram a day. We wish to avoid salivation Give large quantities of sarsaparilla. Conjoin guaicum etc. also Nodes will require no separate treatment Min. acids have been very famous. It does well after the system is reduced by mercury So sulph. quin. etc. when tonics are indicated [illegible] panacea has sometimes done well after a long mercurial course owing probably to its [minute] quantity of corr. sub. If a phlegmosis hide the chancre inject sil. cop. ac. lead or nit. sil. Inflammatory action will require v.s. & cal cathartics Sometimes life is threatened by a local hemorrhage The joints may become affected like rheumatism Partial blindness and deafness occurs If exfoliation comes on inside of the scull, generally the patient dies of paralysis etc. After long use of mercury the system becomes so susceptible that rubbing in a little merc. oint will affect the mouth in 15 min. In such cases Fowler’s solution has done well. Dr [Pardon] [Bowen] of Providence, relied very much on it. Give large quantities of sarsaparilla in the sequel The bones of the limbs sometimes becomes completely brittle Venereal infants mercury Calculus in the bladder May be produced upon a foreign body lodged in the bladder as a nucleus e.g. musket ball bits of a bougie etc. needles by hysterical women! More common in the western states and in Maine Symptoms very obscure pains in loins, vomiting, sediment in the urine sand passing away Nausea and vomiting with excessive pain are most apt to be cured by the passage of calculi along the ureters The pain will be sudden and violent not gradual and dull like that of psoas abscesses Retraction of testes, numbness etc. will also attend These passages through the ureters are commonly called attacks of gravel Passage of calculi through the urethra, gives rise to retention sense of tearing etc. perhap Symptoms of stone in the bladder pain at the extremity of the penis greatest when bladder is empty The pain comes on in paroxysms They are aggravated by walking or riding over a rough road. Pains in the neck of the bladder at stools. Yet these “fits of atone” may come on without any exciting cause. Patients pinch the glands Pass urine frequently have a frequent sense of inclination to go to stool. When the calculus is large there may be a sense of weight in the bladder. The urine becomes finally turbid perhaps bloody Children are said not to be subject to pain in the kidnies and ureters experiencing only stone in the bladder Finally micturition may be very frequent once in 15 min. A thickened and inflamed state of the bladder supervenes finally the patient dies of hectic. Prescribe remedies for irritation in general v.s. in extreme paroxysms Cal. opium as a matter of course It has been customary to cojoin alkalies & uva ursi these relieve though they do not dissolve the stone Prof. H. was for a long time afraid to blister for strangury but he now finds it very beneficial Operation Hippocrates swore his pupils not to perform it. The first mode was to pass the fingers up the rectum pull down the stone into the perinaeum & make an incision directly upon it. This was called the lesser operation or cutting by the gripe Next came the apparatus major so called in consequence of the large number of instruments A small opening was made to the forcibly dilated Next came the high operation above the pubis This has lately been attempted to be revived By this mode a large stone can be extracted without breaking Lately it has been proposed to operate through the rectum The present mode is called the lateral operation and is performed now as [Ches??da] formerly did. Some are inclined to substitute the knife for the gorget First sound perhaps a schirrhus may be sometimes mistake for a stone Prof. S. performed the operation for a calculus in the urethra. If the calculus drops down into the bottom of the bladder introduce your finger into the rectum Mr. Hey sometimes sounded with a silver cath. and felt the stone as the urine flowed. A flexible catheter without a stilette, has sometimes succeeded when other instruments have failed. Examine sitting standing, lying etc. Try repeatedly Administer over night a senna cathartic and an hour before the operation an injection Operation After it the urine flows out at the wound. Dr [Rhea] Barton keeps a flexible catheter in the bladder through the wound Some give opium immediately after the operation. Be guided by circumstances give opium if pat. has been in the habit of taking it Laxatives are very beneficial Children suffer very little But old people are apt to have chills, cold extremities etc. Treat as for shock q.v. Apply cloths, just as to a woman after delivery. Watch for hemorrhage When infl. comes on it is known by pain, chills etc. A very successful surgeon at the west, bleeds ad deliq. immediately after the commencement of delivery Fatal cases exhibit not gangrene but suppuration and abscesses The relief from the operation a very great pat. sleeping better the night after the oper. than for weeks previously Lithotomy in Women Case of a stone formed around a darning needle! extracted for Dr Cogswell The operation through the vagina is easy but the wound is apt not to close & [then] cause an incontinence of urine Sir A. C. introduced the plan by a sponge tent. Rx a sponge & dip it into melted beeswax moderately hot roll it into an oblong shape Introduce it the bees was melts out and the sponge dilates very powerfully often succeeding in a few hours When the stone is too large 1st cut [illegible] director to the left 2nd cut between Le France’s ode (invented by Costa) Place the pat. as for lith. a [illegible] is held by an assistant & depresses the urethra and vagina. Cut with a bistoury above the urethra and obliquely from the the symphisis pubis down close along [illegible] the ischium cut layer by layer until you arrive at the bladder Tumours of the bones Exostosis an increased growth of the body most frequently found in the [cran.] sternum clavicle ribs long bones Sometimes flat sometimes pointed sometimes pedunculated Sir A. C. makes two varieties one from the substance the other from the medulla Prof. H. makes cartilaginous (with bony parts interspersed) and fungoid or medullary Caused by external accidents as blows etc. scrofula syphilis etc. said to be the causes To be distinguished from [aster] sarcoma by its uniform hard [illegible] Seems not to affect the general health, unless the part is so large as to interrupt functions Most commonly the tumour stands out at an angle Sometimes they cease growing and remain stationary No treatment but extirpate is of use Use trepans [illegible] of various kinds, chisel & mallet etc. Operation not dangerous 2nd Osteosarcoma may be hard at the surface but will be soft (perhaps lardaceous!) in the centre (called fungus by Sir A.C.) base broad the whole substance of the bone is converted into it. Sometimes suppurations come on in the interior IT is fashionable to consider them all as fungus haematodes but they differ Fungus haematodes cause absorption of an adjacent bone. The general health is here affected Prof. H. considers internal remedies of little use. The disease is apt to return after extirpation. Boyer advises the actual cautery after extirpation. When on a limb amputate. May be of immense size as large as the body. Prof. H. has known on as large as a milkpail & two tablespoonfuls of laudanum at a dose necessary for the pain Caries soft black cloth stained dark perhaps honey combed from venereal etc. (may be caused perhaps by long unopened abscesses in some cases) Treat by caustics & especially actual cautery. Occurs most in the spongy bones Sometimes resection Caries of the hand penetrates the cranium Especially affects the mastoid process From syphilis We may touch only the mast. process with act. cautery. Remove carious portions Caries of sternum from syphilis Natural cure of caries is by necrosis terminations by depositions For superficial caries stimulating applications are generally sufficient e.g. nit. sil. sulph. copp. etc. Caries may occur on sacrum crest of ilium tubers of schium etc. from lying long on one [portion] Necrosis Death of bone Applied by Prof. S. to the specific disease called “fever sore” Bone first white then dirty yellow finally brown and black often surrounded on the edges by an elevated circle of granulations but finally the necrosed portion from being depressed well as it were rise up & be more elevated Commence with fever which is apt to be considered by the physician as an idiopathic fever followed by the fever sore. Occurs in the cylindrical bones principally oftenest in the tibia next in the os femoris External and internal periosteums dies & then the bone dies of course sometimes however the death is only in spots. Prof. H. is convinced that [illegible] incision often prevents the destruction of the periosteum vide [illegible] Commences with deep seated pain but often the pain is first in the joint & the disease is mistaken for rheumatism In a day or two fever comes on perhaps finally subsultus tendium and delirium Great pain on moving the limb. Pus first accumulates under the periosteum but in the thigh first in bursa under the tendons of the [ham.] In the spongy bones pus collects also in the cancellar structure Caused by cold contusions comminuted fractures caustics applied to ulcers most commonly in boys from excessive bathing in cold water many cases of this kind exposure to rain storms generally causes [illegible] sores unknown the joints near the part are apt to become much flexed Apply a splint pretty early Treatment. Bleeding cathartics blisters and opium Prof. H has found the subsequent irritation as much worse in the latter stages when the treatment was not commenced by evacuations The notion that evacuation shd not be used because the blood may y and bye be wanted. Prof. H. would pay little attention Besides at first we do not know certainly the nature of the affection in the first place in many cases we shall be told of an injury Blisters at the commencement are better than fomentations and poultices Pus will form however As soon as the disease is fully formed make an incision down to the bone through the periosteum we shall generally find pus If there is pus inside the bone bore into it with a nail gimlet It gives the greatest relief be careful not to split the bone Extracts from the notes taken by my friend T. H. Wadsworth of the Lectures on Surgery of Theodore H. Woodward Prefect Castleton Vt. Metastasis is another organ aff. sympath. & more so than the first Adhesion a vital process analogous to assimilation not an infl. for infl. hinders, as does coagulated blood, which has lost its vitality most successful where no heat or pain or mark of infl & then may take place in 18 h. The [illegible] lymph forms a bed for the vessels to ramify in The secretions of a part infl. gradually change to pus & then gradually back again, as in successful cures of clap. Prof. W. uses bandages to most acute infl. contrary to common practice they do good unless the irritability is very great or they are [illegible] fully applied they are particularly useful to deep seated infl. especially if chronic Mortification Prof. W. has seen all the muscles of the arm dissected clean from shoulder down & hanging but by their ends. A small strip of skin remained from wh. new skin was formed & covered then again. The case was caused by the bite of a hog When you bleed in cases where you expect extensive suppuration to come on, [illegible] on [illegible] you may want the vital power back again. You may temporarily relieve pain in any aff. whatever by v.s. you may if [illegible] wish produce syncope or death. In phlog. cases the best refrig. to follow v.s. in tart. ant. in nauseating doses it keeps the skin moist & affects the other secretions For superf. infl. cold is the main quality in external applic. Use spir. 1 pt to 4 water vinegar etc. etc. Somet. when all the [illegible] appear to indicate cold applic. they disagree & produce vomiting, spasm, or even convulsions. Here use fomentations which need not be medicated unless with narcotics which have considerable effect. Astringents added to washes do little good except for appearance. Lead, if very strong has some effect use a sat. sol. Lead applied too long to eye will produce palsy of it. For deep infl. use warmth cold is like water on outside of a blacksmith’s fire, making it hotter within. Use counterirritation Acute infl. term. in chron. is bad to manage & must be looked to it is apt to produce considerable irrit. of stomach. Commonly we want a moderate use of alteratives cal. & op. use bandages friction, liniments gradually change to a more generous diet. The best form of merc. in these chron. aff. is corr. sub. with op. bark may be [wanted] camph & carb. amm. good to allay irrit. & keep skin moist the position shd always be such as to favor the veins in this stage cool washes are not commonly good frict. with merc. oint. good. The const. treat shd be the same or nearly the same is if there was no local aff. The grade of action may be too low for suppuration in acute cases or it may be too high and gangrene or chronic weakness, effusion etc. may be the results Look to it After suppuration pat. somet. wants support, sometimes does as well without. When pus is in an important part, or under fasciae, do not wait but open After opening a large abscess of the chronic sort there is apt to be increase of pain, fever etc. It becomes aff. with acute infl. from the wound & perhaps from taking off the pressure suddenly Hence open them in the valvular manner, squeeze out the matter, bring the edges merely together, plaister & bandage with compression. By this process ac. infl. is prevented & adhesion of sac promoted we have to open several times but at each time there is less matter. Open common abscesses before the skin over them is diseased when it first begins to blush they heal much sooner bandage & compress. This is worth every thing else in the treat. of such tings Sudden stoppage of the secretion of pus is apt to affect important organs Ulcers Irritable ulcers limewater with mucilage good Rx zfs [illegible] hydrar. zfs cetacii zi opii Often they want calm. & op. say 5 gr. cal. at [illegible] & 1 gr. ope. 6 times a day. Prof. W. has cured many by moderate emet. of tur. min. repeated a few times wash of op. & bark sometimes. If you use bandaging it must be with care sometimes a good Sloughing ulcers no pus livid with [vesicle] constant pain granulations if any dark & often slough. Best applic. 50 drops nit. acid to 1 qt. water this more active than mur. acid charcoal as good as saw dust & no better Prof. W’s experience yeast poultice good. Port wine poultices good Stim. internally Most common in old drunkards Fungus ulcers (filled with proud flesh) are most common, changing sometimes to irritable & must be treated as such we must remove the lard edges before they will heal Cantharides in powder is often a good application to ulcers A simple roller if well applied is as good a way of bandaging as Boynton’s Ulcers with thick indurated inverted or everted edges must, in some way have these edges removed. When gangrene is commencing a poultice of yeast & flour etc. or a fomentation of brandy is good When not very deep seated & depending on local causes, a blister sometimes stops it Nitric zi to a pt. good turpentine ess. oils For [illegible] toes of old folks give tonics & stimulants For gangrene with considerable action remaining cold washes are best for others, hot. Diseases of Women The uterus has not quite so much to do with all dis of women as some think Some women regularly menstruate once in 35-45 60 even 90 days, yet are in perf. health & fit [for] business. Prof. W. has known many women have children at 52 Erythema anatomicum Best thing at first as to excite infl. in the part by caustics etc. Internally use stimulants etc. Anthrax Cut through the whole tumour both ways this relieves much, by taking of the stricture & the sloughs get out sooner Use anodyne fomentations etc. Scrofula Prof. W. has more faith in ext. & int. use of iodine then in any thing else known a large swelling much diminished in 18 m. & pat. become less evacuated & her health improves. Inflamed glands are often discussed in their early stages by blistering Wounds The sympt. fev. is commonly synochus but [illegible] with epid. disth. It is important to make arteries bleed if they will in first dressing & tying them Prof. W. prefers on the whole to let one and of lig. lie out where both are cut off, the part is always irritable Lacerated wounds are apt to bleed afterwards & it is best to secure them if possible In traumatic gang. no matter how soon you amputate if pat. has vigor enough unless the cause of the gang. is constitutional, & then though the gang. spread, you shd wait for the line of demarcation In gunshot wounds there is apt to come on deep seated pain from tension of fasciae etc. open & relieve The symptoms from large contused wounds are commonly those of atony & at any rate do not want dep. Second hem. is commonly from 7-12 d. Tetanus may be from injury of nerve but is generally (as Prof. W. thinks) from wound of a part of low vitality. Irritants to the wound are of use also to spine & stomach Give calom. ol. pin. op. etc. perhaps in some cases of considerable action v.s. to increase susceptibility to articles Wound of nerves Nerves unite as well as any part. The temperature of the part containing the divided nerve is colder but if it is covered with flannel it becomes warmer than the other corresponding part covered in the same way Sprains When the soreness is nearly gone, pouring water almost scalding hot, from a height has the best effect, with friction & bandaging often Sutures bandages, ligatures Prof. W. uses only the interrupted & twisted [sutures] An inexperienced hand had better enter the needle both ways from within in forming an interrupted [illegible] Old fashioned needles miserable things. Dr. Miller’s needle with a handle is good Flannel is more elastic & makes a better bandage for parts that are cold & edematous The only kinds of bandages of much use are strips single & double headed roller & 4 tailed Sometimes (not often) a T bandage Dentists silk makes the best ligature Spina Ventosa A bad name meaning internal caries of a long bone not easily known at first. The cavity of the bone increases in size? at first & fills with matter the outside also increases the shell is thin & there is an appearance of distention Oftenest affects the head of bones & is at first every way like white swelling except that the If even early evacuate the matter from the bone if you are certain what the disease is but if seen very early try general remedies & counterirritation as in white swell. In the latter stages the swelling bursts and often long tumors are formed, It will be attended with great pain irritation & discharge & the limb must be removed Ophthalmia In chronic stag nit. sil. & corr. sublimate better than mere astringents or cutting vessels but in some cases the vessels must be divided The applications are apt to be made too often twice a day will do Prof. W. has faith in local bleed. even when the syst. in general want tonics Great relief is afforded by applying at night a fomentation of cut tobacco, & binding on it may be dropped into the eye in cases not very irritable In many cases at the outset nit. sil. does well dropped into the eye, removing irrit. & vascularity. Do not continue warm app too long at least if infl proceeds to supp. use cold washes nit. sil. sub. zinc etc. In many cases Prof. W. has seen blisters near the eye cause irritation apply them to the neck Simple milk lachrymose ophth. may be cured by any