5
Materia
Medica
(rear)
Diseases of women.
obs (front)












Lecture 2nd
Pelvis 1st The sacrum is nearly 
equilabral about 4 or 5 inches in each side
In the female pelvis the concavity of the sacrum
(perpendicularly) is about ¾ of an inch
deep The last vertebra inclines backwards
from the top of the sacrum, which is called 
the promontory of the pelvis.
The coccyx is moveable & curves
much forwards
The Ilius forms by [their] [illegible]
the great basin of the pelvis properly a part
of the abdomen. There are two anterior & 
two posterior spinous processes. The top of 
the pelvis is bounded y the linea ileo pectinea
The ischium has an anterior
& a posterior spine from the latter of which 
proceeds the internal [sacro??] ischeatic ligaments of each side
The pubis is the smallest bone
The ischium & pubis surround the foramen ovale 
Ligaments 1st sacro ischiatic
internal from the spine of the ischum 2nd sacro
ischiatic external from the tuberosity of the
ischium to 


3d Sacro iliac ligaments
Dimensions of the pelvis 1st the superior
strait at the line ileopectinea has
its [antero] posterior from the promontory of 
the sacrum to the symphisis, is 4 ½ or 5 in.
The transverse, at right angles to this, is 4 ¼ or
4 ½ in. The oblique, from the sacro iliac
symphisis to the acetabulum a little shorter
than the last
The inferior strait has its diameters
not parallel to those of the superior
The oblique are measured by Prof [Burns]
from the middle of the sacro ischiatic ligaments
to the junction of the rami of the ischia
& pubes


The axes of the strait
That of the superior strait is an
imaginary line from the umbilicus to about the
one third of the sacrum
That of the inferior strait
It has been thought that at about
the period of labour, the symphisis
pubis 
Deformed pelvises
Every variation of shape does not constitute a
deformity
1st The pelvis may be unnaturally
large in all its dimensions and this is a 
most deformity The uterus remains in th e
pelvis, pressing upon the rectum & bladder so 
as often to confine the patient to her bed during’
the whole period of gestation. The delivery 
also is too speedy & prolapsus uteri, fluor albus
etc. follows delivery. Case of this kind 
M.S.


2 Alterations in the shape of the pelvis
Occur always from rickets, [malacast??] etc
All the cases, almost, which occur in this
country are foreign women. All which Prof. B.
has seen have been Irish women.
The diameter altered is
almost always the antero posterior diameter.
It is laid down as a rule by 
European
The cavity of the pelvis may 
be badly shaped. The sacrum may be 
too straight. It may also be too curved
& throw the point of the coccyx too far forward
The coccyx also may be anchylosed. Bony 
tumours also may exist
Instruments have been
invented for measuring the pelvis. Those
which have to be introduced within the pelvis
are objectionable especially in [illegible]


Baudelacque’s callipers are very accurate
allowing 3 inches for the soft parts & adding
2 lines for a fleshy persons
The hand & finger however
are the best instruments, at the period of labour.
If the finger will not reach the 
promontory of the sacrum we may be
sure that the antero posterior diameter is sufficiently 
large. If the whole hand can be 
introduced
Diameter of the had. 
The long diam. is 5 in. from the occiput
to the chin. The longitudinal 4 ¼ in.  from the 
forehead to the occiput. The perpendicular
is the shortest These diameters may be diminished
5 or 6 lines, not
The neck cannot be twisted
more than a quarter of a [circle]


External organs
Immediately below the clitoris


Menstruation
Commences at first after having been preceded
by general disturbance of the health pains
in the back, hips & loins, disturbance of the bowels
etc. perhaps hysterical symptoms During
the continuance (about 4 days) of the evacuation 
a pale circle surrounds the eyes
It is ascertained from the examination of 
cases of procidentia that the discharge is from 
the uterus & not from the vagina
In this country menstruation commences
on an average at the age of from 14 to 16
The earlier the commencement the earlier the
cessation.
Conception
many theories 1st that the semen is carried
into the fallopian tubes 2nd


Changes produced by conception
The cavity of the uterus enlarges and soon 
a membrane forms on its inner surface
The ovum contained in two membranes passes
down the fallopian tubes and pushes out this
deciduous membrane


The fetus first appears in the ovum as a 
mucilaginous cloud
At the end of 6 weeks the fetus is about
½ an inch long and shaped like a crescent 
or bean. At two months the fetus is 2 inches
long about the size of a bean At 3 months it is 4 or 5 inches 
long external parts perfectly developed the
genitals being large and those of the [illegible]
from their size resembling those of the male
At 6 months the hair is visible the motions 
are felt in the abdomen the relative length
middle near the body of sternum weight 2 pounds
of the head and upper part of the body is greater 
At 7 mo. middle half way between navel & stomach
At 8 mo. skin is firmer and whiter, and hairs are
visible on it middle nearer the navel than
the sternum length 16 in. weight 4 or 5 pounds
gall bladder contains bile etc. etc.
At 9 mo. middle at the navel length
19 in. weight upon an average 8 lb. with
us but in France between 6 & 7 lb. Length of
the male with us 23 in. of the fem. 19 ¾ in.
The nourishment of the fetus is difficult
to explain. Probably it is like a vegetable
from the ovum in the first place.
The most prevalent opinion at
the present day is that the fetus is nourished 



from the blood after it has undergone some
change in the placenta. Some facts seem
to prove that the liver changes the blood & 
gives rise to a peculiar secretion albuminous.
Circulation of the Fetus
The most probable opinion at present is
that the fetal blood is oxygenized in the
lungs of the mother, is taken up from the 
placenta by the umbilical veins and carried
under the liver (principally) into the vena 
cava through the single heart back by 
the umbilical artery into the placenta 
again 


Signs of conception and 
pregnancy
Just after conception the
features become sharpened, the eyes are
surrounded by a dark circle The complexion 
pale. The most important sign is
the cessation of the menses but when the woman
has become pregnant while suckling a child, the
menses not having regularly returned, we cannot
reckon from that period, but women in that
case reckon the rather from the motion of the 
child which first occurs between the fourth 
and fifth month The areola of the nipple
is dark Pricking
sensations are experienced in the breasts
Morning sickness occurs and continues
until with about 2 mo. of delivery
By the fourth month the uterus
projects above the pubis is more easily felt in 
a lean subject By the 6th mo. the fundus
will be at the navel By the 7th about an inch
above and the navel protrudes
Usually by the 6th month the
motion of the child can be felt if the hand 
is first dipped in cold water.


By the fourth month the neck of the 
uterus is softer and shorter
The size of the uterus is judged
of by placing the left forefinger
the 
at upper & anterior part of the vagina
& pressing with the right upon 
the fundus just above the pubes you will feel
the pressure of one finger upon the other the
woman must be in a standing posture
Prof. B. thinks gestation may 
be prolonged beyond the ninth month & 
that he has had considerable evidence of 
the fact.
Case related in which parturition
was fully expected much alarm
was excited at its not coming on
& finally it was found that all the signs
of pregnancy which had existed, proceeded
from an enlarged uterus which 
was reduced by proper remedies.


Natural Labour is that where
the face is to the sacrum and the occiput to the
pubes where the [labour] is over within 24 h.
is where it terminates with safety to the mother
and child & the [secundines] come away well
4 stages are distinguished 1t os uteri is
dilated the membranes are protruded
2nd the head turns into the hollow
of the sacrum & presents at the ext. orif.
3d the child is delivered
4 the secondines come away
In the 1st stage we observe 1st the pains 
commence in the back & loins & pass through to  
the pubis in some cases about the loins & 
thighs first Sometimes very irregular [illegible] endeavoring
These first pains are short
not lasing more than about a minute
After the os uteri is dilated to 
about the size of a crown the second stage
commences the pains from being short & cutting
are protracted, with a sense of burning 
down violent skin hot & dry sense 
of inclination to go to stool from the 
pressure of the uterus on the rectum. During
this period the membranes are ruptured


In the third stage the perinaeum bulges
out the woman demands to get up for 
a stool must not be indulged
it is a delusive sensation. The perinaeum
becomes four or five inches broad
Prof. B. puts his right hand upon 
the occiput, & his left upon the perinaeum
he judges of the degree of pressure by 
the fingers of the left hand & resists with 
the right upon the occiput of the child.
The fourchette is [illegible] in the first
labour do not mistake this for ruptures
of perinaeum Vomiting occurs
frequently and is serviceable to the
facility of the labour
Gathering of the waters
This term is applied to the bulging tumour
of the water on the membranes which 
increases in protrusion at every pain 
& appears as if more water was collecting


False pains
Can be distinguished with certainty only 
by the effect of the pains upon the neck of the
uterus the pains produce no pressure upon 
the neck of the uterus & no dilutation of the
os tineae sometimes you can pass your 
finger into the uterus and feel that the
membranes do not become tense by the 
pains.
Often these false pains appear to be
caused by excessive motion of the
child enquire about this in [illegible] labour
the child has little or no motion 
To relieve these false pains after bleeding give opium. The labour
may be a month or two distant.
It is of importance to understand
the progress of a nat. lab. thoroughly 
Examine during a pain in the intervals
the woman may sit or walk about
Keep up her spirits. Make no certain 
prognostic as to the time or at least
fix a distant time so that the end of the labour may 
fall within it. We are often much 
urged to interfere keep out of the room
on this account Suffer no to one attempt to 


bring on a labour as it is [illegible]
Leave the woman often to allow
her an opportunity to pass water. During
the first stage let her be dressed for labour.
Dress the woman in a 
loose dress with her linen tuked up  
under her arms
Prepare the bed by first making it 
up as usual prepare the lower
part by coverings to protect it
Let the woman lie on her left side
with the knees bent, her feet against 
the bed post her head & shoulders raised by pillows tie a handkerchief or
towel around the other bed post for
the woman to take hold of Some
condemn these efforts of the woman, but 
Prof. B. is satisfied of the advantage of them
The only assistance rendered shd be pressure 
on the back
The French lay the wom. on 
the back. Some women prefer a sitting
posture. It is often advisable to change
the posture for particular circumstances
Conduct the choice of the patient 


If we wish to rupture the membranes it will generally be sufficient to press
hard on the membranes with the end of the
finger the membranes will rupture themselves.
If necessary scratch the membrane
with the nail. If the labour
is very rapid rupture the membranes
yourself, that the water and child
may not both be delivered at once
and empty the uterus too suddenly 
Rather hinder than hasten after the 
passage of the head one pain will expel
the shoulders and another the hips 
Generally as soon as the head is 
born and always when the body 
is born, the child cries. First feel for the
pulsation of the cord. If the child does
not breathe (when the air is freely admitted)
blow on its face dash cold water or spirit
on the face & chest wipe out the mouth
first with a dry & then with a moist rag
close the nostrils of the child with the fingers
& then blow gently into its mouth & if necessary
press gently upon the thorax to facilitate
expiration as this may be continued for 


some time keeping the body war
with hot flannels, all the while Apply 
your hand or better your ear to the region 
of the child’s heart
At first the respiration may be very 
feeble & perhaps at first with long interruptions.
Other means are frictions
ammonia etc. to the nostrils & to the 
surface of the body
Some children, after you have
succeeded, have not stamina enough
to support life. Dropsical effusions 
in the thorax may prevent respiration
& the life kept up in such cases by 
the [illegible], for half an hour Prof. B.
has met with such cases but only in children
of hard drinkers
Sometimes a child is apoplectic
from long detention of its head in the
passage in this case, bleed from
the cord ½ oz to 1 oz milking out the blood
inflate the lungs also etc.



The cord as soon as respiration
is established not waiting till the pulsation
ceases in the [illegible] we might have to 
wait ½ an hour or more
Tie with any sort of a string there
is no danger of cutting the vessels with a small
one A piece of wide tape is convenient
Tie tightly or the ligature may become loose
from the shrinking of the [illegible] Sometimes
the arteries are so firm that a ligature will 
not prevent hem. unless the arteries
are pulled out and tied separately.
It is thought by some necessary 
to tie both ends of the [illegible] but it is better
to allow the vessels of the placenta to 
bleed & thus diminish the size of the placenta
except [illegible] cases
As soon as the child is born
pass your hand over the abdomen if it
is firm and hard up to the scrob. cord.
a twin is within if the uterus is contracted
to a ball above the pubes there is merely 
the afterbirth. Generally the pains
commence again in about 8 or 10 min.
When the edge of the placenta arrives


at the vulva take hold of it, twist
it so as to make a roll of the membranes
& thus no part will be torn
off and left.
Next attend to the comfort
of the woman. If not too feeble let
her be immediately removed to the bed
she is to occupy
Place several folds of cloth
upon the abd. & pin a towel around
to give support, to prevent relaxation 
of the uterus & hemorrhage, & for the
comfort of the patient 
The pat. will now be very 
comfortable & happy, but soon come
on the afterpains by which the coagula
of blood are expelled from the uterus
But few women escape without after pains
those who have already had children
are more liable to them
Ergot administered during the labour
prevents or diminishes the afterpains. Prof. B.
has often administered it with this intention only 
Generally ginger & spts applied
vol. lim. zj ol. or zfs
also a poultice in a pillow case of ar.


herbs & bran
These pains are generally much
increased when the child is put to the breast
Until the 5th or safer still, until 
the 9th day, when the lochia terminate,
keep the pat. on panada, arrow root etc.
not giving cordials, in the old fashioned
way
Let the child suck immediately 
to draw off the colostrum to prevent swelling
& infl. of the breast, & retraction of
the nipple, which prevent it from sucking.
The child too needs the purgation
& is apt to lose the instinct for 
sucking
By the third day the lochia
should be washed off from the external
parts and a gentle purgative castor
oil or magnesia shd be given. The 
bladder must be attended to if necessary
apply a fomentation of onions, or if such
things fail introduce a catheter


The lochia comes on about the 3d cease about the 5th day
ultimately the discharge becomes of a light
pink col. The diminution of the
discharge is looked on as a good symptom
unless vary
If excessive, astringents, as port wine 
tinct. ter. jap.
Ultimately give a pill of op & ac. pl.
aa ij gr. once in an hour or two.
If this is not sufficient inject
ac. pl. & opium into the vag.
When the discharge has a cadaverous
smell, is greenish etc. wash
out the uterus with detergent injections
such as lime water & milk decoction
of oak bark etc. support the
pat.


Introduction of the Catheter
During labour the neck of the bladder 
is often elongated & you may have to 
pass the catheter directly upwards
Next attend to the Child
Be careful that the room is so warm
that the child does not take cold
Keep a cloth warmed at the fire
against the birth of the child
The body of a new born child should
be cleansed of a white unctuous substance
which resembles tar, by rubbing
with lard & wiping with a soft cloth
Then the child if vigorous may be
washed with soap and water
Others after rubbing over with lard
sprinkle with wheat flour or starch





Tie the cord by 
The belly band is a piece of flannel
passed about twice round the belly
Sometimes the child will not bear
to be dressed, from feebleness.
If the child grows cold, wrap it up in 
flannels dipped in hot spirit. And
let these children who cannot bear to be dressed,
let them be wrapped in flannel & 
kept in a warm place
If the meconium does not come
away with 12 or 14 hours, give molasses
& water, or honey and water if these
fail give a teaspoonful of bland castor
oil
Look out for retention of urine
It may arise from imperforate hymen 


or from the orifice of the urethra, either
of the male or female, being closed
up with mucus in which case introduce
a probe, a short distance
If the child must be fed give
cows milk 2 parts water 1 part sweetened
with loaf sugar or if it is required 
to be more purgative, with 
brown sugar
Presentations of head


Breach presentations
4 orders 1st back to the left side of the
mother the body rotates and the back is turned
to the [symphisis] pubis if traction is not 
used the arms lie along the body and come
out with it the face presents at the perineum
support the child’s body with your
left hand the chin issues first then 
the rest of the face and the head issues
with a jerk. The danger is in the
stoppage of the circulation of the cord.
A difficulty arises from the largest parts not
being delivered first. Another is in the
cessation of the pains which is abt to take
place
In the 2nd the right hip of the child
presents to the left acetabulum
3d the abdomen of the child presents to 
the abdomen of the mother the body turns
outward comes out obliquely but the head
comes out face upwards
#4th the revers of the 3d


During labour turn the body obliquely 
so as to bring the head into the position 
it is as in the 1st & 2nd
Presentations of the feet
1st the heel towards the pubis which 
eventually becomes the 1st hip presentation
Presentations of the knees
The knees feel harder
Generally best to bring down the feet


Diff. lab. 1at want of relaxation
febrile state do not give stimulants
2nd Want of action Ergot 1 z ergot to zii
water infusion tablespoonf. every 5 m.
The pains of ergot are distinguished by their increasing
continuance
3d too early rupture of memb. e.g. sudden
exertions as lifting sometimes probably from 
weakness of membranes. If the waters
are not drained [illegible] the labour may not
come on for weeks & be easy
Attachment of placenta over os uteri
may be suspected, from frequent & irregular
hemorrhages. Take the first opportunity
of examining while the blood is flowing
but if the flowing has ceased the finger would
break up the coagulence & perhaps bring on 
the flowing.
When the uterus is sufficiently dilated
to admit the finger the placenta may be
detected take care to distinguish it rom 
coagulated blood
When we cannot tell (early in the pregnancy 
5 or 6th month) about the case, treat as for
uterine hemorrhage apply cold in a horisontal
posture. Sugar of lead 5 or 10 grs with 1 gr. o f
opium repeated once or twice in 24 hours
It will produce no poisonous effects unless continued
for several days. If this fails inject
into vag. zii in ½ pt. of warm rain water
this is very effectual. A strong sinapism
between the shoulder is most effectual.
But the best remedy is a plug of alum Rx


a piece about 2 oz in weight made smooth
and passed up. Alum operates as a local stimulant
& the coagula of blood stop at the passage
also. It is usual to tie a piece of tape around it
When the placenta is over the os uteri, the 
labour will be ushered in by a flow of blood
]If we find the os uteri dilated or dilatable
so that we can introduce the hand we should 
immediately pass up the hand and turn
If necessary break through a part of the placenta.
When the breech of the child is
down it will plug up the passage.
But if the woman is nearly exhausted we
must restrain the hem. by proper application
The woman may die before we can turn
the vagina. A sponge is very good. A silk 
handkerchief. Prof. B has used [illegible]
introduced
in small pledgets [illegible] on to the 
tampon and given ergot allowing the tampon
to issue while pains are on and checking
it when they are off (Case related
articular mortis tampon ergot child dead
mother saved)
In other cases we may proceed
then early and afterwards turn?


Instruments
Forceps apt to be delayed too long
Prof. B. recollects no case in which they
were used too soon
Smellie’s [illegible] consisted in 
curving the [clams] The blunt hook
is now put upon the end of the handle
Place the woman left side (English)
back (French) the back generally preferable.
Empty the bladder & rectum previously.
Keep the instruments in a basin of
warm water before using them
Always apply the forceps on the sides
of the head and over the ears so as to embrace
the head in its oblique diameter over the
cheek, over the ear (occiput [illegible] diameter)
The pressure of the forceps lengthens the head
When each blade has been properly applied
the [male] part of the joint, readily enters 
the female part never lock the
forceps by means of force
Head being in 1t position
take the male blade in the left hand & introduce
it along the palm of the right (with a 


waving motion) carry the blade until 
the centre of the clam is opposite the anterior
fontanelle or the sagittal suture. If pain 
is felt, desist because you injure a [illegible] of the vagina with [illegible] be careful about [illegible]
against the ear with the end of the clam Introduce the
other blade with the other hand, in the same way
Draw & wave from side to 
side when you extract
If the head is high up, draw down,
in the first place.
Do not hurry but let the uterus do 
what it will to expel the child
The position for the use of the forceps are
1st vertex to the arch of the pubis
2 the reverse fore head to arch of pubis
3 vertex to the left foramen cot. cav. ? ovale i.e.
the head in the diameter
In this 3d position the handle of the male
blade will pass near the right thigh of
the mother & the head must make its
last turn after you apply the instruments contrive to turn the occiput 
to the arch of the pubis while you draw
4th the reverse of the 3d
7th head corresponding to the transverse


diameter of the pubis the male blade
passes under the arch of the pubis
As to the case when the forceps are to be applied
while the head is above the superior strait,
Prof. B. has never had such a case.
It will be better to turn and deliver by the
feet The cases of this kind where the forceps shd be
introduced must be very rare if any 
Shoulder presentation
Pass one hand up and push up the shoulder
sufficiently to allow the introduction of the
other hand to seize the feet
It may be necessary after the child
is dead to bring down the hip and use
the blunt hook



Locked or impacted head
Two positions sacro [illegible] or transverse
In the first case apply the forceps as before
In the second we are compelled to apply 
them over the face & occiput
As a general rule the forceps
are to be applied to head [illegible]
directs them for the pelvis. Other methods
are better however for a living child
Where there is more want of action
Prof. B. would give ergot instead of 
the forceps
But where the mother, being
vigorous & exhausted by pains & nature
has done all she can do ergot will 
not do good the forceps must be
applied
When the face presents and you 
cannot turn apply the forceps one blade
under the pubes. As you extract turn 
the face (from being transverse) so that the 
chin shall come under the pubess


Vectis
Can be used for extraction Can be used
to hasten the delivery of the face when that is
to the sacrum
The vectis is used principally for changing
the 4th [illegible] to the 1st & in face
presentations to change them to those of
the head
Breech presentations it may 
be worth while to make footling
Blunt Hook
Generally one is sufficient if not
apply both extract by a see saw 
motion
After delivery of the body the
head may be detained the pulsation of 
the cord cease the child make one or 
two convulsive heavings & will soon die
if not soon delivered. Pass the finger
up and give the head an oblique direction 
which will facilitate the delivery
Use the forceps to hasten delivery 


But in this case the vectis may be advantageously
used. Apply it over the occiput?
Foot & knee knee presenting
foot catching against the margin of the pelvis
Not worth while to confuse the memory
with all the varied presentations
IF the back of the neck side of the 
face etc. etc. push up and turn
Where the labour is very slow
& no part present we may suspect
a bad presentation. It will be necessary
to pass the hand up the vagina
& examine if we do not find a hard
body we shall have the hand foot 
belly etc. proceed to turn after
the membranes are ruptured 



Perforatory & crotchet
1st of the cases where the pelvis is too small
a case which does not often happen in this 
country
4 in. may be left to nature 3 ½ will be slow
& may be delivered alive by the forceps
A patient of Dr Hooker’s was delivered
in whom the diameter was 1 8/10 inches caused 
by [mollities] [ossium]. By means of [cephalotoma]
she was delivered & recovered, after 
having a fistula, communication between
the vag. & the neck of the bladder and a
closure of the os uteri
Make perforation with the perforator
then introduce it and break
down the brain., Then use the crotchet
It may be necessary to bring away first
each parietal bone then the frontal taking
care to keep the scalp whole


2nd where the head is unnaturally 
large from dropsy. Here we have
merely to let out the water and may 
use any instrument as a pair of scissors
Caesarean section
Dr Dewees sides with the French.
He says the perforator is more uncertain 
and is dangerous
The French forbid it when the 
child is alive
Retention of Placenta 
It is now agreed that it ought no t
to be suffered to remain
Pass your hand gradually between 
the placenta and uterus (if the placenta
continue to adhere) detaching it as you 
proceed pull upon the cord with the
other hand bring your hand away
after the placenta and not until 
you have felt the contraction of the uterus
upon your hand When Prof. B.
has had an adhering placenta he
has always found a mal-conformation 


of the placenta or walls of uterus as calculous
concretions etc.
Hemorrhage may make it necessary
to detach the placenta immediately 
Hemorrhage a week or more after
delivery
Hourglass contraction
Generally about the neck of the uterus
Prof. B. has scarcely met with a case since
he has adopted the plan of waiting scarcely 
more than ½ an hour before bringing away 
the placenta.
If it occurs pull upon the 
cord and at the same time insinuate
your hand up to the fundus of the uterus
Hemorrhage after delivery is most
apt to occur after quick, easy labours
caused by want of tonic contraction of the 
uterus
Injections of ac. pl. may be used
previous to [extracting] the placenta.
We are recom. also to inject cold 


water or a spiritous tinct. into the 
cord this is powerful & effectual
probably
We must judge of danger
from the exhaustion of the pat. not
from the quantity of blood lost ½ pt
or 1 pt. is generally lost in an ordinary 
labour. Prof. B. always
uses a plug of alum after delivery
of placenta.
Ergot. Prof. B. always uses it
but after delivery of plac. it is apt
to fail Where he has reason to expect 
hem. he gives it before the termination 
of the labour It never
fails & besides this it diminishes the 
after pains.
When life is in danger
use all your means. Carry 
a piece of alum in your hand
into the uterus. Prof. B. prefers
this to a sponge of vinegar. He has
had to wait 15 min. before the uterus
would contract in the last & 
compelled to sit an hour before the 


uterus would expel his hand.
Concealed hem. does not show
externally and uterus becomes distended
with blood. We should never
leave our patients until we have felt
the uterus firmly contracting between
the navel and pubes
Inversion of the uterus
Caused by pulling upon the cord Said also 
to take place spontaneously 
Prof. B. has seen but one or two cases
The indications are to detach the placenta 
and if possible restore the fundus
Symptoms very severe paleness, coldness
vom. conv. etc.
Place the pat. on her back and
pass up your hand and endeavour to push
back the fundus. But if the fundus
is protruded through the os uteri and
the dangerous symptoms result from the 
stricture perhaps all that it will be 
in our power to do, will be to make the
inversion complete and thus relieve the
stricture leaving a prolapsed uterus


Immediately after delivery
If the placenta does not come away 
apply friction etc. to excite contraction
Dr N.B.I. always excites contraction
if the uterus by pulling and swaying
upon the cord. He finds this perfectly 
safe. Prof. B. says it is also
# Compound pregnancy
We can sometimes guess at it in lean
women. In general we may find it 
difficult to determine, from the large
quantities
If after the birth of the first child
Labour is rather slower on account
of the large size of the uterus and that
too with the first child
Pass your hand upon the abdomen
to ascertain the existence of another child
If you find another child, conceal
it from the mother
The presentation is more apt
to be wrong in twin cases
If the pains do not come on again 
within ½ hour give ergot. You 


will then soon feel the bag of water
protruding and if you find them 
a bad presentation as of the shoulder or 
arm, you may easily turn and deliver
Hemorrhage is more apt to occur
Hence generally it will be best to give
ergot after delivery
Not unfrequently a woman has
been left, with a second child in her
uterus. Case related
Commonly the placentae are 
distinct and united merely by membranous
union. The memb. and the waters
are distinct. Sometimes however the
vessels of the two placentas [inosculate]
hence the precaution of tying both ends
of the divided cord.
The delivery of the placentae
is apt to be rather more difficult
Delivery one cord at a time


Presentation of the Cord
Sometimes a foot or a foot and a half
will protrude. These cases are 
difficult. 
It is safer to attempt to turn
and deliver [footling]. It is exceedingly 
difficult to return the cord
and keep it up. We are directed
to wind the cord on a sponge or rag
and push up. It will generally 
however soon come down again
Dr Dewees mode of using catheter
Prof. B. has not tried.
In one case Prof.  B. has
known a knot in the cord.
Deformed children
Give puzzling presentations
Oftenest the bones of the head are imperfect.
Sometimes you feel
the bone hardened brain. Feels
for the face
A more serious case is that of
hydrocephalus. Sometimes the size 
is enormous. Easily distinguished 


by the feel. The scalp protrudes
like the membranes. By pressing
also you may feel the bones of the cranium
and may even push your
finger through the sutures
The child is of course lost hence
you may as well puncture at once
with a lancet. In one case Prof.
B. let out 4 pds?
Signs of a dead child
Coldness shiverings like an ague
when the child dies Breast ceases
to swell and becomes flaccid
A secretion of milk comes on.
A weight is felt falling when the 
woman turns Cessation of mot. in child
When labour comes on, the waters
are fetid the meconium is evacuated
even in a head presentation
The scalp is flaccid, the hair comes
off etc. Yet the only certain 
sign is the want of pulsation in the cord


Rupture of uterus
By a fall, by violence in turning
or by forceps
Severe rending pain cold clammy 
sweats, sickness faintness & 
vomiting
The seat of the rupture may 
be in the fundus, side or neck.
If the child has wholly escaped
into the abdomen, the difficulty is
great. Gastrotomy seems much preferable
to delivery through the 
[illegible] Cases recorded of recovery 


Retention of menses
They may not commence until after the
20th year in the feeble and delicate
This should excite alarm as long as the
other signs of puberty are wanting
If the patient is robust let the
antiphlogistic treatment be followed.
But for the feeble, nervous, leuco-phlegmatic 
etc. prescribe exercise
shower bath warm flannel clothing
Give tonics especially chalybeate
Blood root madder ½ zs 3 times a day
Guaic. 4 z ½ z carb. sod. [illegible]
zjfs alc. 1 pt. Dewee’s tinct. vide Ellis
Blood toor ½ z sulph. zinc aj
aloes zj ft. pil. 60 2 to 3 in
24 hours regulating the dose by the
effect upon the bowels. This is the 
most useful emmenagogue
Blisters on inside of thighs size
of the hand These effected a cure in a 
pat. 27 years old whose aff. had resisted
all remedies
Cupping on inside of thigh has 


also been found beneficial
Cupping the breasts was reccommended
by the older writers
Savin has also strong emmenagogue
power
Retention may be caused
by other affections e.g. phthisis
In such cases emmenagogues shd
not be given
Suppression of menses
Menses may vary much without
ill health. The interval may be
12 or 6 weeks
The most usual cause
is the application of cold symptoms
severe pain in the head back
and loins colic etc. hysteria etc.
Hip bath anodyne injections
V.S. nervines for the hysteria
We may thus cure the immediate aff.
but the discharge will not thus be
made to return. Use of the pediluvium 
bleeding etc. just before 1 week
the next period & so [illegible] the 


discharge
Chronic suppression is to 
be treated like amenorrhea #
Periodical discharges from 
other parts may take place as a substitute
for the menstrual discharge.
This may continue for life. Case related
ulcer on ankle
Deficiency in quantity gives
rise to the same symptoms & shd be
treated like amenorrhoea
Excessive menst. not common
treat as for hemorrhage
Guaiacum is more agreeable in powder
# Carb ir. & pulv. guaic. aa zi
Sang. in powd zfs. aloes zfs. a small
teaspoonful 2 or 3 times a day


Dysmenorrhea Painful m.
very distressing pains resemble
labour pains pains
relieved by the discharge generally 
Caused by irritable uterus
Hip bath opiates hyoscyamus
diaphoretics
For permanent cure use the 
last described pills. Tinct.
guaic. Dr Dewees has cured with 
Prof B. has often failed with it
Deciduous membrane
Pains not relieved until the membrane
is thrown off. Occurs
in unmarried females also prevents
impregnation in the married
There is danger in the doses
of camphor 2 or 3 recommended 
by Dr Dewees. Prof. B. has produced
dangerous convulsions by them
Electricity has cured. repeated
for a week previous to the [illegible]
Use the emmenagogues mentioned 


Decline of menses
A critical period
Predispositioned to organic disease
are most liable to show themselves
at this period. On the other hand
others are then restored to health
In some the discharge stops suddenly 
in some it becomes profuse
or painful or irregular
Bleed 6 or 8 ounces repeatedly 
Keep the bowels open with the bloodroot
and zinc pills. Stimulant are
hardly ever admissible there is generally 
a disposition to plethora


Abortion
Delivery before 6th month especially 
between 2 & 3 & between 5 & 6. Keep 
on the look out. Drastic cath.
injuries reaching high with the hands
thus compressing the abdomen
Death of the fetus indicated by diminution
of all the signs of pregnancy
shrinking of breasts etc.
If you do not know the fetus to be
dead presume it to be alive. Quiet
laudanum etc. Ac. lead sometimes
for hemorrh.


Leucorrhea
Muco purulent discharge At first
a local dis. astring. inject. oak
bark zinc etc. Ascarides may
attend or be the cause Finally 
tonics gum ammoniae & iron cantharid. stopping for
strangury & then repeating Old cases
[illegible] [illegible] copaiba
Green & fetid discharge
Nit. silver one of the best injections
Cant. not important ([illegible])
sulph. zinc &nit. sil. also valuable
a sort of test of the efficiency of canth. is a 
thickening and opacity of the discharge
from the vagina It will not be necessary 
to keep even a light strangury 
& of course we are not to produce 
dysentery Prof. I.
Nit. sil. best inject. 3 or 4 grs. to oz.




Prolapsus uteri
One of the most common & troublesome
complaints takes place at any period
of life
Caused by relax. of vagina Uterus
kept in place almost solely by vag.
Most com. cause leucorrhea
Women with large pelvis more liable
Symptoms weight, uneasiness about 
loins etc.
Almost always accompanied with 
leucorrheal disch.
Cure at first by strengthening the
vagina, by tonics astringent, rest
recumbent posture
Treat for leucorrhea when that accompanies
Easily ascertained by examination 
or by relations of the pat. herself
Tumour recedes when pat. is on 
her back & is easily reduced
in this posture
Strong sol. of oak bark sulph.
zinc etc. after replacing the 
uterus & confining pat. to her back 


Continue with this treatment
[tonics] etc.
We are often called on when 
the diseases does not exist & we
find disease of [rectum] and vagina.
We do not find the uterus
pressing on the perinaeum
Use the pessary
Women of lax fibre & laborious women
as washerwomen are most
subject and often the disease has
made great progress before we 
are called the pessary will 
give effectual relief
This disease may be overlooked
& cause derangement of bowels
dyspepsia etc. & these complaints
only be prescribed. Prof B. has
known several cases of women confined
to the bed for years and the stomach
only prescribed to when the pessary 
has cured in a week
When the perinaeum is lacerated
the pessary cannot be used 


When the largest sized pessary is
required from extreme relaxation of 
vagina the oval pessary is best
Place the woman on the back
[enter] the pessary perpendicularly 
& after it is entered turn
Extreme prolapsus requires
a pessary with a handle [illegible]
in its place by a bandage
Pregnancy gives great inconvenience pessary not to be used
horizontal posture until the 
fundus rises
Retroversio uteri
Occurs generally between 3d and 4th mo.
fundus is in cavity of sacrum 
urine stopped in its passage
In passing up the hand we do not
find the os tincae & neck of uterus
Distinguished from polypus
which grows slowly & was gradual
in its symptoms
Growth of ovum prevented


Supposed to be caused by distention
of bladder with urine
Attempt reduction immediately
pay no attention to the
danger of producing abortion
First draw off the urine
Attempt reduction by the fingers
in the back part of the vagina
endeavouring to push up the 
fundus uteri. If we fail, place
pat. on hands & knees then introduce
a probang like inst. into the
rectum at the same time press 
with the left hand above the pubes
We may almost always succeed
Cases of failure are recorded 
[illegible] and it is recommended
to introduce a catheter & rupture
the membranes and draw off the
waters thus reducing the size of the 
uterus
Anteversio uteri
Can never be a formidable disease
& may always be remedied by change
of posture


Scrophulous enlargement of
uterus
Resembles schirrhus pain in 
neck back & loins etc.
large & less hard than true
schirrhus not extremely tender
Causes a resemblance of pregnancy
Sometimes the general health is
not much injured
Prof. B. has known a case of 
gradual enlargem. sympath action 
of breast & cessat. of menses
closely counterfeiting pregnancy
Prolapsus is very apt to 
occur with all its inconveniences
Prof. B. has known one case of 
this kind which continued 6 or 7 yrs
bed ridden unable to stand or 
walk cured by blue pill was
to bear 2 children blue pill 
is specific


Irritable uterus
The least touch cannot be borne
pat. cannot sit or stand even
lying merely palliates no relieves 
the pain. The slightest 
touch cannot be borne at the
pubes. Vagina natural os tuniae perhaps a little swollen
Rest cupping counterirr.
blisters hip bath conium & 
[illegible] narcotics blisters & 
setons (Well described by Dr
Gooch & only by him) Case related
Arsenicae
solution was the most successful
remedy & continued to be so
Diseases of ext. org. of [generatim]
phlegm. infl. of labia often occurs
to be treated with poultices frequently 
suppurates but the abscess [illegible]
[illegible] gives great pain discharges
fetid blood issues when an excis.
made 
Excoriations of labia
Soap & water ointm. of ox. zinc etc.



citrin oint. etc.
Warty excrescences not venereal
cured by nit. silver.
Dropsy of labia t pregnancy 
almost as large as the 
child’s head
Prusitus pudendi
very troublesome efflorescence
just within the labia intol. itch
may generally be cured by a wash
of nit. sil. or corr. sub.
[illegible] subj. to great elongation
but not with us
Imperforate hymen
Almost always congenital & discovered
by the nurse and will 
generally yield to pressure of a
probe If the knife is used be
very careful to keep a tent in or
a second operation will be needed 


Rupture of perinaeum
Occurs during labour
Keep the bowels open to prevent distention 
& irritation by passage of 
hardened feces It will generally 
heal up The hare lip operation 
is said always to have failed 
to cut by [palliatives]
Small vagina
may be caused by severe labours
& should be prevented after delivery
Introduce a dry sponge
after a few days a large one
Prolapsus vaginae
Astringents & a pessary


Cauliflower excrescence
Probably a fungus haematodis
vagina filled with a spongy soft tumour
bleeding at the slightest touch Disappears
at death
We cannot [illegible] by the touch
whether a tumour is malignant or benign
Hydatids are clustered vesicles
like a bunch of grapes Some call them
[illegible] They form in all parts of 
the uterus in the ovum & sometimes
the [illegible] itself produces [abortion]
It occurs only in those who have been pregnant
this last disease counterfeits pregnancy
hemorrhage comes on in an 
abortion pains resembling labour pains
etc. Treat as for hemorrh. & 
finally ergot might be useful to expel 
the hydatids
The ovaries are the seat of
scrofulous & other enlargements fecundity
is prevented
Ovarium Dropsy
Consequences in the [Graaffian] vesicle
with small tumours which gradually 
enlarge and as they enlarge, the matter 



becomes more limpid finally the
bulk may be as great as in ascites
from which it is distinguished by 
tumour more circumscribed & greater
thickness of integuments between
the liquid and your hand
Commences by pain & is near
the hip
Affects the health little except
from its bulk
Entirely out of the reach
of constitutional remedies.
Often there are several distinct
vesicles & upon making
one puncture we find the tum.
merely diminished & altered in size
Case Prof. B. drew off only 1 ½ pt
at the first tipping at the next tapping
immediately after 64 pounds
were evacuated
Remember that the coats
of the tumours are nearly as
thick as the walls of the gravid uterus
 


Cancer of uterus
Darting pains bearing down
pains in the groins General
health soon affected countenance
sallow etc.
Os uteri hardened & pressure
on it causes lancinating pain
Hard knotty tumours form about os 
uteri & in the vagina. Menstruation
irregular or substituted by 
hemorrhage.
Distinguished from scrofulous
enlargement by knottiness irregularity 
& hardness. Also cancer rarely 
comes on till after cessation of menses.
A. Cooper never saw a true
carcinoma under 36 years
Treat at first as if we had
mistaken the disease and prescribe
for scrofula. Afterwards palliate
give light nourishing food
keep bowels soluble. Attend to 
cleanliness discharge being intolerably 
fetid inject limewater
hip bath black wash. corr. sub.



3 grs to 1 pt of limewater
Nit. sil. very useful
Chloride of lime for the fetor
[restorat???] discharges by ac. lead, sul.
zinc etc. injected
Opiates
Diuretics especially those which render
the urine bland e.g. uva ursi
gaultheria etc.
Polypus of uterus
Frequent discharges which exhaust
the patient. Hence necessity of manual
examination. Where we cannot
relieve frequently returning discharges
we ought to suspect polypus.
Generally in the cavity of uterus
After it protrudes into the vagina
we can feel it. If attached to the 
neck of the uterus the neck will 
be found passing directly in the 
direction of the uterus
Sometime they are attached to the
ext. surf. of uterus or to vagina 


more common in women who have
borne children But met with in others
They may exist a long time without
being discoverable
Frequently very small tumours
seem to have more effect than large
ones causing more or worse hemorrhages.
They may be large & 
give no inconvenience except by 
bulk & pressure on the bladder
& rectum
There is danger when the tumour
is attached to the fundus it may bring 
it down & produce partial inversion 
Vary from the size of a walnut
to that of a child’s head with a neck
as large as the wrist Case
Other diseases may be mistaken
for polypus. Prolapsus uteri is distinguished 
by the presence of os tunicae
by its sensibility & by its growing
larger from below upwards by 
relief being given when it is pushed
up a polypus causing uneasiness 


when pushed up history of case also
Gooch’s rule always to supply 
a ligature to a tumor with a neck 
is a good one
Sometimes their removal
results from the stricture upon 
the neck by the os tunicae
The ligature is the best mode
of removing them. Prof. B. prefers
the common double cannula
to any of its more complicated substitutes
For a larger tumour the [ring]
probe is the best instrument
If you get away as much as ¾ of
the tumour the rest will disappear
You will know if you have included
the neck of the uterus by the extreme
pain produced










Retention of Menses
Retention is the want Suppression is
the interruption Treatment of both is 
much the same We are to prescribe
however to constitution and symptoms
Either of them is rather the effect than 
the cause of disease
The [cutam.] will sometimes cease
at 25 and often between 30 & 40. They 
may continue also beyond 50 years
Suppression & retention are
usually from want of action 	
Want of expression of countenance
and eyes whiteness of tongue scurvy
as it is called
This form is relieved by tonics
and astringents Lime water is 
much used & is called tonic. Alternate
alkalies with astringents as gum, [illegible],
[illegible] etc. A convenient form is pills
of the extracts with molasses And 
also [iron] & formerly myrrh
was called deobstruent and much 




used in form of Jenkins’ pills
& the myrrh mixture (Griffith’s & [illegible]
Rx
In the worst cases in country practice geranium [illegible]
or statici or agrimonial (which resembles
contrayerva) or cornus can always
be found in the country Lime water can
be made sulph. zinc you will carry 
about you. Add also aromatics as fennel,
dill etc. mints [pyenanthin??]
Generally when you have obviated
the cachetic morbid actions of the constitution 
uterus will take on its own healthy 
natural action. If however the catam.
do not return use emmenagogues
R. sulph. zinc gr i sang. gr. i aloes gr i
[illegible] guaicum table sp. & tinct canth. So much 
guaiacum as not to operate as a cath.
& 20 gtts tinct canth. 2 or 3 times a day
Another disease
Symptoms pain in the side about
an inch above the anterior sup.
spin. proc. inquietude sleeplessness




upon enquiry you will find the discharge
paler or watery or less in quantity material it is unhealthy
Stimulate the spine with tart. emet
oint. or canth. from the neck down 
along the spine. You will generally 
find upon pressure some of the vertebrae
tender. Then give after [irritant]
guaiacum, myrrh. Cathartics
seem to increase the cachery of the 
system. Of course avoid costiveness
Bleed in small quantities if necessary 
in retention or supp. Remember
however that the system does not suffer 
from want of evacuation Ligatures
will do better often than bleeding applied
just before the time for the return of the
catamenia
Sometimes the bowels become
loaded from torpor & inactivity
etc. Prof. I. has no doubt that bleeding
at the lungs and hectic after arise
from this cause. Use repeated
any free injections to wash out the
bowels. Exercise & amusement in 
the open air will do much Injection 



([Dr Savemens]) may be somewhat of a
substitute for exercise. The shower
bath is a good thing & our old remedy
Young women are seldom subject
to dis. of the uterus. Yet young 
women of of strumous habit, in whom 
there is [tineae] is relaxed have prolapsus from 
jumping off a horse etc.
Symptoms pain down the thigh
a sense of drawing down of the stomach
& of the bowels sinking at the stomach
dyspeptic symptoms
Prof. I has known unmarried
women bed rid from this cause, feeling
as if the bowels would come out
if they attempted to rise The os tineae 
is relaxed and there is a tendency to spasmodic
action there. In young women
pessaries do not seem to do well
there is more or less spasmodic action
I have made them with a handle & 
used a T bandage but no with much 
success. Sea bathing has been beneficial.
Elastic gum pessaries are 
best & have cured. Silver ones are 



good. Sponges are used but are
too rough & absorbing the secretions
smell bad & if changed every day
irritate too much. Ivory pessaries
Pessaries are proper when there is 
no disease excepting relaxation
When there is prolapsus you do not
feel the os tineae & the neck distinctly, but
you feel the relaxed and enlarged os tineae
& perhaps the uterus in an oblique position
In such cases we use astringents, as oak
bark etc. but sulph. zinc is better
Keep the bowels open and give aromatics
R. magn zfs or zii chalk. zfs cubebs
zfs carb. soda zfs grana paradisi zjj
a teaspoonful 2 or 3 times a day is often
enough. If there is likelihood
of the liver’s being affected give blue pill
Prof. I. doubt the existence of the 
cauliflower excrescence. HE has seen
relaxed os tineae with its veins varicose
Various diseases are called
cancer. If you find the os tineae
hard & enlarged & unequally & you 


find tumours in the vagina the disease
will certainly prove fatal. You may 
give conium astringents irritate
the sacrum etc. but with no good effect
Sometimes the tumours are fatty
 A phagedenic ulcer affects
the uterus eating away the os tineae
carb. & phosph. ferri have been 
declared specifics
Another disease enlargement of uterus, pain
in it discharge like leucorrhea
perhaps catamenia excessive Os tineae
enlarged also. This terminates in 
medullary cancer of some [writers]
Apply alum to the os tineae astringent
give metallic tonics & narcotics & 
silver pill
There are diseases of the uterus
in which polypi, deciduous membranes
dropsy etc.