mild stimulant Suppurative ophthalmia 4 sorts 1. epid. 2 metastatic (from clap or catarrh) often with a greenish secretion) 3 intermittent (from interm. causes) 4. infantum If the cornea fades & loses its lustre & its edge looks uneven it will certainly slough unless treated as gangrene by stim. ton. etc. Sclerotitis Straight vessels running to iris, well marked turgid & look as if painted florid color violent pain of eye, especially on motion there is apt to be effusion under the conjunctiva making the surface of the [sclerotic] coat unequal. It is apt to affect the choroid. Prof. W. does not know as there is a [chorditis] when chor is aff. there is dullness of function. the iris sluggishly contracting & limited in motion there is great irritability of the eye & division aching pain in forehead. Apt to aff. the iris. Treat as in other ophthalmitides but merch. ac. is especially useful in deep seated inflammations of the eye Rheumatic sclerotitis looks like the other, but aff. also the periosteum of the orbit & the pain is greatest then The pain is greatly aggravated at night sight always dim. iris acts sluggishly Apt to aff. the other coats. Eye dry & hot The pain often aff. half the head it is irregular & never entirely remitting. The fever is of the arthritic character with deranged secretions of the bowels. Prof. W. never saw bleed. do goos in any rheum. Calom & op. are better. Apply leeches & blisters. Keep the pupil dilated with belladonna. IN the last stage quinine arsenic is still better especially in chronic cases. In acute cases the best thing Prof. W. has seen has been actaea or colch. He never saw any local applic. but narcotics do good. There is no tending to chemosis Catarrh rheumatic aff. sclerot. & conjunct. both & has sympt. of both rheum. part goes off before the catarrhal It may terminate in opacities ulcerations of cornea, may ulcerate through. Digest apparatus much disturbed. Catarrhal or Epiderm. ophth. Prof. W. thinks the same as arythem. muco pur conjunctivitis It is apt to leave a villous look of the conjunctiva. Begins with stiffness of eyelids sense of pricking in the eye, especially about the lachrymal [caruncle] pat. cannot be persuaded that he has not sand in his eye & picks scratches & rubs. Conjunctiva of a mottled red, turgid. [Chemosis] commonly imperfect aff. only one side of the cornea (the chemosis is semitransparent & is evidently from serous effusion) Continues 6-8 days & there is a muco purulent secretion. Bad cases run on to the chronic stage, with ulcers of cornea, effusions, & spreading to other textures Prof. W. never saw sloughing in this It is epidemic & contagious General treat. same as for severe common ophth. Local applic. corr. sub. is best 1 gr. to 1 ounce nit. silv. good, but not equal to corr. sub. (common astring, generally irritate & do no good) Blisters In an early stage & even so late as the middle of the acute stage Prof. W. has cut it short by applying saturated solut. nit. oil, with internal use of arsenic quin. etc. Apply red prec. ointm. a piece as big as a pea between the eye lids & suffered to dissolve The pat. is very liable to subsequent attacks Chronic ophthalmias of all sorts are treated pretty much alike. Generally we must restore or change the secretions by merc. and corr. sub. is best. by other deobstruents in lower cases Narcotics & tonics When you apply red prec. ointm. 12 gr to zi is pretty strong Hydrocele Prof. W. prefers operating by seton of [illegible] thread, drawn through the tunica vaginalis & kept there till there is considerable infl. Causes of spasmodic cholera are not contusion & infection but those of wide spreading epidemics A board of 100 medical officers in India declare for non contagion So the medical board of Madras So also the 24 physicians constitution the medical boards of [Moscow] with only 3 dissentients. We sometimes have cases in this country precisely like those of India This is true of other diseases Diseases cannot be distinguished in their ataxic form this is true even of fever & ague which has destroyed patients in the second paroxysm Pneumonia typhodes has exhibited cases among as precisely resembling those of cholera spasmodica Physicians have differed more in their treatment than in regard to its causes large doses of calomel & opium diaphoretic treatment severe pain at stomach & bowels vomiting & purging great thirst coldness extremities cold to a bystander pulse at first languid or small & throbbing & in bad cases quick small & intermitting cold & clammy sweats death like coldness of extremities hiccup etc. etc. death sometimes with us in 24 hours distinguished from dysentery by watery stools & spasmodic griping pains from colic by stools allied to bilious fever yellow fever etc. produced by the same unknown causes, modified in their action it is to bilious fever what a tornado is to a settled stom. Spasmodic cholera of India has prevailed in 1774 & 1787 & in 18- Prevailed extensively in Sydenham’s time The present epidemic commenced in 1817 Said to have originated from bad rice Dr F. thinks that there may have been a predisposition then the disease first broke out in consequence of bad food & afterwards fear & anxiety would be sufficient exciting causes Anecdote of the plague in the French army Anecdote of a small pox case in Fairfield cty [30,000] reduced to 8000 in [Toflia] 17000 in 8 days at Astraca [6000000] in Asia up to 1830 4000 out of 8000 died in [illegible] Cholera called cholera morbus to distinguish that of [illegible] from chol infantum Copious discharge from stom & bow with painful spasmodic action Sometimes defined as the vomiting & purging of bilious matter this is incorrect bile is not vomited healthy bile could be vomited only in [illegible] cases The liver is diseased in connection with the stomach Affects hot climates & the hot seasons of temperate climates July to Sept. Affects the exhalents & absorbent vessels of the stomach the liver & pancreas There is a translation of action from the surface to the intestinal canal & its attendant glands In ataxic forms there [illegible] be no secretion Causes Sudden check of perspiration especially after great heat By unripe fruits large quantities of acids wild grasses, peaches & milk in short any thing which suspends the action of the stomach in case there is a predisposition. When it is epidemic very slight causes will bring it on & hence contagion is alleged Chills languor drowsiness [distention] [pressure] at [prae] [cordia] 14 Surgery Separation of the lower end of the fibula This is the most frequent accident to the ankle according to Prof. H’s experience Yet little has been said upon it A sensation of cracking and tearing attends the reception of the injury The foot is turned inwards, a little so are the toes there is some swelling in the outside & intense pain is felt upon pressing the fibula inwards. To be distinguished from fracture & from effusion into a bursa on the outside of the foot, in consequence of strains Extend the foot a little, turn the toes outwards & press in the lower part of the fibula Apply a very thick compress & bandage & splint and bandage high up the leg for the interosseous lig. may be torn for several inches Compound dislocations of the ankle are very serious accidents. Prof. H. has seen much mischief arise from short splints and tight bandaging Wounds of the Joints The pain is generally on the opposite side of the joint. Violent pain suddenly occurs if after a few days & is generally attributed to taking cold & the attendants attempt to sweat it out etc. Ultimately excessive suppuration occurs The wounds of the joint, communicating externally, are more dangerous by far than internal wounds, as from fractured bones As severe consequences may result from wounds of the superficial bursae, as for instance that on the external surface of the patella The prognosis may generally be a favorable one for the life of the patient but the joint is apt to be anchylosed Prophylactic treatment Draw the lips of the wound together with add. ph. apply a bandage & a splint & confine the pat. to his bed. In some cases, bleed etc. to prevent infl. Treat. of infl. Press out pus etc. if necessary probe the sac etc. In punctured wounds with excessive pain and swelling & violent const. sympt. envelope the whole joint in a blister which will give great relief Let large ulcerating cavities be thoroughly [pencilled] with lunar caustic The irritation will be very much [illegible] by it. Collections that occur about the joint, should, if they do not disperse be opened & corr. sub. be injected we may first try discut. lot. & blist. And in general, keep the joint wet with disc. lot. If inject. of sol. of corr. sub. fail put a little moistened upon the point of a probe & introduce it down to the bottom of the sore. The older surgeons used red precipitate and an almost saturated solution of sul. cup. Be careful that the limb anchyloses in a proper position if knee, straight if elbow, crooked Dislocations of the Tarsal bones When the astragalus in dislocated inwards it is partly turned over the external & under surface being above Prof. H. has known the os noviculare partially disloc. He kept it in its place by a plaister bandage Gun shot wounds A common ball is said to move 2000 ft. in a second more rapidly consequently than the passage of sound hence in a cannonade at night, the flashing is first seen, then the ball whizzes by & lastly is heard the report The contusion is so great that the parts in contact with the ball in its passings are completely killed The orifice at which a ball enters will have its edges depressed the opposite orifice will be ragged The course of a ball may be very circuitous case in which a ball struck the larynx and passed around the neck coming out near where it entered. Tendons may divert its course A ball may carry before it a silk handkerchief 7 be pulled out and lost when the handkerchief is Injuries formerly attributed to the wind of a ball (for when one leg is taken off by a ball, the other is not injured by the [illegible]) are now explained by the oblique stroke of the ball and the yielding nature of the skin. Bones may be comminuted and even the viscera injured, without braking the skin. Secondary hemorrhage rarely occurs (4 cases in 1000, Mr. [Illegible]) after gunshot wounds and primary hemorrhage is of course less common this sort of wounds than in others Baron Larrey mentioned to Dr Heerman that he had lost two pat. only, where a ball had passed directly through the body Compd fract & wounds of the joints are very dangerous Necrosis of a bone is apt to be produced in consequence of a gunshot wound Necrosis of the cranium may be produced 1st ind. is to suppress hem. 2d extract foreign bodies 3d to prevent inflammation 4 promote suppuration & separation of [ischous] 1st by pressure etc. by a tourniquet applied until ligature or amp. can be performed 2d If a ball is too deep to be felt, it should not be cut for. If it can be felt by the probe, let an assistant make the skin tense, and let the surgeon enlarge the wound & extract. If it is on the opposite side of the body, make the skin tense with the thumb and finger & cut down and squeezing it out. Another period for searching for and extracting balls & foreign bodies is that of suppuration & sloughing 2d The French still keep up the old practice of always enlarging the wound. The British surgeon have abandoned the practice. John Hunter originated the plan. The French speak much of debriding the wound by taking off the tension of the fasciae. They uniformly make incision Cold water is the principal discutient lotion of military surgeons With respect to dilating the wound the British surgeons say that the incision soon close unless kept open by tents. Of course for several days the wound looks very foul; the edges puff out & protrude (Hence Larrey speaks of debriding) Poultices & fermentations shd now be applied 3d As soon as suppuration takes place, poultices shd be discontinued & cerate applied Look out for hemor. when the sloughs are cast off. Direct the pat. & the nurses to apply a tourniquet immediately if hemor. commences When hem. takes place we can seldom depend on tying the artery at a distance It will generally be better to cut down at once Sometimes a complete division of the artery will answer In hem. from the popliteal artery, on account of the difficulty of finding the artery in the hem. the artery may be tied higher up The treatment shd be antiphlogistic strictly. Mr. [illegible] directs cal. & ant. at night If severe pain in the head and back occurs with high infl. in the wound, then bleed immediately. But when suppuration occurs we must give opium for irritation Dr Fuller of Columbia mentions that in the last war it was found necessary to bleed in the first place & then to give opium Neither would answer by itself It is now agreed upon that it is best if amputation is necessary to perform it immediately, as soon as the pat. has recovered from the shock & not to wait till the subsidence of the fever etc. Extraction of Foreign Bodies from gunshot & other wounds If they are suffered to remain a cyst forms around them We must take into consideration first the nature 2nd the situation of it 3d the length of time it has been in. For if this is short we had better not delay but if it has been long in & gives no inconvenience, it may be suffered to remain Great suppuration in some cases and in others excessive irritation may result from the retention. Even a needle may cause great irritation Amputation The best authority is now in favour of speedy amputation Baron Larrey does not hesitate to amputate even after bad symptoms have come on as the pat. will be apt to to die certainly without amputation Prof. H. has amputated successfully in cases of crushed limbs, 48 hours after the reception of the injury When a limb has been shot off you amputate of course. But in case of fingers Prof. H. frequently contents himself with picking out the fragments of bone & dressing the wound When the ball has lodged in a joint or when a bone is fractured it will generally be best to amputate When the bone of the arm or thigh has been broken, necrosis takes place, and if death does not supervene, the limb will be apt to be always useless, or with an artificial joint. Bar. Lar. amputates when the os humerus is struck and if struck near the end, he amputates at the joint Very extensive injury of the soft parts may make an amputation necessary or destruction of the principal arteries and nerves. Amputate above the knee, for injury of the upper part or the tibia Even after amputation death may result 1st from infl. of bloodvessels, both arteries & veins # 2d from metastasis [&] pus being found after death in the thorax, in the lips joint etc. Prof. H. would always let such pus out. In our climate & in. G.B. suppuration of the lungs takes place oftener than in warmer ones 3d by necrosis of the bones at a joint. If the amputation was not high enough at first it may be best to amput. again If necrosis occurs after amp. the end of the bone will be sharp and ragged instead of being rounded by the absorbents. If the main nerve is entirely destroyed paralysis occurs Tetanus is apt to occur from gun shot wounds especially in warm climates Bar. Lar. applied blisters & actual cautery often with success. # & that too whether the veins are tied or not Mr. [illegible] sometimes tied the [vein] for hem. without bad consequences Hospital Gangrene Vide [Hemmer’s] mil. surg. The wound will become painful hot, red, dark, finally livid & black in the mean time the fever increases and becomes more typhoid etc. etc. In hosp. gang. contrary to what is common in common gangrene the arteries are affected & hemorrhages take place. Vide John Bell also The disease is unlike any other but resembles most erysipela of cell. mem. etc. The dis. affects all the textures, spreads among the muscle effects the deep parts more especially Caused by bad air, and a crowded state of the hospital. The affected patients should be separated from the others. It may be communicated by the dressings Mr. [Hemmer] found bleeding give give great relief the patient would beg to be bled cath. also he applied arsenic to the sores and ultimately gave [illegible] etc. In all such cases something must be applied to destroy the surface of the sore White swelling [most] exquisite in the knee Divided into rheumatic & scrofulous the first aff. the leg & the second aff. the heads of the bones. S. Cooper denies however that the heads of the bones are enlarged. Mr. Brodie also makes one division in which the artic. cart. are aff. Prof. H. considers white swelling as always in the first place an inflam. of the synovial membranes & bursae We have pain, tumefaction a puffy swelling is seen, under the lig. of pat. wasting of the limb below 1st Acute form pain then swelling like the swell. of ac. rheum. tenderness on press. & [mot.] joint easier when bent headaches furred tongue anorexia pain in other parts of the limb perhaps edema below the joint We are cautioned against confounding this with dropsy of the joint so called which is merely eff. in to burs. muc. etc. To disting. this from acute rheu. it is only necessary to know that several joints have been aff. in succession for acute rheumatism in any one joint may exactly resemble wh. sw. Sometimes pus forms erodes the ligaments & points externally often taking a very circuitous rout 2nd Chron. form pain at first trifling tenderness or pressure puffy sw. beside the pat. wasting of the limb below or edema Often the pat. will be so well as to be encouraged to use the limb, & perhaps sprain it & have a severe case at once In the latter stage both forms are alike. After a while anchylosis forms & the limb is well. But anchylosis seldom takes place except after suppuration. When anchylosis is about to take place, keep a knee nearly (not quite) straight & an elbow bent. In some cases extensive suppuration comes on & hectic so that amputation must be performed in order to save the life of the patient Ind. 1st remove infl. & here we must consider the kind of infl. wheth. ac. or chron. When there is acute infl. of a large joint v.s. & afterwards cupping scarif. & leeches Mercurial cath. as in other infl. of serous memb. Opium for pain. If discut. lot. do not relieve apply blisters But children are sometimes thrown into convulsions by them. Savin cerate is recommended in order to keep blisters open but it is apt to produce spasmodic retraction of the limb at least in children. Boyer also directs for children foment. poultices, [linim.] etc. Let a blister heal up & apply mur. amm. then in a few days apply another blister If these fail, try corrosive sub. Cut a hole say as large as a bowl of a spoon in a plaister put this plaister on & then over this a plaister coated thickly with corr. sub. This creates considerable pain & irrit. & the disct. from it will last perhaps 3 or 4 weeks. Perhaps the gums will be affected a little. The benefit however is often very great the joint diminishing in size an inch perhaps. Issues are used made with caustic kali Bar. Lar. has introduced the moxa. Setons are used but then give children too much irrit. Apply then below generally When the joint is recovering and is very weak & relaxed much advantages may be derived from a plaister bandage Where the complaint is a sequel of acute rheum. merc. are very benef. no particular advant. is to be exp. [illegible] merc. oint. Give op & cal aa gr i Canth. camph & op. aa zj for a liniment Friction also is beneficial in the latter stages If suppurations occur, open immediately The dis. is apt to recur again from improper [exper.] & exertion & from accidental injuries Reaction of the