Dysmenorrhoea
Occurs in persons with some deranged
state of the viscera catamenia comes
on with pain in the back limbs
much unequal excitement head hot
sometimes neuralgic pains Patient
will frequently throw off a deciduous
membrane
Dewees recommended
guaiacum (tinct) & allspice called
Dewees tinct. but it is better to give
the guaiacum by itself and the allspice
if needed Give 5 to 11 gr
camph. repeat every hour until’
you have given a z If you can
keep this on the stomach it will generally 
cure I have given also camphor 
& magnesia 20 gr of each
by mistake she took double the dose
became weak but after a few
hours recovered regular catamenia
Other narcotics may be used but camphor
has been long recommended. Deobstruents
also as sanguinaria may 
be used. Hyoscyamus is better then 


opium or conium
Equalize excitement by irritants
& drafts warm bath etc.
Other articles are ipecac
wild ipecac ([illegible])
External irritants are burgundy pitch
plaster on the sacrum
Sometimes there is a sallow
countenance, atony etc. then support
the patient
Incipient cases of diseased
ovaria the os tineae is spongy and 
flattened These diseases of ovaria
are very various but are called
dropsy & cancer Curable at
first by a course of blue pill, moderate
stimulants, aromatics, absorbents
(for acidity) and deobstruents
in general. I have kept patients under
the use of blue pill and even for a year
occasionally [illegible] it for 2 or 3 yrs
I gave also a compound powder
of alkalies, aromatics and columbo
and kept the patient also under conium


but I find hyoscyamus equal in its 
deobstruent effects even while it is
far superior in its narcotic effects
while it does not like opium produce
constipation & torpor of al. can.
Polypus of uterus
It may exist without unpleasant
symptoms. They do not always bleed
but at the time of catamenia hemorrhage 
is apt to occur. In the 
bleeding kind it may come down
and project beyond the vulva
At the time of the catam. there will 
be pain in hips & back & extending
down the thighs cat. profuse & finally 
terminating in a watery discharge
If the astringents as nutmeg, geranium
and best ac. pl. with op.
given both locally & by the mouth
do not relieve, we may examine
for polypus. There will be a dragging
sense in the uterus etc. Examine & you
will at about an inch & a half you 
will meet with a tumour which you 
will distinguish from a prolapsed uterus


by the absence of the os tinaea &
by feeling a tapering tumour its
neck being embraced by the os
tineae Its surface being smooth & 
delicate. Generally the neck will 
be too high up to be felt.
Retroversion
Well described by J. Hunter in the
London Observations
The trifling complaints spoke of
by Dewees do not deserve to be
considered Retroversion is
when the uterus is carried back down
into the perineum the os tineae is
carried back & up
Symptoms uneasiness constipation 
retention of feces & urine
vomiting, hysteria etc.
Introduce the finger into the vagina
about an inch up you find a resistance
on all sides you carry the finger back
along the prominence and you find a
tumour in the perinaeum and you find
no os tineae but by changing the position 


of the patient say erect or upon hands
& knees you are able to feel partially 
the os tineae The orifice of the urethra
is also drawn up, because the bladder
is drawn up & you do not readily 
find it and cannot readily introduce
the catheter Introduce a small
elastic catheter & draw off the urine
when great relief is obtained
Evacuate the bowels by injections
John Hunter recommended puncturing
the uterus drawing of the waters & producing
abortion
Restore the uterus by placing
patient on hands & knees & introduce a
probang with a ball about an inch in 
diameter covered with lard introduce
the left finger into the vagina
Pass the probang gradually up the 
rectum & let it act upon the fundus of the
uterus so as to push it back in the way it
came down assisting with the left two
fingers. Use the catheter for some days
after and give injection per anum
After the child rises above the pubis there 
is no further danger


# Found in bex humida, convulsiva etc.
# Very large and strong in the 
“dead rattle”


Stethoscope
Continued from the 1st vol. M.M. 1832 & 3
2nd Mucous [rhoncus] occasioned
by the passage of the air through sputa forming
bubbles which produce the sound by their
bursting. The epithets are very large, middling or small
according to the size of the bubbles also
abundant or rare according to the number 
of them. # Found also in haemoptysys
though then there is an indication 
of greater fluidity the bubbles being more
frequent. This originates from the large tubes 
Tracheal rhoncus is also mucous
and may often heard very loud by the steth. when 
not audible to the unassisted ear #
These two the crepitant and mucous
are called moist rhonci
3d Sonorous rh. a flat dull
sound resembling the cooing of a dove
or the large strings of a violincello The 
causes are not known The indications
also unknowns. The sound varies very 
much. resembles the varieties of sound
produced by blowing the nose



4th Sibilant rhon or a dry sharp
whistling sound sometimes
resembles the chirping of a ground bird
pathogn. of asthma
In sonorous rh. but one sound is heard
but in this there are heard a great many 
almost persuading one sometimes
that the chest is filled with young birds
This rhoncus is from small tubes
The former (sonorous) is from one small
tube. This sibiliant may may be caused by a thickening of the [illegible] membrane
5th Crackling rhoncus proceed
emphysema pulmonum (an unnatural
inflation of the lungs at first an unnatural
inflation of the air cells
ultimately the cells burst and the 
connecting cell mem. is inflated
in dissection the pleura may often 
be seen elevated In another
variety the air is effused into the
cell mem. between the lobules of the
lungs) In vesicular emphysema
this rhoncus is not always found
but in the interlobular emphysema 
it is very manifest


The sound is a crackling one, like the
burning of hemlock leaves or like blow
into a dry bladder. Sounds as if air was
entering dried lungs
6th Some authors add the cavernous
found when there are cavities, formed
from tubercles, or from gangrene or from 
abscesses Tubercular excavations
generally contain some fluid, which 
gives rise to a gurgling sound. We
have likewise the term “amphoric resonance
or atricular buzzing, which 
is caused by the communication of the 
cavern by a small orifice resembles
the sound made by blowing into a large
vial When there is no fluid
we have the cavernous respiration
of which the amphoric is a variety
Some make this a variety of the mucous ronchus
Some persons breathe so 
feebly that it will be advisable
to request the patient to make a full & 
quick respiration Otherwise he may 
not notice an engorgement which the 


ordinary painful & cautious respiration
may not slow and he
may suppose a part to be completely
obstructed which which will be [illegible] to be not [illegible] upon
a full & quick respiration
It will also be useful
probably to the patient to make occasionally 
a free respiration especially 
in the commencement & in 
the resolution of pneumonitis (N.B.
when pneum. is going off we hear
the crepitus caused by the air beginning 
to reenter the cells)
Also in incipient adhesions of the
pleura, we may make use of the
same means. Dr H.’s own case
He felt a sense of tearing
Emphysema will only 


Patholog. cond. of the voice
1st Tracheophony or layrngoptony
2 Bronchophony 3d
4th Pectoriolquy
The two first are heard in health 
in limited portions of the chest however
The air of the lungs being in distinct
cells we have a compound medium
but when the lungs are hepatised or
hardened with tubercles So also if
one lung has been entirely destroyed
Case of a child foreign body in the
lung infl. supp. vom.  & prod. of pus
child recovered from the sound
the lung was considered healthy
afterwards a year after the child died
of scarlet fever & the lung was found wanting # 
When apart of a lung is solidified
we find a dull sound upon percussion 
we hear bronchial respiration & bronchophony


Introduction of the catheter
During labour the neck of the bladder 
is often much elongated, and you may 
have to pass the catheter directly upward
Next attend to the child
Be careful that the room is warm
that the child does not take cold
Keep a cloth warmed at the fire
against the birth of the child
The body of a new born child
should be cleansed of a white unctuous
substance, which resembles tar, by 
rubbing with lard and wiping with 
a soft cloth. Then the child, if vigorous 
may be washed with soap & water
Others, after rubbing off the 
lard, sprinkle over wheat flour or 
starch 




Aegophony or Haegophony
goat like tremulous, bleating
voice resounds through a thin stratum of fluid
Pathogn. of empyema
collection of [serum] (Pleuritis)
Commonly not distin. from 
bronchoph. by the inexperienced
It is like a kind of silvery voice vibrating
on the surface of the lungs. Apply 
the cylinder firmly on the chest the ear
to the stethos. lightly (if hard pressed on
it, it will sound like bronchoph.)
When the liquid is small, 
aegoph. will be heard only at the lower
portion of the lung But if we hear
the sound near the root of the lungs (between
the scapulae) we may conclude the 
collection to be large
In strongly marked cases it
may be distinguished by its shrill sharp
sound also by seeming like an echo
of the voice often also the seat of it
may shift with a change of position



Pectoriloquy
the resounding of the voice from within a 
cavity communicating with the tracheae
or bronchia Caused by softened tubercles,
by separation of gangrenous
[eschous] by abscesses formed in any way 
by openings into the mediastinum was perhaps
& perhaps also into the liver
Pathogn. principally of phthisis
In perfect pectoril. the voice
seems at the end of the steth. & often
seems louder In imperfect the voice
does not seem to traverse the whole length
of the instrum. or
Doubtful pectoril. sound slike
aegophog or is too obscure to be defined
In perfect. pect. an amphoric resonance
or cavernous rhoncus will accompany it
and there will be obscured in the
imperfect
If excavations exist in the 
lungs, they can generally be detected by 
the stethoscope & before the use of the
steth. they could not as there is often 


no pain in their region In some
few cases the information conveyed will 
be imperfect or doubtful, but the instrument
is valuable
Pectoril. is modif. by the nat. tone
of the voice clearer & more distinct
when the voice is high though perhaps
less loud. Hence the nat. resonance
of a sharp toned voice may be clearer
than a true pectoriliquy, in the axilla, for
instance, when the voice is grave. But
we can generally determine by comparing
the opposite sides of the chest
2nd modified by the size of the
cavity but then a cavity is large as  a 
pea! will render a true petoriliquy 
5 by the situation of the cavity if it
is deep in the substance, the pectoril.
will be far less clear than when it is
near the surface but when very 
near & with thin collapsing sides
we have only the veiled puff a
var. of cavernous rhonc.
4th by the  slope of the cavity
louder & clearer of sound & smooth very 


loud indeed when the cavity is lined with
a cartilag. sub. Ragged an obscure sound cavities yield
5 by the opening several fistulous
opening will much obscure the sound 
6 more distinct, when the cavity is perfectly
empty sometimes the cavity will be 
filled one day & empty another according
to the abundance & facility of expectoration
Hence, in general, pectoriloquy
indicates a cavity, but a cavity may not
give pect. still there may be other
sighs, as amphoric resonance


Signs given by resp. & voice
1st amphoric resonance & metallic
tinkling.
1st is like blowing into
a vial 2nd like striking a short
metallic cord, or a wine glass or 
tumbler. Both indicate a large
cavity with hard unyielding walls
& filled principally with air & communicating 
by a small orifice
Commonly cav.  resp. amph. res.
& met. tinkling are varieties of the 
cough & [speck.]
Auscultation of the cough
The phenomena are intermediate
between those of the voice & the respir.
Cavernous cough indicates excavations
& cav. rhonc. is made more manifest
by coughing
Also by requesting the patient to cough we
can obtain a full inspiration


1st Clavicular over the clavicle
2nd Infraclavicular from the clavicle to the 4th rib
3d [Mammary] 8th
4th Infram from 8th to cart
3 sternal regions
5 Superior sternal region
6 Middle
7 Inferior
8th Axillary reg. to the 4th rib
9th Lateral reg. fr 4th to 8
10 Inferior lateral reg fr 8th to [cartilage]
11th Acromial ac. proc. of scap
& above
12th Scrofular space of the scap.
Some make superior & inf. scap. reg.
separated by the spine
13 Interscep (2 of them
14 Inferior dorsal (2 of them)


Diseases
Pneumonitis more fatal than any other
acute disease. Infl. of lungs etc. vide Good
To be distinguished from bronchitis & 
pleuritis. Though it may be complicated
with one or both
3 stage 1st obstruction or engagement
2nd hepatization 3d purulent
infiltration
Engorgement is from blood
and serum the lung when cut will 
give a crepitus, & does not sink in water
resp. high small, accelerated, incomplete,
unequal, difficult commonly
cough & pain & expectoration (when no cough or pain 
called latent [illegible] then we must observe the 
respiration & use the stethoscope which 
gives the crepitous rhocus). The 
modification of the rhoncus gives the character
the fluid engorged (if bloody crepitant) if serum, subcrepitant.
Hepatization has the air cells entirely 
obstructed lung sark red sinks in 
water called also [carnification]
absence of vesic. resp. & [illegible] of bronchial
resp & bronchophony (if near the centre 
of the lungs


puerile respiration (produced by a preternaturally 
vigorous action of the healthy
part of the lungs) occurs in both stages
3d Purulent infiltration into the substance surface of 
the lung straw coloured. Lung humid
& soft fingers easily penetrate it 
softer if from serous engorgement generally 
accompanied at its commencement
by chills mucous rhoncus
Percussion gives no difference in the 
first stage of engorgement grows duller
decidedly dull after the stage of
hepat. commences In hepatization we have bronchphony & bronch. resp.
The three first stages are completed in 
from 6 to 8 days the first two in’
5 days But often the disease is irregular
and the regular course may be broken
up by medication You may find all 
the grades of healthy and morbid respiration
within 4 or 5 inches
After dust both lungs are found
affected for the disease is seldom fatal
when one lung only is affected. Respiration 
of one lung may be entirely gone and yet 



the health be pretty good apparently 
Dr H. has often known one lung completely 
hepatized within 36 or 48 hours,
and within 6 or 8 hours find the
disease entirely transferred to the other
lung
Commonly one lung
undergoes resolution
& then the other is affected
Sometimes however both lungs
are engorged and then of course
a fatal suffocation occurs Especially 
is this the case in pneum. notha
vide Good
Case in which death occurred in an hour
another in 3 hours Such cases
hardly deserve the name of pneumonitis
(inc. inf.) but no definite line can
be drawn between them.
The older writers speak of termination 
in abscesses or gangrene
the matter is disputed.
The truth is a regular circumscribed
cavity containing pus is not found
Proper abscesses occur from tubercles
Occasionally a gangrenous abscess occurs
In such cases we have cavernous



rhoncus
By careful medication & good
nursing, resolution may generally be
brought bout this may occur in 
either of the three stages 
Resolution is effected sometimes effected
in a few hours days and week may 
be required
Stethoscope says all well frequently 
when resolution has commenced from hepatization,
when the general symptoms 
show no mitigation first we hear
crepitation etc. etc.
Resolutions of purulent infiltration
Case related pulse slower than it
ought to be owing to cerebral aff. coma etc.
Rx tinct. sang. zi tinct. cinch. comp.
z8 tablespoonful every ½ hour
In the winter of 1831 & 2 we had
pneumonitis oedematosa In the previous winter
we had a pneumonitis which afforded no stethoscopic
sign the disease was rheumatic & yielded 
to actaea alone. There were all the ordinary 
appearances and progress of pneumonitis, viz
diff. resp. bloody expect. etc. 


In the pneumonitis of 31 & 2 we had
no crepitous rhonchus but a sub crepitous rh.
yet the disease went through the 
regular stages and there was even an
uncommon tendency to suppuration. Some
cases however were mere oedema of the lungs
This according to Lacunec is very rarely 
an idiopathic disease It commonly occurs
as a hydropic. disease of cachectic
habits. Good knew but little of it
he thought it could not be distinguished from 
hydrops thoracis It can readily be distinguished
however by the stethoscope
Dr Hooker thinks the disease has often 
been overlooked. When edema of the lung
has been found after death, it has too 
exclusively been attributed to effusion just
before death. To be sure the effusion
is liable to shift or disappear suddenly 
but we find the same thing in 
edema of the limbs. Within the last 18 mo.
we have had such cases of shifting from 
the limbs thence to the head thence to 
the lungs etc.


Dr Hooker thinks that ½ of our fatal
cases of disease terminated in hydrocephalus
Instead of 30 or 40 according to the bills
of mortality, he thinks we may say at least
130. The intellect was not in general materially 
affected
[Lae???]’s account of edema of the lungs
is not a good one. The pathog. signs are
progressive dullness upon percussion & 
sub crepitous rhoncus His subcrepit. rho is
rather a super crepitous rho caused by fluid in large bronchiae
in [illegible] cases.
Haemoptysis
Called also pulmonary apoplexy IT
is an effusion of blood into the substance
Stethoscope shows a crepitus
rhon
Hydrops thoracis
Good says the only decisive indication
is a fluctuation but this can scarcely 
ever be observed
Percussion gives a dull sound
Haegophony exists in the first stage q.v. In the advanced
stages no respiration can be observed 
A very rare idiopathic disease


Empyema detected
in a similar manner
Pleuritis
Acute pain difficulty of lying on
the affected side (yet when adhesions exist
the weight of the lung renders it more
painful to lie on the opposite side
There is bloody sputum & cough
But effusion of serum generally takes
place & then we have haegiophony
Frequently the effusion becomes concrete
& tough and hard, perhaps cartilaginous
Laennec has observed a contraction of
that side of the chest (in the young the
lung of that side not growing so fast)
Pleuorpneumitis
Pleuralgia a rheumatic aff. of
the intercostal muscles relieved by 
opium, actaea or some narcotic
Stethoscope shows no signs of pneumonitis
hence valuable, negatively 


Emphysema
1st Pulmonary or vesicular emphys. 2nd
Interlobular emph.
The first is an effusion which causes
larger & larger globules
The second generally gives oblong or
triangular collections of air
The crackling (crepitant) rhonchus
indicates this especially the 2nd
Caused generally some obstruction 
of one or more of the bronchial vessels
The case of the child who had never spoken 
loud (in Broadway) exhibited emphysema
of the lungs. Tumours & croup
have the same effect. Hepatization or
tubercular degeneration or some [illegible]
of a part of the lungs may cause an emphysema 
of other portions. This is one of the most
common causes. Yet the p.m. ex. shows
emphysema we do not necessarily find
that the stethoscope has given indication
Symptoms are hurried and laboured
respiration lips livid, from 
want of decarbonization of the blood
Easily out of breath etc.


Stethoscopic signs of it are obscure the
respiratory sound is said to be feebler
The sound of percussion is clearer however
Little has been known of this disease until 
of late years
Pneumo thorax
Pneumato thorax might be called
emphysema thoracis. Not distinctly 
described by Good It is a collection 
of air in the cavity of the pleura 
First memoir on the subject by [Itard]
1803? May be caused by a 
wound of the thorax by a communication
between the bronchiae & the cavity of the
pleura by putrefaction and extrication 
of gas
More or less inf. will be apt
to be caused.
Percussion gives a remarkably clear sound 
steth. gives not resp. sound on the affected
side on the opposite side the respiratory
sound will be clearer than natural
If there is a communication between the 


cavity of the pleura & the bronchiae we
have amphoric resonance & occasionally 
upon coughing or speaking, the metallic tinkling
This affection is commonly complicated
with presence of fluid. Inflammation 
caused by the air will be apt to produce
fluid. In this variety we may make
use of what is called the Hippocratic succession
Concretions of the lungs
We find them bony or cartilaginous or chalky
in p.m. exam. especially in old cases
of phthisis. Laennec thinks they are
tubercles which have been cured.
Black pulmonary matter upon 
the surface is found more abundantly 
after pulmonary diseases and phthisis
but found more or less where there had been
no pulmonary disease. Laennec thinks
it more abundant in blacksmiths
Bex. dyspnoea want investigating.
Good’s dyspn. includes 4 or 5
distinct diseases. Sometimes we have 


a sibilant rhoncus. Sometimes it
is caused by emphysema of the lungs.
Phthisis
most of the recent French writers restrict
the term to tubercular phthisis
Cullen considered it a sequel of haemoptysis.
but the latter might with
more propriety be considered a sequel
of the former. Haemoptysis rarely
leads to phthisis.
Good has P.  catarrhiulis P apostematosa
& P. tubercularis. Apostemes,
with excavations, very rarely 
exist, in the lungs, as has now been 
ascertained
P.m. ex. in Paris show that ulceration 
of the bronchial membrane is
(almost) always connected with tubercles
the question is which is the primary 
disease. The French think the 
latter is the primary disease
Of tubercular phthisis
Tubercles are small tumours (tuber)


They commence greyish bout the size
of a grain of mustard (miliary tubercles)
Colour deeper in adults
In examinations we may find not more
than a dozen tubercles or thousands 
Tubercles are found also in other parts
of the body particularly upon the intestines
and in the liver, spleen. etc.
When they become large they first soften
internally then discharge. “Crude
tubercle” collections of non-discharging
tubercles
Tubercles may exist at a very
early age 2 or 3 years. They may be
inherited in infancy. Case of a child of 
3 months. They have been found in 
the fetus 
No one symptom is constantly 
met with in phthisis. Cough, expectoration,
pain etc. may be absent. It is 
doubtful whether the tubercles and ulcerations 
of themselves cause pain.
In this disease the physical signs
generally come too late.


When suppuration and excavation occur
we have mucous rhonchus cavernous
rhonchus and pectoriloquy q.v.
Curability Those who make
the least pretensions do as well as any 
The disease may mitigate and apparently 
cease in summer & revive again
in the winter
It is difficult to get leave to 
examine the bodies of drunkards
There is no doubt that confirmed
phthisis is occasionally cured as shown 
by steth. & p.m. examinations
Affections of the heart
No part of the body is subject to a greater
variety of affections Corvisart
produced the first valuable work
An enlarged heart will be indicated 
by percussion though the pericardium distended with water will give
the same sound
Manual examination is better
Place your hand over the heart & judge
of the regularity etc.


But the steth. is still better & also
shows new phenom 
1st sounds
1 impulse or shock
3d extent of the chest over which the pulsations extend
4th rhythm
1st By the stethoscope we hear two 
sounds first duller & longer then a shorter
& sharper. The former is isochronous 
with the pulse
2nd an impulse on the ear is felt at the
time of the first sound. In children & 
thin chested persons the second may have
a slight impulse
3d extent generally small In fat persons
we have not more than an inch of extent
the extent is increased by high
living etc. & vice versa
4th rhythm i.e. order of succession now
receives much attention cannot be 
thoroughly explained as to its causes. Still
valuable indications may result from it
Laennec says the first sound is produced
by the systole of the ventricles the second


when the auricles contract then a 
period of repose so that ¼ of the
time is occupied by a state of repose
In 1828 Mr. Turner maintained that
the auricles contracted first and was
followed so immediately by that of the
ventricles so that both together cause the
first long dull sound Mr. Turner
also thinks the second sound made by the
beating of the heart (in a diastole) again
inst. the pericardium. Many other
hypotheses have been advanced since
We must conclude Laennec’s hypothesis
to be unfounded. A later hypothesis
supposed the dilation caused the sounds
Another supposes the sound caused 
by the striking together of the sides of the 
ventricles but then the ventricles are
never empty
[Refutation] of Corrigan and Haycraft
Dr Hope has published lately a large octavo
volume on this subject.
1st the auricle contracts so immediately
before the ventricles as to make but one 
sound


2nd the extent of the auricular contraction 
is very small & incomplete
3d the ventricular contraction is the cause
of the impulse & coincides with the pulse
at the wrist
4th the impulse is made by the apex of 
the heart
5th the ventricular
6th the ventricles do not [illegible] themselves
7th
8 after the diastole the ventricles remain
apparen
1st sound caused by systol 2nd by the
diastole of the ventricle
Rhythm 1st auric. syst. 2nd ventric.
sys
3d v. [illegible]
4 v. repose towards the termination of
which auricles begin to contract
Dr Hope attributes the sound to the
agitation of the blood in the ventricles
Dr Hope attributes one sound to the
active dilatation of the heart [illegible]
or elastic



1st mot. auric systole
2nd immediately followed by ventricular
systole & 1st sound
Dr H. thinks the 1st sound produced
by the closure of the auricular vent. valves
& the second by those of the arteries
The sudden arrest of the regurgitation
causes the sounds
The sound occurs at the times of 
the closure of the valves
[illegible] of the sound is such as
might be expected from the striking together
of the valves & the sudden check
of the regurgitation hence the second 
sound is like the lapping of a dog or 
the snapping of a whip
The second sound (by the auric. vent. valv.)
is more gradual as it should be also
the sound is more dull
Dr Hook thinks the first sound
is caused by more than one circumstance
The impulse also is caused (he thinks) by 


the apex of the heart and also by an internal
abrupt succussion caused probably 
by the auricular vent. valves and the
reaction of the chordae tendinae colum.
[illegible] etc. upon the whole mass of the
arterial valve
Dr H. thinks Dr Hope’s account
of the order of the action of the heart is the
tone one
Hence the first sound 
is heard lower down than the first opposite
the apex of the heart the sound
being conducted by the dense contracting
ventricle & coinciding with the impulse
The first sound
1st Hypertrophy of the heart muscle
larger than natural contracts
slower & stronger Impulse stronger less sudden sound
more prolonged less sharp because
the valves close less suddenly 


2nd Dilatation of heart muscle
thinner hence contract more
rapidly but less strongly So too 
the sounds become preternaturally 
abrupt, loud & sharp
In a high degree of hypertrophy
the sound is scarcely perceptible
3d Contraction of the orifices
of the heart
We have the bellows the rasp
serrate & thin whizzing murmurs all varieties
of the same Caused generally by 
diminution of size of cardiac orifices
but often by regurgitations (perhaps
more frequently The murmur 
may exist before death for months & yet
p.m. ex. show no disease of heart
It is observed that in arteries
It is heard in the arteries of the placenta
Slight derangement however may exist about
the valves and not be detected by 
dissection e.g. relaxation of the chord. tend.
It is found that excessive depletion causes
the bellows murmur from this cause or 
a similar one. Dilatation of the heart will 


Cause bellows murmur produced by 
imperfect closure of valves
A murmur rarely supercedes
the second sound the arterial valves
are rarely completely ossified
Simple dilatation of heart
Walls thin heart weakened in action
palpitation but (according to the general law) acts
quicker pulse quick feeble respiration
labored edema of extremities livid
& pale & leaden skin these are affections 
symptomatic of the general affection
If the left cavities are dilated
& the right healthy the lungs are
oppressed edema etc.
If the right sides of heart are diluted
the left continuing healthy, we have edema
of extremities congestion in grain etc.
a pathogn. [symptom] is swelling of jugular
veins. (N.B. pulsation of jugular
is produced by imperfection of the [illegible]
valves manual examination 


shows a dilated heart but not clearly 
which side is affected
Auscultat. gives a feebler impulse & shorter
sharper & clearer sound the extent
of the sounds is increased even extending
into clavicular & axillary & acromial
region
Generally both sides are diluted
but commonly one side more than another
The early stages of dilat. can scarcely
be distinguished from nervous palpit. of
[illegible] etc. (apply stethoscope 
frequently to prevent patients being
alarmed and excited by it N.B. In fevers
steth. useful in conjunction with 
feeling pulse, gives more certain signs)
The bellows murmur is generally 
heard caused by imperfect closure
of ariculo-ventricular valves
Now laennec would lead the [illegible]
to suppose that increased clearness of 
sound attends dilatation But when
the dilat. is excessive the sound is obscured
or superseded by the rushing bellows
murmur



The stethoscope gives no signs of 
dilatation of the auricles (Laennec
was mistaken his work on the lings
is nearly a perfect one)
Hypertrophy
morbid increase of muscular
substance of heart with thickening of its
parietes Excessive growth
weight increased
1st [Chicentric], 2nd Eccentric & 3d
simple hypert.
1st Case the grown incroaches 
on the cavities & diminishes the cavity
Simple is growth outwards merely 
Excentric is dilated & grows thickened outwards
also (vide Bertin) Corvisart
was acquainted only with the last
The two former occur more frequently 
in children & are frequently
congenital (specimen exhibited of
a congenital concentric hypertrophy N.B.
the heart was larger than the childs fist
larger than natural walls enormously 
thick cavity almost obliterated)


N.B open foramen ovale is given
as a cause of such cases then probably 
the hypertrophy is the principal evil.
The for. ovale is generally open for 
3 weeks after birth
The child above was restless from 
birth hemorrhage from umbilical
arteries (caused by strong power of heart)
palpitation very strong great
effusion into cavity of pleura
(hemorrhagic pleurisy) Child
moaned all the while put its hand
to its head etc. right side of heart 
thicker hence effusions in lungs
Tendency to inflammation found
all over the body
The apoplectic habit especially 
predisposed to hypertrophy but
sometimes the sanguine & robust
have dilatation & the feeble & cachectic
have hypertrophy
Pulse in hypertrophy strong
& slow (strength of heart without 


quickness as above) If right side
is hypertrophied the lungs are affected
& [illegible] left is the head will be
affected with serous apoplexy.
Stethoscope gives a slow strong
dull prolonged heavy impulse & 
sound In the left ventricle about
the 5th & 6th ribs in right
about lower part of sternum
Excentric hypert.
by no means uncommon occurs in 
adults incredible size sometimes
Dr Duncan found one weighing 32 oz.
(nat. weight is about 10 oz.) 7 inches long
& f in. broad
Stethoscopic signs are a 
union of dilat. & of simple hyper.
impulse extensive sound sharper
& duller? (more obscure in
its signs)
Polypi
Coagulated lymph questioned whether
formed before death or at death more
generally supposed that they do form before death


Notes of Prof. Knights Lectures
copied principally from Mr. Osgood’s
notes
Curvature of spine
Polypi were very remarkable last 
winter during the hydropic diathes
specimen shown extending through 
as far as the radial artery
Stethoscope to fractures
gives a more distinct & precisely 
located sound
Stethoscope in pregnancy
Gives first the pulsat. & sound of the
fetal heart & the blowing pulsation
through the placenta (a bellows murmur
of the placental arteries which is synchronous
with the pulse of the woman
Both are audible to the stethoscope & to the
ear The stethoscope is preferable from 
considerations of convenience & delicacy
[illegible] sound not heard before 3 or 4th
month Fetal heart heard [illegible] afterwards towards
the end of pregnancy Twins are predicted thus!
Bellows murmur of iliac arteries easily distinguished
Fetal heart gives a double clik and then is silent period


Fracture of clavicle
Mistake often made in supposing
that the sternal end rises, & in endeavouring
consequently to keep it down.
It is the scapular portion which requires 
to be kept in place
Dislocation of last phalanx 
of thumb
Instead of vainly endeavouring
to make sufficient extension 
bend the phalanx back almost to a 
right angle thus get one edge to 
catch upon another & then reduce by 
the lever principle
Bending of the long bones in 
children
Prof. K. has met with frequent
instances of this in children a fracture 
perhaps on the convex side symptoms
distortion with stiffness etc.
Fracture near the head of the 
long bones of children, occurring 


in a part not ossified, yields no crepitus
Amputation of the last or third 
phalanges of the fingers or toes
When swollen your knife may slip
by the joint & cut into the soft cushion
of the ultimate extremity & deceive
you be on your guard
Os femoria
The books represent the neck as 
smaller & they then account for fracture
there But both circumference
& the diameter from above downwards
is in fact greater
The body of the bones may be 
destroyed by disease and the [illegible]
remain
Tibia
When you set a broken tibia bear in 
mind the natural lateral curvature
of its anterior edge
Ankle joint
Dislocation backwards and forwards on 
rare occurrence. [illegible] inw. [illegible] with 


fract. of int. [mall.] Disloc. outwards
generally accompanied with fract. of fib.
1/3 or ¼ [illegible] way upwards superior fragment
of fib. retaining its nat. position
Tarsus & metatarsus
Tarsal bones very rarely dislocated
except in the practice of nat. bone set.
Prof. K. has been informed on good
authority of one or two instances
In amput. foot at tarsus bear in 
mind the uneven line caused by the projection
backward of the second met. bone
or Near the articulation of the
fibula with the astralagus, and a little 
before if three is a small cavity between
the anterior ends of the astralagus
and os calcis which can be readily felt
through the integument This often almost 
[illegible] filled up in sprains, & often
mistaken for a dislocation of a tarsal bone
In amputating at the tarsus the
land marks are the projection of the 
internal cuneiform bone & the projection of the 
metat. bone of lit. toe The former has 


a bursa on its top which is liable to 
effusion and swelling from pressure as
of a boot cured by abstracting the pressure.
The project of metatarsal
bone of lit. toe often mistaken by 
patients for something wrong
Sprains of ankle joint
They are affections of the tendons of the librating muscles
& the affection is either an injury 
of the tendons themselves or a displacement
from the sheath of those of the
external libration muscles
Calf of the leg
Soreness, long continued, & lameness
caused probably by separation of muscular
fibres from tend. of [gastro???]
It has been attributed injury often [illegible]
of plantaris
Wrist hand fingers
Pus formed under the brachial aponeurosis
may point in the palm of the 
hand. The tendons of the fingers are


at first in one common sheath &
then the separate in order to go to the
several fingers. In labouring men
these separate tendons sometimes adhere
to their sheaths causing a curvation and
stiffness of the fingers and a prominence
under the skin when the finger is bent
tendon feeling rounder and harder 
than natural This is not mentioned in 
the books
Ear diseases of 
Always examine for cerumen in cases
of deafness, by throwing the suns rays
strongly into the ear. Deafness from 
this cause occurs oftenest in elderly 
people. The wax gradually accumulates,
but deafness does not occur
until the closure is complete
Sometimes there is a thin coating of cerumen 
over the membrane tymp. destroying 
the [shining] appearance which it 
shd present when healthy. The lining
cuticle of the ext. auditory canal, instead
of secreting cerumen may secrete 


pus without abrasion of surface
When the eustachian tube is closed
puncture the memb. tymp. in the 
lower and anterior part to avoid the
small bones not piercing so [illegible]
a quarter of an inch through
Insects in the ear will be destroyed
by tinct. camphor. Foreign bodies
may generally be removed by a 
scoop. Case a small stone closely 
fitting the cavity Col. Blake pushed
through a tube a piece of cotton dipped
in any alcoholic solution of shellac
when the alc. had evaporated 
the stone was readily drawn out by 
means of the fibres of cotton
Diseases of internal ear Ulceration 
may take place in the muc.
mem. of this part. If the small bones
are destroyed hearing will remain but 
if the labyrinth is destroyed, hearing is lost.’



Puncta Sachrymalia
The course through the superior [illegible]
is the most direct Exceedingly difficult
to introduce a probe through
the puncta half the time we do not 
pass the probe into the sac when we
think we do
Couching
Prof. Knight prefers the posterior
operation for depression 
The [lens] is always depressed
into the vitreous humour there is not 
room in the posterior chamber of the aqueous
humour. Be sure to have the
needle far enough behind to avoid
the ciliary body
Laceration of capsule of [lens]
is performed anteriorly & the aqueous
humours entering though the opening
made by laceration, absorbs
the lens


Foreign bodies in the nose
are generally in the lower sometimes
in the middle meatus
Tonsils or glandulae amygdalae
are between the palate half arches
are often enlarged Their [illegible]
orifices are occasionally filled
with a semi-purulent, or a curdy
matter which may give their surface
the appearance of an ulcerated
one.
Throat foreign bodies in 
Thee when in the aesophagus are either
at its upper extremity in the root of
half cul de sac formed by embrace
of the larynx by the lower end
of the pharynx & then they may be 
swept out by the finger & they 
are at the cardiac orifice of the 
stomach In the former case they 
may often be seen & if we introduce the
finger we must be careful not to mistake
the projecting horns of the os hyoides 
for foreign bodies


Prof. K. has known an ulcer to eat
through the fold of membrane which 
extends literally on both sides of the
epiglottis, so that the passage to the 
larynx could not be protected
death ensued
Fraenum Linguae
The gone is more bound down by 
this fold of the muc. mem. in some individuals
than in others. If it necessary
to divide it, let the incision be
made near the floor of the mouth, to avoid
the [illegible] arteries The small glandular
bodies seen under the membrane are only parts of the sublingual gland
Uvula
when enlarged may occasion a dangerous 
chronic cough. Its removal [shortening] has never
been followed by worse consequences
than a slight subsequent hoarseness


Venesection
The basilic vein is apt to be a rolling
vein. The cephalic is apt to be 
small and deep seated. The median
is most superficial &most
firmly fixed. In order to 
be sure of avoiding the brachial artery
feel for it. The position of the superficial nerve 
we cannot calculate on and no 
one is to blame for wounding it. Prof.
I is incredulous about the injurious consequences 
of wounding it. Avoid 
pricking the tendinous expansion of
the biceps infl. there will be troublesome
Flexors and Extensors
The extensors are the strongest but
the flexors of the legs are the shortest
so that they are completely at rest
only when the limbs are flexed because
we like and sit so much



Bursae mucosae
There is one on the anterior surface
of the patella & one on the olecranon.
There is one under the 
tendon of the rectus femoris which 
always communicates with the
knee joint. There is a corresponding
one below the joint which sometimes
is separate from it
Hip joint
There sometimes occurs after a fall 
or other injury an utter [illegible] of
this joint, with violent pain and 
soreness & requiring many weeks for 
recovery the cause of which is unknown
(acute infl. of Prof Hubbard?)
Some have thought this effect caused 
by bruise of synov. memb. cart. etc.
or by fract. without displacement
Prof. K. has had 2 cases 



Curvature of Spine
First symptom may be a slipping
of the [illegible] from the shoulder
or a projection of the lower angle
of one of the scapulae, mistaken for 
a tumour and sometimes poulticed
etc. for a long time one hip 
may project
The first curve causes a 
second compensating curve, to preserve
the balance of the body.
Examine for curvatures 
by means of a string stretched along 
the spinous processes. The place of the original
curve will generally be [illegible]
indicated
by tenderness or pressure
Cure by strengthening the muscles by 
exercise
Spina bifida
Congenita It has been proposed to 
puncture the tumour this may be
done by a small orifice but a fatal
infl. may ensue. If the tumour
communicates with the brain, pressure
on it will produce symptoms 
of pressure on the brain



Circumflex arteries
In opening [illegible] abscesses about the knee
or elbow joint you are very liable
to wound some one of the numerous
circumflex or recurrent branch hence
make a free incision that you may 
be able to tie an artery if necessary
Arteriotomy
is performed on the temporal art.
[Arterio] feel under the finger much 
larger and nearer the surface than 
they really are. The artery should
not be completely divided. It is 
different to hit it longitudinally
hence & make the incision 
obliquely
Local depletion
May be serviceable in local infl.
Case wound of the hand. The 
divided artery had regular periodical 
[illegible] of bleeding for a while
and then ceasing for a few hours. This
proves an independent local action 


Mem. Obtain the minutes of 
Prof. Knight’s case of partial dislocation
of a cervical vertebra








E. D North
snuff taker !!!!
5
obstetrics
& 
Diseases of women










































5
Materia
Medica
(rear)
Diseases of women.
obs (front)












Lecture 2nd
Pelvis 1st The sacrum is nearly 
equilabral about 4 or 5 inches in each side
In the female pelvis the concavity of the sacrum
(perpendicularly) is about ¾ of an inch
deep The last vertebra inclines backwards
from the top of the sacrum, which is called 
the promontory of the pelvis.
The coccyx is moveable & curves
much forwards
The Ilius forms by [their] [illegible]
the great basin of the pelvis properly a part
of the abdomen. There are two anterior & 
two posterior spinous processes. The top of 
the pelvis is bounded y the linea ileo pectinea
The ischium has an anterior
& a posterior spine from the latter of which 
proceeds the internal [sacro??] ischeatic ligaments of each side
The pubis is the smallest bone
The ischium & pubis surround the foramen ovale 
Ligaments 1st sacro ischiatic
internal from the spine of the ischum 2nd sacro
ischiatic external from the tuberosity of the
ischium to 


3d Sacro iliac ligaments
Dimensions of the pelvis 1st the superior
strait at the line ileopectinea has
its [antero] posterior from the promontory of 
the sacrum to the symphisis, is 4 ½ or 5 in.
The transverse, at right angles to this, is 4 ¼ or
4 ½ in. The oblique, from the sacro iliac
symphisis to the acetabulum a little shorter
than the last
The inferior strait has its diameters
not parallel to those of the superior
The oblique are measured by Prof [Burns]
from the middle of the sacro ischiatic ligaments
to the junction of the rami of the ischia
& pubes


The axes of the strait
That of the superior strait is an
imaginary line from the umbilicus to about the
one third of the sacrum
That of the inferior strait
It has been thought that at about
the period of labour, the symphisis
pubis 
Deformed pelvises
Every variation of shape does not constitute a
deformity
1st The pelvis may be unnaturally
large in all its dimensions and this is a 
most deformity The uterus remains in th e
pelvis, pressing upon the rectum & bladder so 
as often to confine the patient to her bed during’
the whole period of gestation. The delivery 
also is too speedy & prolapsus uteri, fluor albus
etc. follows delivery. Case of this kind 
M.S.


2 Alterations in the shape of the pelvis
Occur always from rickets, [malacast??] etc
All the cases, almost, which occur in this
country are foreign women. All which Prof. B.
has seen have been Irish women.
The diameter altered is
almost always the antero posterior diameter.
It is laid down as a rule by 
European
The cavity of the pelvis may 
be badly shaped. The sacrum may be 
too straight. It may also be too curved
& throw the point of the coccyx too far forward
The coccyx also may be anchylosed. Bony 
tumours also may exist
Instruments have been
invented for measuring the pelvis. Those
which have to be introduced within the pelvis
are objectionable especially in [illegible]


Baudelacque’s callipers are very accurate
allowing 3 inches for the soft parts & adding
2 lines for a fleshy persons
The hand & finger however
are the best instruments, at the period of labour.
If the finger will not reach the 
promontory of the sacrum we may be
sure that the antero posterior diameter is sufficiently 
large. If the whole hand can be 
introduced
Diameter of the had. 
The long diam. is 5 in. from the occiput
to the chin. The longitudinal 4 ¼ in.  from the 
forehead to the occiput. The perpendicular
is the shortest These diameters may be diminished
5 or 6 lines, not
The neck cannot be twisted
more than a quarter of a [circle]


External organs
Immediately below the clitoris


Menstruation
Commences at first after having been preceded
by general disturbance of the health pains
in the back, hips & loins, disturbance of the bowels
etc. perhaps hysterical symptoms During
the continuance (about 4 days) of the evacuation 
a pale circle surrounds the eyes
It is ascertained from the examination of 
cases of procidentia that the discharge is from 
the uterus & not from the vagina
In this country menstruation commences
on an average at the age of from 14 to 16
The earlier the commencement the earlier the
cessation.
Conception
many theories 1st that the semen is carried
into the fallopian tubes 2nd


Changes produced by conception
The cavity of the uterus enlarges and soon 
a membrane forms on its inner surface
The ovum contained in two membranes passes
down the fallopian tubes and pushes out this
deciduous membrane


The fetus first appears in the ovum as a 
mucilaginous cloud
At the end of 6 weeks the fetus is about
½ an inch long and shaped like a crescent 
or bean. At two months the fetus is 2 inches
long about the size of a bean At 3 months it is 4 or 5 inches 
long external parts perfectly developed the
genitals being large and those of the [illegible]
from their size resembling those of the male
At 6 months the hair is visible the motions 
are felt in the abdomen the relative length
middle near the body of sternum weight 2 pounds
of the head and upper part of the body is greater 
At 7 mo. middle half way between navel & stomach
At 8 mo. skin is firmer and whiter, and hairs are
visible on it middle nearer the navel than
the sternum length 16 in. weight 4 or 5 pounds
gall bladder contains bile etc. etc.
At 9 mo. middle at the navel length
19 in. weight upon an average 8 lb. with
us but in France between 6 & 7 lb. Length of
the male with us 23 in. of the fem. 19 ¾ in.
The nourishment of the fetus is difficult
to explain. Probably it is like a vegetable
from the ovum in the first place.
The most prevalent opinion at
the present day is that the fetus is nourished 



from the blood after it has undergone some
change in the placenta. Some facts seem
to prove that the liver changes the blood & 
gives rise to a peculiar secretion albuminous.
Circulation of the Fetus
The most probable opinion at present is
that the fetal blood is oxygenized in the
lungs of the mother, is taken up from the 
placenta by the umbilical veins and carried
under the liver (principally) into the vena 
cava through the single heart back by 
the umbilical artery into the placenta 
again 


Signs of conception and 
pregnancy
Just after conception the
features become sharpened, the eyes are
surrounded by a dark circle The complexion 
pale. The most important sign is
the cessation of the menses but when the woman
has become pregnant while suckling a child, the
menses not having regularly returned, we cannot
reckon from that period, but women in that
case reckon the rather from the motion of the 
child which first occurs between the fourth 
and fifth month The areola of the nipple
is dark Pricking
sensations are experienced in the breasts
Morning sickness occurs and continues
until with about 2 mo. of delivery
By the fourth month the uterus
projects above the pubis is more easily felt in 
a lean subject By the 6th mo. the fundus
will be at the navel By the 7th about an inch
above and the navel protrudes
Usually by the 6th month the
motion of the child can be felt if the hand 
is first dipped in cold water.


By the fourth month the neck of the 
uterus is softer and shorter
The size of the uterus is judged
of by placing the left forefinger
the 
at upper & anterior part of the vagina
& pressing with the right upon 
the fundus just above the pubes you will feel
the pressure of one finger upon the other the
woman must be in a standing posture
Prof. B. thinks gestation may 
be prolonged beyond the ninth month & 
that he has had considerable evidence of 
the fact.
Case related in which parturition
was fully expected much alarm
was excited at its not coming on
& finally it was found that all the signs
of pregnancy which had existed, proceeded
from an enlarged uterus which 
was reduced by proper remedies.


Natural Labour is that where
the face is to the sacrum and the occiput to the
pubes where the [labour] is over within 24 h.
is where it terminates with safety to the mother
and child & the [secundines] come away well
4 stages are distinguished 1t os uteri is
dilated the membranes are protruded
2nd the head turns into the hollow
of the sacrum & presents at the ext. orif.
3d the child is delivered
4 the secondines come away
In the 1st stage we observe 1st the pains 
commence in the back & loins & pass through to  
the pubis in some cases about the loins & 
thighs first Sometimes very irregular [illegible] endeavoring
These first pains are short
not lasing more than about a minute
After the os uteri is dilated to 
about the size of a crown the second stage
commences the pains from being short & cutting
are protracted, with a sense of burning 
down violent skin hot & dry sense 
of inclination to go to stool from the 
pressure of the uterus on the rectum. During
this period the membranes are ruptured


In the third stage the perinaeum bulges
out the woman demands to get up for 
a stool must not be indulged
it is a delusive sensation. The perinaeum
becomes four or five inches broad
Prof. B. puts his right hand upon 
the occiput, & his left upon the perinaeum
he judges of the degree of pressure by 
the fingers of the left hand & resists with 
the right upon the occiput of the child.
The fourchette is [illegible] in the first
labour do not mistake this for ruptures
of perinaeum Vomiting occurs
frequently and is serviceable to the
facility of the labour
Gathering of the waters
This term is applied to the bulging tumour
of the water on the membranes which 
increases in protrusion at every pain 
& appears as if more water was collecting


False pains
Can be distinguished with certainty only 
by the effect of the pains upon the neck of the
uterus the pains produce no pressure upon 
the neck of the uterus & no dilutation of the
os tineae sometimes you can pass your 
finger into the uterus and feel that the
membranes do not become tense by the 
pains.
Often these false pains appear to be
caused by excessive motion of the
child enquire about this in [illegible] labour
the child has little or no motion 
To relieve these false pains after bleeding give opium. The labour
may be a month or two distant.
It is of importance to understand
the progress of a nat. lab. thoroughly 
Examine during a pain in the intervals
the woman may sit or walk about
Keep up her spirits. Make no certain 
prognostic as to the time or at least
fix a distant time so that the end of the labour may 
fall within it. We are often much 
urged to interfere keep out of the room
on this account Suffer no to one attempt to 


bring on a labour as it is [illegible]
Leave the woman often to allow
her an opportunity to pass water. During
the first stage let her be dressed for labour.
Dress the woman in a 
loose dress with her linen tuked up  
under her arms
Prepare the bed by first making it 
up as usual prepare the lower
part by coverings to protect it
Let the woman lie on her left side
with the knees bent, her feet against 
the bed post her head & shoulders raised by pillows tie a handkerchief or
towel around the other bed post for
the woman to take hold of Some
condemn these efforts of the woman, but 
Prof. B. is satisfied of the advantage of them
The only assistance rendered shd be pressure 
on the back
The French lay the wom. on 
the back. Some women prefer a sitting
posture. It is often advisable to change
the posture for particular circumstances
Conduct the choice of the patient 


If we wish to rupture the membranes it will generally be sufficient to press
hard on the membranes with the end of the
finger the membranes will rupture themselves.
If necessary scratch the membrane
with the nail. If the labour
is very rapid rupture the membranes
yourself, that the water and child
may not both be delivered at once
and empty the uterus too suddenly 
Rather hinder than hasten after the 
passage of the head one pain will expel
the shoulders and another the hips 
Generally as soon as the head is 
born and always when the body 
is born, the child cries. First feel for the
pulsation of the cord. If the child does
not breathe (when the air is freely admitted)
blow on its face dash cold water or spirit
on the face & chest wipe out the mouth
first with a dry & then with a moist rag
close the nostrils of the child with the fingers
& then blow gently into its mouth & if necessary
press gently upon the thorax to facilitate
expiration as this may be continued for 


some time keeping the body war
with hot flannels, all the while Apply 
your hand or better your ear to the region 
of the child’s heart
At first the respiration may be very 
feeble & perhaps at first with long interruptions.
Other means are frictions
ammonia etc. to the nostrils & to the 
surface of the body
Some children, after you have
succeeded, have not stamina enough
to support life. Dropsical effusions 
in the thorax may prevent respiration
& the life kept up in such cases by 
the [illegible], for half an hour Prof. B.
has met with such cases but only in children
of hard drinkers
Sometimes a child is apoplectic
from long detention of its head in the
passage in this case, bleed from
the cord ½ oz to 1 oz milking out the blood
inflate the lungs also etc.



The cord as soon as respiration
is established not waiting till the pulsation
ceases in the [illegible] we might have to 
wait ½ an hour or more
Tie with any sort of a string there
is no danger of cutting the vessels with a small
one A piece of wide tape is convenient
Tie tightly or the ligature may become loose
from the shrinking of the [illegible] Sometimes
the arteries are so firm that a ligature will 
not prevent hem. unless the arteries
are pulled out and tied separately.
It is thought by some necessary 
to tie both ends of the [illegible] but it is better
to allow the vessels of the placenta to 
bleed & thus diminish the size of the placenta
except [illegible] cases
As soon as the child is born
pass your hand over the abdomen if it
is firm and hard up to the scrob. cord.
a twin is within if the uterus is contracted
to a ball above the pubes there is merely 
the afterbirth. Generally the pains
commence again in about 8 or 10 min.
When the edge of the placenta arrives


at the vulva take hold of it, twist
it so as to make a roll of the membranes
& thus no part will be torn
off and left.
Next attend to the comfort
of the woman. If not too feeble let
her be immediately removed to the bed
she is to occupy
Place several folds of cloth
upon the abd. & pin a towel around
to give support, to prevent relaxation 
of the uterus & hemorrhage, & for the
comfort of the patient 
The pat. will now be very 
comfortable & happy, but soon come
on the afterpains by which the coagula
of blood are expelled from the uterus
But few women escape without after pains
those who have already had children
are more liable to them
Ergot administered during the labour
prevents or diminishes the afterpains. Prof. B.
has often administered it with this intention only 
Generally ginger & spts applied
vol. lim. zj ol. or zfs
also a poultice in a pillow case of ar.


herbs & bran
These pains are generally much
increased when the child is put to the breast
Until the 5th or safer still, until 
the 9th day, when the lochia terminate,
keep the pat. on panada, arrow root etc.
not giving cordials, in the old fashioned
way
Let the child suck immediately 
to draw off the colostrum to prevent swelling
& infl. of the breast, & retraction of
the nipple, which prevent it from sucking.
The child too needs the purgation
& is apt to lose the instinct for 
sucking
By the third day the lochia
should be washed off from the external
parts and a gentle purgative castor
oil or magnesia shd be given. The 
bladder must be attended to if necessary
apply a fomentation of onions, or if such
things fail introduce a catheter


The lochia comes on about the 3d cease about the 5th day
ultimately the discharge becomes of a light
pink col. The diminution of the
discharge is looked on as a good symptom
unless vary
If excessive, astringents, as port wine 
tinct. ter. jap.
Ultimately give a pill of op & ac. pl.
aa ij gr. once in an hour or two.
If this is not sufficient inject
ac. pl. & opium into the vag.
When the discharge has a cadaverous
smell, is greenish etc. wash
out the uterus with detergent injections
such as lime water & milk decoction
of oak bark etc. support the
pat.


Introduction of the Catheter
During labour the neck of the bladder 
is often elongated & you may have to 
pass the catheter directly upwards
Next attend to the Child
Be careful that the room is so warm
that the child does not take cold
Keep a cloth warmed at the fire
against the birth of the child
The body of a new born child should
be cleansed of a white unctuous substance
which resembles tar, by rubbing
with lard & wiping with a soft cloth
Then the child if vigorous may be
washed with soap and water
Others after rubbing over with lard
sprinkle with wheat flour or starch





Tie the cord by 
The belly band is a piece of flannel
passed about twice round the belly
Sometimes the child will not bear
to be dressed, from feebleness.
If the child grows cold, wrap it up in 
flannels dipped in hot spirit. And
let these children who cannot bear to be dressed,
let them be wrapped in flannel & 
kept in a warm place
If the meconium does not come
away with 12 or 14 hours, give molasses
& water, or honey and water if these
fail give a teaspoonful of bland castor
oil
Look out for retention of urine
It may arise from imperforate hymen 


or from the orifice of the urethra, either
of the male or female, being closed
up with mucus in which case introduce
a probe, a short distance
If the child must be fed give
cows milk 2 parts water 1 part sweetened
with loaf sugar or if it is required 
to be more purgative, with 
brown sugar
Presentations of head


Breach presentations
4 orders 1st back to the left side of the
mother the body rotates and the back is turned
to the [symphisis] pubis if traction is not 
used the arms lie along the body and come
out with it the face presents at the perineum
support the child’s body with your
left hand the chin issues first then 
the rest of the face and the head issues
with a jerk. The danger is in the
stoppage of the circulation of the cord.
A difficulty arises from the largest parts not
being delivered first. Another is in the
cessation of the pains which is abt to take
place
In the 2nd the right hip of the child
presents to the left acetabulum
3d the abdomen of the child presents to 
the abdomen of the mother the body turns
outward comes out obliquely but the head
comes out face upwards
#4th the revers of the 3d


During labour turn the body obliquely 
so as to bring the head into the position 
it is as in the 1st & 2nd
Presentations of the feet
1st the heel towards the pubis which 
eventually becomes the 1st hip presentation
Presentations of the knees
The knees feel harder
Generally best to bring down the feet


Diff. lab. 1at want of relaxation
febrile state do not give stimulants
2nd Want of action Ergot 1 z ergot to zii
water infusion tablespoonf. every 5 m.
The pains of ergot are distinguished by their increasing
continuance
3d too early rupture of memb. e.g. sudden
exertions as lifting sometimes probably from 
weakness of membranes. If the waters
are not drained [illegible] the labour may not
come on for weeks & be easy
Attachment of placenta over os uteri
may be suspected, from frequent & irregular
hemorrhages. Take the first opportunity
of examining while the blood is flowing
but if the flowing has ceased the finger would
break up the coagulence & perhaps bring on 
the flowing.
When the uterus is sufficiently dilated
to admit the finger the placenta may be
detected take care to distinguish it rom 
coagulated blood
When we cannot tell (early in the pregnancy 
5 or 6th month) about the case, treat as for
uterine hemorrhage apply cold in a horisontal
posture. Sugar of lead 5 or 10 grs with 1 gr. o f
opium repeated once or twice in 24 hours
It will produce no poisonous effects unless continued
for several days. If this fails inject
into vag. zii in ½ pt. of warm rain water
this is very effectual. A strong sinapism
between the shoulder is most effectual.
But the best remedy is a plug of alum Rx


a piece about 2 oz in weight made smooth
and passed up. Alum operates as a local stimulant
& the coagula of blood stop at the passage
also. It is usual to tie a piece of tape around it
When the placenta is over the os uteri, the 
labour will be ushered in by a flow of blood
]If we find the os uteri dilated or dilatable
so that we can introduce the hand we should 
immediately pass up the hand and turn
If necessary break through a part of the placenta.
When the breech of the child is
down it will plug up the passage.
But if the woman is nearly exhausted we
must restrain the hem. by proper application
The woman may die before we can turn
the vagina. A sponge is very good. A silk 
handkerchief. Prof. B has used [illegible]
introduced
in small pledgets [illegible] on to the 
tampon and given ergot allowing the tampon
to issue while pains are on and checking
it when they are off (Case related
articular mortis tampon ergot child dead
mother saved)
In other cases we may proceed
then early and afterwards turn?


Instruments
Forceps apt to be delayed too long
Prof. B. recollects no case in which they
were used too soon
Smellie’s [illegible] consisted in 
curving the [clams] The blunt hook
is now put upon the end of the handle
Place the woman left side (English)
back (French) the back generally preferable.
Empty the bladder & rectum previously.
Keep the instruments in a basin of
warm water before using them
Always apply the forceps on the sides
of the head and over the ears so as to embrace
the head in its oblique diameter over the
cheek, over the ear (occiput [illegible] diameter)
The pressure of the forceps lengthens the head
When each blade has been properly applied
the [male] part of the joint, readily enters 
the female part never lock the
forceps by means of force
Head being in 1t position
take the male blade in the left hand & introduce
it along the palm of the right (with a 


waving motion) carry the blade until 
the centre of the clam is opposite the anterior
fontanelle or the sagittal suture. If pain 
is felt, desist because you injure a [illegible] of the vagina with [illegible] be careful about [illegible]
against the ear with the end of the clam Introduce the
other blade with the other hand, in the same way
Draw & wave from side to 
side when you extract
If the head is high up, draw down,
in the first place.
Do not hurry but let the uterus do 
what it will to expel the child
The position for the use of the forceps are
1st vertex to the arch of the pubis
2 the reverse fore head to arch of pubis
3 vertex to the left foramen cot. cav. ? ovale i.e.
the head in the diameter
In this 3d position the handle of the male
blade will pass near the right thigh of
the mother & the head must make its
last turn after you apply the instruments contrive to turn the occiput 
to the arch of the pubis while you draw
4th the reverse of the 3d
7th head corresponding to the transverse


diameter of the pubis the male blade
passes under the arch of the pubis
As to the case when the forceps are to be applied
while the head is above the superior strait,
Prof. B. has never had such a case.
It will be better to turn and deliver by the
feet The cases of this kind where the forceps shd be
introduced must be very rare if any 
Shoulder presentation
Pass one hand up and push up the shoulder
sufficiently to allow the introduction of the
other hand to seize the feet
It may be necessary after the child
is dead to bring down the hip and use
the blunt hook



Locked or impacted head
Two positions sacro [illegible] or transverse
In the first case apply the forceps as before
In the second we are compelled to apply 
them over the face & occiput
As a general rule the forceps
are to be applied to head [illegible]
directs them for the pelvis. Other methods
are better however for a living child
Where there is more want of action
Prof. B. would give ergot instead of 
the forceps
But where the mother, being
vigorous & exhausted by pains & nature
has done all she can do ergot will 
not do good the forceps must be
applied
When the face presents and you 
cannot turn apply the forceps one blade
under the pubes. As you extract turn 
the face (from being transverse) so that the 
chin shall come under the pubess


Vectis
Can be used for extraction Can be used
to hasten the delivery of the face when that is
to the sacrum
The vectis is used principally for changing
the 4th [illegible] to the 1st & in face
presentations to change them to those of
the head
Breech presentations it may 
be worth while to make footling
Blunt Hook
Generally one is sufficient if not
apply both extract by a see saw 
motion
After delivery of the body the
head may be detained the pulsation of 
the cord cease the child make one or 
two convulsive heavings & will soon die
if not soon delivered. Pass the finger
up and give the head an oblique direction 
which will facilitate the delivery
Use the forceps to hasten delivery 


But in this case the vectis may be advantageously
used. Apply it over the occiput?
Foot & knee knee presenting
foot catching against the margin of the pelvis
Not worth while to confuse the memory
with all the varied presentations
IF the back of the neck side of the 
face etc. etc. push up and turn
Where the labour is very slow
& no part present we may suspect
a bad presentation. It will be necessary
to pass the hand up the vagina
& examine if we do not find a hard
body we shall have the hand foot 
belly etc. proceed to turn after
the membranes are ruptured 



Perforatory & crotchet
1st of the cases where the pelvis is too small
a case which does not often happen in this 
country
4 in. may be left to nature 3 ½ will be slow
& may be delivered alive by the forceps
A patient of Dr Hooker’s was delivered
in whom the diameter was 1 8/10 inches caused 
by [mollities] [ossium]. By means of [cephalotoma]
she was delivered & recovered, after 
having a fistula, communication between
the vag. & the neck of the bladder and a
closure of the os uteri
Make perforation with the perforator
then introduce it and break
down the brain., Then use the crotchet
It may be necessary to bring away first
each parietal bone then the frontal taking
care to keep the scalp whole


2nd where the head is unnaturally 
large from dropsy. Here we have
merely to let out the water and may 
use any instrument as a pair of scissors
Caesarean section
Dr Dewees sides with the French.
He says the perforator is more uncertain 
and is dangerous
The French forbid it when the 
child is alive
Retention of Placenta 
It is now agreed that it ought no t
to be suffered to remain
Pass your hand gradually between 
the placenta and uterus (if the placenta
continue to adhere) detaching it as you 
proceed pull upon the cord with the
other hand bring your hand away
after the placenta and not until 
you have felt the contraction of the uterus
upon your hand When Prof. B.
has had an adhering placenta he
has always found a mal-conformation 


of the placenta or walls of uterus as calculous
concretions etc.
Hemorrhage may make it necessary
to detach the placenta immediately 
Hemorrhage a week or more after
delivery
Hourglass contraction
Generally about the neck of the uterus
Prof. B. has scarcely met with a case since
he has adopted the plan of waiting scarcely 
more than ½ an hour before bringing away 
the placenta.
If it occurs pull upon the 
cord and at the same time insinuate
your hand up to the fundus of the uterus
Hemorrhage after delivery is most
apt to occur after quick, easy labours
caused by want of tonic contraction of the 
uterus
Injections of ac. pl. may be used
previous to [extracting] the placenta.
We are recom. also to inject cold 


water or a spiritous tinct. into the 
cord this is powerful & effectual
probably
We must judge of danger
from the exhaustion of the pat. not
from the quantity of blood lost ½ pt
or 1 pt. is generally lost in an ordinary 
labour. Prof. B. always
uses a plug of alum after delivery
of placenta.
Ergot. Prof. B. always uses it
but after delivery of plac. it is apt
to fail Where he has reason to expect 
hem. he gives it before the termination 
of the labour It never
fails & besides this it diminishes the 
after pains.
When life is in danger
use all your means. Carry 
a piece of alum in your hand
into the uterus. Prof. B. prefers
this to a sponge of vinegar. He has
had to wait 15 min. before the uterus
would contract in the last & 
compelled to sit an hour before the 


uterus would expel his hand.
Concealed hem. does not show
externally and uterus becomes distended
with blood. We should never
leave our patients until we have felt
the uterus firmly contracting between
the navel and pubes
Inversion of the uterus
Caused by pulling upon the cord Said also 
to take place spontaneously 
Prof. B. has seen but one or two cases
The indications are to detach the placenta 
and if possible restore the fundus
Symptoms very severe paleness, coldness
vom. conv. etc.
Place the pat. on her back and
pass up your hand and endeavour to push
back the fundus. But if the fundus
is protruded through the os uteri and
the dangerous symptoms result from the 
stricture perhaps all that it will be 
in our power to do, will be to make the
inversion complete and thus relieve the
stricture leaving a prolapsed uterus


Immediately after delivery
If the placenta does not come away 
apply friction etc. to excite contraction
Dr N.B.I. always excites contraction
if the uterus by pulling and swaying
upon the cord. He finds this perfectly 
safe. Prof. B. says it is also
# Compound pregnancy
We can sometimes guess at it in lean
women. In general we may find it 
difficult to determine, from the large
quantities
If after the birth of the first child
Labour is rather slower on account
of the large size of the uterus and that
too with the first child
Pass your hand upon the abdomen
to ascertain the existence of another child
If you find another child, conceal
it from the mother
The presentation is more apt
to be wrong in twin cases
If the pains do not come on again 
within ½ hour give ergot. You 


will then soon feel the bag of water
protruding and if you find them 
a bad presentation as of the shoulder or 
arm, you may easily turn and deliver
Hemorrhage is more apt to occur
Hence generally it will be best to give
ergot after delivery
Not unfrequently a woman has
been left, with a second child in her
uterus. Case related
Commonly the placentae are 
distinct and united merely by membranous
union. The memb. and the waters
are distinct. Sometimes however the
vessels of the two placentas [inosculate]
hence the precaution of tying both ends
of the divided cord.
The delivery of the placentae
is apt to be rather more difficult
Delivery one cord at a time


Presentation of the Cord
Sometimes a foot or a foot and a half
will protrude. These cases are 
difficult. 
It is safer to attempt to turn
and deliver [footling]. It is exceedingly 
difficult to return the cord
and keep it up. We are directed
to wind the cord on a sponge or rag
and push up. It will generally 
however soon come down again
Dr Dewees mode of using catheter
Prof. B. has not tried.
In one case Prof.  B. has
known a knot in the cord.
Deformed children
Give puzzling presentations
Oftenest the bones of the head are imperfect.
Sometimes you feel
the bone hardened brain. Feels
for the face
A more serious case is that of
hydrocephalus. Sometimes the size 
is enormous. Easily distinguished 


by the feel. The scalp protrudes
like the membranes. By pressing
also you may feel the bones of the cranium
and may even push your
finger through the sutures
The child is of course lost hence
you may as well puncture at once
with a lancet. In one case Prof.
B. let out 4 pds?
Signs of a dead child
Coldness shiverings like an ague
when the child dies Breast ceases
to swell and becomes flaccid
A secretion of milk comes on.
A weight is felt falling when the 
woman turns Cessation of mot. in child
When labour comes on, the waters
are fetid the meconium is evacuated
even in a head presentation
The scalp is flaccid, the hair comes
off etc. Yet the only certain 
sign is the want of pulsation in the cord


Rupture of uterus
By a fall, by violence in turning
or by forceps
Severe rending pain cold clammy 
sweats, sickness faintness & 
vomiting
The seat of the rupture may 
be in the fundus, side or neck.
If the child has wholly escaped
into the abdomen, the difficulty is
great. Gastrotomy seems much preferable
to delivery through the 
[illegible] Cases recorded of recovery 


Retention of menses
They may not commence until after the
20th year in the feeble and delicate
This should excite alarm as long as the
other signs of puberty are wanting
If the patient is robust let the
antiphlogistic treatment be followed.
But for the feeble, nervous, leuco-phlegmatic 
etc. prescribe exercise
shower bath warm flannel clothing
Give tonics especially chalybeate
Blood root madder ½ zs 3 times a day
Guaic. 4 z ½ z carb. sod. [illegible]
zjfs alc. 1 pt. Dewee’s tinct. vide Ellis
Blood toor ½ z sulph. zinc aj
aloes zj ft. pil. 60 2 to 3 in
24 hours regulating the dose by the
effect upon the bowels. This is the 
most useful emmenagogue
Blisters on inside of thighs size
of the hand These effected a cure in a 
pat. 27 years old whose aff. had resisted
all remedies
Cupping on inside of thigh has 


also been found beneficial
Cupping the breasts was reccommended
by the older writers
Savin has also strong emmenagogue
power
Retention may be caused
by other affections e.g. phthisis
In such cases emmenagogues shd
not be given
Suppression of menses
Menses may vary much without
ill health. The interval may be
12 or 6 weeks
The most usual cause
is the application of cold symptoms
severe pain in the head back
and loins colic etc. hysteria etc.
Hip bath anodyne injections
V.S. nervines for the hysteria
We may thus cure the immediate aff.
but the discharge will not thus be
made to return. Use of the pediluvium 
bleeding etc. just before 1 week
the next period & so [illegible] the 


discharge
Chronic suppression is to 
be treated like amenorrhea #
Periodical discharges from 
other parts may take place as a substitute
for the menstrual discharge.
This may continue for life. Case related
ulcer on ankle
Deficiency in quantity gives
rise to the same symptoms & shd be
treated like amenorrhoea
Excessive menst. not common
treat as for hemorrhage
Guaiacum is more agreeable in powder
# Carb ir. & pulv. guaic. aa zi
Sang. in powd zfs. aloes zfs. a small
teaspoonful 2 or 3 times a day


Dysmenorrhea Painful m.
very distressing pains resemble
labour pains pains
relieved by the discharge generally 
Caused by irritable uterus
Hip bath opiates hyoscyamus
diaphoretics
For permanent cure use the 
last described pills. Tinct.
guaic. Dr Dewees has cured with 
Prof B. has often failed with it
Deciduous membrane
Pains not relieved until the membrane
is thrown off. Occurs
in unmarried females also prevents
impregnation in the married
There is danger in the doses
of camphor 2 or 3 recommended 
by Dr Dewees. Prof. B. has produced
dangerous convulsions by them
Electricity has cured. repeated
for a week previous to the [illegible]
Use the emmenagogues mentioned 


Decline of menses
A critical period
Predispositioned to organic disease
are most liable to show themselves
at this period. On the other hand
others are then restored to health
In some the discharge stops suddenly 
in some it becomes profuse
or painful or irregular
Bleed 6 or 8 ounces repeatedly 
Keep the bowels open with the bloodroot
and zinc pills. Stimulant are
hardly ever admissible there is generally 
a disposition to plethora


Abortion
Delivery before 6th month especially 
between 2 & 3 & between 5 & 6. Keep 
on the look out. Drastic cath.
injuries reaching high with the hands
thus compressing the abdomen
Death of the fetus indicated by diminution
of all the signs of pregnancy
shrinking of breasts etc.
If you do not know the fetus to be
dead presume it to be alive. Quiet
laudanum etc. Ac. lead sometimes
for hemorrh.


Leucorrhea
Muco purulent discharge At first
a local dis. astring. inject. oak
bark zinc etc. Ascarides may
attend or be the cause Finally 
tonics gum ammoniae & iron cantharid. stopping for
strangury & then repeating Old cases
[illegible] [illegible] copaiba
Green & fetid discharge
Nit. silver one of the best injections
Cant. not important ([illegible])
sulph. zinc &nit. sil. also valuable
a sort of test of the efficiency of canth. is a 
thickening and opacity of the discharge
from the vagina It will not be necessary 
to keep even a light strangury 
& of course we are not to produce 
dysentery Prof. I.
Nit. sil. best inject. 3 or 4 grs. to oz.




Prolapsus uteri
One of the most common & troublesome
complaints takes place at any period
of life
Caused by relax. of vagina Uterus
kept in place almost solely by vag.
Most com. cause leucorrhea
Women with large pelvis more liable
Symptoms weight, uneasiness about 
loins etc.
Almost always accompanied with 
leucorrheal disch.
Cure at first by strengthening the
vagina, by tonics astringent, rest
recumbent posture
Treat for leucorrhea when that accompanies
Easily ascertained by examination 
or by relations of the pat. herself
Tumour recedes when pat. is on 
her back & is easily reduced
in this posture
Strong sol. of oak bark sulph.
zinc etc. after replacing the 
uterus & confining pat. to her back 


Continue with this treatment
[tonics] etc.
We are often called on when 
the diseases does not exist & we
find disease of [rectum] and vagina.
We do not find the uterus
pressing on the perinaeum
Use the pessary
Women of lax fibre & laborious women
as washerwomen are most
subject and often the disease has
made great progress before we 
are called the pessary will 
give effectual relief
This disease may be overlooked
& cause derangement of bowels
dyspepsia etc. & these complaints
only be prescribed. Prof B. has
known several cases of women confined
to the bed for years and the stomach
only prescribed to when the pessary 
has cured in a week
When the perinaeum is lacerated
the pessary cannot be used 


When the largest sized pessary is
required from extreme relaxation of 
vagina the oval pessary is best
Place the woman on the back
[enter] the pessary perpendicularly 
& after it is entered turn
Extreme prolapsus requires
a pessary with a handle [illegible]
in its place by a bandage
Pregnancy gives great inconvenience pessary not to be used
horizontal posture until the 
fundus rises
Retroversio uteri
Occurs generally between 3d and 4th mo.
fundus is in cavity of sacrum 
urine stopped in its passage
In passing up the hand we do not
find the os tincae & neck of uterus
Distinguished from polypus
which grows slowly & was gradual
in its symptoms
Growth of ovum prevented


Supposed to be caused by distention
of bladder with urine
Attempt reduction immediately
pay no attention to the
danger of producing abortion
First draw off the urine
Attempt reduction by the fingers
in the back part of the vagina
endeavouring to push up the 
fundus uteri. If we fail, place
pat. on hands & knees then introduce
a probang like inst. into the
rectum at the same time press 
with the left hand above the pubes
We may almost always succeed
Cases of failure are recorded 
[illegible] and it is recommended
to introduce a catheter & rupture
the membranes and draw off the
waters thus reducing the size of the 
uterus
Anteversio uteri
Can never be a formidable disease
& may always be remedied by change
of posture


Scrophulous enlargement of
uterus
Resembles schirrhus pain in 
neck back & loins etc.
large & less hard than true
schirrhus not extremely tender
Causes a resemblance of pregnancy
Sometimes the general health is
not much injured
Prof. B. has known a case of 
gradual enlargem. sympath action 
of breast & cessat. of menses
closely counterfeiting pregnancy
Prolapsus is very apt to 
occur with all its inconveniences
Prof. B. has known one case of 
this kind which continued 6 or 7 yrs
bed ridden unable to stand or 
walk cured by blue pill was
to bear 2 children blue pill 
is specific


Irritable uterus
The least touch cannot be borne
pat. cannot sit or stand even
lying merely palliates no relieves 
the pain. The slightest 
touch cannot be borne at the
pubes. Vagina natural os tuniae perhaps a little swollen
Rest cupping counterirr.
blisters hip bath conium & 
[illegible] narcotics blisters & 
setons (Well described by Dr
Gooch & only by him) Case related
Arsenicae
solution was the most successful
remedy & continued to be so
Diseases of ext. org. of [generatim]
phlegm. infl. of labia often occurs
to be treated with poultices frequently 
suppurates but the abscess [illegible]
[illegible] gives great pain discharges
fetid blood issues when an excis.
made 
Excoriations of labia
Soap & water ointm. of ox. zinc etc.



citrin oint. etc.
Warty excrescences not venereal
cured by nit. silver.
Dropsy of labia t pregnancy 
almost as large as the 
child’s head
Prusitus pudendi
very troublesome efflorescence
just within the labia intol. itch
may generally be cured by a wash
of nit. sil. or corr. sub.
[illegible] subj. to great elongation
but not with us
Imperforate hymen
Almost always congenital & discovered
by the nurse and will 
generally yield to pressure of a
probe If the knife is used be
very careful to keep a tent in or
a second operation will be needed 


Rupture of perinaeum
Occurs during labour
Keep the bowels open to prevent distention 
& irritation by passage of 
hardened feces It will generally 
heal up The hare lip operation 
is said always to have failed 
to cut by [palliatives]
Small vagina
may be caused by severe labours
& should be prevented after delivery
Introduce a dry sponge
after a few days a large one
Prolapsus vaginae
Astringents & a pessary


Cauliflower excrescence
Probably a fungus haematodis
vagina filled with a spongy soft tumour
bleeding at the slightest touch Disappears
at death
We cannot [illegible] by the touch
whether a tumour is malignant or benign
Hydatids are clustered vesicles
like a bunch of grapes Some call them
[illegible] They form in all parts of 
the uterus in the ovum & sometimes
the [illegible] itself produces [abortion]
It occurs only in those who have been pregnant
this last disease counterfeits pregnancy
hemorrhage comes on in an 
abortion pains resembling labour pains
etc. Treat as for hemorrh. & 
finally ergot might be useful to expel 
the hydatids
The ovaries are the seat of
scrofulous & other enlargements fecundity
is prevented
Ovarium Dropsy
Consequences in the [Graaffian] vesicle
with small tumours which gradually 
enlarge and as they enlarge, the matter 



becomes more limpid finally the
bulk may be as great as in ascites
from which it is distinguished by 
tumour more circumscribed & greater
thickness of integuments between
the liquid and your hand
Commences by pain & is near
the hip
Affects the health little except
from its bulk
Entirely out of the reach
of constitutional remedies.
Often there are several distinct
vesicles & upon making
one puncture we find the tum.
merely diminished & altered in size
Case Prof. B. drew off only 1 ½ pt
at the first tipping at the next tapping
immediately after 64 pounds
were evacuated
Remember that the coats
of the tumours are nearly as
thick as the walls of the gravid uterus
 


Cancer of uterus
Darting pains bearing down
pains in the groins General
health soon affected countenance
sallow etc.
Os uteri hardened & pressure
on it causes lancinating pain
Hard knotty tumours form about os 
uteri & in the vagina. Menstruation
irregular or substituted by 
hemorrhage.
Distinguished from scrofulous
enlargement by knottiness irregularity 
& hardness. Also cancer rarely 
comes on till after cessation of menses.
A. Cooper never saw a true
carcinoma under 36 years
Treat at first as if we had
mistaken the disease and prescribe
for scrofula. Afterwards palliate
give light nourishing food
keep bowels soluble. Attend to 
cleanliness discharge being intolerably 
fetid inject limewater
hip bath black wash. corr. sub.



3 grs to 1 pt of limewater
Nit. sil. very useful
Chloride of lime for the fetor
[restorat???] discharges by ac. lead, sul.
zinc etc. injected
Opiates
Diuretics especially those which render
the urine bland e.g. uva ursi
gaultheria etc.
Polypus of uterus
Frequent discharges which exhaust
the patient. Hence necessity of manual
examination. Where we cannot
relieve frequently returning discharges
we ought to suspect polypus.
Generally in the cavity of uterus
After it protrudes into the vagina
we can feel it. If attached to the 
neck of the uterus the neck will 
be found passing directly in the 
direction of the uterus
Sometime they are attached to the
ext. surf. of uterus or to vagina 


more common in women who have
borne children But met with in others
They may exist a long time without
being discoverable
Frequently very small tumours
seem to have more effect than large
ones causing more or worse hemorrhages.
They may be large & 
give no inconvenience except by 
bulk & pressure on the bladder
& rectum
There is danger when the tumour
is attached to the fundus it may bring 
it down & produce partial inversion 
Vary from the size of a walnut
to that of a child’s head with a neck
as large as the wrist Case
Other diseases may be mistaken
for polypus. Prolapsus uteri is distinguished 
by the presence of os tunicae
by its sensibility & by its growing
larger from below upwards by 
relief being given when it is pushed
up a polypus causing uneasiness 


when pushed up history of case also
Gooch’s rule always to supply 
a ligature to a tumor with a neck 
is a good one
Sometimes their removal
results from the stricture upon 
the neck by the os tunicae
The ligature is the best mode
of removing them. Prof. B. prefers
the common double cannula
to any of its more complicated substitutes
For a larger tumour the [ring]
probe is the best instrument
If you get away as much as ¾ of
the tumour the rest will disappear
You will know if you have included
the neck of the uterus by the extreme
pain produced










Retention of Menses
Retention is the want Suppression is
the interruption Treatment of both is 
much the same We are to prescribe
however to constitution and symptoms
Either of them is rather the effect than 
the cause of disease
The [cutam.] will sometimes cease
at 25 and often between 30 & 40. They 
may continue also beyond 50 years
Suppression & retention are
usually from want of action 	
Want of expression of countenance
and eyes whiteness of tongue scurvy
as it is called
This form is relieved by tonics
and astringents Lime water is 
much used & is called tonic. Alternate
alkalies with astringents as gum, [illegible],
[illegible] etc. A convenient form is pills
of the extracts with molasses And 
also [iron] & formerly myrrh
was called deobstruent and much 




used in form of Jenkins’ pills
& the myrrh mixture (Griffith’s & [illegible]
Rx
In the worst cases in country practice geranium [illegible]
or statici or agrimonial (which resembles
contrayerva) or cornus can always
be found in the country Lime water can
be made sulph. zinc you will carry 
about you. Add also aromatics as fennel,
dill etc. mints [pyenanthin??]
Generally when you have obviated
the cachetic morbid actions of the constitution 
uterus will take on its own healthy 
natural action. If however the catam.
do not return use emmenagogues
R. sulph. zinc gr i sang. gr. i aloes gr i
[illegible] guaicum table sp. & tinct canth. So much 
guaiacum as not to operate as a cath.
& 20 gtts tinct canth. 2 or 3 times a day
Another disease
Symptoms pain in the side about
an inch above the anterior sup.
spin. proc. inquietude sleeplessness




upon enquiry you will find the discharge
paler or watery or less in quantity material it is unhealthy
Stimulate the spine with tart. emet
oint. or canth. from the neck down 
along the spine. You will generally 
find upon pressure some of the vertebrae
tender. Then give after [irritant]
guaiacum, myrrh. Cathartics
seem to increase the cachery of the 
system. Of course avoid costiveness
Bleed in small quantities if necessary 
in retention or supp. Remember
however that the system does not suffer 
from want of evacuation Ligatures
will do better often than bleeding applied
just before the time for the return of the
catamenia
Sometimes the bowels become
loaded from torpor & inactivity
etc. Prof. I. has no doubt that bleeding
at the lungs and hectic after arise
from this cause. Use repeated
any free injections to wash out the
bowels. Exercise & amusement in 
the open air will do much Injection 



([Dr Savemens]) may be somewhat of a
substitute for exercise. The shower
bath is a good thing & our old remedy
Young women are seldom subject
to dis. of the uterus. Yet young 
women of of strumous habit, in whom 
there is [tineae] is relaxed have prolapsus from 
jumping off a horse etc.
Symptoms pain down the thigh
a sense of drawing down of the stomach
& of the bowels sinking at the stomach
dyspeptic symptoms
Prof. I has known unmarried
women bed rid from this cause, feeling
as if the bowels would come out
if they attempted to rise The os tineae 
is relaxed and there is a tendency to spasmodic
action there. In young women
pessaries do not seem to do well
there is more or less spasmodic action
I have made them with a handle & 
used a T bandage but no with much 
success. Sea bathing has been beneficial.
Elastic gum pessaries are 
best & have cured. Silver ones are 



good. Sponges are used but are
too rough & absorbing the secretions
smell bad & if changed every day
irritate too much. Ivory pessaries
Pessaries are proper when there is 
no disease excepting relaxation
When there is prolapsus you do not
feel the os tineae & the neck distinctly, but
you feel the relaxed and enlarged os tineae
& perhaps the uterus in an oblique position
In such cases we use astringents, as oak
bark etc. but sulph. zinc is better
Keep the bowels open and give aromatics
R. magn zfs or zii chalk. zfs cubebs
zfs carb. soda zfs grana paradisi zjj
a teaspoonful 2 or 3 times a day is often
enough. If there is likelihood
of the liver’s being affected give blue pill
Prof. I. doubt the existence of the 
cauliflower excrescence. HE has seen
relaxed os tineae with its veins varicose
Various diseases are called
cancer. If you find the os tineae
hard & enlarged & unequally & you 


find tumours in the vagina the disease
will certainly prove fatal. You may 
give conium astringents irritate
the sacrum etc. but with no good effect
Sometimes the tumours are fatty
 A phagedenic ulcer affects
the uterus eating away the os tineae
carb. & phosph. ferri have been 
declared specifics
Another disease enlargement of uterus, pain
in it discharge like leucorrhea
perhaps catamenia excessive Os tineae
enlarged also. This terminates in 
medullary cancer of some [writers]
Apply alum to the os tineae astringent
give metallic tonics & narcotics & 
silver pill
There are diseases of the uterus
in which polypi, deciduous membranes
dropsy etc.


Dysmenorrhoea
Occurs in persons with some deranged
state of the viscera catamenia comes
on with pain in the back limbs
much unequal excitement head hot
sometimes neuralgic pains Patient
will frequently throw off a deciduous
membrane
Dewees recommended
guaiacum (tinct) & allspice called
Dewees tinct. but it is better to give
the guaiacum by itself and the allspice
if needed Give 5 to 11 gr
camph. repeat every hour until’
you have given a z If you can
keep this on the stomach it will generally 
cure I have given also camphor 
& magnesia 20 gr of each
by mistake she took double the dose
became weak but after a few
hours recovered regular catamenia
Other narcotics may be used but camphor
has been long recommended. Deobstruents
also as sanguinaria may 
be used. Hyoscyamus is better then 


opium or conium
Equalize excitement by irritants
& drafts warm bath etc.
Other articles are ipecac
wild ipecac ([illegible])
External irritants are burgundy pitch
plaster on the sacrum
Sometimes there is a sallow
countenance, atony etc. then support
the patient
Incipient cases of diseased
ovaria the os tineae is spongy and 
flattened These diseases of ovaria
are very various but are called
dropsy & cancer Curable at
first by a course of blue pill, moderate
stimulants, aromatics, absorbents
(for acidity) and deobstruents
in general. I have kept patients under
the use of blue pill and even for a year
occasionally [illegible] it for 2 or 3 yrs
I gave also a compound powder
of alkalies, aromatics and columbo
and kept the patient also under conium


but I find hyoscyamus equal in its 
deobstruent effects even while it is
far superior in its narcotic effects
while it does not like opium produce
constipation & torpor of al. can.
Polypus of uterus
It may exist without unpleasant
symptoms. They do not always bleed
but at the time of catamenia hemorrhage 
is apt to occur. In the 
bleeding kind it may come down
and project beyond the vulva
At the time of the catam. there will 
be pain in hips & back & extending
down the thighs cat. profuse & finally 
terminating in a watery discharge
If the astringents as nutmeg, geranium
and best ac. pl. with op.
given both locally & by the mouth
do not relieve, we may examine
for polypus. There will be a dragging
sense in the uterus etc. Examine & you
will at about an inch & a half you 
will meet with a tumour which you 
will distinguish from a prolapsed uterus


by the absence of the os tinaea &
by feeling a tapering tumour its
neck being embraced by the os
tineae Its surface being smooth & 
delicate. Generally the neck will 
be too high up to be felt.
Retroversion
Well described by J. Hunter in the
London Observations
The trifling complaints spoke of
by Dewees do not deserve to be
considered Retroversion is
when the uterus is carried back down
into the perineum the os tineae is
carried back & up
Symptoms uneasiness constipation 
retention of feces & urine
vomiting, hysteria etc.
Introduce the finger into the vagina
about an inch up you find a resistance
on all sides you carry the finger back
along the prominence and you find a
tumour in the perinaeum and you find
no os tineae but by changing the position 


of the patient say erect or upon hands
& knees you are able to feel partially 
the os tineae The orifice of the urethra
is also drawn up, because the bladder
is drawn up & you do not readily 
find it and cannot readily introduce
the catheter Introduce a small
elastic catheter & draw off the urine
when great relief is obtained
Evacuate the bowels by injections
John Hunter recommended puncturing
the uterus drawing of the waters & producing
abortion
Restore the uterus by placing
patient on hands & knees & introduce a
probang with a ball about an inch in 
diameter covered with lard introduce
the left finger into the vagina
Pass the probang gradually up the 
rectum & let it act upon the fundus of the
uterus so as to push it back in the way it
came down assisting with the left two
fingers. Use the catheter for some days
after and give injection per anum
After the child rises above the pubis there 
is no further danger


# Found in bex humida, convulsiva etc.
# Very large and strong in the 
“dead rattle”


Stethoscope
Continued from the 1st vol. M.M. 1832 & 3
2nd Mucous [rhoncus] occasioned
by the passage of the air through sputa forming
bubbles which produce the sound by their
bursting. The epithets are very large, middling or small
according to the size of the bubbles also
abundant or rare according to the number 
of them. # Found also in haemoptysys
though then there is an indication 
of greater fluidity the bubbles being more
frequent. This originates from the large tubes 
Tracheal rhoncus is also mucous
and may often heard very loud by the steth. when 
not audible to the unassisted ear #
These two the crepitant and mucous
are called moist rhonci
3d Sonorous rh. a flat dull
sound resembling the cooing of a dove
or the large strings of a violincello The 
causes are not known The indications
also unknowns. The sound varies very 
much. resembles the varieties of sound
produced by blowing the nose



4th Sibilant rhon or a dry sharp
whistling sound sometimes
resembles the chirping of a ground bird
pathogn. of asthma
In sonorous rh. but one sound is heard
but in this there are heard a great many 
almost persuading one sometimes
that the chest is filled with young birds
This rhoncus is from small tubes
The former (sonorous) is from one small
tube. This sibiliant may may be caused by a thickening of the [illegible] membrane
5th Crackling rhoncus proceed
emphysema pulmonum (an unnatural
inflation of the lungs at first an unnatural
inflation of the air cells
ultimately the cells burst and the 
connecting cell mem. is inflated
in dissection the pleura may often 
be seen elevated In another
variety the air is effused into the
cell mem. between the lobules of the
lungs) In vesicular emphysema
this rhoncus is not always found
but in the interlobular emphysema 
it is very manifest


The sound is a crackling one, like the
burning of hemlock leaves or like blow
into a dry bladder. Sounds as if air was
entering dried lungs
6th Some authors add the cavernous
found when there are cavities, formed
from tubercles, or from gangrene or from 
abscesses Tubercular excavations
generally contain some fluid, which 
gives rise to a gurgling sound. We
have likewise the term “amphoric resonance
or atricular buzzing, which 
is caused by the communication of the 
cavern by a small orifice resembles
the sound made by blowing into a large
vial When there is no fluid
we have the cavernous respiration
of which the amphoric is a variety
Some make this a variety of the mucous ronchus
Some persons breathe so 
feebly that it will be advisable
to request the patient to make a full & 
quick respiration Otherwise he may 
not notice an engorgement which the 


ordinary painful & cautious respiration
may not slow and he
may suppose a part to be completely
obstructed which which will be [illegible] to be not [illegible] upon
a full & quick respiration
It will also be useful
probably to the patient to make occasionally 
a free respiration especially 
in the commencement & in 
the resolution of pneumonitis (N.B.
when pneum. is going off we hear
the crepitus caused by the air beginning 
to reenter the cells)
Also in incipient adhesions of the
pleura, we may make use of the
same means. Dr H.’s own case
He felt a sense of tearing
Emphysema will only 


Patholog. cond. of the voice
1st Tracheophony or layrngoptony
2 Bronchophony 3d
4th Pectoriolquy
The two first are heard in health 
in limited portions of the chest however
The air of the lungs being in distinct
cells we have a compound medium
but when the lungs are hepatised or
hardened with tubercles So also if
one lung has been entirely destroyed
Case of a child foreign body in the
lung infl. supp. vom.  & prod. of pus
child recovered from the sound
the lung was considered healthy
afterwards a year after the child died
of scarlet fever & the lung was found wanting # 
When apart of a lung is solidified
we find a dull sound upon percussion 
we hear bronchial respiration & bronchophony


Introduction of the catheter
During labour the neck of the bladder 
is often much elongated, and you may 
have to pass the catheter directly upward
Next attend to the child
Be careful that the room is warm
that the child does not take cold
Keep a cloth warmed at the fire
against the birth of the child
The body of a new born child
should be cleansed of a white unctuous
substance, which resembles tar, by 
rubbing with lard and wiping with 
a soft cloth. Then the child, if vigorous 
may be washed with soap & water
Others, after rubbing off the 
lard, sprinkle over wheat flour or 
starch 




Aegophony or Haegophony
goat like tremulous, bleating
voice resounds through a thin stratum of fluid
Pathogn. of empyema
collection of [serum] (Pleuritis)
Commonly not distin. from 
bronchoph. by the inexperienced
It is like a kind of silvery voice vibrating
on the surface of the lungs. Apply 
the cylinder firmly on the chest the ear
to the stethos. lightly (if hard pressed on
it, it will sound like bronchoph.)
When the liquid is small, 
aegoph. will be heard only at the lower
portion of the lung But if we hear
the sound near the root of the lungs (between
the scapulae) we may conclude the 
collection to be large
In strongly marked cases it
may be distinguished by its shrill sharp
sound also by seeming like an echo
of the voice often also the seat of it
may shift with a change of position



Pectoriloquy
the resounding of the voice from within a 
cavity communicating with the tracheae
or bronchia Caused by softened tubercles,
by separation of gangrenous
[eschous] by abscesses formed in any way 
by openings into the mediastinum was perhaps
& perhaps also into the liver
Pathogn. principally of phthisis
In perfect pectoril. the voice
seems at the end of the steth. & often
seems louder In imperfect the voice
does not seem to traverse the whole length
of the instrum. or
Doubtful pectoril. sound slike
aegophog or is too obscure to be defined
In perfect. pect. an amphoric resonance
or cavernous rhoncus will accompany it
and there will be obscured in the
imperfect
If excavations exist in the 
lungs, they can generally be detected by 
the stethoscope & before the use of the
steth. they could not as there is often 


no pain in their region In some
few cases the information conveyed will 
be imperfect or doubtful, but the instrument
is valuable
Pectoril. is modif. by the nat. tone
of the voice clearer & more distinct
when the voice is high though perhaps
less loud. Hence the nat. resonance
of a sharp toned voice may be clearer
than a true pectoriliquy, in the axilla, for
instance, when the voice is grave. But
we can generally determine by comparing
the opposite sides of the chest
2nd modified by the size of the
cavity but then a cavity is large as  a 
pea! will render a true petoriliquy 
5 by the situation of the cavity if it
is deep in the substance, the pectoril.
will be far less clear than when it is
near the surface but when very 
near & with thin collapsing sides
we have only the veiled puff a
var. of cavernous rhonc.
4th by the  slope of the cavity
louder & clearer of sound & smooth very 


loud indeed when the cavity is lined with
a cartilag. sub. Ragged an obscure sound cavities yield
5 by the opening several fistulous
opening will much obscure the sound 
6 more distinct, when the cavity is perfectly
empty sometimes the cavity will be 
filled one day & empty another according
to the abundance & facility of expectoration
Hence, in general, pectoriloquy
indicates a cavity, but a cavity may not
give pect. still there may be other
sighs, as amphoric resonance


Signs given by resp. & voice
1st amphoric resonance & metallic
tinkling.
1st is like blowing into
a vial 2nd like striking a short
metallic cord, or a wine glass or 
tumbler. Both indicate a large
cavity with hard unyielding walls
& filled principally with air & communicating 
by a small orifice
Commonly cav.  resp. amph. res.
& met. tinkling are varieties of the 
cough & [speck.]
Auscultation of the cough
The phenomena are intermediate
between those of the voice & the respir.
Cavernous cough indicates excavations
& cav. rhonc. is made more manifest
by coughing
Also by requesting the patient to cough we
can obtain a full inspiration


1st Clavicular over the clavicle
2nd Infraclavicular from the clavicle to the 4th rib
3d [Mammary] 8th
4th Infram from 8th to cart
3 sternal regions
5 Superior sternal region
6 Middle
7 Inferior
8th Axillary reg. to the 4th rib
9th Lateral reg. fr 4th to 8
10 Inferior lateral reg fr 8th to [cartilage]
11th Acromial ac. proc. of scap
& above
12th Scrofular space of the scap.
Some make superior & inf. scap. reg.
separated by the spine
13 Interscep (2 of them
14 Inferior dorsal (2 of them)


Diseases
Pneumonitis more fatal than any other
acute disease. Infl. of lungs etc. vide Good
To be distinguished from bronchitis & 
pleuritis. Though it may be complicated
with one or both
3 stage 1st obstruction or engagement
2nd hepatization 3d purulent
infiltration
Engorgement is from blood
and serum the lung when cut will 
give a crepitus, & does not sink in water
resp. high small, accelerated, incomplete,
unequal, difficult commonly
cough & pain & expectoration (when no cough or pain 
called latent [illegible] then we must observe the 
respiration & use the stethoscope which 
gives the crepitous rhocus). The 
modification of the rhoncus gives the character
the fluid engorged (if bloody crepitant) if serum, subcrepitant.
Hepatization has the air cells entirely 
obstructed lung sark red sinks in 
water called also [carnification]
absence of vesic. resp. & [illegible] of bronchial
resp & bronchophony (if near the centre 
of the lungs


puerile respiration (produced by a preternaturally 
vigorous action of the healthy
part of the lungs) occurs in both stages
3d Purulent infiltration into the substance surface of 
the lung straw coloured. Lung humid
& soft fingers easily penetrate it 
softer if from serous engorgement generally 
accompanied at its commencement
by chills mucous rhoncus
Percussion gives no difference in the 
first stage of engorgement grows duller
decidedly dull after the stage of
hepat. commences In hepatization we have bronchphony & bronch. resp.
The three first stages are completed in 
from 6 to 8 days the first two in’
5 days But often the disease is irregular
and the regular course may be broken
up by medication You may find all 
the grades of healthy and morbid respiration
within 4 or 5 inches
After dust both lungs are found
affected for the disease is seldom fatal
when one lung only is affected. Respiration 
of one lung may be entirely gone and yet 



the health be pretty good apparently 
Dr H. has often known one lung completely 
hepatized within 36 or 48 hours,
and within 6 or 8 hours find the
disease entirely transferred to the other
lung
Commonly one lung
undergoes resolution
& then the other is affected
Sometimes however both lungs
are engorged and then of course
a fatal suffocation occurs Especially 
is this the case in pneum. notha
vide Good
Case in which death occurred in an hour
another in 3 hours Such cases
hardly deserve the name of pneumonitis
(inc. inf.) but no definite line can
be drawn between them.
The older writers speak of termination 
in abscesses or gangrene
the matter is disputed.
The truth is a regular circumscribed
cavity containing pus is not found
Proper abscesses occur from tubercles
Occasionally a gangrenous abscess occurs
In such cases we have cavernous



rhoncus
By careful medication & good
nursing, resolution may generally be
brought bout this may occur in 
either of the three stages 
Resolution is effected sometimes effected
in a few hours days and week may 
be required
Stethoscope says all well frequently 
when resolution has commenced from hepatization,
when the general symptoms 
show no mitigation first we hear
crepitation etc. etc.
Resolutions of purulent infiltration
Case related pulse slower than it
ought to be owing to cerebral aff. coma etc.
Rx tinct. sang. zi tinct. cinch. comp.
z8 tablespoonful every ½ hour
In the winter of 1831 & 2 we had
pneumonitis oedematosa In the previous winter
we had a pneumonitis which afforded no stethoscopic
sign the disease was rheumatic & yielded 
to actaea alone. There were all the ordinary 
appearances and progress of pneumonitis, viz
diff. resp. bloody expect. etc. 