bones has been practised successfully as a substitute for amp. but not in the knee White swelling of the wrist Hand & fingers both flexed Apply a splint & compress & brace the hand back. It will relieve the pain & give confidence in the use of the arm & great satisfaction Open ever so small a suppuration great relief will be given Nervous affections of the wrists of nervous & hysterical females No swelling but pain, soreness, & inability to use the wrist Blisters seem to do little good. Plaister bandages seemed to be of some service. A similar affection occurs in the ankle joint They get well perhaps after a while. A dangerous affection of the tarsal joints has been met with by Prof. H. Swellings (puffy swellings) like white swelling eventually suppuration perhaps a curdy matter issues little or no pain after suppuration Occurs in children & youth Surgical writers call the aff. a scrof. swelling & advise amputation. White swelling occurs however in the ankle but generally occurs in children, & in the chronic form. It is met with in the children of cotton mills. Prof. H. has treated them with cal. twice a week at first White swelling occurs also in the shoulder and in the elbow An enlargement of the bones at the joints of the fingers occurs in females It has been called gout but Prof. H. thinks it has no analogy. It has been attributed to hard labour but is often met with in others. The disease will commence with pain & swelling similar somewhat to white swelling & ends with permanent enlargement Prof. H. has generally prescribed principally to the constitution applying stimulating applications etc. Iodine has been lately used in white swelling, with advantage Hare Lip Once in a while it is said to occur in the lower lip. May be single or double may affect the bone. Varies from a small notch to a complete di Operation for hare lip first performed in [Winst.] cty by a mountebank Prof. H. at first delayed the operation until the child was some months old But now he operates as soon as called even if the child is but a few days old It seems to be the fact that children with enclosed harelip are more subject to bowel complaints Prof H operates with scissors Put in the lower pin first & push it first upwards & then (in the other half of the lip) downwards to prevent there being any notch in the edge of the lip. Two pins only for children. Wind the threads so as to cover the whole incision Apply over the whole long straps of adhesive plaister. Let the pins remain 3 or 4 days in children & 4 or 5 days in adults Take off the plaister very carefully first each end then the middle Then take out pin by a rotatory motion And afterwards reapply the straps. Double hare lips have a central piece which is not to be cut away but an incision is to be made in the shape of the letter M & then bring all together in one operation thrusting the pins through the whole Cancer of the lip May commence with a crack then a scab finally a hard tubercle which may continue for years, if not tampered with, without much inconvenience. The ulceration may commence in the centre of the tubercle Lancinating pains occur & eventually aff. of the lymphat. glands beneath the jaw etc. etc. Common canker of the lip may be cured by nit. sil. etc. & does not resemble this complaint much Occurs oftenest in middle aged men said to be caused by tobacc. improbable Prognosis favorable in general if the disease has not been tampered with, if the pat. is not intemperate & if the glands are not affected Prof. H. has seen cases of affection of the lip more resembling fungus haematodes than cancer Operate as for hare lip Bronchotomy The operation consists in making an opening into the traches Laryngotomy is an opening into the larynx Bronchtomy has succeeded in some cases of cynanche laryngea or extracting foreign bodies bronchotomy is to be preferred to laryngotomy It is the only certain mode of extricating them. Even if after some time the foreign body is coughed up, the pat. is apt to die of pulmonary consumption Often the substance will be coughed up. It may be necessary to keep the wound open for some time, in order to allow of the exit of fragments The foreign body may be above or below the opening. Irritate the trachea to produce coughing to bring up the body from below Push a body, above sometimes upwards through the rema glottidis, with a probe. If you do not find the body keep the wound open One physician, kept the edges of the wound apart with the blunt hooks Push a probe through the rima into the mouth etc. N.B. Enlarge the opening of the traches with a probe pointed bistoury Operation for fistula lachrymalis peformed Wounds of the throat Lately and English surgeon who happened to reach the pat. within 1 ½ min. after a wound of the carotid & saved the pat. Dr Horner also lately happened to be passing the courthouse when a prisoner cut the branches of the carotid he employed pressure & cut down & tied the trunk the pat. died Wounds of int. jug. vein are sometimes fatal from the rushing of air into the throat. Dr Warren in an operation upon hearing the rushing noise, immediately clapped his thumb on & stopped the operation pat. survived. Taking a full inspiration has been recommended. The int. jug. is much in the way in operations for the extirpation of tumours it bulges out like an intestine Transverse wounds of the traches require sutures though some object to them. Food is apt to come out of the wound use a tube The passage soon closes however Sometimes a fistulous orifice is left as in the case of Desta of Ky. a tube has to be worn for breathing Injuries of the Head 1st external injuries 2d concussion 3d compression 4th inflammation 1st Ext. inj. An incised wound of the scalp is to be treated on general principles It will not be necessary to tie every little artery compression with a dossil of lint will often answer Even if the scalp is extensively separated, the wound may heal by the first intention When there are uneven edges & angles, stitches (the interrupted suture) are useful. Sometimes it is convenient to braid the hair In wounds of the scalp erysipelas is apt to occur & prove troublesome. Treat it as for erys. in general ac. lead or if necessary, blister bleed, [illegible] etc. Delirium is apt to occur but soon subsides Contusions on the head are apt to cause alarm often there is a tumour caused by effusion & the edges being often higher a depression of the bone is imagined and a surgeon will be sent for to trephine 2nd Concussion may be with or without an external wound [illegible] come out of their insensibility without any thing done When first revived, vomiting is apt to occur & generally gives relief pat. breathing better pulse rising Abernethy calls vom. a favorable symptom. But the pat may grow worse afterwards Blood often appears and the attendants think it comes from the stomach but upon examination we shall find it to have come from the mouth, nose, or ears Symptoms generally similar to those of a shock q.v. surface excessively cold After the first symptoms you will generally find the pat. in a profound sleep with a soft pulse Stupor & insensibility more or less perfect In severe cases pupils dilated Delirium may come on incoherence etc. Pain in the head, intolerance of light & sound etc. Sometimes paralysis of one side occurs sometimes fatuity occurs & continue for months etc. etc. Treat by putting pat. in bed applying heat, frictions give hot drinks aromatics moderate quantities of alcohol. After the pulse returns bleed continue the bleeding as long as the pulse rises Dr Phys. restored the circulation by pouring cold water on the head afterwards he bled. Next excite the peristaltic action by calomel. When symptoms of infl. of the brain appear, we must bleed & give cath. Apply cold applications to the head & blisters to the back of the neck. if the unfavorable symptoms continue Dr Rush advised salivation in bad cases & the best surgery in England practise upon this plan, at the present time If languor debility & loss of memory remain long tonics may be required After death, lacerations of the brain are often discovered. Much [???usion] soon changes the symptoms into these which arise from compression of the brain Prof. T. believe the palsy from concussion of the brain to arise from infl. of the [brain] & effusion the palsy is always a secondary symptom never one of the first 3d Compression of brain Infants may not suffer from depositions of the cranium They are said to have depressions without fracture In adults fracture is necessary to compression Sympt. stupor slow depressed & irreg. pulse stertorous breathing dilated pupils. Pat. appears in profound sleep Breathing resembles that of a fatal apoplexy Pupils, perhaps irregularly shaped Paralysis of the opposite side often occurs. Sometimes vomiting which Mr. Ab. thinks a favorable symptom in concussion? It may continue a week at intervals until the depression is removed Whenever it is liable to occur upon raising the head we may consider it as indicating compression The second cause of compression is extravasation of blood which is generally between the cranium and dura mater but may be elsewhere This sort of compression may take place some time after the reception of the injury In concussion the symptoms take place immediately after the injury the pulse is soft equal slow, regular breathing soft pupils not dilated paralysis does not occur immediately & is partial & not hemiplegic. In compression one whole side is more or less affected if paralysis exists Compression may or may not accompany concussion Always examine very carefully for fracture, or depression, even if there is no wound of the scalp the pat. will generally wince when the fractured place is pressed on Bleeding is always proper in compression unless much blood has already been lost. Give cal. also No English or Am. surgeon hesitates to trephine. Yet Desault abandoned the operation because he found it always unsuccessful. This was probably owing to the crowded state of the Hotel Dieu All the symptoms are relieved by the operation the nausea goes off & the pulse rises perhaps 20 in a min. Prof. H. has seen fraction of the cranium in two places. Patient died Mr. Abernethy describes a case of fracture of the basis of the cranium, near the foramen magnum Caused by a fall on the top of the head Trephination was formerly not practiced in Connecticut and all the broken headed patients died. Afterwards it was the practice both in this country and in England to trephine in every case When the brain is wounded we are directed not to operate. Cases related by Prof. H. of benefit from extracting bone driven into the brain. He would make it a rule to extract foreign substance from the brain Inflammation may occur sometime after the operation [illegible] have been known to recover when a [illegible] pin or a bullet had lodged in the brain Oblique wounds, with depression are less dangerous than wounds with sharp instruments If the patients are going to get well you will find no bad symptoms. If you do find them you had better operate Inflammation of the brain does not arise till several days after the accident It may come on (after 4 or 5 days to 2 or 3 weeks) from injuries which produced nothing more than contusion, or concussion or after operation Wound of the arachnoid membrane dangerous Inflammation of serous membranes as of arachnoid memb. dangerous Inflammation of [illegible] Commences with pain in the head extending from pariet. to occip. in tolerance of light and sound delirium coma convulsions paralysis death Perhaps commences with a chill Eruptive diseases as measles are apt to bring on infl. of brain in such circumstances The lips of the wound become dry flabby & pale pus is not secreted Where there is no extern. wound there will often be a puffy tumour of the scalp caused by separation of the pericranium The bone beneath will be dry and dead (The pericranium appears to separate at the same time that the dura mater does) Where there is fracture of cran. without ext. wound, pus may collect under the scull and issue through the fracture, & perhaps (if not let out) make its way through the scalp Prof H. has in many instances seen a subacute form of this aff. takes place weeks or months after, the injury He has known cases of dropsy of the head, not only in children but in adults from injuries Treat by powerful bleedings by mercurial cath. & by blistering These means must be vigorously applied When we have reason to think that the infl. is kept up depressed bone we should operate Recapitulation. Trephination is to be performed 1st [from] compression from depressed bone 2nd for compress. from extrav. blood 3d for compress. from pus 1st Prof. H would trephine a person even if in good health without compression if sharp points of bone were sticking in. 2nd As soon as the circulation is restored [illegible] if compression continues make a incision down to the bone and if there is a fracture, operate If there is no fract. try bleeding etc. If infl. of brain is violet & cannot be remedied if we know exactly where the injury, [is] received, operate, to give a chance for life even if there is no fracture Do not operate for more concussion We are directed not to trephine at the lower part of the os [fronte] over the sinus etc. Mr. Abernethy relates a case in which the dura mater was opened by a surgeon a large quantity of extravasated blood was let out the patient was relieved and recovered Let the dressings remain on as long as you can until suppuration takes place or until the patient complains. Disturb the brain as little as possible Exuberant granulations rise from a wounded brain. We are obliged to resort to compression with sheet lead over lint. If necessary they shd be touched with nit. silv. Keep your pat. in a dark & quiet room head a little raised If symptoms of infl. come on bleed & purge Sometimes the [fungus] of the brain or hernia cerebri is very formidable Prof. H. thinks he has seen two varieties 1st a fleshy fungus 2nd a hernia of the substance of the brain Mr. Abernethy advises bleeding. Prof. H. has never seen a case which required it Where there is a true hernia of the brain the patient generally dies We are not to trephine whenever there is paralysis A subacute infl. may follow concussion & cause paralysis. Prof. H has known persons recover perfectly after pretty severe inflam. & paralysis Once there may be hemiplegia & infl. of the brain without compression. Cases related treated with bleeding and blistering etc. Considerable insanity may follow concussion Great advantage is derived from cal. & op in alterative doses cal. 3 grs op [illegible] gr. After compound fractures there will often be considerable exfoliation of bone an open ulcer may, in this way, be kept up for years, from necrosis. Perhaps this may be an additional reason for Wounds of the Thorax 1st those which do not penetrate the cavity 2nd those which penetrate, but do not wound the viscera 3d those which wound the viscera The first kind require no particular treatment The second give great distress for breath the air rushes in and the lung collapses. Close the wound immediately relief is immediately given by it. The air becomes absorbed by it The third sort, generally require a somewhat doubtful prognosis Bloody expectoration generally takes place. The main indication is to prevent or remove infl. If there is diff. breath coughing etc. bleed, purge & blister Emphysema may be enormous We are advised not to be in haste to discharge & extravasated blood. Place the patient in a proper posture for letting out the blood Where the accumulation of blood is considerable there may be an external ecchymosis which, if it occurs, will always indicate extravasation of blood In urgent cases paracentesis shd be performed for accumulation of air within the thorax Prof. A. has always found emphysema relieved by puncturing the cell. membrane. When an empyema occurs it commences with pain in the side & symptoms of fever (pleuritis or pneumonitis) A chill or more will come on about the time of the suppuration When the pus has collected, the pat. can lie only on this affected side, in order to relieve the other lung from pressure. Respiration is performed by the diaphragm & abdom muscles the abdomen is perhaps fuller perhaps there there is a fluctuation externally perhaps the heart will be pushed over to the other sides Percussion gives a dull sound Make the opening between the 6th or 7th ribs unless there is a tenderness [illegible] about the middle near the upper edge of the lower rib. Make an incision about 2 inches long in adults extend it about an inch & an half through them muscles let the opening be about ½ an inch through the pleura The air rushes in & perhaps the pus may not issue at first in this case turn the pat over keep the wound open with a slip of rag Dress with a compress & rag The discharge may continue for years It often happens that the pus does not occupy the white sac of the pleura being in a sac which is limited in extent by adhesions of the pleura Hence it is important to make the opening if possible at a tender spot or one where there is a protrusion The usual consequences of opening a large abscess result. The whole pleura inflames. There will generally be chills and fever. Small doses of ipecac and calomel do well but opium is the principal remedy. Sometimes a hectic supervenes. This may terminate fatally or may end in health. In one of Prof. H’s cases a pat. recovered after 2 ½ years discharge and a very severe hectic. Larrey says patients under 36 gr are more apt to recover because the cartilages are more flexible Prof H. has succeeded in more than half his cases and in many of them the operation was a month or 6 weeks too late After recovery that side of the chest is smaller. The pleura must adhere, if the pat. is to recover Sometimes lumps of matter were discharged Amputations Less frequent now than 40 years ago In the rev. war, many limbs were improperly amputated by surgeon’s mates Necessary from a variety of causes At the present day many compound fractures are cured which would formerly have been amputated Necrosis now rarely necessitates an amputation Great judgment and firmness are required. Some patients will get angry and send for another physician Amputation was first performed with a red hot knife. Then the surgeons cut directly down. Then Cheselden introduced the double incision Then the flap operation was invented Mr. Liston has lately proposed to transfix the limb. Ben Bell was the first to propose the healing by the first intention At length amputation at the joints was adopted and found to be very safe When patients are very low with chronic disease, it is apt to be supposed that the pat. will die of the operation. This however seldom happens In case of excessive shock from loss of a limb etc. amputation relieves the shock according to naval surgeons Case of Mr. Huskisson Prudence is required in communicating the necessity of amputation. It is very improper to bleed the matter beforehand about the neighborhood. Amputation of the joints of the hand performed N.B. The wrist joint makes a much better and more useful stump Wounds of the face and throat Introduction of a cannula for respiration? Wounds of the eye brow cause a ptosis of the upper eyelid A cicatrix may cause either the upper or the lower lid to retract Incised wounds dividing the supra orbitary nerve cause blindness Vie Coop. Surg. Dict. art. [illegible] Division of the parotid duct may cause a salivary fistula. Salivary fistulae may also result from an abscess or from operations for the extirpation of tumours Prof H has healed them by touching with nit. sil. and applying a dossil of lint and a [illegible] compress Cure by