In the pneumonitis of 31 & 2 we had
no crepitous rhonchus but a sub crepitous rh.
yet the disease went through the 
regular stages and there was even an
uncommon tendency to suppuration. Some
cases however were mere oedema of the lungs
This according to Lacunec is very rarely 
an idiopathic disease It commonly occurs
as a hydropic. disease of cachectic
habits. Good knew but little of it
he thought it could not be distinguished from 
hydrops thoracis It can readily be distinguished
however by the stethoscope
Dr Hooker thinks the disease has often 
been overlooked. When edema of the lung
has been found after death, it has too 
exclusively been attributed to effusion just
before death. To be sure the effusion
is liable to shift or disappear suddenly 
but we find the same thing in 
edema of the limbs. Within the last 18 mo.
we have had such cases of shifting from 
the limbs thence to the head thence to 
the lungs etc.


Dr Hooker thinks that ½ of our fatal
cases of disease terminated in hydrocephalus
Instead of 30 or 40 according to the bills
of mortality, he thinks we may say at least
130. The intellect was not in general materially 
affected
[Lae???]’s account of edema of the lungs
is not a good one. The pathog. signs are
progressive dullness upon percussion & 
sub crepitous rhoncus His subcrepit. rho is
rather a super crepitous rho caused by fluid in large bronchiae
in [illegible] cases.
Haemoptysis
Called also pulmonary apoplexy IT
is an effusion of blood into the substance
Stethoscope shows a crepitus
rhon
Hydrops thoracis
Good says the only decisive indication
is a fluctuation but this can scarcely 
ever be observed
Percussion gives a dull sound
Haegophony exists in the first stage q.v. In the advanced
stages no respiration can be observed 
A very rare idiopathic disease


Empyema detected
in a similar manner
Pleuritis
Acute pain difficulty of lying on
the affected side (yet when adhesions exist
the weight of the lung renders it more
painful to lie on the opposite side
There is bloody sputum & cough
But effusion of serum generally takes
place & then we have haegiophony
Frequently the effusion becomes concrete
& tough and hard, perhaps cartilaginous
Laennec has observed a contraction of
that side of the chest (in the young the
lung of that side not growing so fast)
Pleuorpneumitis
Pleuralgia a rheumatic aff. of
the intercostal muscles relieved by 
opium, actaea or some narcotic
Stethoscope shows no signs of pneumonitis
hence valuable, negatively 


Emphysema
1st Pulmonary or vesicular emphys. 2nd
Interlobular emph.
The first is an effusion which causes
larger & larger globules
The second generally gives oblong or
triangular collections of air
The crackling (crepitant) rhonchus
indicates this especially the 2nd
Caused generally some obstruction 
of one or more of the bronchial vessels
The case of the child who had never spoken 
loud (in Broadway) exhibited emphysema
of the lungs. Tumours & croup
have the same effect. Hepatization or
tubercular degeneration or some [illegible]
of a part of the lungs may cause an emphysema 
of other portions. This is one of the most
common causes. Yet the p.m. ex. shows
emphysema we do not necessarily find
that the stethoscope has given indication
Symptoms are hurried and laboured
respiration lips livid, from 
want of decarbonization of the blood
Easily out of breath etc.


Stethoscopic signs of it are obscure the
respiratory sound is said to be feebler
The sound of percussion is clearer however
Little has been known of this disease until 
of late years
Pneumo thorax
Pneumato thorax might be called
emphysema thoracis. Not distinctly 
described by Good It is a collection 
of air in the cavity of the pleura 
First memoir on the subject by [Itard]
1803? May be caused by a 
wound of the thorax by a communication
between the bronchiae & the cavity of the
pleura by putrefaction and extrication 
of gas
More or less inf. will be apt
to be caused.
Percussion gives a remarkably clear sound 
steth. gives not resp. sound on the affected
side on the opposite side the respiratory
sound will be clearer than natural
If there is a communication between the 


cavity of the pleura & the bronchiae we
have amphoric resonance & occasionally 
upon coughing or speaking, the metallic tinkling
This affection is commonly complicated
with presence of fluid. Inflammation 
caused by the air will be apt to produce
fluid. In this variety we may make
use of what is called the Hippocratic succession
Concretions of the lungs
We find them bony or cartilaginous or chalky
in p.m. exam. especially in old cases
of phthisis. Laennec thinks they are
tubercles which have been cured.
Black pulmonary matter upon 
the surface is found more abundantly 
after pulmonary diseases and phthisis
but found more or less where there had been
no pulmonary disease. Laennec thinks
it more abundant in blacksmiths
Bex. dyspnoea want investigating.
Good’s dyspn. includes 4 or 5
distinct diseases. Sometimes we have 


a sibilant rhoncus. Sometimes it
is caused by emphysema of the lungs.
Phthisis
most of the recent French writers restrict
the term to tubercular phthisis
Cullen considered it a sequel of haemoptysis.
but the latter might with
more propriety be considered a sequel
of the former. Haemoptysis rarely
leads to phthisis.
Good has P.  catarrhiulis P apostematosa
& P. tubercularis. Apostemes,
with excavations, very rarely 
exist, in the lungs, as has now been 
ascertained
P.m. ex. in Paris show that ulceration 
of the bronchial membrane is
(almost) always connected with tubercles
the question is which is the primary 
disease. The French think the 
latter is the primary disease
Of tubercular phthisis
Tubercles are small tumours (tuber)


They commence greyish bout the size
of a grain of mustard (miliary tubercles)
Colour deeper in adults
In examinations we may find not more
than a dozen tubercles or thousands 
Tubercles are found also in other parts
of the body particularly upon the intestines
and in the liver, spleen. etc.
When they become large they first soften
internally then discharge. “Crude
tubercle” collections of non-discharging
tubercles
Tubercles may exist at a very
early age 2 or 3 years. They may be
inherited in infancy. Case of a child of 
3 months. They have been found in 
the fetus 
No one symptom is constantly 
met with in phthisis. Cough, expectoration,
pain etc. may be absent. It is 
doubtful whether the tubercles and ulcerations 
of themselves cause pain.
In this disease the physical signs
generally come too late.


When suppuration and excavation occur
we have mucous rhonchus cavernous
rhonchus and pectoriloquy q.v.
Curability Those who make
the least pretensions do as well as any 
The disease may mitigate and apparently 
cease in summer & revive again
in the winter
It is difficult to get leave to 
examine the bodies of drunkards
There is no doubt that confirmed
phthisis is occasionally cured as shown 
by steth. & p.m. examinations
Affections of the heart
No part of the body is subject to a greater
variety of affections Corvisart
produced the first valuable work
An enlarged heart will be indicated 
by percussion though the pericardium distended with water will give
the same sound
Manual examination is better
Place your hand over the heart & judge
of the regularity etc.


But the steth. is still better & also
shows new phenom 
1st sounds
1 impulse or shock
3d extent of the chest over which the pulsations extend
4th rhythm
1st By the stethoscope we hear two 
sounds first duller & longer then a shorter
& sharper. The former is isochronous 
with the pulse
2nd an impulse on the ear is felt at the
time of the first sound. In children & 
thin chested persons the second may have
a slight impulse
3d extent generally small In fat persons
we have not more than an inch of extent
the extent is increased by high
living etc. & vice versa
4th rhythm i.e. order of succession now
receives much attention cannot be 
thoroughly explained as to its causes. Still
valuable indications may result from it
Laennec says the first sound is produced
by the systole of the ventricles the second


when the auricles contract then a 
period of repose so that ¼ of the
time is occupied by a state of repose
In 1828 Mr. Turner maintained that
the auricles contracted first and was
followed so immediately by that of the
ventricles so that both together cause the
first long dull sound Mr. Turner
also thinks the second sound made by the
beating of the heart (in a diastole) again
inst. the pericardium. Many other
hypotheses have been advanced since
We must conclude Laennec’s hypothesis
to be unfounded. A later hypothesis
supposed the dilation caused the sounds
Another supposes the sound caused 
by the striking together of the sides of the 
ventricles but then the ventricles are
never empty
[Refutation] of Corrigan and Haycraft
Dr Hope has published lately a large octavo
volume on this subject.
1st the auricle contracts so immediately
before the ventricles as to make but one 
sound


2nd the extent of the auricular contraction 
is very small & incomplete
3d the ventricular contraction is the cause
of the impulse & coincides with the pulse
at the wrist
4th the impulse is made by the apex of 
the heart
5th the ventricular
6th the ventricles do not [illegible] themselves
7th
8 after the diastole the ventricles remain
apparen
1st sound caused by systol 2nd by the
diastole of the ventricle
Rhythm 1st auric. syst. 2nd ventric.
sys
3d v. [illegible]
4 v. repose towards the termination of
which auricles begin to contract
Dr Hope attributes the sound to the
agitation of the blood in the ventricles
Dr Hope attributes one sound to the
active dilatation of the heart [illegible]
or elastic



1st mot. auric systole
2nd immediately followed by ventricular
systole & 1st sound
Dr H. thinks the 1st sound produced
by the closure of the auricular vent. valves
& the second by those of the arteries
The sudden arrest of the regurgitation
causes the sounds
The sound occurs at the times of 
the closure of the valves
[illegible] of the sound is such as
might be expected from the striking together
of the valves & the sudden check
of the regurgitation hence the second 
sound is like the lapping of a dog or 
the snapping of a whip
The second sound (by the auric. vent. valv.)
is more gradual as it should be also
the sound is more dull
Dr Hook thinks the first sound
is caused by more than one circumstance
The impulse also is caused (he thinks) by 


the apex of the heart and also by an internal
abrupt succussion caused probably 
by the auricular vent. valves and the
reaction of the chordae tendinae colum.
[illegible] etc. upon the whole mass of the
arterial valve
Dr H. thinks Dr Hope’s account
of the order of the action of the heart is the
tone one
Hence the first sound 
is heard lower down than the first opposite
the apex of the heart the sound
being conducted by the dense contracting
ventricle & coinciding with the impulse
The first sound
1st Hypertrophy of the heart muscle
larger than natural contracts
slower & stronger Impulse stronger less sudden sound
more prolonged less sharp because
the valves close less suddenly 


2nd Dilatation of heart muscle
thinner hence contract more
rapidly but less strongly So too 
the sounds become preternaturally 
abrupt, loud & sharp
In a high degree of hypertrophy
the sound is scarcely perceptible
3d Contraction of the orifices
of the heart
We have the bellows the rasp
serrate & thin whizzing murmurs all varieties
of the same Caused generally by 
diminution of size of cardiac orifices
but often by regurgitations (perhaps
more frequently The murmur 
may exist before death for months & yet
p.m. ex. show no disease of heart
It is observed that in arteries
It is heard in the arteries of the placenta
Slight derangement however may exist about
the valves and not be detected by 
dissection e.g. relaxation of the chord. tend.
It is found that excessive depletion causes
the bellows murmur from this cause or 
a similar one. Dilatation of the heart will 


Cause bellows murmur produced by 
imperfect closure of valves
A murmur rarely supercedes
the second sound the arterial valves
are rarely completely ossified
Simple dilatation of heart
Walls thin heart weakened in action
palpitation but (according to the general law) acts
quicker pulse quick feeble respiration
labored edema of extremities livid
& pale & leaden skin these are affections 
symptomatic of the general affection
If the left cavities are dilated
& the right healthy the lungs are
oppressed edema etc.
If the right sides of heart are diluted
the left continuing healthy, we have edema
of extremities congestion in grain etc.
a pathogn. [symptom] is swelling of jugular
veins. (N.B. pulsation of jugular
is produced by imperfection of the [illegible]
valves manual examination 


shows a dilated heart but not clearly 
which side is affected
Auscultat. gives a feebler impulse & shorter
sharper & clearer sound the extent
of the sounds is increased even extending
into clavicular & axillary & acromial
region
Generally both sides are diluted
but commonly one side more than another
The early stages of dilat. can scarcely
be distinguished from nervous palpit. of
[illegible] etc. (apply stethoscope 
frequently to prevent patients being
alarmed and excited by it N.B. In fevers
steth. useful in conjunction with 
feeling pulse, gives more certain signs)
The bellows murmur is generally 
heard caused by imperfect closure
of ariculo-ventricular valves
Now laennec would lead the [illegible]
to suppose that increased clearness of 
sound attends dilatation But when
the dilat. is excessive the sound is obscured
or superseded by the rushing bellows
murmur



The stethoscope gives no signs of 
dilatation of the auricles (Laennec
was mistaken his work on the lings
is nearly a perfect one)
Hypertrophy
morbid increase of muscular
substance of heart with thickening of its
parietes Excessive growth
weight increased
1st [Chicentric], 2nd Eccentric & 3d
simple hypert.
1st Case the grown incroaches 
on the cavities & diminishes the cavity
Simple is growth outwards merely 
Excentric is dilated & grows thickened outwards
also (vide Bertin) Corvisart
was acquainted only with the last
The two former occur more frequently 
in children & are frequently
congenital (specimen exhibited of
a congenital concentric hypertrophy N.B.
the heart was larger than the childs fist
larger than natural walls enormously 
thick cavity almost obliterated)


N.B open foramen ovale is given
as a cause of such cases then probably 
the hypertrophy is the principal evil.
The for. ovale is generally open for 
3 weeks after birth
The child above was restless from 
birth hemorrhage from umbilical
arteries (caused by strong power of heart)
palpitation very strong great
effusion into cavity of pleura
(hemorrhagic pleurisy) Child
moaned all the while put its hand
to its head etc. right side of heart 
thicker hence effusions in lungs
Tendency to inflammation found
all over the body
The apoplectic habit especially 
predisposed to hypertrophy but
sometimes the sanguine & robust
have dilatation & the feeble & cachectic
have hypertrophy
Pulse in hypertrophy strong
& slow (strength of heart without 


quickness as above) If right side
is hypertrophied the lungs are affected
& [illegible] left is the head will be
affected with serous apoplexy.
Stethoscope gives a slow strong
dull prolonged heavy impulse & 
sound In the left ventricle about
the 5th & 6th ribs in right
about lower part of sternum
Excentric hypert.
by no means uncommon occurs in 
adults incredible size sometimes
Dr Duncan found one weighing 32 oz.
(nat. weight is about 10 oz.) 7 inches long
& f in. broad
Stethoscopic signs are a 
union of dilat. & of simple hyper.
impulse extensive sound sharper
& duller? (more obscure in
its signs)
Polypi
Coagulated lymph questioned whether
formed before death or at death more
generally supposed that they do form before death


Notes of Prof. Knights Lectures
copied principally from Mr. Osgood’s
notes
Curvature of spine
Polypi were very remarkable last 
winter during the hydropic diathes
specimen shown extending through 
as far as the radial artery
Stethoscope to fractures
gives a more distinct & precisely 
located sound
Stethoscope in pregnancy
Gives first the pulsat. & sound of the
fetal heart & the blowing pulsation
through the placenta (a bellows murmur
of the placental arteries which is synchronous
with the pulse of the woman
Both are audible to the stethoscope & to the
ear The stethoscope is preferable from 
considerations of convenience & delicacy
[illegible] sound not heard before 3 or 4th
month Fetal heart heard [illegible] afterwards towards
the end of pregnancy Twins are predicted thus!
Bellows murmur of iliac arteries easily distinguished
Fetal heart gives a double clik and then is silent period


Fracture of clavicle
Mistake often made in supposing
that the sternal end rises, & in endeavouring
consequently to keep it down.
It is the scapular portion which requires 
to be kept in place
Dislocation of last phalanx 
of thumb
Instead of vainly endeavouring
to make sufficient extension 
bend the phalanx back almost to a 
right angle thus get one edge to 
catch upon another & then reduce by 
the lever principle
Bending of the long bones in 
children
Prof. K. has met with frequent
instances of this in children a fracture 
perhaps on the convex side symptoms
distortion with stiffness etc.
Fracture near the head of the 
long bones of children, occurring 


in a part not ossified, yields no crepitus
Amputation of the last or third 
phalanges of the fingers or toes
When swollen your knife may slip
by the joint & cut into the soft cushion
of the ultimate extremity & deceive
you be on your guard
Os femoria
The books represent the neck as 
smaller & they then account for fracture
there But both circumference
& the diameter from above downwards
is in fact greater
The body of the bones may be 
destroyed by disease and the [illegible]
remain
Tibia
When you set a broken tibia bear in 
mind the natural lateral curvature
of its anterior edge
Ankle joint
Dislocation backwards and forwards on 
rare occurrence. [illegible] inw. [illegible] with 


fract. of int. [mall.] Disloc. outwards
generally accompanied with fract. of fib.
1/3 or ¼ [illegible] way upwards superior fragment
of fib. retaining its nat. position
Tarsus & metatarsus
Tarsal bones very rarely dislocated
except in the practice of nat. bone set.
Prof. K. has been informed on good
authority of one or two instances
In amput. foot at tarsus bear in 
mind the uneven line caused by the projection
backward of the second met. bone
or Near the articulation of the
fibula with the astralagus, and a little 
before if three is a small cavity between
the anterior ends of the astralagus
and os calcis which can be readily felt
through the integument This often almost 
[illegible] filled up in sprains, & often
mistaken for a dislocation of a tarsal bone
In amputating at the tarsus the
land marks are the projection of the 
internal cuneiform bone & the projection of the 
metat. bone of lit. toe The former has 


a bursa on its top which is liable to 
effusion and swelling from pressure as
of a boot cured by abstracting the pressure.
The project of metatarsal
bone of lit. toe often mistaken by 
patients for something wrong
Sprains of ankle joint
They are affections of the tendons of the librating muscles
& the affection is either an injury 
of the tendons themselves or a displacement
from the sheath of those of the
external libration muscles
Calf of the leg
Soreness, long continued, & lameness
caused probably by separation of muscular
fibres from tend. of [gastro???]
It has been attributed injury often [illegible]
of plantaris
Wrist hand fingers
Pus formed under the brachial aponeurosis
may point in the palm of the 
hand. The tendons of the fingers are


at first in one common sheath &
then the separate in order to go to the
several fingers. In labouring men
these separate tendons sometimes adhere
to their sheaths causing a curvation and
stiffness of the fingers and a prominence
under the skin when the finger is bent
tendon feeling rounder and harder 
than natural This is not mentioned in 
the books
Ear diseases of 
Always examine for cerumen in cases
of deafness, by throwing the suns rays
strongly into the ear. Deafness from 
this cause occurs oftenest in elderly 
people. The wax gradually accumulates,
but deafness does not occur
until the closure is complete
Sometimes there is a thin coating of cerumen 
over the membrane tymp. destroying 
the [shining] appearance which it 
shd present when healthy. The lining
cuticle of the ext. auditory canal, instead
of secreting cerumen may secrete 


pus without abrasion of surface
When the eustachian tube is closed
puncture the memb. tymp. in the 
lower and anterior part to avoid the
small bones not piercing so [illegible]
a quarter of an inch through
Insects in the ear will be destroyed
by tinct. camphor. Foreign bodies
may generally be removed by a 
scoop. Case a small stone closely 
fitting the cavity Col. Blake pushed
through a tube a piece of cotton dipped
in any alcoholic solution of shellac
when the alc. had evaporated 
the stone was readily drawn out by 
means of the fibres of cotton
Diseases of internal ear Ulceration 
may take place in the muc.
mem. of this part. If the small bones
are destroyed hearing will remain but 
if the labyrinth is destroyed, hearing is lost.’



Puncta Sachrymalia
The course through the superior [illegible]
is the most direct Exceedingly difficult
to introduce a probe through
the puncta half the time we do not 
pass the probe into the sac when we
think we do
Couching
Prof. Knight prefers the posterior
operation for depression 
The [lens] is always depressed
into the vitreous humour there is not 
room in the posterior chamber of the aqueous
humour. Be sure to have the
needle far enough behind to avoid
the ciliary body
Laceration of capsule of [lens]
is performed anteriorly & the aqueous
humours entering though the opening
made by laceration, absorbs
the lens


Foreign bodies in the nose
are generally in the lower sometimes
in the middle meatus
Tonsils or glandulae amygdalae
are between the palate half arches
are often enlarged Their [illegible]
orifices are occasionally filled
with a semi-purulent, or a curdy
matter which may give their surface
the appearance of an ulcerated
one.
Throat foreign bodies in 
Thee when in the aesophagus are either
at its upper extremity in the root of
half cul de sac formed by embrace
of the larynx by the lower end
of the pharynx & then they may be 
swept out by the finger & they 
are at the cardiac orifice of the 
stomach In the former case they 
may often be seen & if we introduce the
finger we must be careful not to mistake
the projecting horns of the os hyoides 
for foreign bodies


Prof. K. has known an ulcer to eat
through the fold of membrane which 
extends literally on both sides of the
epiglottis, so that the passage to the 
larynx could not be protected
death ensued
Fraenum Linguae
The gone is more bound down by 
this fold of the muc. mem. in some individuals
than in others. If it necessary
to divide it, let the incision be
made near the floor of the mouth, to avoid
the [illegible] arteries The small glandular
bodies seen under the membrane are only parts of the sublingual gland
Uvula
when enlarged may occasion a dangerous 
chronic cough. Its removal [shortening] has never
been followed by worse consequences
than a slight subsequent hoarseness


Venesection
The basilic vein is apt to be a rolling
vein. The cephalic is apt to be 
small and deep seated. The median
is most superficial &most
firmly fixed. In order to 
be sure of avoiding the brachial artery
feel for it. The position of the superficial nerve 
we cannot calculate on and no 
one is to blame for wounding it. Prof.
I is incredulous about the injurious consequences 
of wounding it. Avoid 
pricking the tendinous expansion of
the biceps infl. there will be troublesome
Flexors and Extensors
The extensors are the strongest but
the flexors of the legs are the shortest
so that they are completely at rest
only when the limbs are flexed because
we like and sit so much



Bursae mucosae
There is one on the anterior surface
of the patella & one on the olecranon.
There is one under the 
tendon of the rectus femoris which 
always communicates with the
knee joint. There is a corresponding
one below the joint which sometimes
is separate from it
Hip joint
There sometimes occurs after a fall 
or other injury an utter [illegible] of
this joint, with violent pain and 
soreness & requiring many weeks for 
recovery the cause of which is unknown
(acute infl. of Prof Hubbard?)
Some have thought this effect caused 
by bruise of synov. memb. cart. etc.
or by fract. without displacement
Prof. K. has had 2 cases 



Curvature of Spine
First symptom may be a slipping
of the [illegible] from the shoulder
or a projection of the lower angle
of one of the scapulae, mistaken for 
a tumour and sometimes poulticed
etc. for a long time one hip 
may project
The first curve causes a 
second compensating curve, to preserve
the balance of the body.
Examine for curvatures 
by means of a string stretched along 
the spinous processes. The place of the original
curve will generally be [illegible]
indicated
by tenderness or pressure
Cure by strengthening the muscles by 
exercise
Spina bifida
Congenita It has been proposed to 
puncture the tumour this may be
done by a small orifice but a fatal
infl. may ensue. If the tumour
communicates with the brain, pressure
on it will produce symptoms 
of pressure on the brain



Circumflex arteries
In opening [illegible] abscesses about the knee
or elbow joint you are very liable
to wound some one of the numerous
circumflex or recurrent branch hence
make a free incision that you may 
be able to tie an artery if necessary
Arteriotomy
is performed on the temporal art.
[Arterio] feel under the finger much 
larger and nearer the surface than 
they really are. The artery should
not be completely divided. It is 
different to hit it longitudinally
hence & make the incision 
obliquely
Local depletion
May be serviceable in local infl.
Case wound of the hand. The 
divided artery had regular periodical 
[illegible] of bleeding for a while
and then ceasing for a few hours. This
proves an independent local action 


Mem. Obtain the minutes of 
Prof. Knight’s case of partial dislocation
of a cervical vertebra








E. D North
snuff taker !!!!
5
obstetrics
& 
Diseases of women










































5
Materia
Medica
(rear)
Diseases of women.
obs (front)












Lecture 2nd
Pelvis 1st The sacrum is nearly 
equilabral about 4 or 5 inches in each side
In the female pelvis the concavity of the sacrum
(perpendicularly) is about ¾ of an inch
deep The last vertebra inclines backwards
from the top of the sacrum, which is called 
the promontory of the pelvis.
The coccyx is moveable & curves
much forwards
The Ilius forms by [their] [illegible]
the great basin of the pelvis properly a part
of the abdomen. There are two anterior & 
two posterior spinous processes. The top of 
the pelvis is bounded y the linea ileo pectinea
The ischium has an anterior
& a posterior spine from the latter of which 
proceeds the internal [sacro??] ischeatic ligaments of each side
The pubis is the smallest bone
The ischium & pubis surround the foramen ovale 
Ligaments 1st sacro ischiatic
internal from the spine of the ischum 2nd sacro
ischiatic external from the tuberosity of the
ischium to 


3d Sacro iliac ligaments
Dimensions of the pelvis 1st the superior
strait at the line ileopectinea has
its [antero] posterior from the promontory of 
the sacrum to the symphisis, is 4 ½ or 5 in.
The transverse, at right angles to this, is 4 ¼ or
4 ½ in. The oblique, from the sacro iliac
symphisis to the acetabulum a little shorter
than the last
The inferior strait has its diameters
not parallel to those of the superior
The oblique are measured by Prof [Burns]
from the middle of the sacro ischiatic ligaments
to the junction of the rami of the ischia
& pubes


The axes of the strait
That of the superior strait is an
imaginary line from the umbilicus to about the
one third of the sacrum
That of the inferior strait
It has been thought that at about
the period of labour, the symphisis
pubis 
Deformed pelvises
Every variation of shape does not constitute a
deformity
1st The pelvis may be unnaturally
large in all its dimensions and this is a 
most deformity The uterus remains in th e
pelvis, pressing upon the rectum & bladder so 
as often to confine the patient to her bed during’
the whole period of gestation. The delivery 
also is too speedy & prolapsus uteri, fluor albus
etc. follows delivery. Case of this kind 
M.S.


2 Alterations in the shape of the pelvis
Occur always from rickets, [malacast??] etc
All the cases, almost, which occur in this
country are foreign women. All which Prof. B.
has seen have been Irish women.
The diameter altered is
almost always the antero posterior diameter.
It is laid down as a rule by 
European
The cavity of the pelvis may 
be badly shaped. The sacrum may be 
too straight. It may also be too curved
& throw the point of the coccyx too far forward
The coccyx also may be anchylosed. Bony 
tumours also may exist
Instruments have been
invented for measuring the pelvis. Those
which have to be introduced within the pelvis
are objectionable especially in [illegible]


Baudelacque’s callipers are very accurate
allowing 3 inches for the soft parts & adding
2 lines for a fleshy persons
The hand & finger however
are the best instruments, at the period of labour.
If the finger will not reach the 
promontory of the sacrum we may be
sure that the antero posterior diameter is sufficiently 
large. If the whole hand can be 
introduced
Diameter of the had. 
The long diam. is 5 in. from the occiput
to the chin. The longitudinal 4 ¼ in.  from the 
forehead to the occiput. The perpendicular
is the shortest These diameters may be diminished
5 or 6 lines, not
The neck cannot be twisted
more than a quarter of a [circle]


External organs
Immediately below the clitoris


Menstruation
Commences at first after having been preceded
by general disturbance of the health pains
in the back, hips & loins, disturbance of the bowels
etc. perhaps hysterical symptoms During
the continuance (about 4 days) of the evacuation 
a pale circle surrounds the eyes
It is ascertained from the examination of 
cases of procidentia that the discharge is from 
the uterus & not from the vagina
In this country menstruation commences
on an average at the age of from 14 to 16
The earlier the commencement the earlier the
cessation.
Conception
many theories 1st that the semen is carried
into the fallopian tubes 2nd


Changes produced by conception
The cavity of the uterus enlarges and soon 
a membrane forms on its inner surface
The ovum contained in two membranes passes
down the fallopian tubes and pushes out this
deciduous membrane


The fetus first appears in the ovum as a 
mucilaginous cloud
At the end of 6 weeks the fetus is about
½ an inch long and shaped like a crescent 
or bean. At two months the fetus is 2 inches
long about the size of a bean At 3 months it is 4 or 5 inches 
long external parts perfectly developed the
genitals being large and those of the [illegible]
from their size resembling those of the male
At 6 months the hair is visible the motions 
are felt in the abdomen the relative length
middle near the body of sternum weight 2 pounds
of the head and upper part of the body is greater 
At 7 mo. middle half way between navel & stomach
At 8 mo. skin is firmer and whiter, and hairs are
visible on it middle nearer the navel than
the sternum length 16 in. weight 4 or 5 pounds
gall bladder contains bile etc. etc.
At 9 mo. middle at the navel length
19 in. weight upon an average 8 lb. with
us but in France between 6 & 7 lb. Length of
the male with us 23 in. of the fem. 19 ¾ in.
The nourishment of the fetus is difficult
to explain. Probably it is like a vegetable
from the ovum in the first place.
The most prevalent opinion at
the present day is that the fetus is nourished 



from the blood after it has undergone some
change in the placenta. Some facts seem
to prove that the liver changes the blood & 
gives rise to a peculiar secretion albuminous.
Circulation of the Fetus
The most probable opinion at present is
that the fetal blood is oxygenized in the
lungs of the mother, is taken up from the 
placenta by the umbilical veins and carried
under the liver (principally) into the vena 
cava through the single heart back by 
the umbilical artery into the placenta 
again 


Signs of conception and 
pregnancy
Just after conception the
features become sharpened, the eyes are
surrounded by a dark circle The complexion 
pale. The most important sign is
the cessation of the menses but when the woman
has become pregnant while suckling a child, the
menses not having regularly returned, we cannot
reckon from that period, but women in that
case reckon the rather from the motion of the 
child which first occurs between the fourth 
and fifth month The areola of the nipple
is dark Pricking
sensations are experienced in the breasts
Morning sickness occurs and continues
until with about 2 mo. of delivery
By the fourth month the uterus
projects above the pubis is more easily felt in 
a lean subject By the 6th mo. the fundus
will be at the navel By the 7th about an inch
above and the navel protrudes
Usually by the 6th month the
motion of the child can be felt if the hand 
is first dipped in cold water.


By the fourth month the neck of the 
uterus is softer and shorter
The size of the uterus is judged
of by placing the left forefinger
the 
at upper & anterior part of the vagina
& pressing with the right upon 
the fundus just above the pubes you will feel
the pressure of one finger upon the other the
woman must be in a standing posture
Prof. B. thinks gestation may 
be prolonged beyond the ninth month & 
that he has had considerable evidence of 
the fact.
Case related in which parturition
was fully expected much alarm
was excited at its not coming on
& finally it was found that all the signs
of pregnancy which had existed, proceeded
from an enlarged uterus which 
was reduced by proper remedies.


Natural Labour is that where
the face is to the sacrum and the occiput to the
pubes where the [labour] is over within 24 h.
is where it terminates with safety to the mother
and child & the [secundines] come away well
4 stages are distinguished 1t os uteri is
dilated the membranes are protruded
2nd the head turns into the hollow
of the sacrum & presents at the ext. orif.
3d the child is delivered
4 the secondines come away
In the 1st stage we observe 1st the pains 
commence in the back & loins & pass through to  
the pubis in some cases about the loins & 
thighs first Sometimes very irregular [illegible] endeavoring
These first pains are short
not lasing more than about a minute
After the os uteri is dilated to 
about the size of a crown the second stage
commences the pains from being short & cutting
are protracted, with a sense of burning 
down violent skin hot & dry sense 
of inclination to go to stool from the 
pressure of the uterus on the rectum. During
this period the membranes are ruptured


In the third stage the perinaeum bulges
out the woman demands to get up for 
a stool must not be indulged
it is a delusive sensation. The perinaeum
becomes four or five inches broad
Prof. B. puts his right hand upon 
the occiput, & his left upon the perinaeum
he judges of the degree of pressure by 
the fingers of the left hand & resists with 
the right upon the occiput of the child.
The fourchette is [illegible] in the first
labour do not mistake this for ruptures
of perinaeum Vomiting occurs
frequently and is serviceable to the
facility of the labour
Gathering of the waters
This term is applied to the bulging tumour
of the water on the membranes which 
increases in protrusion at every pain 
& appears as if more water was collecting


False pains
Can be distinguished with certainty only 
by the effect of the pains upon the neck of the
uterus the pains produce no pressure upon 
the neck of the uterus & no dilutation of the
os tineae sometimes you can pass your 
finger into the uterus and feel that the
membranes do not become tense by the 
pains.
Often these false pains appear to be
caused by excessive motion of the
child enquire about this in [illegible] labour
the child has little or no motion 
To relieve these false pains after bleeding give opium. The labour
may be a month or two distant.
It is of importance to understand
the progress of a nat. lab. thoroughly 
Examine during a pain in the intervals
the woman may sit or walk about
Keep up her spirits. Make no certain 
prognostic as to the time or at least
fix a distant time so that the end of the labour may 
fall within it. We are often much 
urged to interfere keep out of the room
on this account Suffer no to one attempt to 


bring on a labour as it is [illegible]
Leave the woman often to allow
her an opportunity to pass water. During
the first stage let her be dressed for labour.
Dress the woman in a 
loose dress with her linen tuked up  
under her arms
Prepare the bed by first making it 
up as usual prepare the lower
part by coverings to protect it
Let the woman lie on her left side
with the knees bent, her feet against 
the bed post her head & shoulders raised by pillows tie a handkerchief or
towel around the other bed post for
the woman to take hold of Some
condemn these efforts of the woman, but 
Prof. B. is satisfied of the advantage of them
The only assistance rendered shd be pressure 
on the back
The French lay the wom. on 
the back. Some women prefer a sitting
posture. It is often advisable to change
the posture for particular circumstances
Conduct the choice of the patient 


If we wish to rupture the membranes it will generally be sufficient to press
hard on the membranes with the end of the
finger the membranes will rupture themselves.
If necessary scratch the membrane
with the nail. If the labour
is very rapid rupture the membranes
yourself, that the water and child
may not both be delivered at once
and empty the uterus too suddenly 
Rather hinder than hasten after the 
passage of the head one pain will expel
the shoulders and another the hips 
Generally as soon as the head is 
born and always when the body 
is born, the child cries. First feel for the
pulsation of the cord. If the child does
not breathe (when the air is freely admitted)
blow on its face dash cold water or spirit
on the face & chest wipe out the mouth
first with a dry & then with a moist rag
close the nostrils of the child with the fingers
& then blow gently into its mouth & if necessary
press gently upon the thorax to facilitate
expiration as this may be continued for 


some time keeping the body war
with hot flannels, all the while Apply 
your hand or better your ear to the region 
of the child’s heart
At first the respiration may be very 
feeble & perhaps at first with long interruptions.
Other means are frictions
ammonia etc. to the nostrils & to the 
surface of the body
Some children, after you have
succeeded, have not stamina enough
to support life. Dropsical effusions 
in the thorax may prevent respiration
& the life kept up in such cases by 
the [illegible], for half an hour Prof. B.
has met with such cases but only in children
of hard drinkers
Sometimes a child is apoplectic
from long detention of its head in the
passage in this case, bleed from
the cord ½ oz to 1 oz milking out the blood
inflate the lungs also etc.



The cord as soon as respiration
is established not waiting till the pulsation
ceases in the [illegible] we might have to 
wait ½ an hour or more
Tie with any sort of a string there
is no danger of cutting the vessels with a small
one A piece of wide tape is convenient
Tie tightly or the ligature may become loose
from the shrinking of the [illegible] Sometimes
the arteries are so firm that a ligature will 
not prevent hem. unless the arteries
are pulled out and tied separately.
It is thought by some necessary 
to tie both ends of the [illegible] but it is better
to allow the vessels of the placenta to 
bleed & thus diminish the size of the placenta
except [illegible] cases
As soon as the child is born
pass your hand over the abdomen if it
is firm and hard up to the scrob. cord.
a twin is within if the uterus is contracted
to a ball above the pubes there is merely 
the afterbirth. Generally the pains
commence again in about 8 or 10 min.
When the edge of the placenta arrives


at the vulva take hold of it, twist
it so as to make a roll of the membranes
& thus no part will be torn
off and left.
Next attend to the comfort
of the woman. If not too feeble let
her be immediately removed to the bed
she is to occupy
Place several folds of cloth
upon the abd. & pin a towel around
to give support, to prevent relaxation 
of the uterus & hemorrhage, & for the
comfort of the patient 
The pat. will now be very 
comfortable & happy, but soon come
on the afterpains by which the coagula
of blood are expelled from the uterus
But few women escape without after pains
those who have already had children
are more liable to them
Ergot administered during the labour
prevents or diminishes the afterpains. Prof. B.
has often administered it with this intention only 
Generally ginger & spts applied
vol. lim. zj ol. or zfs
also a poultice in a pillow case of ar.


herbs & bran
These pains are generally much
increased when the child is put to the breast
Until the 5th or safer still, until 
the 9th day, when the lochia terminate,
keep the pat. on panada, arrow root etc.
not giving cordials, in the old fashioned
way
Let the child suck immediately 
to draw off the colostrum to prevent swelling
& infl. of the breast, & retraction of
the nipple, which prevent it from sucking.
The child too needs the purgation
& is apt to lose the instinct for 
sucking
By the third day the lochia
should be washed off from the external
parts and a gentle purgative castor
oil or magnesia shd be given. The 
bladder must be attended to if necessary
apply a fomentation of onions, or if such
things fail introduce a catheter


The lochia comes on about the 3d cease about the 5th day
ultimately the discharge becomes of a light
pink col. The diminution of the
discharge is looked on as a good symptom
unless vary
If excessive, astringents, as port wine 
tinct. ter. jap.
Ultimately give a pill of op & ac. pl.
aa ij gr. once in an hour or two.
If this is not sufficient inject
ac. pl. & opium into the vag.
When the discharge has a cadaverous
smell, is greenish etc. wash
out the uterus with detergent injections
such as lime water & milk decoction
of oak bark etc. support the
pat.


Introduction of the Catheter
During labour the neck of the bladder 
is often elongated & you may have to 
pass the catheter directly upwards
Next attend to the Child
Be careful that the room is so warm
that the child does not take cold
Keep a cloth warmed at the fire
against the birth of the child
The body of a new born child should
be cleansed of a white unctuous substance
which resembles tar, by rubbing
with lard & wiping with a soft cloth
Then the child if vigorous may be
washed with soap and water
Others after rubbing over with lard
sprinkle with wheat flour or starch





Tie the cord by 
The belly band is a piece of flannel
passed about twice round the belly
Sometimes the child will not bear
to be dressed, from feebleness.
If the child grows cold, wrap it up in 
flannels dipped in hot spirit. And
let these children who cannot bear to be dressed,
let them be wrapped in flannel & 
kept in a warm place
If the meconium does not come
away with 12 or 14 hours, give molasses
& water, or honey and water if these
fail give a teaspoonful of bland castor
oil
Look out for retention of urine
It may arise from imperforate hymen 


or from the orifice of the urethra, either
of the male or female, being closed
up with mucus in which case introduce
a probe, a short distance
If the child must be fed give
cows milk 2 parts water 1 part sweetened
with loaf sugar or if it is required 
to be more purgative, with 
brown sugar
Presentations of head


Breach presentations
4 orders 1st back to the left side of the
mother the body rotates and the back is turned
to the [symphisis] pubis if traction is not 
used the arms lie along the body and come
out with it the face presents at the perineum
support the child’s body with your
left hand the chin issues first then 
the rest of the face and the head issues
with a jerk. The danger is in the
stoppage of the circulation of the cord.
A difficulty arises from the largest parts not
being delivered first. Another is in the
cessation of the pains which is abt to take
place
In the 2nd the right hip of the child
presents to the left acetabulum
3d the abdomen of the child presents to 
the abdomen of the mother the body turns
outward comes out obliquely but the head
comes out face upwards
#4th the revers of the 3d


During labour turn the body obliquely 
so as to bring the head into the position 
it is as in the 1st & 2nd
Presentations of the feet
1st the heel towards the pubis which 
eventually becomes the 1st hip presentation
Presentations of the knees
The knees feel harder
Generally best to bring down the feet


Diff. lab. 1at want of relaxation
febrile state do not give stimulants
2nd Want of action Ergot 1 z ergot to zii
water infusion tablespoonf. every 5 m.
The pains of ergot are distinguished by their increasing
continuance
3d too early rupture of memb. e.g. sudden
exertions as lifting sometimes probably from 
weakness of membranes. If the waters
are not drained [illegible] the labour may not
come on for weeks & be easy
Attachment of placenta over os uteri
may be suspected, from frequent & irregular
hemorrhages. Take the first opportunity
of examining while the blood is flowing
but if the flowing has ceased the finger would
break up the coagulence & perhaps bring on 
the flowing.
When the uterus is sufficiently dilated
to admit the finger the placenta may be
detected take care to distinguish it rom 
coagulated blood
When we cannot tell (early in the pregnancy 
5 or 6th month) about the case, treat as for
uterine hemorrhage apply cold in a horisontal
posture. Sugar of lead 5 or 10 grs with 1 gr. o f
opium repeated once or twice in 24 hours
It will produce no poisonous effects unless continued
for several days. If this fails inject
into vag. zii in ½ pt. of warm rain water
this is very effectual. A strong sinapism
between the shoulder is most effectual.
But the best remedy is a plug of alum Rx


a piece about 2 oz in weight made smooth
and passed up. Alum operates as a local stimulant
& the coagula of blood stop at the passage
also. It is usual to tie a piece of tape around it
When the placenta is over the os uteri, the 
labour will be ushered in by a flow of blood
]If we find the os uteri dilated or dilatable
so that we can introduce the hand we should 
immediately pass up the hand and turn
If necessary break through a part of the placenta.
When the breech of the child is
down it will plug up the passage.
But if the woman is nearly exhausted we
must restrain the hem. by proper application
The woman may die before we can turn
the vagina. A sponge is very good. A silk 
handkerchief. Prof. B has used [illegible]
introduced
in small pledgets [illegible] on to the 
tampon and given ergot allowing the tampon
to issue while pains are on and checking
it when they are off (Case related
articular mortis tampon ergot child dead
mother saved)
In other cases we may proceed
then early and afterwards turn?


Instruments
Forceps apt to be delayed too long
Prof. B. recollects no case in which they
were used too soon
Smellie’s [illegible] consisted in 
curving the [clams] The blunt hook
is now put upon the end of the handle
Place the woman left side (English)
back (French) the back generally preferable.
Empty the bladder & rectum previously.
Keep the instruments in a basin of
warm water before using them
Always apply the forceps on the sides
of the head and over the ears so as to embrace
the head in its oblique diameter over the
cheek, over the ear (occiput [illegible] diameter)
The pressure of the forceps lengthens the head
When each blade has been properly applied
the [male] part of the joint, readily enters 
the female part never lock the
forceps by means of force
Head being in 1t position
take the male blade in the left hand & introduce
it along the palm of the right (with a 


waving motion) carry the blade until 
the centre of the clam is opposite the anterior
fontanelle or the sagittal suture. If pain 
is felt, desist because you injure a [illegible] of the vagina with [illegible] be careful about [illegible]
against the ear with the end of the clam Introduce the
other blade with the other hand, in the same way
Draw & wave from side to 
side when you extract
If the head is high up, draw down,
in the first place.
Do not hurry but let the uterus do 
what it will to expel the child
The position for the use of the forceps are
1st vertex to the arch of the pubis
2 the reverse fore head to arch of pubis
3 vertex to the left foramen cot. cav. ? ovale i.e.
the head in the diameter
In this 3d position the handle of the male
blade will pass near the right thigh of
the mother & the head must make its
last turn after you apply the instruments contrive to turn the occiput 
to the arch of the pubis while you draw
4th the reverse of the 3d
7th head corresponding to the transverse


diameter of the pubis the male blade
passes under the arch of the pubis
As to the case when the forceps are to be applied
while the head is above the superior strait,
Prof. B. has never had such a case.
It will be better to turn and deliver by the
feet The cases of this kind where the forceps shd be
introduced must be very rare if any 
Shoulder presentation
Pass one hand up and push up the shoulder
sufficiently to allow the introduction of the
other hand to seize the feet
It may be necessary after the child
is dead to bring down the hip and use
the blunt hook



Locked or impacted head
Two positions sacro [illegible] or transverse
In the first case apply the forceps as before
In the second we are compelled to apply 
them over the face & occiput
As a general rule the forceps
are to be applied to head [illegible]
directs them for the pelvis. Other methods
are better however for a living child
Where there is more want of action
Prof. B. would give ergot instead of 
the forceps
But where the mother, being
vigorous & exhausted by pains & nature
has done all she can do ergot will 
not do good the forceps must be
applied
When the face presents and you 
cannot turn apply the forceps one blade
under the pubes. As you extract turn 
the face (from being transverse) so that the 
chin shall come under the pubess


Vectis
Can be used for extraction Can be used
to hasten the delivery of the face when that is
to the sacrum
The vectis is used principally for changing
the 4th [illegible] to the 1st & in face
presentations to change them to those of
the head
Breech presentations it may 
be worth while to make footling
Blunt Hook
Generally one is sufficient if not
apply both extract by a see saw 
motion
After delivery of the body the
head may be detained the pulsation of 
the cord cease the child make one or 
two convulsive heavings & will soon die
if not soon delivered. Pass the finger
up and give the head an oblique direction 
which will facilitate the delivery
Use the forceps to hasten delivery 


But in this case the vectis may be advantageously
used. Apply it over the occiput?
Foot & knee knee presenting
foot catching against the margin of the pelvis
Not worth while to confuse the memory
with all the varied presentations
IF the back of the neck side of the 
face etc. etc. push up and turn
Where the labour is very slow
& no part present we may suspect
a bad presentation. It will be necessary
to pass the hand up the vagina
& examine if we do not find a hard
body we shall have the hand foot 
belly etc. proceed to turn after
the membranes are ruptured 



Perforatory & crotchet
1st of the cases where the pelvis is too small
a case which does not often happen in this 
country
4 in. may be left to nature 3 ½ will be slow
& may be delivered alive by the forceps
A patient of Dr Hooker’s was delivered
in whom the diameter was 1 8/10 inches caused 
by [mollities] [ossium]. By means of [cephalotoma]
she was delivered & recovered, after 
having a fistula, communication between
the vag. & the neck of the bladder and a
closure of the os uteri
Make perforation with the perforator
then introduce it and break
down the brain., Then use the crotchet
It may be necessary to bring away first
each parietal bone then the frontal taking
care to keep the scalp whole


2nd where the head is unnaturally 
large from dropsy. Here we have
merely to let out the water and may 
use any instrument as a pair of scissors
Caesarean section
Dr Dewees sides with the French.
He says the perforator is more uncertain 
and is dangerous
The French forbid it when the 
child is alive
Retention of Placenta 
It is now agreed that it ought no t
to be suffered to remain
Pass your hand gradually between 
the placenta and uterus (if the placenta
continue to adhere) detaching it as you 
proceed pull upon the cord with the
other hand bring your hand away
after the placenta and not until 
you have felt the contraction of the uterus
upon your hand When Prof. B.
has had an adhering placenta he
has always found a mal-conformation 


of the placenta or walls of uterus as calculous
concretions etc.
Hemorrhage may make it necessary
to detach the placenta immediately 
Hemorrhage a week or more after
delivery
Hourglass contraction
Generally about the neck of the uterus
Prof. B. has scarcely met with a case since
he has adopted the plan of waiting scarcely 
more than ½ an hour before bringing away 
the placenta.
If it occurs pull upon the 
cord and at the same time insinuate
your hand up to the fundus of the uterus
Hemorrhage after delivery is most
apt to occur after quick, easy labours
caused by want of tonic contraction of the 
uterus
Injections of ac. pl. may be used
previous to [extracting] the placenta.
We are recom. also to inject cold 


water or a spiritous tinct. into the 
cord this is powerful & effectual
probably
We must judge of danger
from the exhaustion of the pat. not
from the quantity of blood lost ½ pt
or 1 pt. is generally lost in an ordinary 
labour. Prof. B. always
uses a plug of alum after delivery
of placenta.
Ergot. Prof. B. always uses it
but after delivery of plac. it is apt
to fail Where he has reason to expect 
hem. he gives it before the termination 
of the labour It never
fails & besides this it diminishes the 
after pains.
When life is in danger
use all your means. Carry 
a piece of alum in your hand
into the uterus. Prof. B. prefers
this to a sponge of vinegar. He has
had to wait 15 min. before the uterus
would contract in the last & 
compelled to sit an hour before the 


uterus would expel his hand.
Concealed hem. does not show
externally and uterus becomes distended
with blood. We should never
leave our patients until we have felt
the uterus firmly contracting between
the navel and pubes
Inversion of the uterus
Caused by pulling upon the cord Said also 
to take place spontaneously 
Prof. B. has seen but one or two cases
The indications are to detach the placenta 
and if possible restore the fundus
Symptoms very severe paleness, coldness
vom. conv. etc.
Place the pat. on her back and
pass up your hand and endeavour to push
back the fundus. But if the fundus
is protruded through the os uteri and
the dangerous symptoms result from the 
stricture perhaps all that it will be 
in our power to do, will be to make the
inversion complete and thus relieve the
stricture leaving a prolapsed uterus


Immediately after delivery
If the placenta does not come away 
apply friction etc. to excite contraction
Dr N.B.I. always excites contraction
if the uterus by pulling and swaying
upon the cord. He finds this perfectly 
safe. Prof. B. says it is also
# Compound pregnancy
We can sometimes guess at it in lean
women. In general we may find it 
difficult to determine, from the large
quantities
If after the birth of the first child
Labour is rather slower on account
of the large size of the uterus and that
too with the first child
Pass your hand upon the abdomen
to ascertain the existence of another child
If you find another child, conceal
it from the mother
The presentation is more apt
to be wrong in twin cases
If the pains do not come on again 
within ½ hour give ergot. You 


will then soon feel the bag of water
protruding and if you find them 
a bad presentation as of the shoulder or 
arm, you may easily turn and deliver
Hemorrhage is more apt to occur
Hence generally it will be best to give
ergot after delivery
Not unfrequently a woman has
been left, with a second child in her
uterus. Case related
Commonly the placentae are 
distinct and united merely by membranous
union. The memb. and the waters
are distinct. Sometimes however the
vessels of the two placentas [inosculate]
hence the precaution of tying both ends
of the divided cord.
The delivery of the placentae
is apt to be rather more difficult
Delivery one cord at a time


Presentation of the Cord
Sometimes a foot or a foot and a half
will protrude. These cases are 
difficult. 
It is safer to attempt to turn
and deliver [footling]. It is exceedingly 
difficult to return the cord
and keep it up. We are directed
to wind the cord on a sponge or rag
and push up. It will generally 
however soon come down again
Dr Dewees mode of using catheter
Prof. B. has not tried.
In one case Prof.  B. has
known a knot in the cord.
Deformed children
Give puzzling presentations
Oftenest the bones of the head are imperfect.
Sometimes you feel
the bone hardened brain. Feels
for the face
A more serious case is that of
hydrocephalus. Sometimes the size 
is enormous. Easily distinguished 


by the feel. The scalp protrudes
like the membranes. By pressing
also you may feel the bones of the cranium
and may even push your
finger through the sutures
The child is of course lost hence
you may as well puncture at once
with a lancet. In one case Prof.
B. let out 4 pds?
Signs of a dead child
Coldness shiverings like an ague
when the child dies Breast ceases
to swell and becomes flaccid
A secretion of milk comes on.
A weight is felt falling when the 
woman turns Cessation of mot. in child
When labour comes on, the waters
are fetid the meconium is evacuated
even in a head presentation
The scalp is flaccid, the hair comes
off etc. Yet the only certain 
sign is the want of pulsation in the cord


Rupture of uterus
By a fall, by violence in turning
or by forceps
Severe rending pain cold clammy 
sweats, sickness faintness & 
vomiting
The seat of the rupture may 
be in the fundus, side or neck.
If the child has wholly escaped
into the abdomen, the difficulty is
great. Gastrotomy seems much preferable
to delivery through the 
[illegible] Cases recorded of recovery 


Retention of menses
They may not commence until after the
20th year in the feeble and delicate
This should excite alarm as long as the
other signs of puberty are wanting
If the patient is robust let the
antiphlogistic treatment be followed.
But for the feeble, nervous, leuco-phlegmatic 
etc. prescribe exercise
shower bath warm flannel clothing
Give tonics especially chalybeate
Blood root madder ½ zs 3 times a day
Guaic. 4 z ½ z carb. sod. [illegible]
zjfs alc. 1 pt. Dewee’s tinct. vide Ellis
Blood toor ½ z sulph. zinc aj
aloes zj ft. pil. 60 2 to 3 in
24 hours regulating the dose by the
effect upon the bowels. This is the 
most useful emmenagogue
Blisters on inside of thighs size
of the hand These effected a cure in a 
pat. 27 years old whose aff. had resisted
all remedies
Cupping on inside of thigh has 


also been found beneficial
Cupping the breasts was reccommended
by the older writers
Savin has also strong emmenagogue
power
Retention may be caused
by other affections e.g. phthisis
In such cases emmenagogues shd
not be given
Suppression of menses
Menses may vary much without
ill health. The interval may be
12 or 6 weeks
The most usual cause
is the application of cold symptoms
severe pain in the head back
and loins colic etc. hysteria etc.
Hip bath anodyne injections
V.S. nervines for the hysteria
We may thus cure the immediate aff.
but the discharge will not thus be
made to return. Use of the pediluvium 
bleeding etc. just before 1 week
the next period & so [illegible] the 


discharge
Chronic suppression is to 
be treated like amenorrhea #
Periodical discharges from 
other parts may take place as a substitute
for the menstrual discharge.
This may continue for life. Case related
ulcer on ankle
Deficiency in quantity gives
rise to the same symptoms & shd be
treated like amenorrhoea
Excessive menst. not common
treat as for hemorrhage
Guaiacum is more agreeable in powder
# Carb ir. & pulv. guaic. aa zi
Sang. in powd zfs. aloes zfs. a small
teaspoonful 2 or 3 times a day


Dysmenorrhea Painful m.
very distressing pains resemble
labour pains pains
relieved by the discharge generally 
Caused by irritable uterus
Hip bath opiates hyoscyamus
diaphoretics
For permanent cure use the 
last described pills. Tinct.
guaic. Dr Dewees has cured with 
Prof B. has often failed with it
Deciduous membrane
Pains not relieved until the membrane
is thrown off. Occurs
in unmarried females also prevents
impregnation in the married
There is danger in the doses
of camphor 2 or 3 recommended 
by Dr Dewees. Prof. B. has produced
dangerous convulsions by them
Electricity has cured. repeated
for a week previous to the [illegible]
Use the emmenagogues mentioned 


Decline of menses
A critical period
Predispositioned to organic disease
are most liable to show themselves
at this period. On the other hand
others are then restored to health
In some the discharge stops suddenly 
in some it becomes profuse
or painful or irregular
Bleed 6 or 8 ounces repeatedly 
Keep the bowels open with the bloodroot
and zinc pills. Stimulant are
hardly ever admissible there is generally 
a disposition to plethora


Abortion
Delivery before 6th month especially 
between 2 & 3 & between 5 & 6. Keep 
on the look out. Drastic cath.
injuries reaching high with the hands
thus compressing the abdomen
Death of the fetus indicated by diminution
of all the signs of pregnancy
shrinking of breasts etc.
If you do not know the fetus to be
dead presume it to be alive. Quiet
laudanum etc. Ac. lead sometimes
for hemorrh.


Leucorrhea
Muco purulent discharge At first
a local dis. astring. inject. oak
bark zinc etc. Ascarides may
attend or be the cause Finally 
tonics gum ammoniae & iron cantharid. stopping for
strangury & then repeating Old cases
[illegible] [illegible] copaiba
Green & fetid discharge
Nit. silver one of the best injections
Cant. not important ([illegible])
sulph. zinc &nit. sil. also valuable
a sort of test of the efficiency of canth. is a 
thickening and opacity of the discharge
from the vagina It will not be necessary 
to keep even a light strangury 
& of course we are not to produce 
dysentery Prof. I.
Nit. sil. best inject. 3 or 4 grs. to oz.




Prolapsus uteri
One of the most common & troublesome
complaints takes place at any period
of life
Caused by relax. of vagina Uterus
kept in place almost solely by vag.
Most com. cause leucorrhea
Women with large pelvis more liable
Symptoms weight, uneasiness about 
loins etc.
Almost always accompanied with 
leucorrheal disch.
Cure at first by strengthening the
vagina, by tonics astringent, rest
recumbent posture
Treat for leucorrhea when that accompanies
Easily ascertained by examination 
or by relations of the pat. herself
Tumour recedes when pat. is on 
her back & is easily reduced
in this posture
Strong sol. of oak bark sulph.
zinc etc. after replacing the 
uterus & confining pat. to her back 


Continue with this treatment
[tonics] etc.
We are often called on when 
the diseases does not exist & we
find disease of [rectum] and vagina.
We do not find the uterus
pressing on the perinaeum
Use the pessary
Women of lax fibre & laborious women
as washerwomen are most
subject and often the disease has
made great progress before we 
are called the pessary will 
give effectual relief
This disease may be overlooked
& cause derangement of bowels
dyspepsia etc. & these complaints
only be prescribed. Prof B. has
known several cases of women confined
to the bed for years and the stomach
only prescribed to when the pessary 
has cured in a week
When the perinaeum is lacerated
the pessary cannot be used 


When the largest sized pessary is
required from extreme relaxation of 
vagina the oval pessary is best
Place the woman on the back
[enter] the pessary perpendicularly 
& after it is entered turn
Extreme prolapsus requires
a pessary with a handle [illegible]
in its place by a bandage
Pregnancy gives great inconvenience pessary not to be used
horizontal posture until the 
fundus rises
Retroversio uteri
Occurs generally between 3d and 4th mo.
fundus is in cavity of sacrum 
urine stopped in its passage
In passing up the hand we do not
find the os tincae & neck of uterus
Distinguished from polypus
which grows slowly & was gradual
in its symptoms
Growth of ovum prevented


Supposed to be caused by distention
of bladder with urine
Attempt reduction immediately
pay no attention to the
danger of producing abortion
First draw off the urine
Attempt reduction by the fingers
in the back part of the vagina
endeavouring to push up the 
fundus uteri. If we fail, place
pat. on hands & knees then introduce
a probang like inst. into the
rectum at the same time press 
with the left hand above the pubes
We may almost always succeed
Cases of failure are recorded 
[illegible] and it is recommended
to introduce a catheter & rupture
the membranes and draw off the
waters thus reducing the size of the 
uterus
Anteversio uteri
Can never be a formidable disease
& may always be remedied by change
of posture


Scrophulous enlargement of
uterus
Resembles schirrhus pain in 
neck back & loins etc.
large & less hard than true
schirrhus not extremely tender
Causes a resemblance of pregnancy
Sometimes the general health is
not much injured
Prof. B. has known a case of 
gradual enlargem. sympath action 
of breast & cessat. of menses
closely counterfeiting pregnancy
Prolapsus is very apt to 
occur with all its inconveniences
Prof. B. has known one case of 
this kind which continued 6 or 7 yrs
bed ridden unable to stand or 
walk cured by blue pill was
to bear 2 children blue pill 
is specific


Irritable uterus
The least touch cannot be borne
pat. cannot sit or stand even
lying merely palliates no relieves 
the pain. The slightest 
touch cannot be borne at the
pubes. Vagina natural os tuniae perhaps a little swollen
Rest cupping counterirr.
blisters hip bath conium & 
[illegible] narcotics blisters & 
setons (Well described by Dr
Gooch & only by him) Case related
Arsenicae
solution was the most successful
remedy & continued to be so
Diseases of ext. org. of [generatim]
phlegm. infl. of labia often occurs
to be treated with poultices frequently 
suppurates but the abscess [illegible]
[illegible] gives great pain discharges
fetid blood issues when an excis.
made 
Excoriations of labia
Soap & water ointm. of ox. zinc etc.



citrin oint. etc.
Warty excrescences not venereal
cured by nit. silver.
Dropsy of labia t pregnancy 
almost as large as the 
child’s head
Prusitus pudendi
very troublesome efflorescence
just within the labia intol. itch
may generally be cured by a wash
of nit. sil. or corr. sub.
[illegible] subj. to great elongation
but not with us
Imperforate hymen
Almost always congenital & discovered
by the nurse and will 
generally yield to pressure of a
probe If the knife is used be
very careful to keep a tent in or
a second operation will be needed 


Rupture of perinaeum
Occurs during labour
Keep the bowels open to prevent distention 
& irritation by passage of 
hardened feces It will generally 
heal up The hare lip operation 
is said always to have failed 
to cut by [palliatives]
Small vagina
may be caused by severe labours
& should be prevented after delivery
Introduce a dry sponge
after a few days a large one
Prolapsus vaginae
Astringents & a pessary


Cauliflower excrescence
Probably a fungus haematodis
vagina filled with a spongy soft tumour
bleeding at the slightest touch Disappears
at death
We cannot [illegible] by the touch
whether a tumour is malignant or benign
Hydatids are clustered vesicles
like a bunch of grapes Some call them
[illegible] They form in all parts of 
the uterus in the ovum & sometimes
the [illegible] itself produces [abortion]
It occurs only in those who have been pregnant
this last disease counterfeits pregnancy
hemorrhage comes on in an 
abortion pains resembling labour pains
etc. Treat as for hemorrh. & 
finally ergot might be useful to expel 
the hydatids
The ovaries are the seat of
scrofulous & other enlargements fecundity
is prevented
Ovarium Dropsy
Consequences in the [Graaffian] vesicle
with small tumours which gradually 
enlarge and as they enlarge, the matter 



becomes more limpid finally the
bulk may be as great as in ascites
from which it is distinguished by 
tumour more circumscribed & greater
thickness of integuments between
the liquid and your hand
Commences by pain & is near
the hip
Affects the health little except
from its bulk
Entirely out of the reach
of constitutional remedies.
Often there are several distinct
vesicles & upon making
one puncture we find the tum.
merely diminished & altered in size
Case Prof. B. drew off only 1 ½ pt
at the first tipping at the next tapping
immediately after 64 pounds
were evacuated
Remember that the coats
of the tumours are nearly as
thick as the walls of the gravid uterus
 


Cancer of uterus
Darting pains bearing down
pains in the groins General
health soon affected countenance
sallow etc.
Os uteri hardened & pressure
on it causes lancinating pain
Hard knotty tumours form about os 
uteri & in the vagina. Menstruation
irregular or substituted by 
hemorrhage.
Distinguished from scrofulous
enlargement by knottiness irregularity 
& hardness. Also cancer rarely 
comes on till after cessation of menses.
A. Cooper never saw a true
carcinoma under 36 years
Treat at first as if we had
mistaken the disease and prescribe
for scrofula. Afterwards palliate
give light nourishing food
keep bowels soluble. Attend to 
cleanliness discharge being intolerably 
fetid inject limewater
hip bath black wash. corr. sub.



3 grs to 1 pt of limewater
Nit. sil. very useful
Chloride of lime for the fetor
[restorat???] discharges by ac. lead, sul.
zinc etc. injected
Opiates
Diuretics especially those which render
the urine bland e.g. uva ursi
gaultheria etc.
Polypus of uterus
Frequent discharges which exhaust
the patient. Hence necessity of manual
examination. Where we cannot
relieve frequently returning discharges
we ought to suspect polypus.
Generally in the cavity of uterus
After it protrudes into the vagina
we can feel it. If attached to the 
neck of the uterus the neck will 
be found passing directly in the 
direction of the uterus
Sometime they are attached to the
ext. surf. of uterus or to vagina 


more common in women who have
borne children But met with in others
They may exist a long time without
being discoverable
Frequently very small tumours
seem to have more effect than large
ones causing more or worse hemorrhages.
They may be large & 
give no inconvenience except by 
bulk & pressure on the bladder
& rectum
There is danger when the tumour
is attached to the fundus it may bring 
it down & produce partial inversion 
Vary from the size of a walnut
to that of a child’s head with a neck
as large as the wrist Case
Other diseases may be mistaken
for polypus. Prolapsus uteri is distinguished 
by the presence of os tunicae
by its sensibility & by its growing
larger from below upwards by 
relief being given when it is pushed
up a polypus causing uneasiness 


when pushed up history of case also
Gooch’s rule always to supply 
a ligature to a tumor with a neck 
is a good one
Sometimes their removal
results from the stricture upon 
the neck by the os tunicae
The ligature is the best mode
of removing them. Prof. B. prefers
the common double cannula
to any of its more complicated substitutes
For a larger tumour the [ring]
probe is the best instrument
If you get away as much as ¾ of
the tumour the rest will disappear
You will know if you have included
the neck of the uterus by the extreme
pain produced










Retention of Menses
Retention is the want Suppression is
the interruption Treatment of both is 
much the same We are to prescribe
however to constitution and symptoms
Either of them is rather the effect than 
the cause of disease
The [cutam.] will sometimes cease
at 25 and often between 30 & 40. They 
may continue also beyond 50 years
Suppression & retention are
usually from want of action 	
Want of expression of countenance
and eyes whiteness of tongue scurvy
as it is called
This form is relieved by tonics
and astringents Lime water is 
much used & is called tonic. Alternate
alkalies with astringents as gum, [illegible],
[illegible] etc. A convenient form is pills
of the extracts with molasses And 
also [iron] & formerly myrrh
was called deobstruent and much 




used in form of Jenkins’ pills
& the myrrh mixture (Griffith’s & [illegible]
Rx
In the worst cases in country practice geranium [illegible]
or statici or agrimonial (which resembles
contrayerva) or cornus can always
be found in the country Lime water can
be made sulph. zinc you will carry 
about you. Add also aromatics as fennel,
dill etc. mints [pyenanthin??]
Generally when you have obviated
the cachetic morbid actions of the constitution 
uterus will take on its own healthy 
natural action. If however the catam.
do not return use emmenagogues
R. sulph. zinc gr i sang. gr. i aloes gr i
[illegible] guaicum table sp. & tinct canth. So much 
guaiacum as not to operate as a cath.
& 20 gtts tinct canth. 2 or 3 times a day
Another disease
Symptoms pain in the side about
an inch above the anterior sup.
spin. proc. inquietude sleeplessness




upon enquiry you will find the discharge
paler or watery or less in quantity material it is unhealthy
Stimulate the spine with tart. emet
oint. or canth. from the neck down 
along the spine. You will generally 
find upon pressure some of the vertebrae
tender. Then give after [irritant]
guaiacum, myrrh. Cathartics
seem to increase the cachery of the 
system. Of course avoid costiveness
Bleed in small quantities if necessary 
in retention or supp. Remember
however that the system does not suffer 
from want of evacuation Ligatures
will do better often than bleeding applied
just before the time for the return of the
catamenia
Sometimes the bowels become
loaded from torpor & inactivity
etc. Prof. I. has no doubt that bleeding
at the lungs and hectic after arise
from this cause. Use repeated
any free injections to wash out the
bowels. Exercise & amusement in 
the open air will do much Injection 



([Dr Savemens]) may be somewhat of a
substitute for exercise. The shower
bath is a good thing & our old remedy
Young women are seldom subject
to dis. of the uterus. Yet young 
women of of strumous habit, in whom 
there is [tineae] is relaxed have prolapsus from 
jumping off a horse etc.
Symptoms pain down the thigh
a sense of drawing down of the stomach
& of the bowels sinking at the stomach
dyspeptic symptoms
Prof. I has known unmarried
women bed rid from this cause, feeling
as if the bowels would come out
if they attempted to rise The os tineae 
is relaxed and there is a tendency to spasmodic
action there. In young women
pessaries do not seem to do well
there is more or less spasmodic action
I have made them with a handle & 
used a T bandage but no with much 
success. Sea bathing has been beneficial.
Elastic gum pessaries are 
best & have cured. Silver ones are 



good. Sponges are used but are
too rough & absorbing the secretions
smell bad & if changed every day
irritate too much. Ivory pessaries
Pessaries are proper when there is 
no disease excepting relaxation
When there is prolapsus you do not
feel the os tineae & the neck distinctly, but
you feel the relaxed and enlarged os tineae
& perhaps the uterus in an oblique position
In such cases we use astringents, as oak
bark etc. but sulph. zinc is better
Keep the bowels open and give aromatics
R. magn zfs or zii chalk. zfs cubebs
zfs carb. soda zfs grana paradisi zjj
a teaspoonful 2 or 3 times a day is often
enough. If there is likelihood
of the liver’s being affected give blue pill
Prof. I. doubt the existence of the 
cauliflower excrescence. HE has seen
relaxed os tineae with its veins varicose
Various diseases are called
cancer. If you find the os tineae
hard & enlarged & unequally & you 


find tumours in the vagina the disease
will certainly prove fatal. You may 
give conium astringents irritate
the sacrum etc. but with no good effect
Sometimes the tumours are fatty
 A phagedenic ulcer affects
the uterus eating away the os tineae
carb. & phosph. ferri have been 
declared specifics
Another disease enlargement of uterus, pain
in it discharge like leucorrhea
perhaps catamenia excessive Os tineae
enlarged also. This terminates in 
medullary cancer of some [writers]
Apply alum to the os tineae astringent
give metallic tonics & narcotics & 
silver pill
There are diseases of the uterus
in which polypi, deciduous membranes
dropsy etc.


Dysmenorrhoea
Occurs in persons with some deranged
state of the viscera catamenia comes
on with pain in the back limbs
much unequal excitement head hot
sometimes neuralgic pains Patient
will frequently throw off a deciduous
membrane
Dewees recommended
guaiacum (tinct) & allspice called
Dewees tinct. but it is better to give
the guaiacum by itself and the allspice
if needed Give 5 to 11 gr
camph. repeat every hour until’
you have given a z If you can
keep this on the stomach it will generally 
cure I have given also camphor 
& magnesia 20 gr of each
by mistake she took double the dose
became weak but after a few
hours recovered regular catamenia
Other narcotics may be used but camphor
has been long recommended. Deobstruents
also as sanguinaria may 
be used. Hyoscyamus is better then 


opium or conium
Equalize excitement by irritants
& drafts warm bath etc.
Other articles are ipecac
wild ipecac ([illegible])
External irritants are burgundy pitch
plaster on the sacrum
Sometimes there is a sallow
countenance, atony etc. then support
the patient
Incipient cases of diseased
ovaria the os tineae is spongy and 
flattened These diseases of ovaria
are very various but are called
dropsy & cancer Curable at
first by a course of blue pill, moderate
stimulants, aromatics, absorbents
(for acidity) and deobstruents
in general. I have kept patients under
the use of blue pill and even for a year
occasionally [illegible] it for 2 or 3 yrs
I gave also a compound powder
of alkalies, aromatics and columbo
and kept the patient also under conium


but I find hyoscyamus equal in its 
deobstruent effects even while it is
far superior in its narcotic effects
while it does not like opium produce
constipation & torpor of al. can.
Polypus of uterus
It may exist without unpleasant
symptoms. They do not always bleed
but at the time of catamenia hemorrhage 
is apt to occur. In the 
bleeding kind it may come down
and project beyond the vulva
At the time of the catam. there will 
be pain in hips & back & extending
down the thighs cat. profuse & finally 
terminating in a watery discharge
If the astringents as nutmeg, geranium
and best ac. pl. with op.
given both locally & by the mouth
do not relieve, we may examine
for polypus. There will be a dragging
sense in the uterus etc. Examine & you
will at about an inch & a half you 
will meet with a tumour which you 
will distinguish from a prolapsed uterus


by the absence of the os tinaea &
by feeling a tapering tumour its
neck being embraced by the os
tineae Its surface being smooth & 
delicate. Generally the neck will 
be too high up to be felt.
Retroversion
Well described by J. Hunter in the
London Observations
The trifling complaints spoke of
by Dewees do not deserve to be
considered Retroversion is
when the uterus is carried back down
into the perineum the os tineae is
carried back & up
Symptoms uneasiness constipation 
retention of feces & urine
vomiting, hysteria etc.
Introduce the finger into the vagina
about an inch up you find a resistance
on all sides you carry the finger back
along the prominence and you find a
tumour in the perinaeum and you find
no os tineae but by changing the position 


of the patient say erect or upon hands
& knees you are able to feel partially 
the os tineae The orifice of the urethra
is also drawn up, because the bladder
is drawn up & you do not readily 
find it and cannot readily introduce
the catheter Introduce a small
elastic catheter & draw off the urine
when great relief is obtained
Evacuate the bowels by injections
John Hunter recommended puncturing
the uterus drawing of the waters & producing
abortion
Restore the uterus by placing
patient on hands & knees & introduce a
probang with a ball about an inch in 
diameter covered with lard introduce
the left finger into the vagina
Pass the probang gradually up the 
rectum & let it act upon the fundus of the
uterus so as to push it back in the way it
came down assisting with the left two
fingers. Use the catheter for some days
after and give injection per anum
After the child rises above the pubis there 
is no further danger


# Found in bex humida, convulsiva etc.
# Very large and strong in the 
“dead rattle”


Stethoscope
Continued from the 1st vol. M.M. 1832 & 3
2nd Mucous [rhoncus] occasioned
by the passage of the air through sputa forming
bubbles which produce the sound by their
bursting. The epithets are very large, middling or small
according to the size of the bubbles also
abundant or rare according to the number 
of them. # Found also in haemoptysys
though then there is an indication 
of greater fluidity the bubbles being more
frequent. This originates from the large tubes 
Tracheal rhoncus is also mucous
and may often heard very loud by the steth. when 
not audible to the unassisted ear #
These two the crepitant and mucous
are called moist rhonci
3d Sonorous rh. a flat dull
sound resembling the cooing of a dove
or the large strings of a violincello The 
causes are not known The indications
also unknowns. The sound varies very 
much. resembles the varieties of sound
produced by blowing the nose



4th Sibilant rhon or a dry sharp
whistling sound sometimes
resembles the chirping of a ground bird
pathogn. of asthma
In sonorous rh. but one sound is heard
but in this there are heard a great many 
almost persuading one sometimes
that the chest is filled with young birds
This rhoncus is from small tubes
The former (sonorous) is from one small
tube. This sibiliant may may be caused by a thickening of the [illegible] membrane
5th Crackling rhoncus proceed
emphysema pulmonum (an unnatural
inflation of the lungs at first an unnatural
inflation of the air cells
ultimately the cells burst and the 
connecting cell mem. is inflated
in dissection the pleura may often 
be seen elevated In another
variety the air is effused into the
cell mem. between the lobules of the
lungs) In vesicular emphysema
this rhoncus is not always found
but in the interlobular emphysema 
it is very manifest


The sound is a crackling one, like the
burning of hemlock leaves or like blow
into a dry bladder. Sounds as if air was
entering dried lungs
6th Some authors add the cavernous
found when there are cavities, formed
from tubercles, or from gangrene or from 
abscesses Tubercular excavations
generally contain some fluid, which 
gives rise to a gurgling sound. We
have likewise the term “amphoric resonance
or atricular buzzing, which 
is caused by the communication of the 
cavern by a small orifice resembles
the sound made by blowing into a large
vial When there is no fluid
we have the cavernous respiration
of which the amphoric is a variety
Some make this a variety of the mucous ronchus
Some persons breathe so 
feebly that it will be advisable
to request the patient to make a full & 
quick respiration Otherwise he may 
not notice an engorgement which the 


ordinary painful & cautious respiration
may not slow and he
may suppose a part to be completely
obstructed which which will be [illegible] to be not [illegible] upon
a full & quick respiration
It will also be useful
probably to the patient to make occasionally 
a free respiration especially 
in the commencement & in 
the resolution of pneumonitis (N.B.
when pneum. is going off we hear
the crepitus caused by the air beginning 
to reenter the cells)
Also in incipient adhesions of the
pleura, we may make use of the
same means. Dr H.’s own case
He felt a sense of tearing
Emphysema will only 


Patholog. cond. of the voice
1st Tracheophony or layrngoptony
2 Bronchophony 3d
4th Pectoriolquy
The two first are heard in health 
in limited portions of the chest however
The air of the lungs being in distinct
cells we have a compound medium
but when the lungs are hepatised or
hardened with tubercles So also if
one lung has been entirely destroyed
Case of a child foreign body in the
lung infl. supp. vom.  & prod. of pus
child recovered from the sound
the lung was considered healthy
afterwards a year after the child died
of scarlet fever & the lung was found wanting # 
When apart of a lung is solidified
we find a dull sound upon percussion 
we hear bronchial respiration & bronchophony


Introduction of the catheter
During labour the neck of the bladder 
is often much elongated, and you may 
have to pass the catheter directly upward
Next attend to the child
Be careful that the room is warm
that the child does not take cold
Keep a cloth warmed at the fire
against the birth of the child
The body of a new born child
should be cleansed of a white unctuous
substance, which resembles tar, by 
rubbing with lard and wiping with 
a soft cloth. Then the child, if vigorous 
may be washed with soap & water
Others, after rubbing off the 
lard, sprinkle over wheat flour or 
starch 




Aegophony or Haegophony
goat like tremulous, bleating
voice resounds through a thin stratum of fluid
Pathogn. of empyema
collection of [serum] (Pleuritis)
Commonly not distin. from 
bronchoph. by the inexperienced
It is like a kind of silvery voice vibrating
on the surface of the lungs. Apply 
the cylinder firmly on the chest the ear
to the stethos. lightly (if hard pressed on
it, it will sound like bronchoph.)
When the liquid is small, 
aegoph. will be heard only at the lower
portion of the lung But if we hear
the sound near the root of the lungs (between
the scapulae) we may conclude the 
collection to be large
In strongly marked cases it
may be distinguished by its shrill sharp
sound also by seeming like an echo
of the voice often also the seat of it
may shift with a change of position



Pectoriloquy
the resounding of the voice from within a 
cavity communicating with the tracheae
or bronchia Caused by softened tubercles,
by separation of gangrenous
[eschous] by abscesses formed in any way 
by openings into the mediastinum was perhaps
& perhaps also into the liver
Pathogn. principally of phthisis
In perfect pectoril. the voice
seems at the end of the steth. & often
seems louder In imperfect the voice
does not seem to traverse the whole length
of the instrum. or
Doubtful pectoril. sound slike
aegophog or is too obscure to be defined
In perfect. pect. an amphoric resonance
or cavernous rhoncus will accompany it
and there will be obscured in the
imperfect
If excavations exist in the 
lungs, they can generally be detected by 
the stethoscope & before the use of the
steth. they could not as there is often 


no pain in their region In some
few cases the information conveyed will 
be imperfect or doubtful, but the instrument
is valuable
Pectoril. is modif. by the nat. tone
of the voice clearer & more distinct
when the voice is high though perhaps
less loud. Hence the nat. resonance
of a sharp toned voice may be clearer
than a true pectoriliquy, in the axilla, for
instance, when the voice is grave. But
we can generally determine by comparing
the opposite sides of the chest
2nd modified by the size of the
cavity but then a cavity is large as  a 
pea! will render a true petoriliquy 
5 by the situation of the cavity if it
is deep in the substance, the pectoril.
will be far less clear than when it is
near the surface but when very 
near & with thin collapsing sides
we have only the veiled puff a
var. of cavernous rhonc.
4th by the  slope of the cavity
louder & clearer of sound & smooth very 


loud indeed when the cavity is lined with
a cartilag. sub. Ragged an obscure sound cavities yield
5 by the opening several fistulous
opening will much obscure the sound 
6 more distinct, when the cavity is perfectly
empty sometimes the cavity will be 
filled one day & empty another according
to the abundance & facility of expectoration
Hence, in general, pectoriloquy
indicates a cavity, but a cavity may not
give pect. still there may be other
sighs, as amphoric resonance


Signs given by resp. & voice
1st amphoric resonance & metallic
tinkling.
1st is like blowing into
a vial 2nd like striking a short
metallic cord, or a wine glass or 
tumbler. Both indicate a large
cavity with hard unyielding walls
& filled principally with air & communicating 
by a small orifice
Commonly cav.  resp. amph. res.
& met. tinkling are varieties of the 
cough & [speck.]
Auscultation of the cough
The phenomena are intermediate
between those of the voice & the respir.
Cavernous cough indicates excavations
& cav. rhonc. is made more manifest
by coughing
Also by requesting the patient to cough we
can obtain a full inspiration


1st Clavicular over the clavicle
2nd Infraclavicular from the clavicle to the 4th rib
3d [Mammary] 8th
4th Infram from 8th to cart
3 sternal regions
5 Superior sternal region
6 Middle
7 Inferior
8th Axillary reg. to the 4th rib
9th Lateral reg. fr 4th to 8
10 Inferior lateral reg fr 8th to [cartilage]
11th Acromial ac. proc. of scap
& above
12th Scrofular space of the scap.
Some make superior & inf. scap. reg.
separated by the spine
13 Interscep (2 of them
14 Inferior dorsal (2 of them)


Diseases
Pneumonitis more fatal than any other
acute disease. Infl. of lungs etc. vide Good
To be distinguished from bronchitis & 
pleuritis. Though it may be complicated
with one or both
3 stage 1st obstruction or engagement
2nd hepatization 3d purulent
infiltration
Engorgement is from blood
and serum the lung when cut will 
give a crepitus, & does not sink in water
resp. high small, accelerated, incomplete,
unequal, difficult commonly
cough & pain & expectoration (when no cough or pain 
called latent [illegible] then we must observe the 
respiration & use the stethoscope which 
gives the crepitous rhocus). The 
modification of the rhoncus gives the character
the fluid engorged (if bloody crepitant) if serum, subcrepitant.
Hepatization has the air cells entirely 
obstructed lung sark red sinks in 
water called also [carnification]
absence of vesic. resp. & [illegible] of bronchial
resp & bronchophony (if near the centre 
of the lungs


puerile respiration (produced by a preternaturally 
vigorous action of the healthy
part of the lungs) occurs in both stages
3d Purulent infiltration into the substance surface of 
the lung straw coloured. Lung humid
& soft fingers easily penetrate it 
softer if from serous engorgement generally 
accompanied at its commencement
by chills mucous rhoncus
Percussion gives no difference in the 
first stage of engorgement grows duller
decidedly dull after the stage of
hepat. commences In hepatization we have bronchphony & bronch. resp.
The three first stages are completed in 
from 6 to 8 days the first two in’
5 days But often the disease is irregular
and the regular course may be broken
up by medication You may find all 
the grades of healthy and morbid respiration
within 4 or 5 inches
After dust both lungs are found
affected for the disease is seldom fatal
when one lung only is affected. Respiration 
of one lung may be entirely gone and yet 



the health be pretty good apparently 
Dr H. has often known one lung completely 
hepatized within 36 or 48 hours,
and within 6 or 8 hours find the
disease entirely transferred to the other
lung
Commonly one lung
undergoes resolution
& then the other is affected
Sometimes however both lungs
are engorged and then of course
a fatal suffocation occurs Especially 
is this the case in pneum. notha
vide Good
Case in which death occurred in an hour
another in 3 hours Such cases
hardly deserve the name of pneumonitis
(inc. inf.) but no definite line can
be drawn between them.
The older writers speak of termination 
in abscesses or gangrene
the matter is disputed.
The truth is a regular circumscribed
cavity containing pus is not found
Proper abscesses occur from tubercles
Occasionally a gangrenous abscess occurs
In such cases we have cavernous



rhoncus
By careful medication & good
nursing, resolution may generally be
brought bout this may occur in 
either of the three stages 
Resolution is effected sometimes effected
in a few hours days and week may 
be required
Stethoscope says all well frequently 
when resolution has commenced from hepatization,
when the general symptoms 
show no mitigation first we hear
crepitation etc. etc.
Resolutions of purulent infiltration
Case related pulse slower than it
ought to be owing to cerebral aff. coma etc.
Rx tinct. sang. zi tinct. cinch. comp.
z8 tablespoonful every ½ hour
In the winter of 1831 & 2 we had
pneumonitis oedematosa In the previous winter
we had a pneumonitis which afforded no stethoscopic
sign the disease was rheumatic & yielded 
to actaea alone. There were all the ordinary 
appearances and progress of pneumonitis, viz
diff. resp. bloody expect. etc. 


In the pneumonitis of 31 & 2 we had
no crepitous rhonchus but a sub crepitous rh.
yet the disease went through the 
regular stages and there was even an
uncommon tendency to suppuration. Some
cases however were mere oedema of the lungs
This according to Lacunec is very rarely 
an idiopathic disease It commonly occurs
as a hydropic. disease of cachectic
habits. Good knew but little of it
he thought it could not be distinguished from 
hydrops thoracis It can readily be distinguished
however by the stethoscope
Dr Hooker thinks the disease has often 
been overlooked. When edema of the lung
has been found after death, it has too 
exclusively been attributed to effusion just
before death. To be sure the effusion
is liable to shift or disappear suddenly 
but we find the same thing in 
edema of the limbs. Within the last 18 mo.
we have had such cases of shifting from 
the limbs thence to the head thence to 
the lungs etc.


Dr Hooker thinks that ½ of our fatal
cases of disease terminated in hydrocephalus
Instead of 30 or 40 according to the bills
of mortality, he thinks we may say at least
130. The intellect was not in general materially 
affected
[Lae???]’s account of edema of the lungs
is not a good one. The pathog. signs are
progressive dullness upon percussion & 
sub crepitous rhoncus His subcrepit. rho is
rather a super crepitous rho caused by fluid in large bronchiae
in [illegible] cases.
Haemoptysis
Called also pulmonary apoplexy IT
is an effusion of blood into the substance
Stethoscope shows a crepitus
rhon
Hydrops thoracis
Good says the only decisive indication
is a fluctuation but this can scarcely 
ever be observed
Percussion gives a dull sound
Haegophony exists in the first stage q.v. In the advanced
stages no respiration can be observed 
A very rare idiopathic disease


Empyema detected
in a similar manner
Pleuritis
Acute pain difficulty of lying on
the affected side (yet when adhesions exist
the weight of the lung renders it more
painful to lie on the opposite side
There is bloody sputum & cough
But effusion of serum generally takes
place & then we have haegiophony
Frequently the effusion becomes concrete
& tough and hard, perhaps cartilaginous
Laennec has observed a contraction of
that side of the chest (in the young the
lung of that side not growing so fast)
Pleuorpneumitis
Pleuralgia a rheumatic aff. of
the intercostal muscles relieved by 
opium, actaea or some narcotic
Stethoscope shows no signs of pneumonitis
hence valuable, negatively 


Emphysema
1st Pulmonary or vesicular emphys. 2nd
Interlobular emph.
The first is an effusion which causes
larger & larger globules
The second generally gives oblong or
triangular collections of air
The crackling (crepitant) rhonchus
indicates this especially the 2nd
Caused generally some obstruction 
of one or more of the bronchial vessels
The case of the child who had never spoken 
loud (in Broadway) exhibited emphysema
of the lungs. Tumours & croup
have the same effect. Hepatization or
tubercular degeneration or some [illegible]
of a part of the lungs may cause an emphysema 
of other portions. This is one of the most
common causes. Yet the p.m. ex. shows
emphysema we do not necessarily find
that the stethoscope has given indication
Symptoms are hurried and laboured
respiration lips livid, from 
want of decarbonization of the blood
Easily out of breath etc.