means of a trocar & a cannula etc. Desault’s method Another method & probably a better one Diseases of the antrum 1st Abscesses pain in the side of the face & soreness chills [illegible] with face pain may be in one or more molar teeth Discharge often into the nose but the orifice not being free the discharge continues, for sometime. Pus frequently very fetid yellowish green. Pain often so great in the teeth that the pat. has one extracted If this lays open the antrum a cure is effected The bone may be absorbed and the abscess open on the cheek or under the eye Distinguished from tic doloreux by the febrile state, by the tumefaction the soreness pain not in paroxysms general state and habit is different Cure by making a dependent opening. Extract the 1st or second of the true molar teeth unless one tooth is particularly affected. Make or enlarge the opening by a gimlet (say) Keep a bougie in to prevent the orifice from closing. Inject soap and water spirit and water etc. Let the pat. wear the bougie 2 or 3 weeks eventually use a probe & finally knitting needle When the discharge becomes serous we may conclude the membrane to be nearly sound. Even if the discharge has taken place into the nose or on the cheek if it does not soon cease make this dependent opening Sometimes the pointing of the abscess is into the mouth near the gums generally it will then be best to enlarge the opening use a bougie etc. 2nd Polypus of the antrum There is generally a polypus in the nose or a polyp. in the nose extends into the antrum. If it grows with antrum exclusively it must be extracted by opening the antrum externally through the cheek 3d Fungus of the antrum Affects adults and children Little or no pain until pressure is made by the humor on the bones The bones becomes absorbed or softened and a springy feel may be perceived It may project into the mouth externally or under the eye, protruding it The disease becomes horrible, the whole side of the face becomes affected. General health affected vomiting etc. Death Distinguished from abscess by its slow progress. abscess of pain at first want of pus etc. It is said that some cases have been cured. Probably many of the approach more to the character of polypus The bones become so soft that it may be easily cut with a knife Desault makes an opening just above the mouth or just inside of it scoops out the fungus and applies the actual cautery (through a cannula) thoroughly throughout the whole antrum and if the fungus grows again repeats the cauterising He says he has effected several cures Prof. Gibson describes some crooked knives which he has invented for the purpose of scooping out the antrum Polypus of the nose These tumours have no sensibility though they bleed 1st the soft kind with narrow neck & nearly the colour of a system reddish pale & shining 2nd with a broad base usually of a red colour 3d malignant as fungi etc. The first kind is enlarged in damp weather. The second kind resembles fungous flesh. The last kind is a true fungus haematoded accompanied with lancinating pains etc. they may produce fistula lachrymalis Mr. Abernethy cured some patients by prescribing for the disordered stomach Extirpation by the forceps is the only made of cure. A ligature cannot be applied Tear off repeatedly until you have got a great part of it away Introduce through a cone of paper some caustic kali. The polypus will disappear but will return again generally. Blood root snuff will do well after an operation When they extend into the throat apply a cannula (J. Bell) Prof. H. once extracted a polypus 4 in. long. It extended into the antrum It was contracted in the middle like a wasp These [illegible] or [illegible] kind are more dangerous apt to cause absorption of the bones. Rx savin leaves zi opium zj a good snuff. For polypus in the throat J. Bell passes a wire by a cannula, through the nostrils takes hold of it in the throat etc. Tumours on the gums Usually dark red, spongy [illegible] if suffered to grow they press upon and loosen the teeth. Extract the teeth, if dependent on them But they may appear on the outside on the inside, or between the teeth etc. Cut them away and cauterise immediately. The actual cautery is the only cure and they may reappear even after this is used They are covered by the internal membrane of the mouth, which must be lacerated. Prof. H. has known from an abscess a fistulous orifice through the gum continuing for years fungus may sprout up in them. Extract the tooth clip off the fungus cauterize Sulphuric ac. has been used also corr. sub Enlarged tonsils may obstruct the breathing Give cal. 2 or 3 times a week. Gargle with borax or with nit. sil. 3 or 4 gr. to oz. Or touch with nit sil. Removal has been proposed by ligature. The knife is better. Prof. H. severs the tonsil with a tenaculum and quickly slice off a part with a tenaculum Dr Hosack Jun. has an instrument. Great relief is rendered. A probe pointed knife is not necessary Diseases of the Eyelids 1st Infl. of lim. memb. red swollen hot, dry finally increased secretion of mucus (so that [rings], [hatos] etc. are seen) In the morning the lids will be glued together. May proceed to ulceration of the edges, with loss of lashes Caused and kept up by reading at night by smoke by drinking cider etc. Apply cold water frequently Sometimes bleed the recommendation is for cupping and leeches Prof. H. has known great benefit from v.s. Calomel is to be given. The best collyrium is nit. sil. dropped in twice a day. Apply an ointment if red precipitate about 30 gr. to 1 oz of lard at night let a little of it penetrate the eye If this gives too much irritation apply Turner’s cerate If there is much heat apply ac. pl. Vide Coop. Surg. Dict. art. ophth. for Dr Small’s method of curing ophthalmia by compression Granular conjunctiva Caused by the continuance of the preceding. Granular specks enlarged vessels sometimes a fringed fold like a cock’s comb just where the membrane passes off upon the ball of the eye sometimes warty excrescences Apply nit. sil. or sulph. cop. in substance to the granulations. Sulph. copper is most effectual Evert the lid apply the caustic then wash then return the lid. Pare off with a knife or clip off with scissors hard granulations Prof. H. has seen little advantage from scarifying If you can, clip off [illegible] veins with scissors this sort of bleeding is much more efficacious than scarifying Concretion of the lids Sometimes congenital oftener the result of opththalmia total or partial Divide with scissors Open the eyes frequently in a day or two touch with nit. sil. Ectropium Generally caused by cicatrizes from burns etc. A chronic inflammation is apt to come on in the eye Sir W. Adams cut out a piece S. Cooper cuts off a part of the thickened membrane That variety which occurs in old men may be cured by applying nit. sil. & then using compression. Wear goggles Trichiasis may be cured by wrong direction of the hairs or by turning in of the lid (entropium The eye may be destroyed by it Caused by cicatrices near the edge which causes the new hairs to grow wrong. Pull out the hairs and touch with aq. amm. or nit. sil. When resulting from relaxations apply adhesive plaister or cut out a piece with scissors or touch with strong sulphuric or nitric acid over an oval shaped part When there is a wrong direction of the edge cut out a slip of the lining membrane in order to allow the lid to turn out If all means fail of curing cut off the edges of the lids [illegible] of the upper lid Has been cured by adhesive straps; by nit. ac. as above by cutting out a slip [illegible] Hordeotum (stye) Ordinarily nothing to be done but to poultice. Sometimes the suppuration is imperfect especially in delicate females a tumour may thus be left behind and give great alarm, being mistaken for a wen or a cancer. There may be a granulation of the inner surface of the abscess just as in scrofulous abscesses. They are readily cured by touching with nit. sil. If they do not burst and the skin is whole over them so that they resemble a wen lay them thoroughly open and touch with nit. silv. Encysted tumours of the lid Commence without inflammation They are to be taken out either internally or externally when they do not adhere to the lining membrane of the eye, you may often succeed by splitting the tumour open and pulling out the cyst. Ophthalmia Inflammation of the eye May be considered in reference to the whole or a part of the eye but if one part is affected the rest are apt to become so Endemic in Egypt and Ohio burning sense of dryness copious hot scalding tears the eye is kept closed severe pain in head and face perhaps in the cheek or frontal sinus Redness and swelling of the eye. If the schoatica is affected the redness is of a darker colour (and apparently stationary) If the conjunctiva is the part in flamed the redness is brighter and the membrane is so much swollen that the cornea appears depressed Ultimately the cornea appears dusky a little. The aqueous tumour becomes somewhat opaque The cornea may eventually be cast off suppuration of the eye internally causing it to run out Caused by operations, by foreign bodies Amospheric influence Endemic influence etc. Prof. H. has known it alternate with intermittent The most powerful remedies shd be used First stand blood letting. The British surgeons in Egypt drew 60 ounces It is of no consequence from what part you bleed Prof. H. would bleed ad deliq. (in an upright posture) give [illegible] ca. followed by neutral salts afterwards apply ac. lead Collyquiums are forbidden but nit. sil. is dropped in with great advantages (3 or 4 or more grains to the pint more for chronic ophth.) If the pain etc. recurs repeat the bleeding & calomel. Antimony is much relied on in Europe. Prof. H has used it only as an adjuvant Use the nit. sil. 3 or 4 times a day not too strong just strong enough to create a little uneasiness at first If the eyelids stack together, by a discharge from the [illegible] apply a mild mercurial ointment Prof. H. never could see any advantage from bleeding from temp. art. or jug. vein Cupping and leeches may be used but shd not be relied on to the exclusion of general bleeding Letting out the aqueous humour has been practised with advantage. Vide S. C. surge. Dict. Blisters to the nape of the neck are beneficial When the disease becomes chronic a variety of remedies are used Nit. sil. continues to be beneficial It makes the surface of the eye feel smoother Vinous tinct. op. (Sydenhams laudanum) op. zii cinn. & cloves aa zi wine 1 pint digest a week This is often beneficial causing smarting at first but afterward relief Rx sulph zinc & ac. lead aa grs vi wat. oz ii we have ac. zinc. This is a good collyrium Scarification seems to be of little use Opium is useful. Dover’s powder is a good form. As soon as the pat. can bear this light accustom the eye gradually to the use of opium Tonics are seldom indicated. But in intermittent centuries Sul. quinine is highly useful. Bleeding etc. may be conjoined with sul. [illegible] (Vide the late periodicals) Cataract May originate from wounds & other causes Its commencement indicated by [halos] as observed around a candle & other such appearances To be distinguished from aneurism, by opacity, by some sensibility to light contraction and dilatation of pupils etc. It may be complicated with aneurism In aneurism flashes scintillations etc. are felt. Proceed to operate without debilitating the patient with low diet & a state of anxiety and apprehension It is customary now to dilate the pupil with belladonna or stramonium previous to the operation Apply it to the eye, eye lid etc. the night before [illegible] [illegible] hour before drop a little in the eye Enter the needle about a [line] & a half from the edge of the cornea the needle having its surfaces horizontal Pass the needle up to the top of the cataract turn the edges perpendicular press the edge down lacerate the capsule thoroughly then turn the needle horizontal again and carry the cataract directly downwards. If your needle horizontal again and carry the cataract directly downwards. If your needle is a crooked one turn the point first backwards in lacerating then downwards If the cataract proves to be a milky one lacerate a little and do the best you can After you have depressed, withdraw the needle partly and if the cataract rise depress again A caseous cataract must be cut to pieces and pushed through the pupil into the anterior chamber A secondary cataract must be pushed through also If the operation is to be repeated let an interval of at least two months intervene If both eyes are affected it is a good rule to operate upon one at a time. This is often safely disregarded with safety, however. Be very cautious about using the eye for some time. Wear a green shade at first. If there is much pain, bleed & give opium [Ceratonixis] or Laceration For a long time only tow operations vide extraction & depression. It was found however the congenital cataracts (which are generally membranes would be absorbed after laceration First established by [Saunders], at the eye infirmary in London Two modes of operating the anterior & posterior First dilate the pupil and belladonna or stramonium Mr Saunders used the anterior mode & made an opening through the centre We are directed not to wound the iris; but some surgeons do not hesitate to do this Mr Saunders was frequently obliged to repeat his operation a number of times Extraction The advantages are that the operation in successful at once that a hard depressed cataract lies on the retina & irritates the eye etc. ON the other hand, secondary membranous cataract is said to recur sometimes after extraction the vitreous humour sometimes escapes. Prof. H. has always found a scar across the centre of the cornea, afterwards It is said that inflammation is more liable to occur. This is [denied] by others who say the extraction is the safest in this respect. Enter the knife at first perpendicularly then carry it horisontally Put the patient abed and keep him on his back. Both eyes must be kept closed for some days. The [illegible] humour flows for some time. When the eyes are first opened, if we find any of the iris protruding, we must endeavour to restore it. Extract of belladonna will perhaps assist this Iritis Redness dark caused by syphilis & mercury Terminate by [permanent] contraction & closure of pupil or by [illegible] pupil. May extend to crystalline loss of the cornea Treat by one full bleeding Never mind weakening your patient provided you save his eye Bring the system under the full influence of mercury as soon as possible Though the disease is sometimes caused by mercury yet this is proper for its cure. Conjoin opium say 1 gr. op. & 2 grs. cal. 2 or 3 times a day. Merc. oint. is rubbed into the eyebrow Along with these remedies are used to prevent permanent contraction of the pupil. Stramonium & belladonna Rx Red prec. 6 grs. op. 8 gr. lard z2 apply warm fomentations. Collyrium of corros. sub. & Sydenham’s laudanum is used Keep the patients eye in the dark Push the remedies if necessary Prolapsis of the iris May result from a wound or by suppuration A brownish tumor (or purple) size from a pin’s head to a pea, as large as a hazelnut Called staphyloma of the iris Exquisite pain is felt upon closing the eye Pupil on one side In recent cases the prolapsus must be returned and the eye kept at rest If this does not succeed the application of stramonium may draw it back In [older] cases where it is of long standing or where the protrusion follows upon ulceration then putting back with a probe will not answer we may touch this with nit. sil. pain follows at first but a leathery covering is formed which protects the part Collyrium of ac. or sulph. of zinc is also a good application. It may be necessary to draw out a portion with a hook & cut it off with scissors Prof. H has treated several cases caused by wounds with a pen knife with nit. sil. severed [illegible] successfully Inflammation of Cornea Mr. Travers questions the propriety of considering the cornea as subject to infl. Deposits of opaque matter however do form. An ulceration of the lining membrane may follow and discharge into the aqueous humour. Inflammation of the conjunction may If you perceive the cornea growing opaque redouble your exertions Ulcerations of Cornea 1st Irritable ulcers as [illegible] [illegible] like a of moss Eye very irritable feels as if sand was in the eye tears feel s scalding hot eye kept closed children hold their heads down Touch the ulcers with nit. sil. once in 2 or 3 days For young children we may inject a strong solution 6 to 10 gr. to the oz. The cicatrices from these ulcers generally wear away. 2nd Indolent, deep sloughing ulcers larger thicker slough may be ¼ to 1/3 of an inch in diameter. Use the caustic more freely When they change from their grayish to a pink colour, we may expect them to heal soon. Patients may in the latter stages need tonics much mischief is often done by injudicious purging Abscesses of the eye The pus settles down in the lower part of the anterior chamber & exhibits a half moon shape. Make a puncture with a spear pointed lancet. In one case Prof. H. found the cornea opaque the iris inflamed and the pupil about closing the puncture gave immediate relief Little vesicles may form & when they burst give rise to irritable ulcers Opacity of the cornea Mr Travers advises coll. of nit. sil. & alternately of corr. sub. (the latter 1 gr. or ½ gr. to the [illegible]. Divide the enlarged vessels with a hook & scissors this gives great relief it destroys the vessels Various substances are blown in e.g. levigated glass, calamine, white sugar The utility of these seems very doubtful Dupuytren advises 1st general v.s. or leeches 2d a seton in the back 3d Rx lap. cal. calm. & candied sugar equal weights in powder. He says that specks and commencing opacity may be relieved by the powder alone Mr Travers perseveres in a course of mercury Staphyloma Cornea projects to that the eye cannot be closed causing great irritation tears etc. The cornea is perfectly opaque & vision entirely lost First pass a ligature transversely through the cornea then pass a cataract keep through & finish the operation with scissors Fungous tumours of the cornea A small hook & scissors are the proper instruments Follow with nit. sil. Clip off enlarged bloodvessels Pterygium [illegible] of the [illegible] [illegible] A reddish triangular membrane the pupil growing from the internal angle of the eye. Sometimes it stops just at the cornea At others it passes over Sometimes but rarely, it arises from the external canthus It [causes] a proneness to infl. of the conjuctiva Dust lodges on the membrane & is not easily removed If combined with ulcers, these must be first cured Extirpate this elevate the membrane with forceps or a hook & clip off with scissors as far as the edge of the cornea It is unnecessary to remove it as far back as the canthus. Even if little points remain on the cornea they will be absorbed, if you interrupt the continuity Encanthus An excrescence growing from the [caruncula] lacyrymalis producing great irritation Cut off with scissors. Prof. H. has known a large one cured by touching repeatedly with nit. sil. Dropsy of the eye Generally proceed by external always by internal infl. Cornea always opaque Sometimes appeared confined to the anterior chamber The sclerotica becomes thin & bluish like a soft shelled egg irregular also. May be caused by a wound Tape the eye with a spear pointed lancet or a cornea knife Repeat the operation No infl. follows ultimately the cornea grows thicker and retracts. This is the mode for the anterior dropsy. Whether the dropsy of the whole ball can be cured in