Stethoscopic signs of it are obscure the
respiratory sound is said to be feebler
The sound of percussion is clearer however
Little has been known of this disease until 
of late years
Pneumo thorax
Pneumato thorax might be called
emphysema thoracis. Not distinctly 
described by Good It is a collection 
of air in the cavity of the pleura 
First memoir on the subject by [Itard]
1803? May be caused by a 
wound of the thorax by a communication
between the bronchiae & the cavity of the
pleura by putrefaction and extrication 
of gas
More or less inf. will be apt
to be caused.
Percussion gives a remarkably clear sound 
steth. gives not resp. sound on the affected
side on the opposite side the respiratory
sound will be clearer than natural
If there is a communication between the 


cavity of the pleura & the bronchiae we
have amphoric resonance & occasionally 
upon coughing or speaking, the metallic tinkling
This affection is commonly complicated
with presence of fluid. Inflammation 
caused by the air will be apt to produce
fluid. In this variety we may make
use of what is called the Hippocratic succession
Concretions of the lungs
We find them bony or cartilaginous or chalky
in p.m. exam. especially in old cases
of phthisis. Laennec thinks they are
tubercles which have been cured.
Black pulmonary matter upon 
the surface is found more abundantly 
after pulmonary diseases and phthisis
but found more or less where there had been
no pulmonary disease. Laennec thinks
it more abundant in blacksmiths
Bex. dyspnoea want investigating.
Good’s dyspn. includes 4 or 5
distinct diseases. Sometimes we have 


a sibilant rhoncus. Sometimes it
is caused by emphysema of the lungs.
Phthisis
most of the recent French writers restrict
the term to tubercular phthisis
Cullen considered it a sequel of haemoptysis.
but the latter might with
more propriety be considered a sequel
of the former. Haemoptysis rarely
leads to phthisis.
Good has P.  catarrhiulis P apostematosa
& P. tubercularis. Apostemes,
with excavations, very rarely 
exist, in the lungs, as has now been 
ascertained
P.m. ex. in Paris show that ulceration 
of the bronchial membrane is
(almost) always connected with tubercles
the question is which is the primary 
disease. The French think the 
latter is the primary disease
Of tubercular phthisis
Tubercles are small tumours (tuber)


They commence greyish bout the size
of a grain of mustard (miliary tubercles)
Colour deeper in adults
In examinations we may find not more
than a dozen tubercles or thousands 
Tubercles are found also in other parts
of the body particularly upon the intestines
and in the liver, spleen. etc.
When they become large they first soften
internally then discharge. “Crude
tubercle” collections of non-discharging
tubercles
Tubercles may exist at a very
early age 2 or 3 years. They may be
inherited in infancy. Case of a child of 
3 months. They have been found in 
the fetus 
No one symptom is constantly 
met with in phthisis. Cough, expectoration,
pain etc. may be absent. It is 
doubtful whether the tubercles and ulcerations 
of themselves cause pain.
In this disease the physical signs
generally come too late.


When suppuration and excavation occur
we have mucous rhonchus cavernous
rhonchus and pectoriloquy q.v.
Curability Those who make
the least pretensions do as well as any 
The disease may mitigate and apparently 
cease in summer & revive again
in the winter
It is difficult to get leave to 
examine the bodies of drunkards
There is no doubt that confirmed
phthisis is occasionally cured as shown 
by steth. & p.m. examinations
Affections of the heart
No part of the body is subject to a greater
variety of affections Corvisart
produced the first valuable work
An enlarged heart will be indicated 
by percussion though the pericardium distended with water will give
the same sound
Manual examination is better
Place your hand over the heart & judge
of the regularity etc.


But the steth. is still better & also
shows new phenom 
1st sounds
1 impulse or shock
3d extent of the chest over which the pulsations extend
4th rhythm
1st By the stethoscope we hear two 
sounds first duller & longer then a shorter
& sharper. The former is isochronous 
with the pulse
2nd an impulse on the ear is felt at the
time of the first sound. In children & 
thin chested persons the second may have
a slight impulse
3d extent generally small In fat persons
we have not more than an inch of extent
the extent is increased by high
living etc. & vice versa
4th rhythm i.e. order of succession now
receives much attention cannot be 
thoroughly explained as to its causes. Still
valuable indications may result from it
Laennec says the first sound is produced
by the systole of the ventricles the second


when the auricles contract then a 
period of repose so that ¼ of the
time is occupied by a state of repose
In 1828 Mr. Turner maintained that
the auricles contracted first and was
followed so immediately by that of the
ventricles so that both together cause the
first long dull sound Mr. Turner
also thinks the second sound made by the
beating of the heart (in a diastole) again
inst. the pericardium. Many other
hypotheses have been advanced since
We must conclude Laennec’s hypothesis
to be unfounded. A later hypothesis
supposed the dilation caused the sounds
Another supposes the sound caused 
by the striking together of the sides of the 
ventricles but then the ventricles are
never empty
[Refutation] of Corrigan and Haycraft
Dr Hope has published lately a large octavo
volume on this subject.
1st the auricle contracts so immediately
before the ventricles as to make but one 
sound


2nd the extent of the auricular contraction 
is very small & incomplete
3d the ventricular contraction is the cause
of the impulse & coincides with the pulse
at the wrist
4th the impulse is made by the apex of 
the heart
5th the ventricular
6th the ventricles do not [illegible] themselves
7th
8 after the diastole the ventricles remain
apparen
1st sound caused by systol 2nd by the
diastole of the ventricle
Rhythm 1st auric. syst. 2nd ventric.
sys
3d v. [illegible]
4 v. repose towards the termination of
which auricles begin to contract
Dr Hope attributes the sound to the
agitation of the blood in the ventricles
Dr Hope attributes one sound to the
active dilatation of the heart [illegible]
or elastic



1st mot. auric systole
2nd immediately followed by ventricular
systole & 1st sound
Dr H. thinks the 1st sound produced
by the closure of the auricular vent. valves
& the second by those of the arteries
The sudden arrest of the regurgitation
causes the sounds
The sound occurs at the times of 
the closure of the valves
[illegible] of the sound is such as
might be expected from the striking together
of the valves & the sudden check
of the regurgitation hence the second 
sound is like the lapping of a dog or 
the snapping of a whip
The second sound (by the auric. vent. valv.)
is more gradual as it should be also
the sound is more dull
Dr Hook thinks the first sound
is caused by more than one circumstance
The impulse also is caused (he thinks) by 


the apex of the heart and also by an internal
abrupt succussion caused probably 
by the auricular vent. valves and the
reaction of the chordae tendinae colum.
[illegible] etc. upon the whole mass of the
arterial valve
Dr H. thinks Dr Hope’s account
of the order of the action of the heart is the
tone one
Hence the first sound 
is heard lower down than the first opposite
the apex of the heart the sound
being conducted by the dense contracting
ventricle & coinciding with the impulse
The first sound
1st Hypertrophy of the heart muscle
larger than natural contracts
slower & stronger Impulse stronger less sudden sound
more prolonged less sharp because
the valves close less suddenly 


2nd Dilatation of heart muscle
thinner hence contract more
rapidly but less strongly So too 
the sounds become preternaturally 
abrupt, loud & sharp
In a high degree of hypertrophy
the sound is scarcely perceptible
3d Contraction of the orifices
of the heart
We have the bellows the rasp
serrate & thin whizzing murmurs all varieties
of the same Caused generally by 
diminution of size of cardiac orifices
but often by regurgitations (perhaps
more frequently The murmur 
may exist before death for months & yet
p.m. ex. show no disease of heart
It is observed that in arteries
It is heard in the arteries of the placenta
Slight derangement however may exist about
the valves and not be detected by 
dissection e.g. relaxation of the chord. tend.
It is found that excessive depletion causes
the bellows murmur from this cause or 
a similar one. Dilatation of the heart will 


Cause bellows murmur produced by 
imperfect closure of valves
A murmur rarely supercedes
the second sound the arterial valves
are rarely completely ossified
Simple dilatation of heart
Walls thin heart weakened in action
palpitation but (according to the general law) acts
quicker pulse quick feeble respiration
labored edema of extremities livid
& pale & leaden skin these are affections 
symptomatic of the general affection
If the left cavities are dilated
& the right healthy the lungs are
oppressed edema etc.
If the right sides of heart are diluted
the left continuing healthy, we have edema
of extremities congestion in grain etc.
a pathogn. [symptom] is swelling of jugular
veins. (N.B. pulsation of jugular
is produced by imperfection of the [illegible]
valves manual examination 


shows a dilated heart but not clearly 
which side is affected
Auscultat. gives a feebler impulse & shorter
sharper & clearer sound the extent
of the sounds is increased even extending
into clavicular & axillary & acromial
region
Generally both sides are diluted
but commonly one side more than another
The early stages of dilat. can scarcely
be distinguished from nervous palpit. of
[illegible] etc. (apply stethoscope 
frequently to prevent patients being
alarmed and excited by it N.B. In fevers
steth. useful in conjunction with 
feeling pulse, gives more certain signs)
The bellows murmur is generally 
heard caused by imperfect closure
of ariculo-ventricular valves
Now laennec would lead the [illegible]
to suppose that increased clearness of 
sound attends dilatation But when
the dilat. is excessive the sound is obscured
or superseded by the rushing bellows
murmur



The stethoscope gives no signs of 
dilatation of the auricles (Laennec
was mistaken his work on the lings
is nearly a perfect one)
Hypertrophy
morbid increase of muscular
substance of heart with thickening of its
parietes Excessive growth
weight increased
1st [Chicentric], 2nd Eccentric & 3d
simple hypert.
1st Case the grown incroaches 
on the cavities & diminishes the cavity
Simple is growth outwards merely 
Excentric is dilated & grows thickened outwards
also (vide Bertin) Corvisart
was acquainted only with the last
The two former occur more frequently 
in children & are frequently
congenital (specimen exhibited of
a congenital concentric hypertrophy N.B.
the heart was larger than the childs fist
larger than natural walls enormously 
thick cavity almost obliterated)


N.B open foramen ovale is given
as a cause of such cases then probably 
the hypertrophy is the principal evil.
The for. ovale is generally open for 
3 weeks after birth
The child above was restless from 
birth hemorrhage from umbilical
arteries (caused by strong power of heart)
palpitation very strong great
effusion into cavity of pleura
(hemorrhagic pleurisy) Child
moaned all the while put its hand
to its head etc. right side of heart 
thicker hence effusions in lungs
Tendency to inflammation found
all over the body
The apoplectic habit especially 
predisposed to hypertrophy but
sometimes the sanguine & robust
have dilatation & the feeble & cachectic
have hypertrophy
Pulse in hypertrophy strong
& slow (strength of heart without 


quickness as above) If right side
is hypertrophied the lungs are affected
& [illegible] left is the head will be
affected with serous apoplexy.
Stethoscope gives a slow strong
dull prolonged heavy impulse & 
sound In the left ventricle about
the 5th & 6th ribs in right
about lower part of sternum
Excentric hypert.
by no means uncommon occurs in 
adults incredible size sometimes
Dr Duncan found one weighing 32 oz.
(nat. weight is about 10 oz.) 7 inches long
& f in. broad
Stethoscopic signs are a 
union of dilat. & of simple hyper.
impulse extensive sound sharper
& duller? (more obscure in
its signs)
Polypi
Coagulated lymph questioned whether
formed before death or at death more
generally supposed that they do form before death


Notes of Prof. Knights Lectures
copied principally from Mr. Osgood’s
notes
Curvature of spine
Polypi were very remarkable last 
winter during the hydropic diathes
specimen shown extending through 
as far as the radial artery
Stethoscope to fractures
gives a more distinct & precisely 
located sound
Stethoscope in pregnancy
Gives first the pulsat. & sound of the
fetal heart & the blowing pulsation
through the placenta (a bellows murmur
of the placental arteries which is synchronous
with the pulse of the woman
Both are audible to the stethoscope & to the
ear The stethoscope is preferable from 
considerations of convenience & delicacy
[illegible] sound not heard before 3 or 4th
month Fetal heart heard [illegible] afterwards towards
the end of pregnancy Twins are predicted thus!
Bellows murmur of iliac arteries easily distinguished
Fetal heart gives a double clik and then is silent period


Fracture of clavicle
Mistake often made in supposing
that the sternal end rises, & in endeavouring
consequently to keep it down.
It is the scapular portion which requires 
to be kept in place
Dislocation of last phalanx 
of thumb
Instead of vainly endeavouring
to make sufficient extension 
bend the phalanx back almost to a 
right angle thus get one edge to 
catch upon another & then reduce by 
the lever principle
Bending of the long bones in 
children
Prof. K. has met with frequent
instances of this in children a fracture 
perhaps on the convex side symptoms
distortion with stiffness etc.
Fracture near the head of the 
long bones of children, occurring 


in a part not ossified, yields no crepitus
Amputation of the last or third 
phalanges of the fingers or toes
When swollen your knife may slip
by the joint & cut into the soft cushion
of the ultimate extremity & deceive
you be on your guard
Os femoria
The books represent the neck as 
smaller & they then account for fracture
there But both circumference
& the diameter from above downwards
is in fact greater
The body of the bones may be 
destroyed by disease and the [illegible]
remain
Tibia
When you set a broken tibia bear in 
mind the natural lateral curvature
of its anterior edge
Ankle joint
Dislocation backwards and forwards on 
rare occurrence. [illegible] inw. [illegible] with 


fract. of int. [mall.] Disloc. outwards
generally accompanied with fract. of fib.
1/3 or ¼ [illegible] way upwards superior fragment
of fib. retaining its nat. position
Tarsus & metatarsus
Tarsal bones very rarely dislocated
except in the practice of nat. bone set.
Prof. K. has been informed on good
authority of one or two instances
In amput. foot at tarsus bear in 
mind the uneven line caused by the projection
backward of the second met. bone
or Near the articulation of the
fibula with the astralagus, and a little 
before if three is a small cavity between
the anterior ends of the astralagus
and os calcis which can be readily felt
through the integument This often almost 
[illegible] filled up in sprains, & often
mistaken for a dislocation of a tarsal bone
In amputating at the tarsus the
land marks are the projection of the 
internal cuneiform bone & the projection of the 
metat. bone of lit. toe The former has 


a bursa on its top which is liable to 
effusion and swelling from pressure as
of a boot cured by abstracting the pressure.
The project of metatarsal
bone of lit. toe often mistaken by 
patients for something wrong
Sprains of ankle joint
They are affections of the tendons of the librating muscles
& the affection is either an injury 
of the tendons themselves or a displacement
from the sheath of those of the
external libration muscles
Calf of the leg
Soreness, long continued, & lameness
caused probably by separation of muscular
fibres from tend. of [gastro???]
It has been attributed injury often [illegible]
of plantaris
Wrist hand fingers
Pus formed under the brachial aponeurosis
may point in the palm of the 
hand. The tendons of the fingers are


at first in one common sheath &
then the separate in order to go to the
several fingers. In labouring men
these separate tendons sometimes adhere
to their sheaths causing a curvation and
stiffness of the fingers and a prominence
under the skin when the finger is bent
tendon feeling rounder and harder 
than natural This is not mentioned in 
the books
Ear diseases of 
Always examine for cerumen in cases
of deafness, by throwing the suns rays
strongly into the ear. Deafness from 
this cause occurs oftenest in elderly 
people. The wax gradually accumulates,
but deafness does not occur
until the closure is complete
Sometimes there is a thin coating of cerumen 
over the membrane tymp. destroying 
the [shining] appearance which it 
shd present when healthy. The lining
cuticle of the ext. auditory canal, instead
of secreting cerumen may secrete 


pus without abrasion of surface
When the eustachian tube is closed
puncture the memb. tymp. in the 
lower and anterior part to avoid the
small bones not piercing so [illegible]
a quarter of an inch through
Insects in the ear will be destroyed
by tinct. camphor. Foreign bodies
may generally be removed by a 
scoop. Case a small stone closely 
fitting the cavity Col. Blake pushed
through a tube a piece of cotton dipped
in any alcoholic solution of shellac
when the alc. had evaporated 
the stone was readily drawn out by 
means of the fibres of cotton
Diseases of internal ear Ulceration 
may take place in the muc.
mem. of this part. If the small bones
are destroyed hearing will remain but 
if the labyrinth is destroyed, hearing is lost.’



Puncta Sachrymalia
The course through the superior [illegible]
is the most direct Exceedingly difficult
to introduce a probe through
the puncta half the time we do not 
pass the probe into the sac when we
think we do
Couching
Prof. Knight prefers the posterior
operation for depression 
The [lens] is always depressed
into the vitreous humour there is not 
room in the posterior chamber of the aqueous
humour. Be sure to have the
needle far enough behind to avoid
the ciliary body
Laceration of capsule of [lens]
is performed anteriorly & the aqueous
humours entering though the opening
made by laceration, absorbs
the lens


Foreign bodies in the nose
are generally in the lower sometimes
in the middle meatus
Tonsils or glandulae amygdalae
are between the palate half arches
are often enlarged Their [illegible]
orifices are occasionally filled
with a semi-purulent, or a curdy
matter which may give their surface
the appearance of an ulcerated
one.
Throat foreign bodies in 
Thee when in the aesophagus are either
at its upper extremity in the root of
half cul de sac formed by embrace
of the larynx by the lower end
of the pharynx & then they may be 
swept out by the finger & they 
are at the cardiac orifice of the 
stomach In the former case they 
may often be seen & if we introduce the
finger we must be careful not to mistake
the projecting horns of the os hyoides 
for foreign bodies


Prof. K. has known an ulcer to eat
through the fold of membrane which 
extends literally on both sides of the
epiglottis, so that the passage to the 
larynx could not be protected
death ensued
Fraenum Linguae
The gone is more bound down by 
this fold of the muc. mem. in some individuals
than in others. If it necessary
to divide it, let the incision be
made near the floor of the mouth, to avoid
the [illegible] arteries The small glandular
bodies seen under the membrane are only parts of the sublingual gland
Uvula
when enlarged may occasion a dangerous 
chronic cough. Its removal [shortening] has never
been followed by worse consequences
than a slight subsequent hoarseness


Venesection
The basilic vein is apt to be a rolling
vein. The cephalic is apt to be 
small and deep seated. The median
is most superficial &most
firmly fixed. In order to 
be sure of avoiding the brachial artery
feel for it. The position of the superficial nerve 
we cannot calculate on and no 
one is to blame for wounding it. Prof.
I is incredulous about the injurious consequences 
of wounding it. Avoid 
pricking the tendinous expansion of
the biceps infl. there will be troublesome
Flexors and Extensors
The extensors are the strongest but
the flexors of the legs are the shortest
so that they are completely at rest
only when the limbs are flexed because
we like and sit so much



Bursae mucosae
There is one on the anterior surface
of the patella & one on the olecranon.
There is one under the 
tendon of the rectus femoris which 
always communicates with the
knee joint. There is a corresponding
one below the joint which sometimes
is separate from it
Hip joint
There sometimes occurs after a fall 
or other injury an utter [illegible] of
this joint, with violent pain and 
soreness & requiring many weeks for 
recovery the cause of which is unknown
(acute infl. of Prof Hubbard?)
Some have thought this effect caused 
by bruise of synov. memb. cart. etc.
or by fract. without displacement
Prof. K. has had 2 cases 



Curvature of Spine
First symptom may be a slipping
of the [illegible] from the shoulder
or a projection of the lower angle
of one of the scapulae, mistaken for 
a tumour and sometimes poulticed
etc. for a long time one hip 
may project
The first curve causes a 
second compensating curve, to preserve
the balance of the body.
Examine for curvatures 
by means of a string stretched along 
the spinous processes. The place of the original
curve will generally be [illegible]
indicated
by tenderness or pressure
Cure by strengthening the muscles by 
exercise
Spina bifida
Congenita It has been proposed to 
puncture the tumour this may be
done by a small orifice but a fatal
infl. may ensue. If the tumour
communicates with the brain, pressure
on it will produce symptoms 
of pressure on the brain



Circumflex arteries
In opening [illegible] abscesses about the knee
or elbow joint you are very liable
to wound some one of the numerous
circumflex or recurrent branch hence
make a free incision that you may 
be able to tie an artery if necessary
Arteriotomy
is performed on the temporal art.
[Arterio] feel under the finger much 
larger and nearer the surface than 
they really are. The artery should
not be completely divided. It is 
different to hit it longitudinally
hence & make the incision 
obliquely
Local depletion
May be serviceable in local infl.
Case wound of the hand. The 
divided artery had regular periodical 
[illegible] of bleeding for a while
and then ceasing for a few hours. This
proves an independent local action 


Mem. Obtain the minutes of 
Prof. Knight’s case of partial dislocation
of a cervical vertebra








E. D North
snuff taker !!!!
5
obstetrics
& 
Diseases of women










































5
Materia
Medica
(rear)
Diseases of women.
obs (front)












Lecture 2nd
Pelvis 1st The sacrum is nearly 
equilabral about 4 or 5 inches in each side
In the female pelvis the concavity of the sacrum
(perpendicularly) is about ¾ of an inch
deep The last vertebra inclines backwards
from the top of the sacrum, which is called 
the promontory of the pelvis.
The coccyx is moveable & curves
much forwards
The Ilius forms by [their] [illegible]
the great basin of the pelvis properly a part
of the abdomen. There are two anterior & 
two posterior spinous processes. The top of 
the pelvis is bounded y the linea ileo pectinea
The ischium has an anterior
& a posterior spine from the latter of which 
proceeds the internal [sacro??] ischeatic ligaments of each side
The pubis is the smallest bone
The ischium & pubis surround the foramen ovale 
Ligaments 1st sacro ischiatic
internal from the spine of the ischum 2nd sacro
ischiatic external from the tuberosity of the
ischium to 


3d Sacro iliac ligaments
Dimensions of the pelvis 1st the superior
strait at the line ileopectinea has
its [antero] posterior from the promontory of 
the sacrum to the symphisis, is 4 ½ or 5 in.
The transverse, at right angles to this, is 4 ¼ or
4 ½ in. The oblique, from the sacro iliac
symphisis to the acetabulum a little shorter
than the last
The inferior strait has its diameters
not parallel to those of the superior
The oblique are measured by Prof [Burns]
from the middle of the sacro ischiatic ligaments
to the junction of the rami of the ischia
& pubes


The axes of the strait
That of the superior strait is an
imaginary line from the umbilicus to about the
one third of the sacrum
That of the inferior strait
It has been thought that at about
the period of labour, the symphisis
pubis 
Deformed pelvises
Every variation of shape does not constitute a
deformity
1st The pelvis may be unnaturally
large in all its dimensions and this is a 
most deformity The uterus remains in th e
pelvis, pressing upon the rectum & bladder so 
as often to confine the patient to her bed during’
the whole period of gestation. The delivery 
also is too speedy & prolapsus uteri, fluor albus
etc. follows delivery. Case of this kind 
M.S.


2 Alterations in the shape of the pelvis
Occur always from rickets, [malacast??] etc
All the cases, almost, which occur in this
country are foreign women. All which Prof. B.
has seen have been Irish women.
The diameter altered is
almost always the antero posterior diameter.
It is laid down as a rule by 
European
The cavity of the pelvis may 
be badly shaped. The sacrum may be 
too straight. It may also be too curved
& throw the point of the coccyx too far forward
The coccyx also may be anchylosed. Bony 
tumours also may exist
Instruments have been
invented for measuring the pelvis. Those
which have to be introduced within the pelvis
are objectionable especially in [illegible]


Baudelacque’s callipers are very accurate
allowing 3 inches for the soft parts & adding
2 lines for a fleshy persons
The hand & finger however
are the best instruments, at the period of labour.
If the finger will not reach the 
promontory of the sacrum we may be
sure that the antero posterior diameter is sufficiently 
large. If the whole hand can be 
introduced
Diameter of the had. 
The long diam. is 5 in. from the occiput
to the chin. The longitudinal 4 ¼ in.  from the 
forehead to the occiput. The perpendicular
is the shortest These diameters may be diminished
5 or 6 lines, not
The neck cannot be twisted
more than a quarter of a [circle]


External organs
Immediately below the clitoris


Menstruation
Commences at first after having been preceded
by general disturbance of the health pains
in the back, hips & loins, disturbance of the bowels
etc. perhaps hysterical symptoms During
the continuance (about 4 days) of the evacuation 
a pale circle surrounds the eyes
It is ascertained from the examination of 
cases of procidentia that the discharge is from 
the uterus & not from the vagina
In this country menstruation commences
on an average at the age of from 14 to 16
The earlier the commencement the earlier the
cessation.
Conception
many theories 1st that the semen is carried
into the fallopian tubes 2nd


Changes produced by conception
The cavity of the uterus enlarges and soon 
a membrane forms on its inner surface
The ovum contained in two membranes passes
down the fallopian tubes and pushes out this
deciduous membrane


The fetus first appears in the ovum as a 
mucilaginous cloud
At the end of 6 weeks the fetus is about
½ an inch long and shaped like a crescent 
or bean. At two months the fetus is 2 inches
long about the size of a bean At 3 months it is 4 or 5 inches 
long external parts perfectly developed the
genitals being large and those of the [illegible]
from their size resembling those of the male
At 6 months the hair is visible the motions 
are felt in the abdomen the relative length
middle near the body of sternum weight 2 pounds
of the head and upper part of the body is greater 
At 7 mo. middle half way between navel & stomach
At 8 mo. skin is firmer and whiter, and hairs are
visible on it middle nearer the navel than
the sternum length 16 in. weight 4 or 5 pounds
gall bladder contains bile etc. etc.
At 9 mo. middle at the navel length
19 in. weight upon an average 8 lb. with
us but in France between 6 & 7 lb. Length of
the male with us 23 in. of the fem. 19 ¾ in.
The nourishment of the fetus is difficult
to explain. Probably it is like a vegetable
from the ovum in the first place.
The most prevalent opinion at
the present day is that the fetus is nourished 



from the blood after it has undergone some
change in the placenta. Some facts seem
to prove that the liver changes the blood & 
gives rise to a peculiar secretion albuminous.
Circulation of the Fetus
The most probable opinion at present is
that the fetal blood is oxygenized in the
lungs of the mother, is taken up from the 
placenta by the umbilical veins and carried
under the liver (principally) into the vena 
cava through the single heart back by 
the umbilical artery into the placenta 
again 


Signs of conception and 
pregnancy
Just after conception the
features become sharpened, the eyes are
surrounded by a dark circle The complexion 
pale. The most important sign is
the cessation of the menses but when the woman
has become pregnant while suckling a child, the
menses not having regularly returned, we cannot
reckon from that period, but women in that
case reckon the rather from the motion of the 
child which first occurs between the fourth 
and fifth month The areola of the nipple
is dark Pricking
sensations are experienced in the breasts
Morning sickness occurs and continues
until with about 2 mo. of delivery
By the fourth month the uterus
projects above the pubis is more easily felt in 
a lean subject By the 6th mo. the fundus
will be at the navel By the 7th about an inch
above and the navel protrudes
Usually by the 6th month the
motion of the child can be felt if the hand 
is first dipped in cold water.


By the fourth month the neck of the 
uterus is softer and shorter
The size of the uterus is judged
of by placing the left forefinger
the 
at upper & anterior part of the vagina
& pressing with the right upon 
the fundus just above the pubes you will feel
the pressure of one finger upon the other the
woman must be in a standing posture
Prof. B. thinks gestation may 
be prolonged beyond the ninth month & 
that he has had considerable evidence of 
the fact.
Case related in which parturition
was fully expected much alarm
was excited at its not coming on
& finally it was found that all the signs
of pregnancy which had existed, proceeded
from an enlarged uterus which 
was reduced by proper remedies.


Natural Labour is that where
the face is to the sacrum and the occiput to the
pubes where the [labour] is over within 24 h.
is where it terminates with safety to the mother
and child & the [secundines] come away well
4 stages are distinguished 1t os uteri is
dilated the membranes are protruded
2nd the head turns into the hollow
of the sacrum & presents at the ext. orif.
3d the child is delivered
4 the secondines come away
In the 1st stage we observe 1st the pains 
commence in the back & loins & pass through to  
the pubis in some cases about the loins & 
thighs first Sometimes very irregular [illegible] endeavoring
These first pains are short
not lasing more than about a minute
After the os uteri is dilated to 
about the size of a crown the second stage
commences the pains from being short & cutting
are protracted, with a sense of burning 
down violent skin hot & dry sense 
of inclination to go to stool from the 
pressure of the uterus on the rectum. During
this period the membranes are ruptured


In the third stage the perinaeum bulges
out the woman demands to get up for 
a stool must not be indulged
it is a delusive sensation. The perinaeum
becomes four or five inches broad
Prof. B. puts his right hand upon 
the occiput, & his left upon the perinaeum
he judges of the degree of pressure by 
the fingers of the left hand & resists with 
the right upon the occiput of the child.
The fourchette is [illegible] in the first
labour do not mistake this for ruptures
of perinaeum Vomiting occurs
frequently and is serviceable to the
facility of the labour
Gathering of the waters
This term is applied to the bulging tumour
of the water on the membranes which 
increases in protrusion at every pain 
& appears as if more water was collecting


False pains
Can be distinguished with certainty only 
by the effect of the pains upon the neck of the
uterus the pains produce no pressure upon 
the neck of the uterus & no dilutation of the
os tineae sometimes you can pass your 
finger into the uterus and feel that the
membranes do not become tense by the 
pains.
Often these false pains appear to be
caused by excessive motion of the
child enquire about this in [illegible] labour
the child has little or no motion 
To relieve these false pains after bleeding give opium. The labour
may be a month or two distant.
It is of importance to understand
the progress of a nat. lab. thoroughly 
Examine during a pain in the intervals
the woman may sit or walk about
Keep up her spirits. Make no certain 
prognostic as to the time or at least
fix a distant time so that the end of the labour may 
fall within it. We are often much 
urged to interfere keep out of the room
on this account Suffer no to one attempt to 


bring on a labour as it is [illegible]
Leave the woman often to allow
her an opportunity to pass water. During
the first stage let her be dressed for labour.
Dress the woman in a 
loose dress with her linen tuked up  
under her arms
Prepare the bed by first making it 
up as usual prepare the lower
part by coverings to protect it
Let the woman lie on her left side
with the knees bent, her feet against 
the bed post her head & shoulders raised by pillows tie a handkerchief or
towel around the other bed post for
the woman to take hold of Some
condemn these efforts of the woman, but 
Prof. B. is satisfied of the advantage of them
The only assistance rendered shd be pressure 
on the back
The French lay the wom. on 
the back. Some women prefer a sitting
posture. It is often advisable to change
the posture for particular circumstances
Conduct the choice of the patient 


If we wish to rupture the membranes it will generally be sufficient to press
hard on the membranes with the end of the
finger the membranes will rupture themselves.
If necessary scratch the membrane
with the nail. If the labour
is very rapid rupture the membranes
yourself, that the water and child
may not both be delivered at once
and empty the uterus too suddenly 
Rather hinder than hasten after the 
passage of the head one pain will expel
the shoulders and another the hips 
Generally as soon as the head is 
born and always when the body 
is born, the child cries. First feel for the
pulsation of the cord. If the child does
not breathe (when the air is freely admitted)
blow on its face dash cold water or spirit
on the face & chest wipe out the mouth
first with a dry & then with a moist rag
close the nostrils of the child with the fingers
& then blow gently into its mouth & if necessary
press gently upon the thorax to facilitate
expiration as this may be continued for 


some time keeping the body war
with hot flannels, all the while Apply 
your hand or better your ear to the region 
of the child’s heart
At first the respiration may be very 
feeble & perhaps at first with long interruptions.
Other means are frictions
ammonia etc. to the nostrils & to the 
surface of the body
Some children, after you have
succeeded, have not stamina enough
to support life. Dropsical effusions 
in the thorax may prevent respiration
& the life kept up in such cases by 
the [illegible], for half an hour Prof. B.
has met with such cases but only in children
of hard drinkers
Sometimes a child is apoplectic
from long detention of its head in the
passage in this case, bleed from
the cord ½ oz to 1 oz milking out the blood
inflate the lungs also etc.



The cord as soon as respiration
is established not waiting till the pulsation
ceases in the [illegible] we might have to 
wait ½ an hour or more
Tie with any sort of a string there
is no danger of cutting the vessels with a small
one A piece of wide tape is convenient
Tie tightly or the ligature may become loose
from the shrinking of the [illegible] Sometimes
the arteries are so firm that a ligature will 
not prevent hem. unless the arteries
are pulled out and tied separately.
It is thought by some necessary 
to tie both ends of the [illegible] but it is better
to allow the vessels of the placenta to 
bleed & thus diminish the size of the placenta
except [illegible] cases
As soon as the child is born
pass your hand over the abdomen if it
is firm and hard up to the scrob. cord.
a twin is within if the uterus is contracted
to a ball above the pubes there is merely 
the afterbirth. Generally the pains
commence again in about 8 or 10 min.
When the edge of the placenta arrives


at the vulva take hold of it, twist
it so as to make a roll of the membranes
& thus no part will be torn
off and left.
Next attend to the comfort
of the woman. If not too feeble let
her be immediately removed to the bed
she is to occupy
Place several folds of cloth
upon the abd. & pin a towel around
to give support, to prevent relaxation 
of the uterus & hemorrhage, & for the
comfort of the patient 
The pat. will now be very 
comfortable & happy, but soon come
on the afterpains by which the coagula
of blood are expelled from the uterus
But few women escape without after pains
those who have already had children
are more liable to them
Ergot administered during the labour
prevents or diminishes the afterpains. Prof. B.
has often administered it with this intention only 
Generally ginger & spts applied
vol. lim. zj ol. or zfs
also a poultice in a pillow case of ar.


herbs & bran
These pains are generally much
increased when the child is put to the breast
Until the 5th or safer still, until 
the 9th day, when the lochia terminate,
keep the pat. on panada, arrow root etc.
not giving cordials, in the old fashioned
way
Let the child suck immediately 
to draw off the colostrum to prevent swelling
& infl. of the breast, & retraction of
the nipple, which prevent it from sucking.
The child too needs the purgation
& is apt to lose the instinct for 
sucking
By the third day the lochia
should be washed off from the external
parts and a gentle purgative castor
oil or magnesia shd be given. The 
bladder must be attended to if necessary
apply a fomentation of onions, or if such
things fail introduce a catheter


The lochia comes on about the 3d cease about the 5th day
ultimately the discharge becomes of a light
pink col. The diminution of the
discharge is looked on as a good symptom
unless vary
If excessive, astringents, as port wine 
tinct. ter. jap.
Ultimately give a pill of op & ac. pl.
aa ij gr. once in an hour or two.
If this is not sufficient inject
ac. pl. & opium into the vag.
When the discharge has a cadaverous
smell, is greenish etc. wash
out the uterus with detergent injections
such as lime water & milk decoction
of oak bark etc. support the
pat.


Introduction of the Catheter
During labour the neck of the bladder 
is often elongated & you may have to 
pass the catheter directly upwards
Next attend to the Child
Be careful that the room is so warm
that the child does not take cold
Keep a cloth warmed at the fire
against the birth of the child
The body of a new born child should
be cleansed of a white unctuous substance
which resembles tar, by rubbing
with lard & wiping with a soft cloth
Then the child if vigorous may be
washed with soap and water
Others after rubbing over with lard
sprinkle with wheat flour or starch





Tie the cord by 
The belly band is a piece of flannel
passed about twice round the belly
Sometimes the child will not bear
to be dressed, from feebleness.
If the child grows cold, wrap it up in 
flannels dipped in hot spirit. And
let these children who cannot bear to be dressed,
let them be wrapped in flannel & 
kept in a warm place
If the meconium does not come
away with 12 or 14 hours, give molasses
& water, or honey and water if these
fail give a teaspoonful of bland castor
oil
Look out for retention of urine
It may arise from imperforate hymen 


or from the orifice of the urethra, either
of the male or female, being closed
up with mucus in which case introduce
a probe, a short distance
If the child must be fed give
cows milk 2 parts water 1 part sweetened
with loaf sugar or if it is required 
to be more purgative, with 
brown sugar
Presentations of head


Breach presentations
4 orders 1st back to the left side of the
mother the body rotates and the back is turned
to the [symphisis] pubis if traction is not 
used the arms lie along the body and come
out with it the face presents at the perineum
support the child’s body with your
left hand the chin issues first then 
the rest of the face and the head issues
with a jerk. The danger is in the
stoppage of the circulation of the cord.
A difficulty arises from the largest parts not
being delivered first. Another is in the
cessation of the pains which is abt to take
place
In the 2nd the right hip of the child
presents to the left acetabulum
3d the abdomen of the child presents to 
the abdomen of the mother the body turns
outward comes out obliquely but the head
comes out face upwards
#4th the revers of the 3d


During labour turn the body obliquely 
so as to bring the head into the position 
it is as in the 1st & 2nd
Presentations of the feet
1st the heel towards the pubis which 
eventually becomes the 1st hip presentation
Presentations of the knees
The knees feel harder
Generally best to bring down the feet


Diff. lab. 1at want of relaxation
febrile state do not give stimulants
2nd Want of action Ergot 1 z ergot to zii
water infusion tablespoonf. every 5 m.
The pains of ergot are distinguished by their increasing
continuance
3d too early rupture of memb. e.g. sudden
exertions as lifting sometimes probably from 
weakness of membranes. If the waters
are not drained [illegible] the labour may not
come on for weeks & be easy
Attachment of placenta over os uteri
may be suspected, from frequent & irregular
hemorrhages. Take the first opportunity
of examining while the blood is flowing
but if the flowing has ceased the finger would
break up the coagulence & perhaps bring on 
the flowing.
When the uterus is sufficiently dilated
to admit the finger the placenta may be
detected take care to distinguish it rom 
coagulated blood
When we cannot tell (early in the pregnancy 
5 or 6th month) about the case, treat as for
uterine hemorrhage apply cold in a horisontal
posture. Sugar of lead 5 or 10 grs with 1 gr. o f
opium repeated once or twice in 24 hours
It will produce no poisonous effects unless continued
for several days. If this fails inject
into vag. zii in ½ pt. of warm rain water
this is very effectual. A strong sinapism
between the shoulder is most effectual.
But the best remedy is a plug of alum Rx


a piece about 2 oz in weight made smooth
and passed up. Alum operates as a local stimulant
& the coagula of blood stop at the passage
also. It is usual to tie a piece of tape around it
When the placenta is over the os uteri, the 
labour will be ushered in by a flow of blood
]If we find the os uteri dilated or dilatable
so that we can introduce the hand we should 
immediately pass up the hand and turn
If necessary break through a part of the placenta.
When the breech of the child is
down it will plug up the passage.
But if the woman is nearly exhausted we
must restrain the hem. by proper application
The woman may die before we can turn
the vagina. A sponge is very good. A silk 
handkerchief. Prof. B has used [illegible]
introduced
in small pledgets [illegible] on to the 
tampon and given ergot allowing the tampon
to issue while pains are on and checking
it when they are off (Case related
articular mortis tampon ergot child dead
mother saved)
In other cases we may proceed
then early and afterwards turn?