this way is not so clear S. Cooper directs a piece of the cornea to be cut out of the size of a pea Travers says all the humours cannot be evacuated except by cutting out a part of the iris Cancer of the eye When seated in the conjunctiva, there is a thickening of this membrane and perhaps the cornea is obscured. Eventually the whole eye is involved. Ulcer with hard edges. Extirpate with a straight edged scalpel Restrain haemorrhage by pinching a torsion of the arteries with forceps Prof H. would put neither lint nor sponge within the orbit. He would dress with comp. & laud. Fungus haematodes of eye Formerly called cancer In the first stage the pupil is dilated iris discoloured (dark green or amber) The fungus can be seen in the bottom of the eye like burnished iron. The schlerotic coat becomes knobby, bluish etc. Finally the cornea & sclerotica ulcerate Fungus finally protrudes dark red bleeds easily. Cancer begins externally & eats away it is a disease of advanced life. Fungus is a disease of childhood? Still these two diseases resemble each other more in the eye than elsewhere Prognostic after extirpation very doubtful. Amaurosis Function of the eye without any external appearance except want of contractility in the pupil. Dil. pupil said to be a symptom May be caused by infl. of the retina by tumours pressing on the nerve or the brain. Occurs after excessive use of the eye in viewing the minute objects Vision has been restored by proper remedies for infl of eye it begin early and pushed vigorously, when it arises from acute inflammation of the retina Acute infl. of retina destroys vision suddenly Chronic infl. destroys it gradually Corr. sub. has been preserved to cal. in this disease. On the continent of Eur. Antimony is celebrated for this complaint Cases caused by epilepsy, tumours of the brain etc. are of course hopeless Pretern. dilat. of pupil Seldom an idiopath. complaint Pret. contr. of pupil Myosis Constant rolling of the eye (just as in congenital cataract) Commonly caused by infl. may be attended by opaque lens or capsule or not. For recent cases apply belladonna Push remedies diligently if there is inflammation Closed pupils may be attended with opaque cornea or not opaque lens & capsuled or the eye may be full and prominent, or flattened and with a large [illegible] Ascertain carefully whether there is remaining any sensibility of the retina Three modes of operating 1st a simple incision 2d removing a piece of the iris 3d tearing the iris away from its attachment 1st Chelelden’s mode Another way is to make an incision with a knife & then with scissors make two incisions & shaped 2nd make an incision seize the iris & clip it off and if it does not retire push it back with a probe If the lens is opaque, extract it 3d Scarpe’s mode. Prof. H. has operated in this way. Introduce a couching needle as for coaching separate the upper edge ½ of an inch & depress it. In one case Prof. H. was interrupted by a sudden hemorrhage within the eye An irregular pupil of course is made Ranula A bluish tumour under the tongue Caused by obstruction of the duct (probably) Dupuytren introduced two connected buttons [illegible] Prof. H. opens thoroughly & touches thoroughly with nit. silver. Division of the frenum Prof. H. has had one case of a ligamentous frenum [binding] down the frenum Wounds of the tongue Stich it together use Physicks forceps Enlargement of the tongue Caused by mercury, which has sometimes made it so large that it would nearly be bitten in two by the incisor teeth Ulcer [illegible] & tumours of the tongue. Caused by irritation of the teeth by disorder of the digestive organs etc. Cancers may grown there. Encysted tumours may grow there. Use alum borax nit. sil. (nit. sil. 15 gr to 2 pt as a gargle). Ulcers of saliv. touch with nit. sil. Internal use of opium is the best remedy for salivation purgatives are injurious Solution of corr. sub. is a good garble for a number of minute ulcers. Extirpate cancers & tumours Mr. Coster cuts out a v. shaped piece when the tumor is on the tip of the tongue bringing the edges together with stitches Cauterise to stop hemorrhage Enlarged tonsils A curved bistoury is recommended Prof. H. uses an abscess lancet on a stick for an abscess. If no pus issues, no harm has been done the scarification will do goo Prof. H. has several times met with inflammations and an abscess on one side of the tongue near the roof very painful Open with great relief. [illegible] to [illegible] abscess of bursae mucosae. the abscess collects suddenly lined with a smooth membrane incline to close up, like bursae mucosae N.B. abscesses near the surface of mucous membranes are apt to be fetid the air apparently acting through the membrane Cut off enlarged [illegible] with scissors no fear about haemorrhage Osteosarcoma Formerly the patients were suffering to die Dr of Tennessee was the first to perform the operation In some cases the wound has not healed after the operation leaving the patient in a horrid state Dr Cogswell related case of this kind in a man living in Fairfield cty who had been operated on in Philadelphia. Prof. H. would prefer Mons. Costes mode of operating Sarcoma Cellulosum Bronchocele, goitre etc. Endemic in Derbyshire N. Hampshire Vermont western part of N.Y. etc. Occurs generally in young females Mr Wilmer was the first to publish an account of the treatment by burnt sponge. It was communicated to him with several useless additions to the remedy Prof. H. has met with sudden enlargements of the tumours accompanied with sore throat, pain in the head etc. He bled with advantage applied mur. amm. gave calomel etc. Wounds of Abdomen Wounds of the integuments require no particular treatment except to keep the muscles relaxed. Keep also a bandage over the parts in order to prevent hernia Penetrating wounds as by a stab require no particular treatment. Use the interrupted suture. Prof. H. has found no danger in carrying the stitches through the peritoneum. Let the patient avoid coughing laughing, straining at stool. Use a bed pan If intestines protrude with a warm and moist hand, return the viscera gradually return the omentum last. We must not be deterred from returning them by infl. or by a dark colour. Gangrene of the omentum may be distinguished by the blood’s not returning after pressure Gangrene of the intestine may be distinguished by an ash colour such shd not be returned. Larrey’s and others advise to cut off a gangrenous portion of intestine & return the remainder tying the vessels [using] a [leather] ligature] Close with interrupted suture using two needles for the same thread so as to carry the stitch from within outwards. It may be necessary to dilate the wound When an intestine is wounded the villous coat protrudes & turns out Sir A. C. in operating for strang. hernia found a small wound of intestines, he [illegible] it with his thumb & finger & tied a ligature around. The man did well Sew with the glover’s suture (over & over) It is found that a wounded intestine adheres by its peritoneal coat to the wall of the abdomen. The ligatures are cast off the cavity of the intestine & need not be kept out of the external wound Never enlarge a wound to search for a wound of the intestines. Larrey occasionally enlarged a wound in order to afford a freer passage for feces. His patients were eventually cured Vomiting is apt to occur V.S. will relieve it. Purgatives should not be given. Let your stitch, with the external wound remain as long as 8 days Wounds of the Bladder Urine issues In all cases except where the neck is wounded, keep a flexible catheter in the urethra. If there is extravasation of urine in the cell. memb. or scrotum make incisions to allow of its exit Laxatives are found to be very useful Castor oil & senna Passage of rake handles etc. into the anus etc. Prof. H. had one case in which a rake handle passed 22 inch. through the diaphragm. He died of affect. of the lungs spit blood etc. The thorax should have been opened. He has seen many cases of similar wounds of the vagina. In short has seen some odd things! falls on crowbars stumps of scrub oaks etc. all penetrating a greater or less number of inches. Bleed & starve. Blister the abdomen. Paracentesis of abdomen Do not perform the operation for less than a gallon of liquid. The operation is apt however to be delayed to long in cases of dropsy. Dr Fothergill advocated the practice of [illegible] early in dropsy Prof H. has noticed an increase of urine after the operation. He has known some cases of complete cure by tapping. Sometimes in encysted dropsy the accumulation remains stationary for years The fluid may be in one or more cysts or may be in the cavity of the peritoneum The former may come on with out much derangement of health. The latter is apt to be accompanied with a general hydropic diathesis When the fluid is in the peritoneal sac the tumour is general from the first In the early stages the fluid will be most at the lower part of the abdomen, when the patient is erect. The intestines float Ovarian dropsy is near the ilius the tumour shifts its place in different positions of the body at first At length however it enlarges and becomes adherent and a fluctuation is felt. When the accumulation is very large it can hardly be distinguished from ascites except by the history of the case. In one case the tumour burst from a fall The fluid was effused into the peritoneum, and the patient died in 20 hours Dropsy of the uterus must be exceedingly rare of course the os uteri must be closed by disease etc. Hydatids may be found in the uterus Mr [Rostan] says that in ascites a sound like that of tympanitis is given upon percussion at the upper part at the sides in encysted dropsy In ovarian dropsy the fluid may penetrate between the vagina & rectum & may be felt Encysted dropsy can scarcely be affected by medication Tapping must be resorted to. Put a broad bandage (from the ribs to the hips) around pin it behind Cut a hole in the bandage opposite the linea alba. If there is a hernia at the umbilicus if so, puncture there the walls being much thinner Let an assistant press the sides of the abdomen. Plunge in the trocar (If you push gradually the trocar will enter with difficulty) As the fluid flows, keep tightening the bandage. Towards the close press the abdomen in all directions Withdraw the canula if then the fluid continues to flow, let it run & be received on cloth. You may turn the patient over. Tap with the patient recumbent on the edges of the bed. When sitting the patient may faint. He may faint also if the bandage is not first applied. By means of the bandage we avoid all the danger of the operation After the operation dress with lint a compress & sticking plaister & bandage together Let a bandage be worn for months afterwards or even for years. It gives great relief The largest quantity which Prof. H. has drawn off was 32 gl yet in 23 days 23 quarts more accumulated. This case was caused by schirrhous liver which weighted about 13 pounds One patient was tapped in 13 places Another was tapped in 6 places at another in 6more finally in 6 others & the patient recovered One place where the operation was performed was between the vagina & rectum where two quarts were drawn off Occasionally the wound does not close. This is apt to be caused by the exhausted state of the constitution. It may arise from improper dressing. Stay by and watch whether the opening [illegible] If you cannot stay by and the orifice continues to flow and you cannot stay by use the twisted suture Diseased ovaria Prof. Smith operated to successfully Vide his memoirs Mr. [Losans] was generally unsuccessful. Prof. H has read all the accounts in the English language & thinks the operation scarcely advisable Hernia A protrusion of the peritoneum containing some of the viscera Sometimes hereditary Produced (especially if there is a predisposition) ty strains in lifting. Generally the causes are unknown 1st Inguinal 2d Femoral 3 Umbilica 4 Ventral 1st Inguinal 4 species. 1st oblique 2d direct 3d congenital along the spermatic cord 4th encysted hernial sac suspended in the tunica vaginalis The sac grows thicker as the hernia is [illegible] When it passes no further than the groin inguinal hernia is called bubonocele when it passes farther it is called scrotal 1st Oblique inguinal hernia Symptoms Distinguished from hydrocele by the latter’s not being affected by coughing by its transparency by the cord’s being felt Hydrocele of the cord is distinguished with more difficulty by coughing not affecting it Haematocele Hernia humoralis varicocele Mistaken are very often made and [illegible] applied to these diseases. Varic. happens twice as often as the [illegible] Hernia in the right [illegible] Hull’s truss is the best. It should be worn constantly day & night (A. Cooper) Dr Hull & Prof. H. think it sufficient to wear it during the day Many cases may be cured by a truss but let it be worn long after the hernia is cured. Dr. Hull denies that accidental protrusions will totally prevent the cure (as A. Coop. says) Children as they grow larger must have a new truss The use of the truss produces an adhesion of the neck of the sack Irreducible hernia Hernia may be irreducible from various causes from adhesions from a sudden protrusion of a large quantity of intestine The tumour (within) may be of a pear shape If the hernia cannot be reduced a bag truss should be worn. They are inconvenient and dangerous Sir A. C. has known a hernia supposed to be irreducible, finally reduced by ice applied 4 or 5 days. Prof. Smith distinguished between strangulated & incarcerated hernia. But the latter seems to be little more than an irreducible hernia Symptoms of strangulated hernia Pain constipation (though there may be tenesmus) [illegible] of [illegible] tumour very tender vomiting hiccup cold sweats etc. Omental hernia, when strangulated produces similar symptoms, but generally neither so violent or rapid Post mortem appearances exhibit infl. of the intestine perhaps over the whole peritoneal & in the latter case the death may be sudden within 48 hours In other cases operations have succeeded 1 or 2 weeks after the strangulation A small hernia exhibits more violent symptoms than a large To reduce place the patient on a bed his head & pelvis elevated thigh at right angles (bladder previously emptied) Embrace the tumour with both hands, as you would an elastic gum bottle. Prof. H. has practiced this mode for 20 years (It is Gohagan’s of Iceland) HE finds it better than A. Coopers of kneading. Gohagan advises to keep the pressure steadily for an hour changing the hand if fatigued Have a bowl of cold water at hand, and occasionally wet the hand Use ice also salt & water. Do not use violent pressure. If we fail with the [illegible] bleed to fainting & immediately try again with the [taxis] Bleeding lessens the tenderness & soreness It will also tend to prevent subsequent peritoneal infl. Warm bath may be tried Prof. H. has used tobacco injection zi to a pint half at a time a dangerous remedy however. It produces universal relaxation and then perhaps the tumour may be reduced Sir A. C. says calomel is often useful assisted by a [illegible3] of compd est. colocynth Strangulated hernia has often been mistaken for colic (perhaps the patient may be ignorant of the existence of a rupture or breach as they call it) Purgatives are dangerous apt to cause infl. After bleeding Prof. H. has used opium with advantage especially in old hernias of old men. Direct inguinal hernia Seldom large may be caused by a blow A rare species A truss is applied nearly in the same way as for oblique hern. Epigastric artery on the outside [illegible] muscle partly in front of the tumour An old large omental hernia may not be so soon fatal as a small & recent one Still all hernial (if [illegible]) are dangerous & when strangulated, an operation must not be too long delayed. Death may occur in a day or two in some few cases. Mr Hey lost many cases by operation too late. So with Desault. So with Prof. H. much mischief is often done, by violent and long continued handling It is the best rule to operate soon. Less pain is often felt in the operation than in the [previous] taxis Place the pat. on his back on a table feet in a chair set between the thighs If the hernia is small & the skin lax the surgeon & an assistant may pin it up the integument transversely [illegible] and [illegible] his knife through this gives less pain ‘ Do not carry the incision quite to the bottom of the tumour Divide each fascia with a director The sack when you get to it is usually known by its shining appearance though it may be purple etc. caused by a bloody fluid within Rub a fold of it between your finger & thumb so as to be certain that you have no intestine or omentum adhering to it. Pinch up a small fold with forceps and make a small incision then introduce a director and enlarge a little then introduce your finger as a director [illegible] reduce the intestine if you can If you cannot introduce your finger as a director carry the point of your knife along it arriving at the stricture depress the handle of your knife and divide gradually Divide freely enough to allow the entrance of your finger. It may be necessary after dividing a stricture at the external ring to divide another at the internal ring Divide upwards & outwards or perhaps better, always upwards Adhesions may always be broken up with the finger. Return the intestine first & then the omentum Prof. H. now passes his suture through the sac Sir F. Earle recommended this vide Hey and since he has adopted this practice has never had a case of a second protrusion. If more than 2 sutures are needed put the lower ones through the superficial integuments only Place the sutures about an inch apart Dress about the 4th or 5th day. If a stool does not come away in a few hours give castor oil or if this fails, calomel Dress with a T bandage etc. If the intestine is gangrenous (it is not so when merely purple & dark bloody) Sir A. C. says a gangrenous intestine will have a fetid smell Prof. H. has noticed this in incipient gangrene A gangrenous intestine is the strongest reason for operating If the intest. decidedly gangren. Prof. H. would not even divide the stricture, but make an incision into it and allow the feces to issue. Cut off mortified oment. with scissors Case in which the gut has burst Prof. H. did not do anything but leave the case to nature after opening the sac. After about a month the fever took their nat. course Dr Phys. in one case found two parts of intestine parallel [illegible] he made an incision into each in order to allow the fasc. to pass from one to the other The pat. dies from want of passage for feces Vide Travers After the operation if peritoneal infl. continues, treat by v.s. by cal. or by cal. & op. Diarrhoea sometimes takes place, both after the taxis and after the operation Treat with opium For direct ing. her. divide upw. & inwards Hernia of inguinal canal No distinct tumour exists except upon coughing May become strangulated & is often mistaken for peritoneal infl. Vide Sir A. C. for the operation Make the incision through the [tendon] of ext. oblique, very carefully etc. Oblique inguinal hernia in females. On coughing the tumour protrudes downwards this In femoral hernia the tumour protrudes upwards on coughing Operate as upon the male Congenital hernia Called [wind] ruptures by the nurses Tumour is within the tunica vaginalis Take care not to injure the testicle & leave the lower portions of the tunica vaginalis entire so as to contain the testis Encysted hernia of Mr. Hey The whole sac is protruded into the tunica vaginalis Open the tun. vag. & then search for the sac Femoral Hernia