Instruments
Forceps apt to be delayed too long
Prof. B. recollects no case in which they
were used too soon
Smellie’s [illegible] consisted in 
curving the [clams] The blunt hook
is now put upon the end of the handle
Place the woman left side (English)
back (French) the back generally preferable.
Empty the bladder & rectum previously.
Keep the instruments in a basin of
warm water before using them
Always apply the forceps on the sides
of the head and over the ears so as to embrace
the head in its oblique diameter over the
cheek, over the ear (occiput [illegible] diameter)
The pressure of the forceps lengthens the head
When each blade has been properly applied
the [male] part of the joint, readily enters 
the female part never lock the
forceps by means of force
Head being in 1t position
take the male blade in the left hand & introduce
it along the palm of the right (with a 


waving motion) carry the blade until 
the centre of the clam is opposite the anterior
fontanelle or the sagittal suture. If pain 
is felt, desist because you injure a [illegible] of the vagina with [illegible] be careful about [illegible]
against the ear with the end of the clam Introduce the
other blade with the other hand, in the same way
Draw & wave from side to 
side when you extract
If the head is high up, draw down,
in the first place.
Do not hurry but let the uterus do 
what it will to expel the child
The position for the use of the forceps are
1st vertex to the arch of the pubis
2 the reverse fore head to arch of pubis
3 vertex to the left foramen cot. cav. ? ovale i.e.
the head in the diameter
In this 3d position the handle of the male
blade will pass near the right thigh of
the mother & the head must make its
last turn after you apply the instruments contrive to turn the occiput 
to the arch of the pubis while you draw
4th the reverse of the 3d
7th head corresponding to the transverse


diameter of the pubis the male blade
passes under the arch of the pubis
As to the case when the forceps are to be applied
while the head is above the superior strait,
Prof. B. has never had such a case.
It will be better to turn and deliver by the
feet The cases of this kind where the forceps shd be
introduced must be very rare if any 
Shoulder presentation
Pass one hand up and push up the shoulder
sufficiently to allow the introduction of the
other hand to seize the feet
It may be necessary after the child
is dead to bring down the hip and use
the blunt hook



Locked or impacted head
Two positions sacro [illegible] or transverse
In the first case apply the forceps as before
In the second we are compelled to apply 
them over the face & occiput
As a general rule the forceps
are to be applied to head [illegible]
directs them for the pelvis. Other methods
are better however for a living child
Where there is more want of action
Prof. B. would give ergot instead of 
the forceps
But where the mother, being
vigorous & exhausted by pains & nature
has done all she can do ergot will 
not do good the forceps must be
applied
When the face presents and you 
cannot turn apply the forceps one blade
under the pubes. As you extract turn 
the face (from being transverse) so that the 
chin shall come under the pubess


Vectis
Can be used for extraction Can be used
to hasten the delivery of the face when that is
to the sacrum
The vectis is used principally for changing
the 4th [illegible] to the 1st & in face
presentations to change them to those of
the head
Breech presentations it may 
be worth while to make footling
Blunt Hook
Generally one is sufficient if not
apply both extract by a see saw 
motion
After delivery of the body the
head may be detained the pulsation of 
the cord cease the child make one or 
two convulsive heavings & will soon die
if not soon delivered. Pass the finger
up and give the head an oblique direction 
which will facilitate the delivery
Use the forceps to hasten delivery 


But in this case the vectis may be advantageously
used. Apply it over the occiput?
Foot & knee knee presenting
foot catching against the margin of the pelvis
Not worth while to confuse the memory
with all the varied presentations
IF the back of the neck side of the 
face etc. etc. push up and turn
Where the labour is very slow
& no part present we may suspect
a bad presentation. It will be necessary
to pass the hand up the vagina
& examine if we do not find a hard
body we shall have the hand foot 
belly etc. proceed to turn after
the membranes are ruptured 



Perforatory & crotchet
1st of the cases where the pelvis is too small
a case which does not often happen in this 
country
4 in. may be left to nature 3 ½ will be slow
& may be delivered alive by the forceps
A patient of Dr Hooker’s was delivered
in whom the diameter was 1 8/10 inches caused 
by [mollities] [ossium]. By means of [cephalotoma]
she was delivered & recovered, after 
having a fistula, communication between
the vag. & the neck of the bladder and a
closure of the os uteri
Make perforation with the perforator
then introduce it and break
down the brain., Then use the crotchet
It may be necessary to bring away first
each parietal bone then the frontal taking
care to keep the scalp whole


2nd where the head is unnaturally 
large from dropsy. Here we have
merely to let out the water and may 
use any instrument as a pair of scissors
Caesarean section
Dr Dewees sides with the French.
He says the perforator is more uncertain 
and is dangerous
The French forbid it when the 
child is alive
Retention of Placenta 
It is now agreed that it ought no t
to be suffered to remain
Pass your hand gradually between 
the placenta and uterus (if the placenta
continue to adhere) detaching it as you 
proceed pull upon the cord with the
other hand bring your hand away
after the placenta and not until 
you have felt the contraction of the uterus
upon your hand When Prof. B.
has had an adhering placenta he
has always found a mal-conformation 


of the placenta or walls of uterus as calculous
concretions etc.
Hemorrhage may make it necessary
to detach the placenta immediately 
Hemorrhage a week or more after
delivery
Hourglass contraction
Generally about the neck of the uterus
Prof. B. has scarcely met with a case since
he has adopted the plan of waiting scarcely 
more than ½ an hour before bringing away 
the placenta.
If it occurs pull upon the 
cord and at the same time insinuate
your hand up to the fundus of the uterus
Hemorrhage after delivery is most
apt to occur after quick, easy labours
caused by want of tonic contraction of the 
uterus
Injections of ac. pl. may be used
previous to [extracting] the placenta.
We are recom. also to inject cold 


water or a spiritous tinct. into the 
cord this is powerful & effectual
probably
We must judge of danger
from the exhaustion of the pat. not
from the quantity of blood lost ½ pt
or 1 pt. is generally lost in an ordinary 
labour. Prof. B. always
uses a plug of alum after delivery
of placenta.
Ergot. Prof. B. always uses it
but after delivery of plac. it is apt
to fail Where he has reason to expect 
hem. he gives it before the termination 
of the labour It never
fails & besides this it diminishes the 
after pains.
When life is in danger
use all your means. Carry 
a piece of alum in your hand
into the uterus. Prof. B. prefers
this to a sponge of vinegar. He has
had to wait 15 min. before the uterus
would contract in the last & 
compelled to sit an hour before the 


uterus would expel his hand.
Concealed hem. does not show
externally and uterus becomes distended
with blood. We should never
leave our patients until we have felt
the uterus firmly contracting between
the navel and pubes
Inversion of the uterus
Caused by pulling upon the cord Said also 
to take place spontaneously 
Prof. B. has seen but one or two cases
The indications are to detach the placenta 
and if possible restore the fundus
Symptoms very severe paleness, coldness
vom. conv. etc.
Place the pat. on her back and
pass up your hand and endeavour to push
back the fundus. But if the fundus
is protruded through the os uteri and
the dangerous symptoms result from the 
stricture perhaps all that it will be 
in our power to do, will be to make the
inversion complete and thus relieve the
stricture leaving a prolapsed uterus


Immediately after delivery
If the placenta does not come away 
apply friction etc. to excite contraction
Dr N.B.I. always excites contraction
if the uterus by pulling and swaying
upon the cord. He finds this perfectly 
safe. Prof. B. says it is also
# Compound pregnancy
We can sometimes guess at it in lean
women. In general we may find it 
difficult to determine, from the large
quantities
If after the birth of the first child
Labour is rather slower on account
of the large size of the uterus and that
too with the first child
Pass your hand upon the abdomen
to ascertain the existence of another child
If you find another child, conceal
it from the mother
The presentation is more apt
to be wrong in twin cases
If the pains do not come on again 
within ½ hour give ergot. You 


will then soon feel the bag of water
protruding and if you find them 
a bad presentation as of the shoulder or 
arm, you may easily turn and deliver
Hemorrhage is more apt to occur
Hence generally it will be best to give
ergot after delivery
Not unfrequently a woman has
been left, with a second child in her
uterus. Case related
Commonly the placentae are 
distinct and united merely by membranous
union. The memb. and the waters
are distinct. Sometimes however the
vessels of the two placentas [inosculate]
hence the precaution of tying both ends
of the divided cord.
The delivery of the placentae
is apt to be rather more difficult
Delivery one cord at a time


Presentation of the Cord
Sometimes a foot or a foot and a half
will protrude. These cases are 
difficult. 
It is safer to attempt to turn
and deliver [footling]. It is exceedingly 
difficult to return the cord
and keep it up. We are directed
to wind the cord on a sponge or rag
and push up. It will generally 
however soon come down again
Dr Dewees mode of using catheter
Prof. B. has not tried.
In one case Prof.  B. has
known a knot in the cord.
Deformed children
Give puzzling presentations
Oftenest the bones of the head are imperfect.
Sometimes you feel
the bone hardened brain. Feels
for the face
A more serious case is that of
hydrocephalus. Sometimes the size 
is enormous. Easily distinguished 


by the feel. The scalp protrudes
like the membranes. By pressing
also you may feel the bones of the cranium
and may even push your
finger through the sutures
The child is of course lost hence
you may as well puncture at once
with a lancet. In one case Prof.
B. let out 4 pds?
Signs of a dead child
Coldness shiverings like an ague
when the child dies Breast ceases
to swell and becomes flaccid
A secretion of milk comes on.
A weight is felt falling when the 
woman turns Cessation of mot. in child
When labour comes on, the waters
are fetid the meconium is evacuated
even in a head presentation
The scalp is flaccid, the hair comes
off etc. Yet the only certain 
sign is the want of pulsation in the cord


Rupture of uterus
By a fall, by violence in turning
or by forceps
Severe rending pain cold clammy 
sweats, sickness faintness & 
vomiting
The seat of the rupture may 
be in the fundus, side or neck.
If the child has wholly escaped
into the abdomen, the difficulty is
great. Gastrotomy seems much preferable
to delivery through the 
[illegible] Cases recorded of recovery 


Retention of menses
They may not commence until after the
20th year in the feeble and delicate
This should excite alarm as long as the
other signs of puberty are wanting
If the patient is robust let the
antiphlogistic treatment be followed.
But for the feeble, nervous, leuco-phlegmatic 
etc. prescribe exercise
shower bath warm flannel clothing
Give tonics especially chalybeate
Blood root madder ½ zs 3 times a day
Guaic. 4 z ½ z carb. sod. [illegible]
zjfs alc. 1 pt. Dewee’s tinct. vide Ellis
Blood toor ½ z sulph. zinc aj
aloes zj ft. pil. 60 2 to 3 in
24 hours regulating the dose by the
effect upon the bowels. This is the 
most useful emmenagogue
Blisters on inside of thighs size
of the hand These effected a cure in a 
pat. 27 years old whose aff. had resisted
all remedies
Cupping on inside of thigh has 


also been found beneficial
Cupping the breasts was reccommended
by the older writers
Savin has also strong emmenagogue
power
Retention may be caused
by other affections e.g. phthisis
In such cases emmenagogues shd
not be given
Suppression of menses
Menses may vary much without
ill health. The interval may be
12 or 6 weeks
The most usual cause
is the application of cold symptoms
severe pain in the head back
and loins colic etc. hysteria etc.
Hip bath anodyne injections
V.S. nervines for the hysteria
We may thus cure the immediate aff.
but the discharge will not thus be
made to return. Use of the pediluvium 
bleeding etc. just before 1 week
the next period & so [illegible] the 


discharge
Chronic suppression is to 
be treated like amenorrhea #
Periodical discharges from 
other parts may take place as a substitute
for the menstrual discharge.
This may continue for life. Case related
ulcer on ankle
Deficiency in quantity gives
rise to the same symptoms & shd be
treated like amenorrhoea
Excessive menst. not common
treat as for hemorrhage
Guaiacum is more agreeable in powder
# Carb ir. & pulv. guaic. aa zi
Sang. in powd zfs. aloes zfs. a small
teaspoonful 2 or 3 times a day


Dysmenorrhea Painful m.
very distressing pains resemble
labour pains pains
relieved by the discharge generally 
Caused by irritable uterus
Hip bath opiates hyoscyamus
diaphoretics
For permanent cure use the 
last described pills. Tinct.
guaic. Dr Dewees has cured with 
Prof B. has often failed with it
Deciduous membrane
Pains not relieved until the membrane
is thrown off. Occurs
in unmarried females also prevents
impregnation in the married
There is danger in the doses
of camphor 2 or 3 recommended 
by Dr Dewees. Prof. B. has produced
dangerous convulsions by them
Electricity has cured. repeated
for a week previous to the [illegible]
Use the emmenagogues mentioned 


Decline of menses
A critical period
Predispositioned to organic disease
are most liable to show themselves
at this period. On the other hand
others are then restored to health
In some the discharge stops suddenly 
in some it becomes profuse
or painful or irregular
Bleed 6 or 8 ounces repeatedly 
Keep the bowels open with the bloodroot
and zinc pills. Stimulant are
hardly ever admissible there is generally 
a disposition to plethora


Abortion
Delivery before 6th month especially 
between 2 & 3 & between 5 & 6. Keep 
on the look out. Drastic cath.
injuries reaching high with the hands
thus compressing the abdomen
Death of the fetus indicated by diminution
of all the signs of pregnancy
shrinking of breasts etc.
If you do not know the fetus to be
dead presume it to be alive. Quiet
laudanum etc. Ac. lead sometimes
for hemorrh.


Leucorrhea
Muco purulent discharge At first
a local dis. astring. inject. oak
bark zinc etc. Ascarides may
attend or be the cause Finally 
tonics gum ammoniae & iron cantharid. stopping for
strangury & then repeating Old cases
[illegible] [illegible] copaiba
Green & fetid discharge
Nit. silver one of the best injections
Cant. not important ([illegible])
sulph. zinc &nit. sil. also valuable
a sort of test of the efficiency of canth. is a 
thickening and opacity of the discharge
from the vagina It will not be necessary 
to keep even a light strangury 
& of course we are not to produce 
dysentery Prof. I.
Nit. sil. best inject. 3 or 4 grs. to oz.




Prolapsus uteri
One of the most common & troublesome
complaints takes place at any period
of life
Caused by relax. of vagina Uterus
kept in place almost solely by vag.
Most com. cause leucorrhea
Women with large pelvis more liable
Symptoms weight, uneasiness about 
loins etc.
Almost always accompanied with 
leucorrheal disch.
Cure at first by strengthening the
vagina, by tonics astringent, rest
recumbent posture
Treat for leucorrhea when that accompanies
Easily ascertained by examination 
or by relations of the pat. herself
Tumour recedes when pat. is on 
her back & is easily reduced
in this posture
Strong sol. of oak bark sulph.
zinc etc. after replacing the 
uterus & confining pat. to her back 


Continue with this treatment
[tonics] etc.
We are often called on when 
the diseases does not exist & we
find disease of [rectum] and vagina.
We do not find the uterus
pressing on the perinaeum
Use the pessary
Women of lax fibre & laborious women
as washerwomen are most
subject and often the disease has
made great progress before we 
are called the pessary will 
give effectual relief
This disease may be overlooked
& cause derangement of bowels
dyspepsia etc. & these complaints
only be prescribed. Prof B. has
known several cases of women confined
to the bed for years and the stomach
only prescribed to when the pessary 
has cured in a week
When the perinaeum is lacerated
the pessary cannot be used 


When the largest sized pessary is
required from extreme relaxation of 
vagina the oval pessary is best
Place the woman on the back
[enter] the pessary perpendicularly 
& after it is entered turn
Extreme prolapsus requires
a pessary with a handle [illegible]
in its place by a bandage
Pregnancy gives great inconvenience pessary not to be used
horizontal posture until the 
fundus rises
Retroversio uteri
Occurs generally between 3d and 4th mo.
fundus is in cavity of sacrum 
urine stopped in its passage
In passing up the hand we do not
find the os tincae & neck of uterus
Distinguished from polypus
which grows slowly & was gradual
in its symptoms
Growth of ovum prevented


Supposed to be caused by distention
of bladder with urine
Attempt reduction immediately
pay no attention to the
danger of producing abortion
First draw off the urine
Attempt reduction by the fingers
in the back part of the vagina
endeavouring to push up the 
fundus uteri. If we fail, place
pat. on hands & knees then introduce
a probang like inst. into the
rectum at the same time press 
with the left hand above the pubes
We may almost always succeed
Cases of failure are recorded 
[illegible] and it is recommended
to introduce a catheter & rupture
the membranes and draw off the
waters thus reducing the size of the 
uterus
Anteversio uteri
Can never be a formidable disease
& may always be remedied by change
of posture


Scrophulous enlargement of
uterus
Resembles schirrhus pain in 
neck back & loins etc.
large & less hard than true
schirrhus not extremely tender
Causes a resemblance of pregnancy
Sometimes the general health is
not much injured
Prof. B. has known a case of 
gradual enlargem. sympath action 
of breast & cessat. of menses
closely counterfeiting pregnancy
Prolapsus is very apt to 
occur with all its inconveniences
Prof. B. has known one case of 
this kind which continued 6 or 7 yrs
bed ridden unable to stand or 
walk cured by blue pill was
to bear 2 children blue pill 
is specific


Irritable uterus
The least touch cannot be borne
pat. cannot sit or stand even
lying merely palliates no relieves 
the pain. The slightest 
touch cannot be borne at the
pubes. Vagina natural os tuniae perhaps a little swollen
Rest cupping counterirr.
blisters hip bath conium & 
[illegible] narcotics blisters & 
setons (Well described by Dr
Gooch & only by him) Case related
Arsenicae
solution was the most successful
remedy & continued to be so
Diseases of ext. org. of [generatim]
phlegm. infl. of labia often occurs
to be treated with poultices frequently 
suppurates but the abscess [illegible]
[illegible] gives great pain discharges
fetid blood issues when an excis.
made 
Excoriations of labia
Soap & water ointm. of ox. zinc etc.



citrin oint. etc.
Warty excrescences not venereal
cured by nit. silver.
Dropsy of labia t pregnancy 
almost as large as the 
child’s head
Prusitus pudendi
very troublesome efflorescence
just within the labia intol. itch
may generally be cured by a wash
of nit. sil. or corr. sub.
[illegible] subj. to great elongation
but not with us
Imperforate hymen
Almost always congenital & discovered
by the nurse and will 
generally yield to pressure of a
probe If the knife is used be
very careful to keep a tent in or
a second operation will be needed 


Rupture of perinaeum
Occurs during labour
Keep the bowels open to prevent distention 
& irritation by passage of 
hardened feces It will generally 
heal up The hare lip operation 
is said always to have failed 
to cut by [palliatives]
Small vagina
may be caused by severe labours
& should be prevented after delivery
Introduce a dry sponge
after a few days a large one
Prolapsus vaginae
Astringents & a pessary


Cauliflower excrescence
Probably a fungus haematodis
vagina filled with a spongy soft tumour
bleeding at the slightest touch Disappears
at death
We cannot [illegible] by the touch
whether a tumour is malignant or benign
Hydatids are clustered vesicles
like a bunch of grapes Some call them
[illegible] They form in all parts of 
the uterus in the ovum & sometimes
the [illegible] itself produces [abortion]
It occurs only in those who have been pregnant
this last disease counterfeits pregnancy
hemorrhage comes on in an 
abortion pains resembling labour pains
etc. Treat as for hemorrh. & 
finally ergot might be useful to expel 
the hydatids
The ovaries are the seat of
scrofulous & other enlargements fecundity
is prevented
Ovarium Dropsy
Consequences in the [Graaffian] vesicle
with small tumours which gradually 
enlarge and as they enlarge, the matter 



becomes more limpid finally the
bulk may be as great as in ascites
from which it is distinguished by 
tumour more circumscribed & greater
thickness of integuments between
the liquid and your hand
Commences by pain & is near
the hip
Affects the health little except
from its bulk
Entirely out of the reach
of constitutional remedies.
Often there are several distinct
vesicles & upon making
one puncture we find the tum.
merely diminished & altered in size
Case Prof. B. drew off only 1 ½ pt
at the first tipping at the next tapping
immediately after 64 pounds
were evacuated
Remember that the coats
of the tumours are nearly as
thick as the walls of the gravid uterus
 


Cancer of uterus
Darting pains bearing down
pains in the groins General
health soon affected countenance
sallow etc.
Os uteri hardened & pressure
on it causes lancinating pain
Hard knotty tumours form about os 
uteri & in the vagina. Menstruation
irregular or substituted by 
hemorrhage.
Distinguished from scrofulous
enlargement by knottiness irregularity 
& hardness. Also cancer rarely 
comes on till after cessation of menses.
A. Cooper never saw a true
carcinoma under 36 years
Treat at first as if we had
mistaken the disease and prescribe
for scrofula. Afterwards palliate
give light nourishing food
keep bowels soluble. Attend to 
cleanliness discharge being intolerably 
fetid inject limewater
hip bath black wash. corr. sub.



3 grs to 1 pt of limewater
Nit. sil. very useful
Chloride of lime for the fetor
[restorat???] discharges by ac. lead, sul.
zinc etc. injected
Opiates
Diuretics especially those which render
the urine bland e.g. uva ursi
gaultheria etc.
Polypus of uterus
Frequent discharges which exhaust
the patient. Hence necessity of manual
examination. Where we cannot
relieve frequently returning discharges
we ought to suspect polypus.
Generally in the cavity of uterus
After it protrudes into the vagina
we can feel it. If attached to the 
neck of the uterus the neck will 
be found passing directly in the 
direction of the uterus
Sometime they are attached to the
ext. surf. of uterus or to vagina 


more common in women who have
borne children But met with in others
They may exist a long time without
being discoverable
Frequently very small tumours
seem to have more effect than large
ones causing more or worse hemorrhages.
They may be large & 
give no inconvenience except by 
bulk & pressure on the bladder
& rectum
There is danger when the tumour
is attached to the fundus it may bring 
it down & produce partial inversion 
Vary from the size of a walnut
to that of a child’s head with a neck
as large as the wrist Case
Other diseases may be mistaken
for polypus. Prolapsus uteri is distinguished 
by the presence of os tunicae
by its sensibility & by its growing
larger from below upwards by 
relief being given when it is pushed
up a polypus causing uneasiness 


when pushed up history of case also
Gooch’s rule always to supply 
a ligature to a tumor with a neck 
is a good one
Sometimes their removal
results from the stricture upon 
the neck by the os tunicae
The ligature is the best mode
of removing them. Prof. B. prefers
the common double cannula
to any of its more complicated substitutes
For a larger tumour the [ring]
probe is the best instrument
If you get away as much as ¾ of
the tumour the rest will disappear
You will know if you have included
the neck of the uterus by the extreme
pain produced










Retention of Menses
Retention is the want Suppression is
the interruption Treatment of both is 
much the same We are to prescribe
however to constitution and symptoms
Either of them is rather the effect than 
the cause of disease
The [cutam.] will sometimes cease
at 25 and often between 30 & 40. They 
may continue also beyond 50 years
Suppression & retention are
usually from want of action 	
Want of expression of countenance
and eyes whiteness of tongue scurvy
as it is called
This form is relieved by tonics
and astringents Lime water is 
much used & is called tonic. Alternate
alkalies with astringents as gum, [illegible],
[illegible] etc. A convenient form is pills
of the extracts with molasses And 
also [iron] & formerly myrrh
was called deobstruent and much 




used in form of Jenkins’ pills
& the myrrh mixture (Griffith’s & [illegible]
Rx
In the worst cases in country practice geranium [illegible]
or statici or agrimonial (which resembles
contrayerva) or cornus can always
be found in the country Lime water can
be made sulph. zinc you will carry 
about you. Add also aromatics as fennel,
dill etc. mints [pyenanthin??]
Generally when you have obviated
the cachetic morbid actions of the constitution 
uterus will take on its own healthy 
natural action. If however the catam.
do not return use emmenagogues
R. sulph. zinc gr i sang. gr. i aloes gr i
[illegible] guaicum table sp. & tinct canth. So much 
guaiacum as not to operate as a cath.
& 20 gtts tinct canth. 2 or 3 times a day
Another disease
Symptoms pain in the side about
an inch above the anterior sup.
spin. proc. inquietude sleeplessness




upon enquiry you will find the discharge
paler or watery or less in quantity material it is unhealthy
Stimulate the spine with tart. emet
oint. or canth. from the neck down 
along the spine. You will generally 
find upon pressure some of the vertebrae
tender. Then give after [irritant]
guaiacum, myrrh. Cathartics
seem to increase the cachery of the 
system. Of course avoid costiveness
Bleed in small quantities if necessary 
in retention or supp. Remember
however that the system does not suffer 
from want of evacuation Ligatures
will do better often than bleeding applied
just before the time for the return of the
catamenia
Sometimes the bowels become
loaded from torpor & inactivity
etc. Prof. I. has no doubt that bleeding
at the lungs and hectic after arise
from this cause. Use repeated
any free injections to wash out the
bowels. Exercise & amusement in 
the open air will do much Injection 



([Dr Savemens]) may be somewhat of a
substitute for exercise. The shower
bath is a good thing & our old remedy
Young women are seldom subject
to dis. of the uterus. Yet young 
women of of strumous habit, in whom 
there is [tineae] is relaxed have prolapsus from 
jumping off a horse etc.
Symptoms pain down the thigh
a sense of drawing down of the stomach
& of the bowels sinking at the stomach
dyspeptic symptoms
Prof. I has known unmarried
women bed rid from this cause, feeling
as if the bowels would come out
if they attempted to rise The os tineae 
is relaxed and there is a tendency to spasmodic
action there. In young women
pessaries do not seem to do well
there is more or less spasmodic action
I have made them with a handle & 
used a T bandage but no with much 
success. Sea bathing has been beneficial.
Elastic gum pessaries are 
best & have cured. Silver ones are 



good. Sponges are used but are
too rough & absorbing the secretions
smell bad & if changed every day
irritate too much. Ivory pessaries
Pessaries are proper when there is 
no disease excepting relaxation
When there is prolapsus you do not
feel the os tineae & the neck distinctly, but
you feel the relaxed and enlarged os tineae
& perhaps the uterus in an oblique position
In such cases we use astringents, as oak
bark etc. but sulph. zinc is better
Keep the bowels open and give aromatics
R. magn zfs or zii chalk. zfs cubebs
zfs carb. soda zfs grana paradisi zjj
a teaspoonful 2 or 3 times a day is often
enough. If there is likelihood
of the liver’s being affected give blue pill
Prof. I. doubt the existence of the 
cauliflower excrescence. HE has seen
relaxed os tineae with its veins varicose
Various diseases are called
cancer. If you find the os tineae
hard & enlarged & unequally & you 


find tumours in the vagina the disease
will certainly prove fatal. You may 
give conium astringents irritate
the sacrum etc. but with no good effect
Sometimes the tumours are fatty
 A phagedenic ulcer affects
the uterus eating away the os tineae
carb. & phosph. ferri have been 
declared specifics
Another disease enlargement of uterus, pain
in it discharge like leucorrhea
perhaps catamenia excessive Os tineae
enlarged also. This terminates in 
medullary cancer of some [writers]
Apply alum to the os tineae astringent
give metallic tonics & narcotics & 
silver pill
There are diseases of the uterus
in which polypi, deciduous membranes
dropsy etc.


Dysmenorrhoea
Occurs in persons with some deranged
state of the viscera catamenia comes
on with pain in the back limbs
much unequal excitement head hot
sometimes neuralgic pains Patient
will frequently throw off a deciduous
membrane
Dewees recommended
guaiacum (tinct) & allspice called
Dewees tinct. but it is better to give
the guaiacum by itself and the allspice
if needed Give 5 to 11 gr
camph. repeat every hour until’
you have given a z If you can
keep this on the stomach it will generally 
cure I have given also camphor 
& magnesia 20 gr of each
by mistake she took double the dose
became weak but after a few
hours recovered regular catamenia
Other narcotics may be used but camphor
has been long recommended. Deobstruents
also as sanguinaria may 
be used. Hyoscyamus is better then 


opium or conium
Equalize excitement by irritants
& drafts warm bath etc.
Other articles are ipecac
wild ipecac ([illegible])
External irritants are burgundy pitch
plaster on the sacrum
Sometimes there is a sallow
countenance, atony etc. then support
the patient
Incipient cases of diseased
ovaria the os tineae is spongy and 
flattened These diseases of ovaria
are very various but are called
dropsy & cancer Curable at
first by a course of blue pill, moderate
stimulants, aromatics, absorbents
(for acidity) and deobstruents
in general. I have kept patients under
the use of blue pill and even for a year
occasionally [illegible] it for 2 or 3 yrs
I gave also a compound powder
of alkalies, aromatics and columbo
and kept the patient also under conium


but I find hyoscyamus equal in its 
deobstruent effects even while it is
far superior in its narcotic effects
while it does not like opium produce
constipation & torpor of al. can.
Polypus of uterus
It may exist without unpleasant
symptoms. They do not always bleed
but at the time of catamenia hemorrhage 
is apt to occur. In the 
bleeding kind it may come down
and project beyond the vulva
At the time of the catam. there will 
be pain in hips & back & extending
down the thighs cat. profuse & finally 
terminating in a watery discharge
If the astringents as nutmeg, geranium
and best ac. pl. with op.
given both locally & by the mouth
do not relieve, we may examine
for polypus. There will be a dragging
sense in the uterus etc. Examine & you
will at about an inch & a half you 
will meet with a tumour which you 
will distinguish from a prolapsed uterus


by the absence of the os tinaea &
by feeling a tapering tumour its
neck being embraced by the os
tineae Its surface being smooth & 
delicate. Generally the neck will 
be too high up to be felt.
Retroversion
Well described by J. Hunter in the
London Observations
The trifling complaints spoke of
by Dewees do not deserve to be
considered Retroversion is
when the uterus is carried back down
into the perineum the os tineae is
carried back & up
Symptoms uneasiness constipation 
retention of feces & urine
vomiting, hysteria etc.
Introduce the finger into the vagina
about an inch up you find a resistance
on all sides you carry the finger back
along the prominence and you find a
tumour in the perinaeum and you find
no os tineae but by changing the position 


of the patient say erect or upon hands
& knees you are able to feel partially 
the os tineae The orifice of the urethra
is also drawn up, because the bladder
is drawn up & you do not readily 
find it and cannot readily introduce
the catheter Introduce a small
elastic catheter & draw off the urine
when great relief is obtained
Evacuate the bowels by injections
John Hunter recommended puncturing
the uterus drawing of the waters & producing
abortion
Restore the uterus by placing
patient on hands & knees & introduce a
probang with a ball about an inch in 
diameter covered with lard introduce
the left finger into the vagina
Pass the probang gradually up the 
rectum & let it act upon the fundus of the
uterus so as to push it back in the way it
came down assisting with the left two
fingers. Use the catheter for some days
after and give injection per anum
After the child rises above the pubis there 
is no further danger


# Found in bex humida, convulsiva etc.
# Very large and strong in the 
“dead rattle”


Stethoscope
Continued from the 1st vol. M.M. 1832 & 3
2nd Mucous [rhoncus] occasioned
by the passage of the air through sputa forming
bubbles which produce the sound by their
bursting. The epithets are very large, middling or small
according to the size of the bubbles also
abundant or rare according to the number 
of them. # Found also in haemoptysys
though then there is an indication 
of greater fluidity the bubbles being more
frequent. This originates from the large tubes 
Tracheal rhoncus is also mucous
and may often heard very loud by the steth. when 
not audible to the unassisted ear #
These two the crepitant and mucous
are called moist rhonci
3d Sonorous rh. a flat dull
sound resembling the cooing of a dove
or the large strings of a violincello The 
causes are not known The indications
also unknowns. The sound varies very 
much. resembles the varieties of sound
produced by blowing the nose



4th Sibilant rhon or a dry sharp
whistling sound sometimes
resembles the chirping of a ground bird
pathogn. of asthma
In sonorous rh. but one sound is heard
but in this there are heard a great many 
almost persuading one sometimes
that the chest is filled with young birds
This rhoncus is from small tubes
The former (sonorous) is from one small
tube. This sibiliant may may be caused by a thickening of the [illegible] membrane
5th Crackling rhoncus proceed
emphysema pulmonum (an unnatural
inflation of the lungs at first an unnatural
inflation of the air cells
ultimately the cells burst and the 
connecting cell mem. is inflated
in dissection the pleura may often 
be seen elevated In another
variety the air is effused into the
cell mem. between the lobules of the
lungs) In vesicular emphysema
this rhoncus is not always found
but in the interlobular emphysema 
it is very manifest


The sound is a crackling one, like the
burning of hemlock leaves or like blow
into a dry bladder. Sounds as if air was
entering dried lungs
6th Some authors add the cavernous
found when there are cavities, formed
from tubercles, or from gangrene or from 
abscesses Tubercular excavations
generally contain some fluid, which 
gives rise to a gurgling sound. We
have likewise the term “amphoric resonance
or atricular buzzing, which 
is caused by the communication of the 
cavern by a small orifice resembles
the sound made by blowing into a large
vial When there is no fluid
we have the cavernous respiration
of which the amphoric is a variety
Some make this a variety of the mucous ronchus
Some persons breathe so 
feebly that it will be advisable
to request the patient to make a full & 
quick respiration Otherwise he may 
not notice an engorgement which the 


ordinary painful & cautious respiration
may not slow and he
may suppose a part to be completely
obstructed which which will be [illegible] to be not [illegible] upon
a full & quick respiration
It will also be useful
probably to the patient to make occasionally 
a free respiration especially 
in the commencement & in 
the resolution of pneumonitis (N.B.
when pneum. is going off we hear
the crepitus caused by the air beginning 
to reenter the cells)
Also in incipient adhesions of the
pleura, we may make use of the
same means. Dr H.’s own case
He felt a sense of tearing
Emphysema will only 


Patholog. cond. of the voice
1st Tracheophony or layrngoptony
2 Bronchophony 3d
4th Pectoriolquy
The two first are heard in health 
in limited portions of the chest however
The air of the lungs being in distinct
cells we have a compound medium
but when the lungs are hepatised or
hardened with tubercles So also if
one lung has been entirely destroyed
Case of a child foreign body in the
lung infl. supp. vom.  & prod. of pus
child recovered from the sound
the lung was considered healthy
afterwards a year after the child died
of scarlet fever & the lung was found wanting # 
When apart of a lung is solidified
we find a dull sound upon percussion 
we hear bronchial respiration & bronchophony


Introduction of the catheter
During labour the neck of the bladder 
is often much elongated, and you may 
have to pass the catheter directly upward
Next attend to the child
Be careful that the room is warm
that the child does not take cold
Keep a cloth warmed at the fire
against the birth of the child
The body of a new born child
should be cleansed of a white unctuous
substance, which resembles tar, by 
rubbing with lard and wiping with 
a soft cloth. Then the child, if vigorous 
may be washed with soap & water
Others, after rubbing off the 
lard, sprinkle over wheat flour or 
starch 




Aegophony or Haegophony
goat like tremulous, bleating
voice resounds through a thin stratum of fluid
Pathogn. of empyema
collection of [serum] (Pleuritis)
Commonly not distin. from 
bronchoph. by the inexperienced
It is like a kind of silvery voice vibrating
on the surface of the lungs. Apply 
the cylinder firmly on the chest the ear
to the stethos. lightly (if hard pressed on
it, it will sound like bronchoph.)
When the liquid is small, 
aegoph. will be heard only at the lower
portion of the lung But if we hear
the sound near the root of the lungs (between
the scapulae) we may conclude the 
collection to be large
In strongly marked cases it
may be distinguished by its shrill sharp
sound also by seeming like an echo
of the voice often also the seat of it
may shift with a change of position



Pectoriloquy
the resounding of the voice from within a 
cavity communicating with the tracheae
or bronchia Caused by softened tubercles,
by separation of gangrenous
[eschous] by abscesses formed in any way 
by openings into the mediastinum was perhaps
& perhaps also into the liver
Pathogn. principally of phthisis
In perfect pectoril. the voice
seems at the end of the steth. & often
seems louder In imperfect the voice
does not seem to traverse the whole length
of the instrum. or
Doubtful pectoril. sound slike
aegophog or is too obscure to be defined
In perfect. pect. an amphoric resonance
or cavernous rhoncus will accompany it
and there will be obscured in the
imperfect
If excavations exist in the 
lungs, they can generally be detected by 
the stethoscope & before the use of the
steth. they could not as there is often 


no pain in their region In some
few cases the information conveyed will 
be imperfect or doubtful, but the instrument
is valuable
Pectoril. is modif. by the nat. tone
of the voice clearer & more distinct
when the voice is high though perhaps
less loud. Hence the nat. resonance
of a sharp toned voice may be clearer
than a true pectoriliquy, in the axilla, for
instance, when the voice is grave. But
we can generally determine by comparing
the opposite sides of the chest
2nd modified by the size of the
cavity but then a cavity is large as  a 
pea! will render a true petoriliquy 
5 by the situation of the cavity if it
is deep in the substance, the pectoril.
will be far less clear than when it is
near the surface but when very 
near & with thin collapsing sides
we have only the veiled puff a
var. of cavernous rhonc.
4th by the  slope of the cavity
louder & clearer of sound & smooth very 


loud indeed when the cavity is lined with
a cartilag. sub. Ragged an obscure sound cavities yield
5 by the opening several fistulous
opening will much obscure the sound 
6 more distinct, when the cavity is perfectly
empty sometimes the cavity will be 
filled one day & empty another according
to the abundance & facility of expectoration
Hence, in general, pectoriloquy
indicates a cavity, but a cavity may not
give pect. still there may be other
sighs, as amphoric resonance


Signs given by resp. & voice
1st amphoric resonance & metallic
tinkling.
1st is like blowing into
a vial 2nd like striking a short
metallic cord, or a wine glass or 
tumbler. Both indicate a large
cavity with hard unyielding walls
& filled principally with air & communicating 
by a small orifice
Commonly cav.  resp. amph. res.
& met. tinkling are varieties of the 
cough & [speck.]
Auscultation of the cough
The phenomena are intermediate
between those of the voice & the respir.
Cavernous cough indicates excavations
& cav. rhonc. is made more manifest
by coughing
Also by requesting the patient to cough we
can obtain a full inspiration


1st Clavicular over the clavicle
2nd Infraclavicular from the clavicle to the 4th rib
3d [Mammary] 8th
4th Infram from 8th to cart
3 sternal regions
5 Superior sternal region
6 Middle
7 Inferior
8th Axillary reg. to the 4th rib
9th Lateral reg. fr 4th to 8
10 Inferior lateral reg fr 8th to [cartilage]
11th Acromial ac. proc. of scap
& above
12th Scrofular space of the scap.
Some make superior & inf. scap. reg.
separated by the spine
13 Interscep (2 of them
14 Inferior dorsal (2 of them)


Diseases
Pneumonitis more fatal than any other
acute disease. Infl. of lungs etc. vide Good
To be distinguished from bronchitis & 
pleuritis. Though it may be complicated
with one or both
3 stage 1st obstruction or engagement
2nd hepatization 3d purulent
infiltration
Engorgement is from blood
and serum the lung when cut will 
give a crepitus, & does not sink in water
resp. high small, accelerated, incomplete,
unequal, difficult commonly
cough & pain & expectoration (when no cough or pain 
called latent [illegible] then we must observe the 
respiration & use the stethoscope which 
gives the crepitous rhocus). The 
modification of the rhoncus gives the character
the fluid engorged (if bloody crepitant) if serum, subcrepitant.
Hepatization has the air cells entirely 
obstructed lung sark red sinks in 
water called also [carnification]
absence of vesic. resp. & [illegible] of bronchial
resp & bronchophony (if near the centre 
of the lungs


puerile respiration (produced by a preternaturally 
vigorous action of the healthy
part of the lungs) occurs in both stages
3d Purulent infiltration into the substance surface of 
the lung straw coloured. Lung humid
& soft fingers easily penetrate it 
softer if from serous engorgement generally 
accompanied at its commencement
by chills mucous rhoncus
Percussion gives no difference in the 
first stage of engorgement grows duller
decidedly dull after the stage of
hepat. commences In hepatization we have bronchphony & bronch. resp.
The three first stages are completed in 
from 6 to 8 days the first two in’
5 days But often the disease is irregular
and the regular course may be broken
up by medication You may find all 
the grades of healthy and morbid respiration
within 4 or 5 inches
After dust both lungs are found
affected for the disease is seldom fatal
when one lung only is affected. Respiration 
of one lung may be entirely gone and yet 



the health be pretty good apparently 
Dr H. has often known one lung completely 
hepatized within 36 or 48 hours,
and within 6 or 8 hours find the
disease entirely transferred to the other
lung
Commonly one lung
undergoes resolution
& then the other is affected
Sometimes however both lungs
are engorged and then of course
a fatal suffocation occurs Especially 
is this the case in pneum. notha
vide Good
Case in which death occurred in an hour
another in 3 hours Such cases
hardly deserve the name of pneumonitis
(inc. inf.) but no definite line can
be drawn between them.
The older writers speak of termination 
in abscesses or gangrene
the matter is disputed.
The truth is a regular circumscribed
cavity containing pus is not found
Proper abscesses occur from tubercles
Occasionally a gangrenous abscess occurs
In such cases we have cavernous



rhoncus
By careful medication & good
nursing, resolution may generally be
brought bout this may occur in 
either of the three stages 
Resolution is effected sometimes effected
in a few hours days and week may 
be required
Stethoscope says all well frequently 
when resolution has commenced from hepatization,
when the general symptoms 
show no mitigation first we hear
crepitation etc. etc.
Resolutions of purulent infiltration
Case related pulse slower than it
ought to be owing to cerebral aff. coma etc.
Rx tinct. sang. zi tinct. cinch. comp.
z8 tablespoonful every ½ hour
In the winter of 1831 & 2 we had
pneumonitis oedematosa In the previous winter
we had a pneumonitis which afforded no stethoscopic
sign the disease was rheumatic & yielded 
to actaea alone. There were all the ordinary 
appearances and progress of pneumonitis, viz
diff. resp. bloody expect. etc. 


In the pneumonitis of 31 & 2 we had
no crepitous rhonchus but a sub crepitous rh.
yet the disease went through the 
regular stages and there was even an
uncommon tendency to suppuration. Some
cases however were mere oedema of the lungs
This according to Lacunec is very rarely 
an idiopathic disease It commonly occurs
as a hydropic. disease of cachectic
habits. Good knew but little of it
he thought it could not be distinguished from 
hydrops thoracis It can readily be distinguished
however by the stethoscope
Dr Hooker thinks the disease has often 
been overlooked. When edema of the lung
has been found after death, it has too 
exclusively been attributed to effusion just
before death. To be sure the effusion
is liable to shift or disappear suddenly 
but we find the same thing in 
edema of the limbs. Within the last 18 mo.
we have had such cases of shifting from 
the limbs thence to the head thence to 
the lungs etc.


Dr Hooker thinks that ½ of our fatal
cases of disease terminated in hydrocephalus
Instead of 30 or 40 according to the bills
of mortality, he thinks we may say at least
130. The intellect was not in general materially 
affected
[Lae???]’s account of edema of the lungs
is not a good one. The pathog. signs are
progressive dullness upon percussion & 
sub crepitous rhoncus His subcrepit. rho is
rather a super crepitous rho caused by fluid in large bronchiae
in [illegible] cases.
Haemoptysis
Called also pulmonary apoplexy IT
is an effusion of blood into the substance
Stethoscope shows a crepitus
rhon
Hydrops thoracis
Good says the only decisive indication
is a fluctuation but this can scarcely 
ever be observed
Percussion gives a dull sound
Haegophony exists in the first stage q.v. In the advanced
stages no respiration can be observed 
A very rare idiopathic disease


Empyema detected
in a similar manner
Pleuritis
Acute pain difficulty of lying on
the affected side (yet when adhesions exist
the weight of the lung renders it more
painful to lie on the opposite side
There is bloody sputum & cough
But effusion of serum generally takes
place & then we have haegiophony
Frequently the effusion becomes concrete
& tough and hard, perhaps cartilaginous
Laennec has observed a contraction of
that side of the chest (in the young the
lung of that side not growing so fast)
Pleuorpneumitis
Pleuralgia a rheumatic aff. of
the intercostal muscles relieved by 
opium, actaea or some narcotic
Stethoscope shows no signs of pneumonitis
hence valuable, negatively 


Emphysema
1st Pulmonary or vesicular emphys. 2nd
Interlobular emph.
The first is an effusion which causes
larger & larger globules
The second generally gives oblong or
triangular collections of air
The crackling (crepitant) rhonchus
indicates this especially the 2nd
Caused generally some obstruction 
of one or more of the bronchial vessels
The case of the child who had never spoken 
loud (in Broadway) exhibited emphysema
of the lungs. Tumours & croup
have the same effect. Hepatization or
tubercular degeneration or some [illegible]
of a part of the lungs may cause an emphysema 
of other portions. This is one of the most
common causes. Yet the p.m. ex. shows
emphysema we do not necessarily find
that the stethoscope has given indication
Symptoms are hurried and laboured
respiration lips livid, from 
want of decarbonization of the blood
Easily out of breath etc.


Stethoscopic signs of it are obscure the
respiratory sound is said to be feebler
The sound of percussion is clearer however
Little has been known of this disease until 
of late years
Pneumo thorax
Pneumato thorax might be called
emphysema thoracis. Not distinctly 
described by Good It is a collection 
of air in the cavity of the pleura 
First memoir on the subject by [Itard]
1803? May be caused by a 
wound of the thorax by a communication
between the bronchiae & the cavity of the
pleura by putrefaction and extrication 
of gas
More or less inf. will be apt
to be caused.
Percussion gives a remarkably clear sound 
steth. gives not resp. sound on the affected
side on the opposite side the respiratory
sound will be clearer than natural
If there is a communication between the 


cavity of the pleura & the bronchiae we
have amphoric resonance & occasionally 
upon coughing or speaking, the metallic tinkling
This affection is commonly complicated
with presence of fluid. Inflammation 
caused by the air will be apt to produce
fluid. In this variety we may make
use of what is called the Hippocratic succession
Concretions of the lungs
We find them bony or cartilaginous or chalky
in p.m. exam. especially in old cases
of phthisis. Laennec thinks they are
tubercles which have been cured.
Black pulmonary matter upon 
the surface is found more abundantly 
after pulmonary diseases and phthisis
but found more or less where there had been
no pulmonary disease. Laennec thinks
it more abundant in blacksmiths
Bex. dyspnoea want investigating.
Good’s dyspn. includes 4 or 5
distinct diseases. Sometimes we have 


a sibilant rhoncus. Sometimes it
is caused by emphysema of the lungs.
Phthisis
most of the recent French writers restrict
the term to tubercular phthisis
Cullen considered it a sequel of haemoptysis.
but the latter might with
more propriety be considered a sequel
of the former. Haemoptysis rarely
leads to phthisis.
Good has P.  catarrhiulis P apostematosa
& P. tubercularis. Apostemes,
with excavations, very rarely 
exist, in the lungs, as has now been 
ascertained
P.m. ex. in Paris show that ulceration 
of the bronchial membrane is
(almost) always connected with tubercles
the question is which is the primary 
disease. The French think the 
latter is the primary disease
Of tubercular phthisis
Tubercles are small tumours (tuber)


They commence greyish bout the size
of a grain of mustard (miliary tubercles)
Colour deeper in adults
In examinations we may find not more
than a dozen tubercles or thousands 
Tubercles are found also in other parts
of the body particularly upon the intestines
and in the liver, spleen. etc.
When they become large they first soften
internally then discharge. “Crude
tubercle” collections of non-discharging
tubercles
Tubercles may exist at a very
early age 2 or 3 years. They may be
inherited in infancy. Case of a child of 
3 months. They have been found in 
the fetus 
No one symptom is constantly 
met with in phthisis. Cough, expectoration,
pain etc. may be absent. It is 
doubtful whether the tubercles and ulcerations 
of themselves cause pain.
In this disease the physical signs
generally come too late.


When suppuration and excavation occur
we have mucous rhonchus cavernous
rhonchus and pectoriloquy q.v.
Curability Those who make
the least pretensions do as well as any 
The disease may mitigate and apparently 
cease in summer & revive again
in the winter
It is difficult to get leave to 
examine the bodies of drunkards
There is no doubt that confirmed
phthisis is occasionally cured as shown 
by steth. & p.m. examinations
Affections of the heart
No part of the body is subject to a greater
variety of affections Corvisart
produced the first valuable work
An enlarged heart will be indicated 
by percussion though the pericardium distended with water will give
the same sound
Manual examination is better
Place your hand over the heart & judge
of the regularity etc.