Prof. H. has cured one case in a male Prod or first a pain on suddenly stretching the limb. Finally a small swelling appears increases passes downwards inwards, forwards & the upwards over Poupart’s ligam. Sometimes passes downwards along the saphena vein Has been mistaken for [illegible] abscess or for an enlarged lymphat. Has been opened for an abscess Occurs oftenest in women who have borne many children Generally intestinal and small Often irreducible A truss does not cure so certainly. Women who wear a truss can dispense with it during pregnancy. Taxis often fails Strangulation causes severe symptoms We may try the taxis but should not use much force Delays are dangerous the hernia being small & the stricture sharp edged. Death has taken place in 17 hours. Patients will be apt to die about the 5th day Operation. Place pat. as before Carry your incision downwards beginning above the tumour. Sir A. C. advises another [illegible] transverse below Prof. H. has never made this. It is said that a superf. vein will be divided Prof. H. has often operated, and never met with this In his last operation not two teaspoonfuls of blood were lost N.B. we do not reduce the hernial sac only its contents Old sacs are generally adherent Divide the stricture upwards & a little inwards towards the umbilcal Divide freely enough to allow the introduction of the finger Endeavour to pull the neck of the sac out before dividing If the obturator artery surrounds its neck we can feel it with the finger Umbilical Hernia may become very large. Colicky pains flatus faintness at the stomach etc. In children called wind rupture also The superficial integuments will often be thinner in some places than in others appearing like an abscess Frequently than are two openings from within, into the sac. Occurs oftenest in females and in corpulent men Caused by ascites if so, then tap at that place Treat it in infants, with a conical piece of wood or ivory confined with adhesive straps Desault cured such cases by tying a tight ligature around the neck of the tumour after reducing the intestine Let older patients wear Hulls truss. If irreducible let a broad bandage be worn Sir A. c. advises to reduce without dividing the sac Prof. H. would be averse to attempting to operate without dividing the sac The hernial sac is apt to adhere to the skin so that the incision is [illegible] directly into the sac [?ntoal] Hernia Generally in the linea [similanaris] The stomach is sometimes included Symptoms of dyspepsia etc. may often be relieved by a truss Tobacco injections are very useful in this and the preceding species Irreducible hernias cause colic, constipations etc. requiring cath. sometimes there occurs pain and vomiting requiring perhaps v.s. and always opium in full doses When an irreducible hernia becomes inflamed there, less local soreness than when strangul. The pain is more universal and wandering over the abdomen. the abdomen is not swollen there is not hiccup etc. Give a large dose of opium Thyroidal hernia, occurs at the frama ovale. Pudendal hernia ix a variety of inguinal never requires an operation. Vaginal hernia occurs between the vag. & rect. use a pessary. A hernia occurs between the bladder and rectum in the male Hernia occurs (rarely) at the ischiotic sac. Prof. H. has seen one case of the latter in a boy. After all operations apply a truss when the pat. gets up Preternatural anus As the wound becomes smaller tighten the compresses and bandages When a little mucus is discharged from the rectum, solicit a natural passage with injections Finally tighten the dressings and touch with nit. sil. or sulph. cop. In permanent cases we have eversion of the villous coat etc. Desault introduced a roll of lining into the two ends, and kept thus the two in contact Dupuytren where there were two portions parallel punched the adjacent coat and caused a perforation for the feces (he continues a particular kind of forceps) the patient was cured Imperforate anus Make a crucial incision & keep in a bougie where there is no external anus When there is an anus, but the rectum terminates in a cul de sac the case is more difficult & they generally terminate fatally Stricture of the rectum Commences with difficulty of discharge [pellets] of matter imperfect evacuation pains in the hip, back etc. finally costiveness cathartics perhaps cause a liquid discharge, and often an apparent diarrhoea but the bowels remain full of hardened matter Colic flatulence acidity, dyspepsia. Reduced to liquid & bland food often the patients chew meat & spit it out swallowing the juice. Ill effects are generally felt, only sometime after the swallowing of food Hemorrhoids etc. may occur May be from hereditary malconformation. consider also by habitual costiveness Distinguished from hemorrhoids by the pure blood discharged from the latter & [illegible] the pellets of feces also by the apparent dysentery Structure of the colon is distinguished from it by absence of the straining freedom from dysentery seat of the pain also by the strictures being too high to be reached Always examine by the finger & if that will not reach by a bougie make bougies of dyachylon & wax 11 inches long for an adult Bear in mind the curved form of the rectum, when you introduce it Introduce by address not by force. To lessen the irritation, first inject 30 to 60 drops of laudanum Carry it as far as the sigmoid flexure when it has entered this, a little wind will issue Examine whether there are not more strictures than one Let the large end of the bougie pass up beyond the sphincter or the latter will be internally irritated. Let the loop hang out. Dr McClellan prefers the flexible metallic bougie The irritation may be excessive at the first application but it diminishes by use There may be a prolapsus of the colon through the stricture which must be pushed up by the bougie In this case also give cold injections to brace the parts bougies give great relief unless desperate cases Phlegmasis dolens Spergamosis puerperarum Dr Davis maintains that it is caused by an infl. of the iliac veins this is hypothetical Difficult to determine this as the disease is rarely fatal Origin very obscure. It seems to be preceded by increased fetor & abundance of the lochiae Occurs after all sorts of labours and in all sorts of patients. Said not to occur a second time but Prof. H. has met with instances. Occurs also in males after fevers Prof. H. thinks it probably Commences at an uncertain period after delivery by pain and swelling in the groin. The limbs swell rapidly Pain considerable pain in the groin also motion very painful. At this stage the surface does not put on pressure no serum issues upon puncture no coldness as in anasarca The constitutional shock is sometimes very great coldness, faintness The other thigh may be affected The swelling begins to go down, first in the groin and labia Prof. H. treats mainly by calomel which he says gives great relief. He follows with opium for the irritation He always applies bandages from the first This gives great relief. He wets the bandage with ac. lead or mur. amm. Apply a clean bandage every day Repeat the cal. frequently Dr Hosack treats as for a dropsy with ipecac and squills. After the relief of the disease a deep seated pain in the thigh. This Prof. H. has relieved by a large blister and this is the only case in which Prof H. has found blisters give relief Inflammation of the cell. memb. on the hips back etc. of puerperal women Often mistaken for phlegmasia dolens They suppurate and should be opened There will be redness instead of the general tumefaction and the white [shiny] appearance They may become gangrenous and terminate fatally i.e. the glands no suspicion of venereal disease Retention of Urine may be brought on in old persons by neglecting the calls of nature Suppression of urine belongs to the department of Theory & practice Retention caused 1st by paralysis of bladder 2d Inf. of neck of blad. 3d press if foreign bodies 4th press of gravid uterus 5th enlargement of the prostrate gland 6th strictures In the first place7th constant desire to pass pain thirst nausea of vomiting costiveness cathartics etc. not operate an injection pipe can scarcely be introduced The bladder may ulcerate into the peritoneum and the pat. die thus or he may die of const. irrit. and in the latter case he becomes comatose before death. These may be the symptoms of paralysis of the bladder 2nd infl. of neck of bladder may be caused by cantharides by ulcers in the perinaeum by infl. of vagina produced by instrument 3d Stones in the bladder scarcely cause complete retention 4th the gravid uterus may cause complete retention A retroversion the uterus will always cause retention Some think it is caused by retention 5th Enlargement of prostate gland will cause a difficulty of passing and the true nature of the affection will scarcely be suspected. Eventually a complete retention may come on and then when the catheter is introduced in large quantity will be drawn off at once Sometimes when the urine begins to dribble away the complaint is mistaken for diabetes Other causes have been named [Parturient] women have died from this cause The ultimate consequences are peritoneal infl. fever dry tongue delirium etc. Other diseases seen to be produced is phthisis pulmonalis etc. Introduce the catheter by drawing the penis [illegible] in the first place keep the end close under the os pubis Sometimes with drawing the stilette a little to increase the curve At other times withdraw the stilette wholly Diseased Prostate Begins with frequent & imperfect micturition ultimately the patient becomes costive pains are felt in the part also in the back & hips a constant necessity for cathartics and when a stool is obtained urine flows more freely. The patient often will not call on a surgeon until the latter stages of the disease Finally opium must be taken constantly and the patient wears out perhaps with pulmonay consumption Much has been said about repeatedly introducing the catheter or suffering it to remain in. Prof. H. in inclined to the former. It will at always be necessary to withdraw the catheter twice a week to clean off calcareous matter. Other remedies are proper for sudden attacks e.g. v.s. warm bath injections of laudanum etc. even in a last resort injections of tobacco For chronic cases tinct. mur. feri a highly recommended If a catheter cannot be introduced try a small bougie Generally the smallest catheters can be introduced as well as a bougie Read the remarks of different surgeons about introducing the catheter as J. Bell C. Bell S. Cooper etc. Such cases are better treated now than formerly less [illegible] is wasted now with diuretics Cases combined with stupor of the brain, are best remedied by tinct. cantharides. The cath. should however be used The French surgeons use a conical catheter and force a passage. This is not to be initiated If a young surgeon cannot introduce the catheter, let him send for an older one. If a catheter cannot be introduced. The bladder must be punctured Make an incision in the bria alba 1 or 3 inches long. Cut down to the bladder and introduce a large curved trocar piercing obliquely When the stilette is out push the canula further in Either leave the canula in or introduce through it a flexible catheter & keep it in Mr. Abernethy thought it better to separate the [pyrimalis] muscles For stricture of the urethra, in some cases, such a catheter or canula Hydrocele 1st take care the canula is in the tun. vag 2nd Place your patient against a wall keep the injection in 15 m. (Prof. H.) Take care to fill the tum. full Use 3 parts wine 1 water Make a large puncture 8th If you inject into the cell. mem. stop immediately Great pain is produced Sometimes faintness Hence have some one by to assist you in case of fainting After about 3 days the swelling begins to abate In a fortnight the may perhaps be cured Encysted hydrocele of the spermatic cord Haematocele Sarcocele Fungus haematodes of the testicle Schirrhus of testicle Hydrosarcocele Fungus of the testicle cured by caustics. Venereal enlargement of testicle Hydatids of the testicle may be very large and confounded with hydrocele Cure by castration. has been kept in 2 or 3 years Southern mode is to open into the rectum etc. Irritable testicle seems to be a neuralgic aff. Try v.s. cal & afterwards arsenic & conium. Use opium all the while iron and sulph. quin. are rec. & are useful. Put off castration if you can Suppuration of testicle Open the abscesses & keep in a little slip of [illegible] for a [illegible] membrane will close very speedily It may be necessary to introduce nit. sil. Or if you have not room for this you may dip your probe in nitric acid & thus form a little nit. silv. Circocele Begins gradually finally the veins feel like a bundle of earth worms Let the pat. be down and press at the abd. ring, and a circocele will be enlarged & thus it may be distinguished from hernia Apt to give alarm but not dangerous Cause obscure there may be in such cases a disposition to have varicose vein # Patients are often subject to paroxysms of pain. v.s. cal. & other laxatives Apply cold discutients. Quiet your pat. about the danger. Keep the parts constantly suspended. The spermatic art. has been taken up why it is difficult to determine. Generally by quieting the patient you will have little trouble. Much mischief has resulted from wearing trusses for them # perhaps caused by accumulated feces & by injuries Chimney sweeper’s cancer Caused in the scrotum by soot Perhaps the testicle may become affected It is said that the disease may be cured even after the lymphatic glands have become affected Probably a variety of cancerous tubercle of the skin Sarcomatous enlarge. of scrot. may weight 50 or more pounds Testicles not affected Penis disappears. Integuments of lower part of abdomen drawn down. Skin may be rough & scabby. Probably a variety of elephantiasis. Vide Larrey’s mem. of it in Egypt. Extirpate not dangerous is the operation Vide the case of a Chinese lately in London 60 or 70 pounds died immediately Gonorrhoea Infl. of muc. mem. of urethra sometimes extending to the glans Arises from impure [connexion] Whether the same or not, it is treated different from lues syphilis A milder disease now then formerly in London Vide Abernethy Cured more readily when it occurs immediately after connexion, then when it occurs after a week or more Different phys. treat it very differently probably because it often (as is said) cures itself & because it may be interrupted by various [illegible] Bals. cop. is very popular now formerly it was used only for gleet. Cubebs are said to be equally effectual. Give bals. cop. 1 teasp. 2 or 3 times a day If it purges giv e opium Rx bals. cop. & nit. eth zi aa. tinct. op. & tinct. camph aa zi t.sp. 3 or 4 times a day Apply cold lotions In France they give nit., pot. & sulph. sod. etc. Ac. pl. 14 gr. to ½ pt. or sulph zinc grs 10 or both together, for an inject. if the discharge continues Ultimately corr. sub. 1 gr. to 1 oz 1/2 pt or nit. silv. 3 or 4 grs. to 1 oz water Make inject. stronger [illegible] For gleet give bals. cop. & add tinct. canth. 20 or 30 drops Apply blisters to perinaeum if necessary Treat sympathetic buboes with discutients with blisters Treat chordee with opium dover’s powders etc. If urine is frequently passed & with pain use the catheter it giving [illegible] relief Opium is the best remedy for chronic aff. of bladder as a sequel Uva ursi is recom. also Whether the bladder or prostate is aff. use the cath. Hernia humoralis Infl. of testicle Caused by gonorrhoea by injuries by metastasis of hydrothorax etc. by metastasis from aff. of head mumps Not produced in the early stages of gonorrhoea but in the decline though to be brought on by stimulant injections Caused also by aff. of prostate & various urinary affections Flatulence borbogyna pain testicle swells when large flattened in bad cases a redness of the skin Pain & constitut. irrit. very great from the distention of the firm serous membrane Bleed cal. salts Horizontal posture suspensory bandage ac. plumbi Prof. H. troubles himself little about the running [illegible] the infl. of the testicle is cured generally the gonorrhoea ceases Where a serous effusion in the whole scrotum takes place, shave & blister the whole scrotum If a hardness remains (especially of the epidydimis) treat with camphorated mercurial ointment Pus should always be evacuated if it is not evacuated, a fungus will spring out nit. sil. Phymosis Congenital accidental generally goes off (when natural) at puberty if not we may be called on to remedy the complaint. In venereal diseases ulcers may be concealed, or ulcers may arise from the sebaceous glands may irritate The urine may irritate Sometimes the prepuce may be enormously distended. Sometimes infants are born without any orifice When there is an opening it is sufficient to slit up the prepuce. If now cut off the end When distended make an opening with a lancet. As to the size of the opening, calculate upon a retraction in [healing]. Use a sharp pointed knife upon a director If the [prepuce] is schirrhous in old men circumcise & you will do this more easily if you slit up first Everted urethra Case in an infant Mischief from tying a ligature around the penis by boys troubled in bed. Swelling may cause the string to disappear cases mistaken for phymosis etc. Paraphymosis When the prepuce cannot immediately be brought back, every moment increases the difficulty, as the glans continually swell. Gout swelling, infiltration etc. occurs. Apply cold water etc. & then the patient must submit to have the prepuce returned place him against the wall, & have him held Compress the glans a long time shifting your hands in order to keep them cold & when you have the glans sufficiently reduced, return the prepuce if you fail, try again It is not necessary to divide the stricture Le Franc, also always succeeded without division Stricture of urethra May exist to a slight extent Most commonly 6 or 7 inch from external orifice just behind the bulb next to this is 4 ½ in. frequently ‘ there are more than one & almost always one at 7 inch dist. (E. [illegible] May be on one side of the canal In old stricture we have an almost cartilaginous hardness Symptoms alteration in form or size of stream of urine may be forked Dose not tend to a spontaneous cure but to grow worse & worse Difficulty of passing urine increased by cold by drunkenness by hard exercise Ultimately irritation chills, fever, anasarca excessive pain anorexia aphthae etc. etc. A discharge may come on and be mistaken for gleet especially after gonorrhoea hernia haemorrhalis nocturnal emissions & semen thrown back into the bladder May be mistaken for gonorrhoea, gleet infl. & abscess of urethra or prostate calculi in bladder or urethra. Pain in passing urine greater in gonorrhoea Diseased prostate is generally in old men & admits the catheter for 7 ½ inch. & a catheter can generally be passed by skill in enlarged prostate enlarged prostate can be felt by the finger in the rectum. Caused after sometimes by gonorrhoea (as a remote consequence) By injury of the perinaeum by stone in the bladder by warm climates Treatment Ascertain the existence of a stricture by means of a bougie Warm & oil & [illegible] your bougie if you fail pass a smaller one. We may be obliged to desist from pain, irritation, shivering faintness etc. But the urethra becomes insensible after a time. Where a very small bougie is needed catgut is recommended it swells in the part When we have succeeded in passing a bougie the cure is in our power (S. Cooper) Eventually we can keep in the bougie for several hours When we cannot pass a bougie introduce caustic it lessens the irritability Prof. H. has lately preferred a small catheter with a piece of nit. sil. in the end. Some use the caustic kali Flexible metallic catheters are much used of late Bougies undoubtedly do goo besides their mechanical dilatation. They stimulate the parts Patience and perseverance are needed Retention of urine hemorrhage (when the slough separates) may occur Prof. S. laid open the stricture internally Fistula in perinaea Caused by strictures by calculi etc. Touch with nit. sil. Dr Physick passed a piece of tape laterally & tied it tight over the fistulous orifice Vide Dorsey’s Surg. In worse cases, pass a straight sound down to the stricture pass in a probe & feel its end. Cut down to the end of the sound Dr Stevens proposes to inject a coloured liquid into the cath. to assist in finding the urethra Always cure the stricture first Mr. Earle performed [a] [talication] operation Sir A. Cooper’s treatment of retention of urine remarks on Incontinence of urine 1st from paralysis of sphincter from general palsy from long continued peritoneal [illegible] from retention 2nd from injuries causing a communication by ulceration into the vagina or by a cancer 3d during sleep affect children under puberty 4th S. Cooper mentions an irritable state in which the pat. is constantly compelled to urinate. This is merely a symptom of hysteria hemorrhoids stone in the bladder etc. 1st When occurring from paralysis treat for the general aff. and introduce the catheter frequently. When from difficult labour introd. cath. freq. 2nd plans of cure by sutures 3d It has been lately supposed to be caused by lying on the back not so Prof. H. has cured by cantharides Sometimes connected with disorder of digestive organs great thirst etc. Imperforate vagina Sometimes the labia, wholly or partially adhere Separate sometimes with your thumb (vide Denman) When not discovered till the period of menstruation very troublesome Prof H. has had several cases. Sense of weight pain in the loins finally difficulty of passing urine in the first symptom noticed in some cases difficulty at stool swelling of abdomen nausea hiccup etc. Much variation in the nature of the closure sometimes membrane sometimes very thick Examine whether there be not more than an obstruction perhaps a ligamentous band Hemorrhoids Two kinds varicose & organized If the blood comes from the intestines above it will be black if not, florid? Prolapsus ani often often accompanies If very superficial and near the verge they may often be clipped off Prof. [illegible] [illegible] when from the intestine extirpates by a ligation Pass a needle through & tie each way Fistula in ano Prof. H. is convinced that it arises from infl. & suppuration of the bursa muc. behind the rectum Causes obscure perhaps hemorrhoids Begins with pain, fever etc. When the abscess bursts externally it is called external fistula when internally blind fist. when ext. & int. complete fistula Const. sympt. & pain very severe Open early & keep open with a bougie when external When blind pus on feces a tumour at [anus] very fetid, as is usual with abscesses in muc. memb. No plan of cure succeeds but laying open Pass your finger up the rectum & meet your finger with a probe pointed bistoury then cut down through the sphincter Introduce ling Be careful to distinguish from lumbar abscesses etc. pointing near this part. Cancer of the rectum. The extremity of the rectum has been extirpated. Distortions of the feet Club foot valgi & vari There is a malformation of the tarsal bones. Probably the affection is caused by some wrong position in the uterus Seeds to be more or less hereditary in some families. There is an institution in Paris for distortion s attended with great success When the foot turns directly upwards towards the tibia it is easily remedied by a roller an elastic splint and a bandage. Club feet are easily restored by the hand the difficulty is to keep it in its place. B. Bell’s mode by a [shoe] etc. [Machines] of wood carved out. Prof. H. has succeeded very well by a tin shoe with one side running up the leg He has succeeded well also with stiff saddler’s leather. But Smith’s splint in superior to all other modes. Apply to F. Gregory of Uxbridge Mass. The great object is to keep the sole of the foot, flat on the ground & turn the toes out as much as you can Palsy of the lower limb from diseased spine vide Pott. Generally affects children The child will be observed to stumble the toes point downwards, remarkably The limb looks remarkably smooth and tense, instead of flabby and wasted. Upon examination we shall find the [illegible] vertebrae, projecting Ultimately the bladder is affected with strangury perhaps there will be incontinence of urine. The patient may die of marasmus etc. Remote cause obscure Prognosis doubtful Caries and abscesses are often met with Mr. Pott invented the mode of treatment by issues, and was very successful in a number of cases Lateral distortions of the spine are said not to produce paralysis Paralysis appears to be caused only by this angular distortion. There will be also pains in the loins etc. Sensation is erroneous with respect to the heat of the limb Pat. thinking it hot when cold & v. versa Sometimes sensation remains, at other times the paralysis is complete. Sometimes the abdominal muscles are paralytic sometimes the urine & feces come away unconsciously. Large sores may be caused in the ischia & trochar [less] by lying in one position There is generally a permanent anchylosis after the cure Experience shows exercise to be injurious. Hence some propose to cure by rest Opium will almost always be needed. Ultimately sul. quin. Very probably iodine might be beneficial. Sometimes a seton has been substituted for an issue Once in 2 or 3 months an old issue should be suffered to dry up & a new one made Lateral distortions of verteb. We are generally first consulted for a projection of one shoulder blade Caused by long sitting in one posture etc. Darwin thinks position in bed to have some influence and directs those children who sleep together, to change sides occasionally. Mr. Casey’s machine has a staffed back. lifts pat. up by shoulders Carrying weight on the head proposed Depend principally upon exercise in the open air and sleep upon a hard mattress. Such a plan as this will make the distortion stationary, and restore the general health But Prof. H. has not known it permanently & effectually cures the distortion Give soda, iron, rhubarb etc. Setons and issues seem to do little good. Friction and sharpening are useful Mr. Harrison lays much stress upon manipulation on the back and this too for all kinds of vertebral distortion Diseases of the medulla spinalis, producing paralysis without aff. of vertebrae Affects mostly children from 2 or 6 mo. to 2 yrs old. Generally begins with a febrile affection, and soon a paralysyms & hemiplegia sometimes one side first one limb, then another Adults sometimes affected in a similar manner. Dentition has been thought a cause. This cannot always be the case. Scrofula has been considered the cause also but scrofula is uncommon in the country where nevertheless this aff. is met with. It is often attributed to the little calomel given in the commencing fever But many cases have received no medication at all Prof. H. considers the disease an inflammation of the serous membrane of the spinal marrow. Sometimes the disease is chronic and unattended with commending fever. Sometimes the brain may be affected thus; vide Amaurosis Prof. H. treats acute paraplegia and’ hemiplegia etc. first by v.s. mercurial & other cathartics and a succession of blisters. As has lately used more pinching up hard a small ball of cotton & [illegible] it dowm by the blow pipe Tart. emetic ointment etc. Prof. H. has often succeeded this for children but sometimes fails. Chronic cases he treats in a similar manner [Moxa] near the ear seems to have great influence upon paralysis of the face When the spinal marrow comes on during a fever Prof. H. has succeeded often in curing it Some cases seem to be caused by parturition The more acute the disease the easier cured. For chronic cases Disease of hip joint morbus [coxarious] [illegible] form 1t violent irritat. acute fev. etc. 2nd a chronic form coming on gradually counterfeits all diseases 1st begins with acute pain generally in the knee high irritative fever emaciation sallowness etc. Apt to be mistaken for aff. of the knee Not the slightest motion is allowed confined to one posture in bed limb elongated knees separated Eventually there will be shortened the [illegible] of the bone being on the dorsum of the ilium this shortening is ascertained by comparing thickness & ankles Prof. H. has known the length [illegible] in the first stage amount to 1 or 2 inches Supposed to be caused by scrofula this cannot always be so The disease is more rapid in children than in adults Distinguished from lumbar abscess by the history and appearance Sometimes after the spontaneous dislocation health will come on & nothing but lameness remains Generally there is some amendment when pus issues The prognostic is favorable if amendment follows evacuation if there is no hectic etc. In the chronic form we have first a slight lameness in walking pain is often exclusively at the knee sometimes at the hip over the [illegible] nerve This form is often caused by scrofula Seems often to arise from violence also from exposure to cold and sometimes no cause can be conjectured Many cases of sciatica are thought by Prof. H. & I. to be affections of hip joint Injuries will increase the disease as by nat. bonesetters Case related of this sort Treat. the acute form by v.s. & cal. apply ac lead (cold or warm) give opium freely from the first to relieve the pain better in the first place in form of dover powder. If the ain does not subsid. apply a blister Issues are too slow If the disease is attacked early it may generally be cured Treat the chronic form in a similar manner blisters seton is [illegible] & [illegible] Keep the limb absolutely at rest & secure this object by using Smith’s splint Make issues with caustic kali through a hole in a plaister & cover with another plaster In 6 or 8 hours it will have made a sore. Apply your issue generally back of the trochanter Prof. H. has succeed with them in the inside of the thigh near the knee. Setons are introduced on the anterior part of the joint Do not push your counterirritation too far with children Renew your setons and issues once in 6 w. or two mo. Prof. H. has applied tart. emet. Moxa now fashionable. Larrey does not wish for suppuration thinking the heat mainly beneficial The bowels are apt to be costive, from [illegible] to pass a stool manual assistance is sometimes necessary at stool The constitutional weakness and irritation are very great op. op. & cal conium etc. bark quinine Unopened abscesses are very dangerous Patients are apt to die suddenly with them Mr. Abernethy kept the pat. at rest at first (in the chronic) and gave the blue pill etc. for the constitution [the] prohibited motion for a long time etc. This practice not energetic enough for the acute form. Iodine now recommended We stand much in need of a better mode of treating this disease Considerable difficulty with parents often Venereal diseases formerly considered a unit. Mr. Hunter described the chancre But Mr. Hunter’s disease is now but rarely met with. Carmichael describes the true chancer & severe other sorts of sores on the penis A French writer has denied the existence of a specific syphilis Prof. H considers the inoculation of small pox and other poisons similar to the venereal contagion The first effects are entirely local 1st a little pimple or vesicle with serum or pus It degenerates into an ulcer of a foul & ragged appearance. Next the absorbents are affected Net an infl. of lymph. gland in the groin. Next ulcer in the throat or eruptions on the skin or both Net [nodes] tibia sternum fore arm perhaps ossa nasi It is now found that very many venereal sores may be cured without mercury. Such cases are now generally called syphiloid Many experiments have been made in the army more or less successful without mercury Mr. Hunter’s chancre has elevated edges & a hard base Prof H would pencil it thoroughly with nit. sil. afterwards wash with a saturated sol. of sulph. copper Then the black wash (cal. & lime water) Keep the pat. quiet in his room. If consulted early do nothing more If the chancre is early destroyed there will be no bubo When a bubo forms & suppurates, open and touch thoroughly with nit. sil. The ulcer in the throat looks very ill, yet gives less pain in swallowing then would be expected. The [pat.] will often deny its existence The eruption on the skin is quite singular looking like mallows cheeses Some prefer blue pill some corr. sub. others calomel others mercurial ointment. Sydenham gave 20 gr. doses of cal. Dr Carter of Natches has revised this practice procuring bilious discharges say 2 a week & salivation comes on Give corr. sub. in a bread pill 1/8 gr. Patients will scarcely bear more than ¾ gr. a day without a dysenteric aff. of the bowels Blue pill [5] gr. at night if this fails give it oftener Mercurial fumigation Mercl oint. rub in about a dram a day. We wish to avoid salivation Give large quantities of sarsaparilla. Conjoin guaicum etc. also Nodes will require no separate treatment Min. acids have been very famous. It does well after the system is reduced by mercury So sulph. quin. etc. when tonics are indicated [illegible] panacea has sometimes done well after a long mercurial course owing probably to its [minute] quantity of corr. sub. If a phlegmosis hide the chancre inject sil. cop. ac. lead or nit. sil. Inflammatory action will require v.s. & cal cathartics Sometimes life is threatened by a local hemorrhage The joints may become affected like rheumatism Partial blindness and deafness occurs If exfoliation comes on inside of the scull, generally the patient dies of paralysis etc. After long use of mercury the system becomes so susceptible that rubbing in a little merc. oint will affect the mouth in 15 min. In such cases Fowler’s solution has done well. Dr [Pardon] [Bowen] of Providence, relied very much on it. Give large quantities of sarsaparilla in the sequel The bones of the limbs sometimes becomes completely brittle Venereal infants mercury Calculus in the bladder May be produced upon a foreign body lodged in the bladder as a nucleus e.g. musket ball bits of a bougie etc. needles by hysterical women! More common in the western states and in Maine Symptoms very obscure pains in loins, vomiting, sediment in the urine sand passing away Nausea and vomiting with excessive pain are most apt to be cured by the passage of calculi along the ureters The pain will be sudden and violent not gradual and dull like that of psoas abscesses Retraction of testes, numbness etc. will also attend These passages through the ureters are commonly called attacks of gravel Passage of calculi through the urethra, gives rise to retention sense of tearing etc. perhap Symptoms of stone in the bladder pain at the extremity of the penis greatest when bladder is empty The pain comes on in paroxysms They are aggravated by walking or riding over a rough road. Pains in the neck of the bladder at stools. Yet these “fits of atone” may come on without any exciting cause. Patients pinch the glands Pass urine frequently have a frequent sense of inclination to go to stool. When the calculus is large there may be a sense of weight in the bladder. The urine becomes finally turbid perhaps bloody Children are said not to be subject to pain in the kidnies and ureters experiencing only stone in the bladder Finally micturition may be very frequent once in 15 min. A thickened and inflamed state of the bladder supervenes finally the patient dies of hectic. Prescribe remedies for irritation in general v.s. in extreme paroxysms Cal. opium as a matter of course It has been customary to cojoin alkalies & uva ursi these relieve though they do not dissolve the stone Prof. H. was for a long time afraid to blister for strangury but he now finds it very beneficial Operation Hippocrates swore his pupils not to perform it. The first mode was to pass the fingers up the rectum pull down the stone into the perinaeum & make an incision directly upon it. This was called the lesser operation or cutting by the gripe Next came the apparatus major so called in consequence of the large number of instruments A small opening was made to the forcibly dilated Next came the high operation above the pubis This has lately been attempted to be revived By this mode a large stone can be extracted without breaking Lately it has been proposed to operate through the rectum The present mode is called the lateral operation and is performed now as [Ches??da] formerly did. Some are inclined to substitute the knife for the gorget First sound perhaps a schirrhus may be sometimes mistake for a stone Prof. S. performed the operation for a calculus in the urethra. If the calculus drops down into the bottom of the bladder introduce your finger into the rectum Mr. Hey sometimes sounded with a silver cath. and felt the stone as the urine flowed. A flexible catheter without a stilette, has sometimes succeeded when other instruments have failed. Examine sitting standing, lying etc. Try repeatedly Administer over night a senna cathartic and an hour before the operation an injection Operation After it the urine flows out at the wound. Dr [Rhea] Barton keeps a flexible catheter in the bladder through the wound Some give opium immediately after the operation. Be guided by circumstances give opium if pat. has been in the habit of taking it Laxatives are very beneficial Children suffer very little But old people are apt to have chills, cold extremities etc. Treat as for shock q.v. Apply cloths, just as to a woman after delivery. Watch for hemorrhage When infl. comes on it is known by pain, chills etc. A very successful surgeon at the west, bleeds ad deliq. immediately after the commencement of delivery Fatal cases exhibit not gangrene but suppuration and abscesses The relief from the operation a very great pat. sleeping better the night after the oper. than for weeks previously Lithotomy in Women Case of a stone formed around a darning needle! extracted for Dr Cogswell The operation through the vagina is easy but the wound is apt not to close & [then] cause an incontinence of urine Sir A. C. introduced the plan by a sponge tent. Rx a sponge & dip it into melted beeswax moderately hot roll it into an oblong shape Introduce it the bees was melts out and the sponge dilates very powerfully often succeeding in a few hours When the stone is too large 1st cut [illegible] director to the left 2nd cut between Le France’s ode (invented by Costa) Place the pat. as for lith. a [illegible] is held by an assistant & depresses the urethra and vagina. Cut with a bistoury above the urethra and obliquely from the the symphisis pubis down close along [illegible] the ischium cut layer by layer until you arrive at the bladder Tumours of the bones Exostosis an increased growth of the body most frequently found in the [cran.] sternum clavicle ribs long bones Sometimes flat sometimes pointed sometimes pedunculated Sir A. C. makes two varieties one from the substance the other from the medulla Prof. H. makes cartilaginous (with bony parts interspersed) and fungoid or medullary Caused by external accidents as blows etc. scrofula syphilis etc. said to be the causes To be distinguished from [aster] sarcoma by its uniform hard [illegible] Seems not to affect the general health, unless the part is so large as to interrupt functions Most commonly the tumour stands out at an angle Sometimes they cease growing and remain stationary No treatment but extirpate is of use Use trepans [illegible] of various kinds, chisel & mallet etc. Operation not dangerous 2nd Osteosarcoma may be hard at the surface but will be soft (perhaps lardaceous!) in the centre (called fungus by Sir A.C.) base broad the whole substance of the bone is converted into it. Sometimes suppurations come on in the interior IT is fashionable to consider them all as fungus haematodes but they differ Fungus haematodes cause absorption of an adjacent bone. The general health is here affected Prof. H. considers internal remedies of little use. The disease is apt to return after extirpation. Boyer advises the actual cautery after extirpation. When on a limb amputate. May be of immense size as large as the body. Prof. H. has known on as large as a milkpail & two tablespoonfuls of laudanum at a dose necessary for the pain Caries soft black cloth stained dark perhaps honey combed from venereal etc. (may be caused perhaps by long unopened abscesses in some cases) Treat by caustics & especially actual cautery. Occurs most in the spongy bones Sometimes resection Caries of the hand penetrates the cranium Especially affects the mastoid process From syphilis We may touch only the mast. process with act. cautery. Remove carious portions Caries of sternum from syphilis Natural cure of caries is by necrosis terminations by depositions For superficial caries stimulating applications are generally sufficient e.g. nit. sil. sulph. copp. etc. Caries may occur on sacrum crest of ilium tubers of schium etc. from lying long on one [portion] Necrosis Death of bone Applied by Prof. S. to the specific disease called “fever sore” Bone first white then dirty yellow finally brown and black often surrounded on the edges by an elevated circle of granulations but finally the necrosed portion from being depressed well as it were rise up & be more elevated Commence with fever which is apt to be considered by the physician as an idiopathic fever followed by the fever sore. Occurs in the cylindrical bones principally oftenest in the tibia next in the os femoris External and internal periosteums dies & then the bone dies of course sometimes however the death is only in spots. Prof. H. is convinced that [illegible] incision often prevents the destruction of the periosteum vide [illegible] Commences with deep seated pain but often the pain is first in the joint & the disease is mistaken for rheumatism In a day or two fever comes on perhaps finally subsultus tendium and delirium Great pain on moving the limb. Pus first accumulates under the periosteum but in the thigh first in bursa under the tendons of the [ham.] In the spongy bones pus collects also in the cancellar structure Caused by cold contusions comminuted fractures caustics applied to ulcers most commonly in boys from excessive bathing in cold water many cases of this kind exposure to rain storms generally causes [illegible] sores unknown the joints near the part are apt to become much flexed Apply a splint pretty early Treatment. Bleeding cathartics blisters and opium Prof. H has found the subsequent irritation as much worse in the latter stages when the treatment was not commenced by evacuations The notion that evacuation shd not be used because the blood may y and bye be wanted. Prof. H. would pay little attention Besides at first we do not know certainly the nature of the affection in the first place in many cases we shall be told of an injury Blisters at the commencement are better than fomentations and poultices Pus will form however As soon as the disease is fully formed make an incision down to the bone through the periosteum we shall generally find pus If there is pus inside the bone bore into it with a nail gimlet It gives the greatest relief be careful not to split the bone Extracts from the notes taken by my friend T. H. Wadsworth of the Lectures on Surgery of Theodore H. Woodward Prefect Castleton Vt. Metastasis is another organ aff. sympath. & more so than the first Adhesion a vital process analogous to assimilation not an infl. for infl. hinders, as does coagulated blood, which has lost its vitality most successful where no heat or pain or mark of infl & then may take place in 18 h. The [illegible] lymph forms a bed for the vessels to ramify in The secretions of a part infl. gradually change to pus & then gradually back again, as in successful cures of clap. Prof. W. uses bandages to most acute infl. contrary to common practice they do good unless the irritability is very great or they are [illegible] fully applied they are particularly useful to deep seated infl. especially if chronic Mortification Prof. W. has seen all the muscles of the arm dissected clean from shoulder down & hanging but by their ends. A small strip of skin remained from wh. new skin was formed & covered then again. The case was caused by the bite of a hog When you bleed in cases where you expect extensive suppuration to come on, [illegible] on [illegible] you may want the vital power back again. You may temporarily relieve pain in any aff. whatever by v.s. you may if [illegible] wish produce syncope or death. In phlog. cases the best refrig. to follow v.s. in tart. ant. in nauseating doses it keeps the skin moist & affects the other secretions For superf. infl. cold is the main quality in external applic. Use spir. 1 pt to 4 water vinegar etc. etc. Somet. when all the [illegible] appear to indicate cold applic. they disagree & produce vomiting, spasm, or even convulsions. Here use fomentations which need not be medicated unless with narcotics which have considerable effect. Astringents added to washes do little good except for appearance. Lead, if very strong has some effect use a sat. sol. Lead applied too long to eye will produce palsy of it. For deep infl. use warmth cold is like water on outside of a blacksmith’s fire, making it hotter within. Use counterirritation Acute infl. term. in chron. is bad to manage & must be looked to it is apt to produce considerable irrit. of stomach. Commonly we want a moderate use of alteratives cal. & op. use bandages friction, liniments gradually change to a more generous diet. The best form of merc. in these chron. aff. is corr. sub. with op. bark may be [wanted] camph & carb. amm. good to allay irrit. & keep skin moist the position shd always be such as to favor the veins in this stage cool washes are not commonly good frict. with merc. oint. good. The const. treat shd be the same or nearly the same is if there was no local aff. The grade of action may be too low for suppuration in acute cases or it may be too high and gangrene or chronic weakness, effusion etc. may be the results Look to it After suppuration pat. somet. wants support, sometimes does as well without. When pus is in an important part, or under fasciae, do not wait but open After opening a large abscess of the chronic sort there is apt to be increase of pain, fever etc. It becomes aff. with acute infl. from the wound & perhaps from taking off the pressure suddenly Hence open them in the valvular manner, squeeze out the matter, bring the edges merely together, plaister & bandage with compression. By this process ac. infl. is prevented & adhesion of sac promoted we have to open several times but at each time there is less matter. Open common abscesses before the skin over them is diseased when it first begins to blush they heal much sooner bandage & compress. This is worth every thing else in the treat. of such tings Sudden stoppage of the secretion of pus is apt to affect important organs Ulcers Irritable ulcers limewater with mucilage good Rx zfs [illegible] hydrar. zfs cetacii zi opii Often they want calm. & op. say 5 gr. cal. at [illegible] & 1 gr. ope. 6 times a day. Prof. W. has cured many by moderate emet. of tur. min. repeated a few times wash of op. & bark sometimes. If you use bandaging it must be with care sometimes a good Sloughing ulcers no pus livid with [vesicle] constant pain granulations if any dark & often slough. Best applic. 50 drops nit. acid to 1 qt. water this more active than mur. acid charcoal as good as saw dust & no better Prof. W’s experience yeast poultice good. Port wine poultices good Stim. internally Most common in old drunkards Fungus ulcers (filled with proud flesh) are most common, changing sometimes to irritable & must be treated as such we must remove the lard edges before they will heal Cantharides in powder is often a good application to ulcers A simple roller if well applied is as good a way of bandaging as Boynton’s Ulcers with thick indurated inverted or everted edges must, in some way have these edges removed. When gangrene is commencing a poultice of yeast & flour etc. or a fomentation of brandy is good When not very deep seated & depending on local causes, a blister sometimes stops it Nitric zi to a pt. good turpentine ess. oils For [illegible] toes of old folks give tonics & stimulants For gangrene with considerable action remaining cold washes are best for others, hot. Diseases of Women The uterus has not quite so much to do with all dis of women as some think Some women regularly menstruate once in 35-45 60 even 90 days, yet are in perf. health & fit [for] business. Prof. W. has known many women have children at 52 Erythema anatomicum Best thing at first as to excite infl. in the part by caustics etc. Internally use stimulants etc. Anthrax Cut through the whole tumour both ways this relieves much, by taking of the stricture & the sloughs get out sooner Use anodyne fomentations etc. Scrofula Prof. W. has more faith in ext. & int. use of iodine then in any thing else known a large swelling much diminished in 18 m. & pat. become less evacuated & her health improves. Inflamed glands are often discussed in their early stages by blistering Wounds The sympt. fev. is commonly synochus but [illegible] with epid. disth. It is important to make arteries bleed if they will in first dressing & tying them Prof. W. prefers on the whole to let one and of lig. lie out where both are cut off, the part is always irritable Lacerated wounds are apt to bleed afterwards & it is best to secure them if possible In traumatic gang. no matter how soon you amputate if pat. has vigor enough unless the cause of the gang. is constitutional, & then though the gang. spread, you shd wait for the line of demarcation In gunshot wounds there is apt to come on deep seated pain from tension of fasciae etc. open & relieve The symptoms from large contused wounds are commonly those of atony & at any rate do not want dep. Second hem. is commonly from 7-12 d. Tetanus may be from injury of nerve but is generally (as Prof. W. thinks) from wound of a part of low vitality. Irritants to the wound are of use also to spine & stomach Give calom. ol. pin. op. etc. perhaps in some cases of considerable action v.s. to increase susceptibility to articles Wound of nerves Nerves unite as well as any part. The temperature of the part containing the divided nerve is colder but if it is covered with flannel it becomes warmer than the other corresponding part covered in the same way Sprains When the soreness is nearly gone, pouring water almost scalding hot, from a height has the best effect, with friction & bandaging often Sutures bandages, ligatures Prof. W. uses only the interrupted & twisted [sutures] An inexperienced hand had better enter the needle both ways from within in forming an interrupted [illegible] Old fashioned needles miserable things. Dr. Miller’s needle with a handle is good Flannel is more elastic & makes a better bandage for parts that are cold & edematous The only kinds of bandages of much use are strips single & double headed roller & 4 tailed Sometimes (not often) a T bandage Dentists silk makes the best ligature Spina Ventosa A bad name meaning internal caries of a long bone not easily known at first. The cavity of the bone increases in size? at first & fills with matter the outside also increases the shell is thin & there is an appearance of distention Oftenest affects the head of bones & is at first every way like white swelling except that the If even early evacuate the matter from the bone if you are certain what the disease is but if seen very early try general remedies & counterirritation as in white swell. In the latter stages the swelling bursts and often long tumors are formed, It will be attended with great pain irritation & discharge & the limb must be removed Ophthalmia In chronic stag nit. sil. & corr. sublimate better than mere astringents or cutting vessels but in some cases the vessels must be divided The applications are apt to be made too often twice a day will do Prof. W. has faith in local bleed. even when the syst. in general want tonics Great relief is afforded by applying at night a fomentation of cut tobacco, & binding on it may be dropped into the eye in cases not very irritable In many cases at the outset nit. sil. does well dropped into the eye, removing irrit. & vascularity. Do not continue warm app too long at least if infl proceeds to supp. use cold washes nit. sil. sub. zinc etc. In many cases Prof. W. has seen blisters near the eye cause irritation apply them to the neck Simple milk lachrymose ophth. may be cured by any mild stimulant Suppurative ophthalmia 4 sorts 1. epid. 2 metastatic (from clap or catarrh) often with a greenish secretion) 3 intermittent (from interm. causes) 4. infantum If the cornea fades & loses its lustre & its edge looks uneven it will certainly slough unless treated as gangrene by stim. ton. etc. Sclerotitis Straight vessels running to iris, well marked turgid & look as if painted florid color violent pain of eye, especially on motion there is apt to be effusion under the conjunctiva making the surface of the [sclerotic] coat unequal. It is apt to affect the choroid. Prof. W. does not know as there is a [chorditis] when chor is aff. there is dullness of function. the iris sluggishly contracting & limited in motion there is great irritability of the eye & division aching pain in forehead. Apt to aff. the iris. Treat as in other ophthalmitides but merch. ac. is especially useful in deep seated inflammations of the eye Rheumatic sclerotitis looks like the other, but aff. also the periosteum of the orbit & the pain is greatest then The pain is greatly aggravated at night sight always dim. iris acts sluggishly Apt to aff. the other coats. Eye dry & hot The pain often aff. half the head it is irregular & never entirely remitting. The fever is of the arthritic character with deranged secretions of the bowels. Prof. W. never saw bleed. do goos in any rheum. Calom & op. are better. Apply leeches & blisters. Keep the pupil dilated with belladonna. IN the last stage quinine arsenic is still better especially in chronic cases. In acute cases the best thing Prof. W. has seen has been actaea or colch. He never saw any local applic. but narcotics do good. There is no tending to chemosis Catarrh rheumatic aff. sclerot. & conjunct. both & has sympt. of both rheum. part goes off before the catarrhal It may terminate in opacities ulcerations of cornea, may ulcerate through. Digest apparatus much disturbed. Catarrhal or Epiderm. ophth. Prof. W. thinks the same as arythem. muco pur conjunctivitis It is apt to leave a villous look of the conjunctiva. Begins with stiffness of eyelids sense of pricking in the eye, especially about the lachrymal [caruncle] pat. cannot be persuaded that he has not sand in his eye & picks scratches & rubs. Conjunctiva of a mottled red, turgid. [Chemosis] commonly imperfect aff. only one side of the cornea (the chemosis is semitransparent & is evidently from serous effusion) Continues 6-8 days & there is a muco purulent secretion. Bad cases run on to the chronic stage, with ulcers of cornea, effusions, & spreading to other textures Prof. W. never saw sloughing in this It is epidemic & contagious General treat. same as for severe common ophth. Local applic. corr. sub. is best 1 gr. to 1 ounce nit. silv. good, but not equal to corr. sub. (common astring, generally irritate & do no good) Blisters In an early stage & even so late as the middle of the acute stage Prof. W. has cut it short by applying saturated solut. nit. oil, with internal use of arsenic quin. etc. Apply red prec. ointm. a piece as big as a pea between the eye lids & suffered to dissolve The pat. is very liable to subsequent attacks Chronic ophthalmias of all sorts are treated pretty much alike. Generally we must restore or change the secretions by merc. and corr. sub. is best. by other deobstruents in lower cases Narcotics & tonics When you apply red prec. ointm. 12 gr to zi is pretty strong Hydrocele Prof. W. prefers operating by seton of [illegible] thread, drawn through the tunica vaginalis & kept there till there is considerable infl. Causes of spasmodic cholera are not contusion & infection but those of wide spreading epidemics A board of 100 medical officers in India declare for non contagion So the medical board of Madras So also the 24 physicians constitution the medical boards of [Moscow] with only 3 dissentients. We sometimes have cases in this country precisely like those of India This is true of other diseases Diseases cannot be distinguished in their ataxic form this is true even of fever & ague which has destroyed patients in the second paroxysm Pneumonia typhodes has exhibited cases among as precisely resembling those of cholera spasmodica Physicians have differed more in their treatment than in regard to its causes large doses of calomel & opium diaphoretic treatment severe pain at stomach & bowels vomiting & purging great thirst coldness extremities cold to a bystander pulse at first languid or small & throbbing & in bad cases quick small & intermitting cold & clammy sweats death like coldness of extremities hiccup etc. etc. death sometimes with us in 24 hours distinguished from dysentery by watery stools & spasmodic griping pains from colic by stools allied to bilious fever yellow fever etc. produced by the same unknown causes, modified in their action it is to bilious fever what a tornado is to a settled stom. Spasmodic cholera of India has prevailed in 1774 & 1787 & in 18- Prevailed extensively in Sydenham’s time The present epidemic commenced in 1817 Said to have originated from bad rice Dr F. thinks that there may have been a predisposition then the disease first broke out in consequence of bad food & afterwards fear & anxiety would be sufficient exciting causes Anecdote of the plague in the French army Anecdote of a small pox case in Fairfield cty [30,000] reduced to 8000 in [Toflia] 17000 in 8 days at Astraca [6000000] in Asia up to 1830 4000 out of 8000 died in [illegible] Cholera called cholera morbus to distinguish that of [illegible] from chol infantum Copious discharge from stom & bow with painful spasmodic action Sometimes defined as the vomiting & purging of bilious matter this is incorrect bile is not vomited healthy bile could be vomited only in [illegible] cases The liver is diseased in connection with the stomach Affects hot climates & the hot seasons of temperate climates July to Sept. Affects the exhalents & absorbent vessels of the stomach the liver & pancreas There is a translation of action from the surface to the intestinal canal & its attendant glands In ataxic forms there [illegible] be no secretion Causes Sudden check of perspiration especially after great heat By unripe fruits large quantities of acids wild grasses, peaches & milk in short any thing which suspends the action of the stomach in case there is a predisposition. When it is epidemic very slight causes will bring it on & hence contagion is alleged Chills languor drowsiness [distention] [pressure] at [prae] [cordia]