But the steth. is still better & also
shows new phenom 
1st sounds
1 impulse or shock
3d extent of the chest over which the pulsations extend
4th rhythm
1st By the stethoscope we hear two 
sounds first duller & longer then a shorter
& sharper. The former is isochronous 
with the pulse
2nd an impulse on the ear is felt at the
time of the first sound. In children & 
thin chested persons the second may have
a slight impulse
3d extent generally small In fat persons
we have not more than an inch of extent
the extent is increased by high
living etc. & vice versa
4th rhythm i.e. order of succession now
receives much attention cannot be 
thoroughly explained as to its causes. Still
valuable indications may result from it
Laennec says the first sound is produced
by the systole of the ventricles the second


when the auricles contract then a 
period of repose so that ¼ of the
time is occupied by a state of repose
In 1828 Mr. Turner maintained that
the auricles contracted first and was
followed so immediately by that of the
ventricles so that both together cause the
first long dull sound Mr. Turner
also thinks the second sound made by the
beating of the heart (in a diastole) again
inst. the pericardium. Many other
hypotheses have been advanced since
We must conclude Laennec’s hypothesis
to be unfounded. A later hypothesis
supposed the dilation caused the sounds
Another supposes the sound caused 
by the striking together of the sides of the 
ventricles but then the ventricles are
never empty
[Refutation] of Corrigan and Haycraft
Dr Hope has published lately a large octavo
volume on this subject.
1st the auricle contracts so immediately
before the ventricles as to make but one 
sound


2nd the extent of the auricular contraction 
is very small & incomplete
3d the ventricular contraction is the cause
of the impulse & coincides with the pulse
at the wrist
4th the impulse is made by the apex of 
the heart
5th the ventricular
6th the ventricles do not [illegible] themselves
7th
8 after the diastole the ventricles remain
apparen
1st sound caused by systol 2nd by the
diastole of the ventricle
Rhythm 1st auric. syst. 2nd ventric.
sys
3d v. [illegible]
4 v. repose towards the termination of
which auricles begin to contract
Dr Hope attributes the sound to the
agitation of the blood in the ventricles
Dr Hope attributes one sound to the
active dilatation of the heart [illegible]
or elastic



1st mot. auric systole
2nd immediately followed by ventricular
systole & 1st sound
Dr H. thinks the 1st sound produced
by the closure of the auricular vent. valves
& the second by those of the arteries
The sudden arrest of the regurgitation
causes the sounds
The sound occurs at the times of 
the closure of the valves
[illegible] of the sound is such as
might be expected from the striking together
of the valves & the sudden check
of the regurgitation hence the second 
sound is like the lapping of a dog or 
the snapping of a whip
The second sound (by the auric. vent. valv.)
is more gradual as it should be also
the sound is more dull
Dr Hook thinks the first sound
is caused by more than one circumstance
The impulse also is caused (he thinks) by 


the apex of the heart and also by an internal
abrupt succussion caused probably 
by the auricular vent. valves and the
reaction of the chordae tendinae colum.
[illegible] etc. upon the whole mass of the
arterial valve
Dr H. thinks Dr Hope’s account
of the order of the action of the heart is the
tone one
Hence the first sound 
is heard lower down than the first opposite
the apex of the heart the sound
being conducted by the dense contracting
ventricle & coinciding with the impulse
The first sound
1st Hypertrophy of the heart muscle
larger than natural contracts
slower & stronger Impulse stronger less sudden sound
more prolonged less sharp because
the valves close less suddenly 


2nd Dilatation of heart muscle
thinner hence contract more
rapidly but less strongly So too 
the sounds become preternaturally 
abrupt, loud & sharp
In a high degree of hypertrophy
the sound is scarcely perceptible
3d Contraction of the orifices
of the heart
We have the bellows the rasp
serrate & thin whizzing murmurs all varieties
of the same Caused generally by 
diminution of size of cardiac orifices
but often by regurgitations (perhaps
more frequently The murmur 
may exist before death for months & yet
p.m. ex. show no disease of heart
It is observed that in arteries
It is heard in the arteries of the placenta
Slight derangement however may exist about
the valves and not be detected by 
dissection e.g. relaxation of the chord. tend.
It is found that excessive depletion causes
the bellows murmur from this cause or 
a similar one. Dilatation of the heart will 


Cause bellows murmur produced by 
imperfect closure of valves
A murmur rarely supercedes
the second sound the arterial valves
are rarely completely ossified
Simple dilatation of heart
Walls thin heart weakened in action
palpitation but (according to the general law) acts
quicker pulse quick feeble respiration
labored edema of extremities livid
& pale & leaden skin these are affections 
symptomatic of the general affection
If the left cavities are dilated
& the right healthy the lungs are
oppressed edema etc.
If the right sides of heart are diluted
the left continuing healthy, we have edema
of extremities congestion in grain etc.
a pathogn. [symptom] is swelling of jugular
veins. (N.B. pulsation of jugular
is produced by imperfection of the [illegible]
valves manual examination 


shows a dilated heart but not clearly 
which side is affected
Auscultat. gives a feebler impulse & shorter
sharper & clearer sound the extent
of the sounds is increased even extending
into clavicular & axillary & acromial
region
Generally both sides are diluted
but commonly one side more than another
The early stages of dilat. can scarcely
be distinguished from nervous palpit. of
[illegible] etc. (apply stethoscope 
frequently to prevent patients being
alarmed and excited by it N.B. In fevers
steth. useful in conjunction with 
feeling pulse, gives more certain signs)
The bellows murmur is generally 
heard caused by imperfect closure
of ariculo-ventricular valves
Now laennec would lead the [illegible]
to suppose that increased clearness of 
sound attends dilatation But when
the dilat. is excessive the sound is obscured
or superseded by the rushing bellows
murmur



The stethoscope gives no signs of 
dilatation of the auricles (Laennec
was mistaken his work on the lings
is nearly a perfect one)
Hypertrophy
morbid increase of muscular
substance of heart with thickening of its
parietes Excessive growth
weight increased
1st [Chicentric], 2nd Eccentric & 3d
simple hypert.
1st Case the grown incroaches 
on the cavities & diminishes the cavity
Simple is growth outwards merely 
Excentric is dilated & grows thickened outwards
also (vide Bertin) Corvisart
was acquainted only with the last
The two former occur more frequently 
in children & are frequently
congenital (specimen exhibited of
a congenital concentric hypertrophy N.B.
the heart was larger than the childs fist
larger than natural walls enormously 
thick cavity almost obliterated)


N.B open foramen ovale is given
as a cause of such cases then probably 
the hypertrophy is the principal evil.
The for. ovale is generally open for 
3 weeks after birth
The child above was restless from 
birth hemorrhage from umbilical
arteries (caused by strong power of heart)
palpitation very strong great
effusion into cavity of pleura
(hemorrhagic pleurisy) Child
moaned all the while put its hand
to its head etc. right side of heart 
thicker hence effusions in lungs
Tendency to inflammation found
all over the body
The apoplectic habit especially 
predisposed to hypertrophy but
sometimes the sanguine & robust
have dilatation & the feeble & cachectic
have hypertrophy
Pulse in hypertrophy strong
& slow (strength of heart without 


quickness as above) If right side
is hypertrophied the lungs are affected
& [illegible] left is the head will be
affected with serous apoplexy.
Stethoscope gives a slow strong
dull prolonged heavy impulse & 
sound In the left ventricle about
the 5th & 6th ribs in right
about lower part of sternum
Excentric hypert.
by no means uncommon occurs in 
adults incredible size sometimes
Dr Duncan found one weighing 32 oz.
(nat. weight is about 10 oz.) 7 inches long
& f in. broad
Stethoscopic signs are a 
union of dilat. & of simple hyper.
impulse extensive sound sharper
& duller? (more obscure in
its signs)
Polypi
Coagulated lymph questioned whether
formed before death or at death more
generally supposed that they do form before death


Notes of Prof. Knights Lectures
copied principally from Mr. Osgood’s
notes
Curvature of spine
Polypi were very remarkable last 
winter during the hydropic diathes
specimen shown extending through 
as far as the radial artery
Stethoscope to fractures
gives a more distinct & precisely 
located sound
Stethoscope in pregnancy
Gives first the pulsat. & sound of the
fetal heart & the blowing pulsation
through the placenta (a bellows murmur
of the placental arteries which is synchronous
with the pulse of the woman
Both are audible to the stethoscope & to the
ear The stethoscope is preferable from 
considerations of convenience & delicacy
[illegible] sound not heard before 3 or 4th
month Fetal heart heard [illegible] afterwards towards
the end of pregnancy Twins are predicted thus!
Bellows murmur of iliac arteries easily distinguished
Fetal heart gives a double clik and then is silent period


Fracture of clavicle
Mistake often made in supposing
that the sternal end rises, & in endeavouring
consequently to keep it down.
It is the scapular portion which requires 
to be kept in place
Dislocation of last phalanx 
of thumb
Instead of vainly endeavouring
to make sufficient extension 
bend the phalanx back almost to a 
right angle thus get one edge to 
catch upon another & then reduce by 
the lever principle
Bending of the long bones in 
children
Prof. K. has met with frequent
instances of this in children a fracture 
perhaps on the convex side symptoms
distortion with stiffness etc.
Fracture near the head of the 
long bones of children, occurring 


in a part not ossified, yields no crepitus
Amputation of the last or third 
phalanges of the fingers or toes
When swollen your knife may slip
by the joint & cut into the soft cushion
of the ultimate extremity & deceive
you be on your guard
Os femoria
The books represent the neck as 
smaller & they then account for fracture
there But both circumference
& the diameter from above downwards
is in fact greater
The body of the bones may be 
destroyed by disease and the [illegible]
remain
Tibia
When you set a broken tibia bear in 
mind the natural lateral curvature
of its anterior edge
Ankle joint
Dislocation backwards and forwards on 
rare occurrence. [illegible] inw. [illegible] with 


fract. of int. [mall.] Disloc. outwards
generally accompanied with fract. of fib.
1/3 or ¼ [illegible] way upwards superior fragment
of fib. retaining its nat. position
Tarsus & metatarsus
Tarsal bones very rarely dislocated
except in the practice of nat. bone set.
Prof. K. has been informed on good
authority of one or two instances
In amput. foot at tarsus bear in 
mind the uneven line caused by the projection
backward of the second met. bone
or Near the articulation of the
fibula with the astralagus, and a little 
before if three is a small cavity between
the anterior ends of the astralagus
and os calcis which can be readily felt
through the integument This often almost 
[illegible] filled up in sprains, & often
mistaken for a dislocation of a tarsal bone
In amputating at the tarsus the
land marks are the projection of the 
internal cuneiform bone & the projection of the 
metat. bone of lit. toe The former has 


a bursa on its top which is liable to 
effusion and swelling from pressure as
of a boot cured by abstracting the pressure.
The project of metatarsal
bone of lit. toe often mistaken by 
patients for something wrong
Sprains of ankle joint
They are affections of the tendons of the librating muscles
& the affection is either an injury 
of the tendons themselves or a displacement
from the sheath of those of the
external libration muscles
Calf of the leg
Soreness, long continued, & lameness
caused probably by separation of muscular
fibres from tend. of [gastro???]
It has been attributed injury often [illegible]
of plantaris
Wrist hand fingers
Pus formed under the brachial aponeurosis
may point in the palm of the 
hand. The tendons of the fingers are


at first in one common sheath &
then the separate in order to go to the
several fingers. In labouring men
these separate tendons sometimes adhere
to their sheaths causing a curvation and
stiffness of the fingers and a prominence
under the skin when the finger is bent
tendon feeling rounder and harder 
than natural This is not mentioned in 
the books
Ear diseases of 
Always examine for cerumen in cases
of deafness, by throwing the suns rays
strongly into the ear. Deafness from 
this cause occurs oftenest in elderly 
people. The wax gradually accumulates,
but deafness does not occur
until the closure is complete
Sometimes there is a thin coating of cerumen 
over the membrane tymp. destroying 
the [shining] appearance which it 
shd present when healthy. The lining
cuticle of the ext. auditory canal, instead
of secreting cerumen may secrete 


pus without abrasion of surface
When the eustachian tube is closed
puncture the memb. tymp. in the 
lower and anterior part to avoid the
small bones not piercing so [illegible]
a quarter of an inch through
Insects in the ear will be destroyed
by tinct. camphor. Foreign bodies
may generally be removed by a 
scoop. Case a small stone closely 
fitting the cavity Col. Blake pushed
through a tube a piece of cotton dipped
in any alcoholic solution of shellac
when the alc. had evaporated 
the stone was readily drawn out by 
means of the fibres of cotton
Diseases of internal ear Ulceration 
may take place in the muc.
mem. of this part. If the small bones
are destroyed hearing will remain but 
if the labyrinth is destroyed, hearing is lost.’



Puncta Sachrymalia
The course through the superior [illegible]
is the most direct Exceedingly difficult
to introduce a probe through
the puncta half the time we do not 
pass the probe into the sac when we
think we do
Couching
Prof. Knight prefers the posterior
operation for depression 
The [lens] is always depressed
into the vitreous humour there is not 
room in the posterior chamber of the aqueous
humour. Be sure to have the
needle far enough behind to avoid
the ciliary body
Laceration of capsule of [lens]
is performed anteriorly & the aqueous
humours entering though the opening
made by laceration, absorbs
the lens


Foreign bodies in the nose
are generally in the lower sometimes
in the middle meatus
Tonsils or glandulae amygdalae
are between the palate half arches
are often enlarged Their [illegible]
orifices are occasionally filled
with a semi-purulent, or a curdy
matter which may give their surface
the appearance of an ulcerated
one.
Throat foreign bodies in 
Thee when in the aesophagus are either
at its upper extremity in the root of
half cul de sac formed by embrace
of the larynx by the lower end
of the pharynx & then they may be 
swept out by the finger & they 
are at the cardiac orifice of the 
stomach In the former case they 
may often be seen & if we introduce the
finger we must be careful not to mistake
the projecting horns of the os hyoides 
for foreign bodies


Prof. K. has known an ulcer to eat
through the fold of membrane which 
extends literally on both sides of the
epiglottis, so that the passage to the 
larynx could not be protected
death ensued
Fraenum Linguae
The gone is more bound down by 
this fold of the muc. mem. in some individuals
than in others. If it necessary
to divide it, let the incision be
made near the floor of the mouth, to avoid
the [illegible] arteries The small glandular
bodies seen under the membrane are only parts of the sublingual gland
Uvula
when enlarged may occasion a dangerous 
chronic cough. Its removal [shortening] has never
been followed by worse consequences
than a slight subsequent hoarseness


Venesection
The basilic vein is apt to be a rolling
vein. The cephalic is apt to be 
small and deep seated. The median
is most superficial &most
firmly fixed. In order to 
be sure of avoiding the brachial artery
feel for it. The position of the superficial nerve 
we cannot calculate on and no 
one is to blame for wounding it. Prof.
I is incredulous about the injurious consequences 
of wounding it. Avoid 
pricking the tendinous expansion of
the biceps infl. there will be troublesome
Flexors and Extensors
The extensors are the strongest but
the flexors of the legs are the shortest
so that they are completely at rest
only when the limbs are flexed because
we like and sit so much



Bursae mucosae
There is one on the anterior surface
of the patella & one on the olecranon.
There is one under the 
tendon of the rectus femoris which 
always communicates with the
knee joint. There is a corresponding
one below the joint which sometimes
is separate from it
Hip joint
There sometimes occurs after a fall 
or other injury an utter [illegible] of
this joint, with violent pain and 
soreness & requiring many weeks for 
recovery the cause of which is unknown
(acute infl. of Prof Hubbard?)
Some have thought this effect caused 
by bruise of synov. memb. cart. etc.
or by fract. without displacement
Prof. K. has had 2 cases 



Curvature of Spine
First symptom may be a slipping
of the [illegible] from the shoulder
or a projection of the lower angle
of one of the scapulae, mistaken for 
a tumour and sometimes poulticed
etc. for a long time one hip 
may project
The first curve causes a 
second compensating curve, to preserve
the balance of the body.
Examine for curvatures 
by means of a string stretched along 
the spinous processes. The place of the original
curve will generally be [illegible]
indicated
by tenderness or pressure
Cure by strengthening the muscles by 
exercise
Spina bifida
Congenita It has been proposed to 
puncture the tumour this may be
done by a small orifice but a fatal
infl. may ensue. If the tumour
communicates with the brain, pressure
on it will produce symptoms 
of pressure on the brain



Circumflex arteries
In opening [illegible] abscesses about the knee
or elbow joint you are very liable
to wound some one of the numerous
circumflex or recurrent branch hence
make a free incision that you may 
be able to tie an artery if necessary
Arteriotomy
is performed on the temporal art.
[Arterio] feel under the finger much 
larger and nearer the surface than 
they really are. The artery should
not be completely divided. It is 
different to hit it longitudinally
hence & make the incision 
obliquely
Local depletion
May be serviceable in local infl.
Case wound of the hand. The 
divided artery had regular periodical 
[illegible] of bleeding for a while
and then ceasing for a few hours. This
proves an independent local action 


Mem. Obtain the minutes of 
Prof. Knight’s case of partial dislocation
of a cervical vertebra








E. D North
snuff taker !!!!
5
obstetrics
& 
Diseases of women










































5
Materia
Medica
(rear)
Diseases of women.
obs (front)












Lecture 2nd
Pelvis 1st The sacrum is nearly 
equilabral about 4 or 5 inches in each side
In the female pelvis the concavity of the sacrum
(perpendicularly) is about ¾ of an inch
deep The last vertebra inclines backwards
from the top of the sacrum, which is called 
the promontory of the pelvis.
The coccyx is moveable & curves
much forwards
The Ilius forms by [their] [illegible]
the great basin of the pelvis properly a part
of the abdomen. There are two anterior & 
two posterior spinous processes. The top of 
the pelvis is bounded y the linea ileo pectinea
The ischium has an anterior
& a posterior spine from the latter of which 
proceeds the internal [sacro??] ischeatic ligaments of each side
The pubis is the smallest bone
The ischium & pubis surround the foramen ovale 
Ligaments 1st sacro ischiatic
internal from the spine of the ischum 2nd sacro
ischiatic external from the tuberosity of the
ischium to 


3d Sacro iliac ligaments
Dimensions of the pelvis 1st the superior
strait at the line ileopectinea has
its [antero] posterior from the promontory of 
the sacrum to the symphisis, is 4 ½ or 5 in.
The transverse, at right angles to this, is 4 ¼ or
4 ½ in. The oblique, from the sacro iliac
symphisis to the acetabulum a little shorter
than the last
The inferior strait has its diameters
not parallel to those of the superior
The oblique are measured by Prof [Burns]
from the middle of the sacro ischiatic ligaments
to the junction of the rami of the ischia
& pubes


The axes of the strait
That of the superior strait is an
imaginary line from the umbilicus to about the
one third of the sacrum
That of the inferior strait
It has been thought that at about
the period of labour, the symphisis
pubis 
Deformed pelvises
Every variation of shape does not constitute a
deformity
1st The pelvis may be unnaturally
large in all its dimensions and this is a 
most deformity The uterus remains in th e
pelvis, pressing upon the rectum & bladder so 
as often to confine the patient to her bed during’
the whole period of gestation. The delivery 
also is too speedy & prolapsus uteri, fluor albus
etc. follows delivery. Case of this kind 
M.S.


2 Alterations in the shape of the pelvis
Occur always from rickets, [malacast??] etc
All the cases, almost, which occur in this
country are foreign women. All which Prof. B.
has seen have been Irish women.
The diameter altered is
almost always the antero posterior diameter.
It is laid down as a rule by 
European
The cavity of the pelvis may 
be badly shaped. The sacrum may be 
too straight. It may also be too curved
& throw the point of the coccyx too far forward
The coccyx also may be anchylosed. Bony 
tumours also may exist
Instruments have been
invented for measuring the pelvis. Those
which have to be introduced within the pelvis
are objectionable especially in [illegible]


Baudelacque’s callipers are very accurate
allowing 3 inches for the soft parts & adding
2 lines for a fleshy persons
The hand & finger however
are the best instruments, at the period of labour.
If the finger will not reach the 
promontory of the sacrum we may be
sure that the antero posterior diameter is sufficiently 
large. If the whole hand can be 
introduced
Diameter of the had. 
The long diam. is 5 in. from the occiput
to the chin. The longitudinal 4 ¼ in.  from the 
forehead to the occiput. The perpendicular
is the shortest These diameters may be diminished
5 or 6 lines, not
The neck cannot be twisted
more than a quarter of a [circle]


External organs
Immediately below the clitoris


Menstruation
Commences at first after having been preceded
by general disturbance of the health pains
in the back, hips & loins, disturbance of the bowels
etc. perhaps hysterical symptoms During
the continuance (about 4 days) of the evacuation 
a pale circle surrounds the eyes
It is ascertained from the examination of 
cases of procidentia that the discharge is from 
the uterus & not from the vagina
In this country menstruation commences
on an average at the age of from 14 to 16
The earlier the commencement the earlier the
cessation.
Conception
many theories 1st that the semen is carried
into the fallopian tubes 2nd


Changes produced by conception
The cavity of the uterus enlarges and soon 
a membrane forms on its inner surface
The ovum contained in two membranes passes
down the fallopian tubes and pushes out this
deciduous membrane


The fetus first appears in the ovum as a 
mucilaginous cloud
At the end of 6 weeks the fetus is about
½ an inch long and shaped like a crescent 
or bean. At two months the fetus is 2 inches
long about the size of a bean At 3 months it is 4 or 5 inches 
long external parts perfectly developed the
genitals being large and those of the [illegible]
from their size resembling those of the male
At 6 months the hair is visible the motions 
are felt in the abdomen the relative length
middle near the body of sternum weight 2 pounds
of the head and upper part of the body is greater 
At 7 mo. middle half way between navel & stomach
At 8 mo. skin is firmer and whiter, and hairs are
visible on it middle nearer the navel than
the sternum length 16 in. weight 4 or 5 pounds
gall bladder contains bile etc. etc.
At 9 mo. middle at the navel length
19 in. weight upon an average 8 lb. with
us but in France between 6 & 7 lb. Length of
the male with us 23 in. of the fem. 19 ¾ in.
The nourishment of the fetus is difficult
to explain. Probably it is like a vegetable
from the ovum in the first place.
The most prevalent opinion at
the present day is that the fetus is nourished 



from the blood after it has undergone some
change in the placenta. Some facts seem
to prove that the liver changes the blood & 
gives rise to a peculiar secretion albuminous.
Circulation of the Fetus
The most probable opinion at present is
that the fetal blood is oxygenized in the
lungs of the mother, is taken up from the 
placenta by the umbilical veins and carried
under the liver (principally) into the vena 
cava through the single heart back by 
the umbilical artery into the placenta 
again 


Signs of conception and 
pregnancy
Just after conception the
features become sharpened, the eyes are
surrounded by a dark circle The complexion 
pale. The most important sign is
the cessation of the menses but when the woman
has become pregnant while suckling a child, the
menses not having regularly returned, we cannot
reckon from that period, but women in that
case reckon the rather from the motion of the 
child which first occurs between the fourth 
and fifth month The areola of the nipple
is dark Pricking
sensations are experienced in the breasts
Morning sickness occurs and continues
until with about 2 mo. of delivery
By the fourth month the uterus
projects above the pubis is more easily felt in 
a lean subject By the 6th mo. the fundus
will be at the navel By the 7th about an inch
above and the navel protrudes
Usually by the 6th month the
motion of the child can be felt if the hand 
is first dipped in cold water.


By the fourth month the neck of the 
uterus is softer and shorter
The size of the uterus is judged
of by placing the left forefinger
the 
at upper & anterior part of the vagina
& pressing with the right upon 
the fundus just above the pubes you will feel
the pressure of one finger upon the other the
woman must be in a standing posture
Prof. B. thinks gestation may 
be prolonged beyond the ninth month & 
that he has had considerable evidence of 
the fact.
Case related in which parturition
was fully expected much alarm
was excited at its not coming on
& finally it was found that all the signs
of pregnancy which had existed, proceeded
from an enlarged uterus which 
was reduced by proper remedies.


Natural Labour is that where
the face is to the sacrum and the occiput to the
pubes where the [labour] is over within 24 h.
is where it terminates with safety to the mother
and child & the [secundines] come away well
4 stages are distinguished 1t os uteri is
dilated the membranes are protruded
2nd the head turns into the hollow
of the sacrum & presents at the ext. orif.
3d the child is delivered
4 the secondines come away
In the 1st stage we observe 1st the pains 
commence in the back & loins & pass through to  
the pubis in some cases about the loins & 
thighs first Sometimes very irregular [illegible] endeavoring
These first pains are short
not lasing more than about a minute
After the os uteri is dilated to 
about the size of a crown the second stage
commences the pains from being short & cutting
are protracted, with a sense of burning 
down violent skin hot & dry sense 
of inclination to go to stool from the 
pressure of the uterus on the rectum. During
this period the membranes are ruptured


In the third stage the perinaeum bulges
out the woman demands to get up for 
a stool must not be indulged
it is a delusive sensation. The perinaeum
becomes four or five inches broad
Prof. B. puts his right hand upon 
the occiput, & his left upon the perinaeum
he judges of the degree of pressure by 
the fingers of the left hand & resists with 
the right upon the occiput of the child.
The fourchette is [illegible] in the first
labour do not mistake this for ruptures
of perinaeum Vomiting occurs
frequently and is serviceable to the
facility of the labour
Gathering of the waters
This term is applied to the bulging tumour
of the water on the membranes which 
increases in protrusion at every pain 
& appears as if more water was collecting


False pains
Can be distinguished with certainty only 
by the effect of the pains upon the neck of the
uterus the pains produce no pressure upon 
the neck of the uterus & no dilutation of the
os tineae sometimes you can pass your 
finger into the uterus and feel that the
membranes do not become tense by the 
pains.
Often these false pains appear to be
caused by excessive motion of the
child enquire about this in [illegible] labour
the child has little or no motion 
To relieve these false pains after bleeding give opium. The labour
may be a month or two distant.
It is of importance to understand
the progress of a nat. lab. thoroughly 
Examine during a pain in the intervals
the woman may sit or walk about
Keep up her spirits. Make no certain 
prognostic as to the time or at least
fix a distant time so that the end of the labour may 
fall within it. We are often much 
urged to interfere keep out of the room
on this account Suffer no to one attempt to 


bring on a labour as it is [illegible]
Leave the woman often to allow
her an opportunity to pass water. During
the first stage let her be dressed for labour.
Dress the woman in a 
loose dress with her linen tuked up  
under her arms
Prepare the bed by first making it 
up as usual prepare the lower
part by coverings to protect it
Let the woman lie on her left side
with the knees bent, her feet against 
the bed post her head & shoulders raised by pillows tie a handkerchief or
towel around the other bed post for
the woman to take hold of Some
condemn these efforts of the woman, but 
Prof. B. is satisfied of the advantage of them
The only assistance rendered shd be pressure 
on the back
The French lay the wom. on 
the back. Some women prefer a sitting
posture. It is often advisable to change
the posture for particular circumstances
Conduct the choice of the patient 


If we wish to rupture the membranes it will generally be sufficient to press
hard on the membranes with the end of the
finger the membranes will rupture themselves.
If necessary scratch the membrane
with the nail. If the labour
is very rapid rupture the membranes
yourself, that the water and child
may not both be delivered at once
and empty the uterus too suddenly 
Rather hinder than hasten after the 
passage of the head one pain will expel
the shoulders and another the hips 
Generally as soon as the head is 
born and always when the body 
is born, the child cries. First feel for the
pulsation of the cord. If the child does
not breathe (when the air is freely admitted)
blow on its face dash cold water or spirit
on the face & chest wipe out the mouth
first with a dry & then with a moist rag
close the nostrils of the child with the fingers
& then blow gently into its mouth & if necessary
press gently upon the thorax to facilitate
expiration as this may be continued for 


some time keeping the body war
with hot flannels, all the while Apply 
your hand or better your ear to the region 
of the child’s heart
At first the respiration may be very 
feeble & perhaps at first with long interruptions.
Other means are frictions
ammonia etc. to the nostrils & to the 
surface of the body
Some children, after you have
succeeded, have not stamina enough
to support life. Dropsical effusions 
in the thorax may prevent respiration
& the life kept up in such cases by 
the [illegible], for half an hour Prof. B.
has met with such cases but only in children
of hard drinkers
Sometimes a child is apoplectic
from long detention of its head in the
passage in this case, bleed from
the cord ½ oz to 1 oz milking out the blood
inflate the lungs also etc.



The cord as soon as respiration
is established not waiting till the pulsation
ceases in the [illegible] we might have to 
wait ½ an hour or more
Tie with any sort of a string there
is no danger of cutting the vessels with a small
one A piece of wide tape is convenient
Tie tightly or the ligature may become loose
from the shrinking of the [illegible] Sometimes
the arteries are so firm that a ligature will 
not prevent hem. unless the arteries
are pulled out and tied separately.
It is thought by some necessary 
to tie both ends of the [illegible] but it is better
to allow the vessels of the placenta to 
bleed & thus diminish the size of the placenta
except [illegible] cases
As soon as the child is born
pass your hand over the abdomen if it
is firm and hard up to the scrob. cord.
a twin is within if the uterus is contracted
to a ball above the pubes there is merely 
the afterbirth. Generally the pains
commence again in about 8 or 10 min.
When the edge of the placenta arrives


at the vulva take hold of it, twist
it so as to make a roll of the membranes
& thus no part will be torn
off and left.
Next attend to the comfort
of the woman. If not too feeble let
her be immediately removed to the bed
she is to occupy
Place several folds of cloth
upon the abd. & pin a towel around
to give support, to prevent relaxation 
of the uterus & hemorrhage, & for the
comfort of the patient 
The pat. will now be very 
comfortable & happy, but soon come
on the afterpains by which the coagula
of blood are expelled from the uterus
But few women escape without after pains
those who have already had children
are more liable to them
Ergot administered during the labour
prevents or diminishes the afterpains. Prof. B.
has often administered it with this intention only 
Generally ginger & spts applied
vol. lim. zj ol. or zfs
also a poultice in a pillow case of ar.


herbs & bran
These pains are generally much
increased when the child is put to the breast
Until the 5th or safer still, until 
the 9th day, when the lochia terminate,
keep the pat. on panada, arrow root etc.
not giving cordials, in the old fashioned
way
Let the child suck immediately 
to draw off the colostrum to prevent swelling
& infl. of the breast, & retraction of
the nipple, which prevent it from sucking.
The child too needs the purgation
& is apt to lose the instinct for 
sucking
By the third day the lochia
should be washed off from the external
parts and a gentle purgative castor
oil or magnesia shd be given. The 
bladder must be attended to if necessary
apply a fomentation of onions, or if such
things fail introduce a catheter


The lochia comes on about the 3d cease about the 5th day
ultimately the discharge becomes of a light
pink col. The diminution of the
discharge is looked on as a good symptom
unless vary
If excessive, astringents, as port wine 
tinct. ter. jap.
Ultimately give a pill of op & ac. pl.
aa ij gr. once in an hour or two.
If this is not sufficient inject
ac. pl. & opium into the vag.
When the discharge has a cadaverous
smell, is greenish etc. wash
out the uterus with detergent injections
such as lime water & milk decoction
of oak bark etc. support the
pat.


Introduction of the Catheter
During labour the neck of the bladder 
is often elongated & you may have to 
pass the catheter directly upwards
Next attend to the Child
Be careful that the room is so warm
that the child does not take cold
Keep a cloth warmed at the fire
against the birth of the child
The body of a new born child should
be cleansed of a white unctuous substance
which resembles tar, by rubbing
with lard & wiping with a soft cloth
Then the child if vigorous may be
washed with soap and water
Others after rubbing over with lard
sprinkle with wheat flour or starch





Tie the cord by 
The belly band is a piece of flannel
passed about twice round the belly
Sometimes the child will not bear
to be dressed, from feebleness.
If the child grows cold, wrap it up in 
flannels dipped in hot spirit. And
let these children who cannot bear to be dressed,
let them be wrapped in flannel & 
kept in a warm place
If the meconium does not come
away with 12 or 14 hours, give molasses
& water, or honey and water if these
fail give a teaspoonful of bland castor
oil
Look out for retention of urine
It may arise from imperforate hymen 


or from the orifice of the urethra, either
of the male or female, being closed
up with mucus in which case introduce
a probe, a short distance
If the child must be fed give
cows milk 2 parts water 1 part sweetened
with loaf sugar or if it is required 
to be more purgative, with 
brown sugar
Presentations of head


Breach presentations
4 orders 1st back to the left side of the
mother the body rotates and the back is turned
to the [symphisis] pubis if traction is not 
used the arms lie along the body and come
out with it the face presents at the perineum
support the child’s body with your
left hand the chin issues first then 
the rest of the face and the head issues
with a jerk. The danger is in the
stoppage of the circulation of the cord.
A difficulty arises from the largest parts not
being delivered first. Another is in the
cessation of the pains which is abt to take
place
In the 2nd the right hip of the child
presents to the left acetabulum
3d the abdomen of the child presents to 
the abdomen of the mother the body turns
outward comes out obliquely but the head
comes out face upwards
#4th the revers of the 3d


During labour turn the body obliquely 
so as to bring the head into the position 
it is as in the 1st & 2nd
Presentations of the feet
1st the heel towards the pubis which 
eventually becomes the 1st hip presentation
Presentations of the knees
The knees feel harder
Generally best to bring down the feet


Diff. lab. 1at want of relaxation
febrile state do not give stimulants
2nd Want of action Ergot 1 z ergot to zii
water infusion tablespoonf. every 5 m.
The pains of ergot are distinguished by their increasing
continuance
3d too early rupture of memb. e.g. sudden
exertions as lifting sometimes probably from 
weakness of membranes. If the waters
are not drained [illegible] the labour may not
come on for weeks & be easy
Attachment of placenta over os uteri
may be suspected, from frequent & irregular
hemorrhages. Take the first opportunity
of examining while the blood is flowing
but if the flowing has ceased the finger would
break up the coagulence & perhaps bring on 
the flowing.
When the uterus is sufficiently dilated
to admit the finger the placenta may be
detected take care to distinguish it rom 
coagulated blood
When we cannot tell (early in the pregnancy 
5 or 6th month) about the case, treat as for
uterine hemorrhage apply cold in a horisontal
posture. Sugar of lead 5 or 10 grs with 1 gr. o f
opium repeated once or twice in 24 hours
It will produce no poisonous effects unless continued
for several days. If this fails inject
into vag. zii in ½ pt. of warm rain water
this is very effectual. A strong sinapism
between the shoulder is most effectual.
But the best remedy is a plug of alum Rx


a piece about 2 oz in weight made smooth
and passed up. Alum operates as a local stimulant
& the coagula of blood stop at the passage
also. It is usual to tie a piece of tape around it
When the placenta is over the os uteri, the 
labour will be ushered in by a flow of blood
]If we find the os uteri dilated or dilatable
so that we can introduce the hand we should 
immediately pass up the hand and turn
If necessary break through a part of the placenta.
When the breech of the child is
down it will plug up the passage.
But if the woman is nearly exhausted we
must restrain the hem. by proper application
The woman may die before we can turn
the vagina. A sponge is very good. A silk 
handkerchief. Prof. B has used [illegible]
introduced
in small pledgets [illegible] on to the 
tampon and given ergot allowing the tampon
to issue while pains are on and checking
it when they are off (Case related
articular mortis tampon ergot child dead
mother saved)
In other cases we may proceed
then early and afterwards turn?


Instruments
Forceps apt to be delayed too long
Prof. B. recollects no case in which they
were used too soon
Smellie’s [illegible] consisted in 
curving the [clams] The blunt hook
is now put upon the end of the handle
Place the woman left side (English)
back (French) the back generally preferable.
Empty the bladder & rectum previously.
Keep the instruments in a basin of
warm water before using them
Always apply the forceps on the sides
of the head and over the ears so as to embrace
the head in its oblique diameter over the
cheek, over the ear (occiput [illegible] diameter)
The pressure of the forceps lengthens the head
When each blade has been properly applied
the [male] part of the joint, readily enters 
the female part never lock the
forceps by means of force
Head being in 1t position
take the male blade in the left hand & introduce
it along the palm of the right (with a 


waving motion) carry the blade until 
the centre of the clam is opposite the anterior
fontanelle or the sagittal suture. If pain 
is felt, desist because you injure a [illegible] of the vagina with [illegible] be careful about [illegible]
against the ear with the end of the clam Introduce the
other blade with the other hand, in the same way
Draw & wave from side to 
side when you extract
If the head is high up, draw down,
in the first place.
Do not hurry but let the uterus do 
what it will to expel the child
The position for the use of the forceps are
1st vertex to the arch of the pubis
2 the reverse fore head to arch of pubis
3 vertex to the left foramen cot. cav. ? ovale i.e.
the head in the diameter
In this 3d position the handle of the male
blade will pass near the right thigh of
the mother & the head must make its
last turn after you apply the instruments contrive to turn the occiput 
to the arch of the pubis while you draw
4th the reverse of the 3d
7th head corresponding to the transverse


diameter of the pubis the male blade
passes under the arch of the pubis
As to the case when the forceps are to be applied
while the head is above the superior strait,
Prof. B. has never had such a case.
It will be better to turn and deliver by the
feet The cases of this kind where the forceps shd be
introduced must be very rare if any 
Shoulder presentation
Pass one hand up and push up the shoulder
sufficiently to allow the introduction of the
other hand to seize the feet
It may be necessary after the child
is dead to bring down the hip and use
the blunt hook



Locked or impacted head
Two positions sacro [illegible] or transverse
In the first case apply the forceps as before
In the second we are compelled to apply 
them over the face & occiput
As a general rule the forceps
are to be applied to head [illegible]
directs them for the pelvis. Other methods
are better however for a living child
Where there is more want of action
Prof. B. would give ergot instead of 
the forceps
But where the mother, being
vigorous & exhausted by pains & nature
has done all she can do ergot will 
not do good the forceps must be
applied
When the face presents and you 
cannot turn apply the forceps one blade
under the pubes. As you extract turn 
the face (from being transverse) so that the 
chin shall come under the pubess


Vectis
Can be used for extraction Can be used
to hasten the delivery of the face when that is
to the sacrum
The vectis is used principally for changing
the 4th [illegible] to the 1st & in face
presentations to change them to those of
the head
Breech presentations it may 
be worth while to make footling
Blunt Hook
Generally one is sufficient if not
apply both extract by a see saw 
motion
After delivery of the body the
head may be detained the pulsation of 
the cord cease the child make one or 
two convulsive heavings & will soon die
if not soon delivered. Pass the finger
up and give the head an oblique direction 
which will facilitate the delivery
Use the forceps to hasten delivery 


But in this case the vectis may be advantageously
used. Apply it over the occiput?
Foot & knee knee presenting
foot catching against the margin of the pelvis
Not worth while to confuse the memory
with all the varied presentations
IF the back of the neck side of the 
face etc. etc. push up and turn
Where the labour is very slow
& no part present we may suspect
a bad presentation. It will be necessary
to pass the hand up the vagina
& examine if we do not find a hard
body we shall have the hand foot 
belly etc. proceed to turn after
the membranes are ruptured 



Perforatory & crotchet
1st of the cases where the pelvis is too small
a case which does not often happen in this 
country
4 in. may be left to nature 3 ½ will be slow
& may be delivered alive by the forceps
A patient of Dr Hooker’s was delivered
in whom the diameter was 1 8/10 inches caused 
by [mollities] [ossium]. By means of [cephalotoma]
she was delivered & recovered, after 
having a fistula, communication between
the vag. & the neck of the bladder and a
closure of the os uteri
Make perforation with the perforator
then introduce it and break
down the brain., Then use the crotchet
It may be necessary to bring away first
each parietal bone then the frontal taking
care to keep the scalp whole


2nd where the head is unnaturally 
large from dropsy. Here we have
merely to let out the water and may 
use any instrument as a pair of scissors
Caesarean section
Dr Dewees sides with the French.
He says the perforator is more uncertain 
and is dangerous
The French forbid it when the 
child is alive
Retention of Placenta 
It is now agreed that it ought no t
to be suffered to remain
Pass your hand gradually between 
the placenta and uterus (if the placenta
continue to adhere) detaching it as you 
proceed pull upon the cord with the
other hand bring your hand away
after the placenta and not until 
you have felt the contraction of the uterus
upon your hand When Prof. B.
has had an adhering placenta he
has always found a mal-conformation 


of the placenta or walls of uterus as calculous
concretions etc.
Hemorrhage may make it necessary
to detach the placenta immediately 
Hemorrhage a week or more after
delivery
Hourglass contraction
Generally about the neck of the uterus
Prof. B. has scarcely met with a case since
he has adopted the plan of waiting scarcely 
more than ½ an hour before bringing away 
the placenta.
If it occurs pull upon the 
cord and at the same time insinuate
your hand up to the fundus of the uterus
Hemorrhage after delivery is most
apt to occur after quick, easy labours
caused by want of tonic contraction of the 
uterus
Injections of ac. pl. may be used
previous to [extracting] the placenta.
We are recom. also to inject cold 


water or a spiritous tinct. into the 
cord this is powerful & effectual
probably
We must judge of danger
from the exhaustion of the pat. not
from the quantity of blood lost ½ pt
or 1 pt. is generally lost in an ordinary 
labour. Prof. B. always
uses a plug of alum after delivery
of placenta.
Ergot. Prof. B. always uses it
but after delivery of plac. it is apt
to fail Where he has reason to expect 
hem. he gives it before the termination 
of the labour It never
fails & besides this it diminishes the 
after pains.
When life is in danger
use all your means. Carry 
a piece of alum in your hand
into the uterus. Prof. B. prefers
this to a sponge of vinegar. He has
had to wait 15 min. before the uterus
would contract in the last & 
compelled to sit an hour before the 


uterus would expel his hand.
Concealed hem. does not show
externally and uterus becomes distended
with blood. We should never
leave our patients until we have felt
the uterus firmly contracting between
the navel and pubes
Inversion of the uterus
Caused by pulling upon the cord Said also 
to take place spontaneously 
Prof. B. has seen but one or two cases
The indications are to detach the placenta 
and if possible restore the fundus
Symptoms very severe paleness, coldness
vom. conv. etc.
Place the pat. on her back and
pass up your hand and endeavour to push
back the fundus. But if the fundus
is protruded through the os uteri and
the dangerous symptoms result from the 
stricture perhaps all that it will be 
in our power to do, will be to make the
inversion complete and thus relieve the
stricture leaving a prolapsed uterus


Immediately after delivery
If the placenta does not come away 
apply friction etc. to excite contraction
Dr N.B.I. always excites contraction
if the uterus by pulling and swaying
upon the cord. He finds this perfectly 
safe. Prof. B. says it is also
# Compound pregnancy
We can sometimes guess at it in lean
women. In general we may find it 
difficult to determine, from the large
quantities
If after the birth of the first child
Labour is rather slower on account
of the large size of the uterus and that
too with the first child
Pass your hand upon the abdomen
to ascertain the existence of another child
If you find another child, conceal
it from the mother
The presentation is more apt
to be wrong in twin cases
If the pains do not come on again 
within ½ hour give ergot. You 


will then soon feel the bag of water
protruding and if you find them 
a bad presentation as of the shoulder or 
arm, you may easily turn and deliver
Hemorrhage is more apt to occur
Hence generally it will be best to give
ergot after delivery
Not unfrequently a woman has
been left, with a second child in her
uterus. Case related
Commonly the placentae are 
distinct and united merely by membranous
union. The memb. and the waters
are distinct. Sometimes however the
vessels of the two placentas [inosculate]
hence the precaution of tying both ends
of the divided cord.
The delivery of the placentae
is apt to be rather more difficult
Delivery one cord at a time


Presentation of the Cord
Sometimes a foot or a foot and a half
will protrude. These cases are 
difficult. 
It is safer to attempt to turn
and deliver [footling]. It is exceedingly 
difficult to return the cord
and keep it up. We are directed
to wind the cord on a sponge or rag
and push up. It will generally 
however soon come down again
Dr Dewees mode of using catheter
Prof. B. has not tried.
In one case Prof.  B. has
known a knot in the cord.
Deformed children
Give puzzling presentations
Oftenest the bones of the head are imperfect.
Sometimes you feel
the bone hardened brain. Feels
for the face
A more serious case is that of
hydrocephalus. Sometimes the size 
is enormous. Easily distinguished 


by the feel. The scalp protrudes
like the membranes. By pressing
also you may feel the bones of the cranium
and may even push your
finger through the sutures
The child is of course lost hence
you may as well puncture at once
with a lancet. In one case Prof.
B. let out 4 pds?
Signs of a dead child
Coldness shiverings like an ague
when the child dies Breast ceases
to swell and becomes flaccid
A secretion of milk comes on.
A weight is felt falling when the 
woman turns Cessation of mot. in child
When labour comes on, the waters
are fetid the meconium is evacuated
even in a head presentation
The scalp is flaccid, the hair comes
off etc. Yet the only certain 
sign is the want of pulsation in the cord


Rupture of uterus
By a fall, by violence in turning
or by forceps
Severe rending pain cold clammy 
sweats, sickness faintness & 
vomiting
The seat of the rupture may 
be in the fundus, side or neck.
If the child has wholly escaped
into the abdomen, the difficulty is
great. Gastrotomy seems much preferable
to delivery through the 
[illegible] Cases recorded of recovery 


Retention of menses
They may not commence until after the
20th year in the feeble and delicate
This should excite alarm as long as the
other signs of puberty are wanting
If the patient is robust let the
antiphlogistic treatment be followed.
But for the feeble, nervous, leuco-phlegmatic 
etc. prescribe exercise
shower bath warm flannel clothing
Give tonics especially chalybeate
Blood root madder ½ zs 3 times a day
Guaic. 4 z ½ z carb. sod. [illegible]
zjfs alc. 1 pt. Dewee’s tinct. vide Ellis
Blood toor ½ z sulph. zinc aj
aloes zj ft. pil. 60 2 to 3 in
24 hours regulating the dose by the
effect upon the bowels. This is the 
most useful emmenagogue
Blisters on inside of thighs size
of the hand These effected a cure in a 
pat. 27 years old whose aff. had resisted
all remedies
Cupping on inside of thigh has 


also been found beneficial
Cupping the breasts was reccommended
by the older writers
Savin has also strong emmenagogue
power
Retention may be caused
by other affections e.g. phthisis
In such cases emmenagogues shd
not be given
Suppression of menses
Menses may vary much without
ill health. The interval may be
12 or 6 weeks
The most usual cause
is the application of cold symptoms
severe pain in the head back
and loins colic etc. hysteria etc.
Hip bath anodyne injections
V.S. nervines for the hysteria
We may thus cure the immediate aff.
but the discharge will not thus be
made to return. Use of the pediluvium 
bleeding etc. just before 1 week
the next period & so [illegible] the 


discharge
Chronic suppression is to 
be treated like amenorrhea #
Periodical discharges from 
other parts may take place as a substitute
for the menstrual discharge.
This may continue for life. Case related
ulcer on ankle
Deficiency in quantity gives
rise to the same symptoms & shd be
treated like amenorrhoea
Excessive menst. not common
treat as for hemorrhage
Guaiacum is more agreeable in powder
# Carb ir. & pulv. guaic. aa zi
Sang. in powd zfs. aloes zfs. a small
teaspoonful 2 or 3 times a day


Dysmenorrhea Painful m.
very distressing pains resemble
labour pains pains
relieved by the discharge generally 
Caused by irritable uterus
Hip bath opiates hyoscyamus
diaphoretics
For permanent cure use the 
last described pills. Tinct.
guaic. Dr Dewees has cured with 
Prof B. has often failed with it
Deciduous membrane
Pains not relieved until the membrane
is thrown off. Occurs
in unmarried females also prevents
impregnation in the married
There is danger in the doses
of camphor 2 or 3 recommended 
by Dr Dewees. Prof. B. has produced
dangerous convulsions by them
Electricity has cured. repeated
for a week previous to the [illegible]
Use the emmenagogues mentioned 


Decline of menses
A critical period
Predispositioned to organic disease
are most liable to show themselves
at this period. On the other hand
others are then restored to health
In some the discharge stops suddenly 
in some it becomes profuse
or painful or irregular
Bleed 6 or 8 ounces repeatedly 
Keep the bowels open with the bloodroot
and zinc pills. Stimulant are
hardly ever admissible there is generally 
a disposition to plethora


Abortion
Delivery before 6th month especially 
between 2 & 3 & between 5 & 6. Keep 
on the look out. Drastic cath.
injuries reaching high with the hands
thus compressing the abdomen
Death of the fetus indicated by diminution
of all the signs of pregnancy
shrinking of breasts etc.
If you do not know the fetus to be
dead presume it to be alive. Quiet
laudanum etc. Ac. lead sometimes
for hemorrh.


Leucorrhea
Muco purulent discharge At first
a local dis. astring. inject. oak
bark zinc etc. Ascarides may
attend or be the cause Finally 
tonics gum ammoniae & iron cantharid. stopping for
strangury & then repeating Old cases
[illegible] [illegible] copaiba
Green & fetid discharge
Nit. silver one of the best injections
Cant. not important ([illegible])
sulph. zinc &nit. sil. also valuable
a sort of test of the efficiency of canth. is a 
thickening and opacity of the discharge
from the vagina It will not be necessary 
to keep even a light strangury 
& of course we are not to produce 
dysentery Prof. I.
Nit. sil. best inject. 3 or 4 grs. to oz.




Prolapsus uteri
One of the most common & troublesome
complaints takes place at any period
of life
Caused by relax. of vagina Uterus
kept in place almost solely by vag.
Most com. cause leucorrhea
Women with large pelvis more liable
Symptoms weight, uneasiness about 
loins etc.
Almost always accompanied with 
leucorrheal disch.
Cure at first by strengthening the
vagina, by tonics astringent, rest
recumbent posture
Treat for leucorrhea when that accompanies
Easily ascertained by examination 
or by relations of the pat. herself
Tumour recedes when pat. is on 
her back & is easily reduced
in this posture
Strong sol. of oak bark sulph.
zinc etc. after replacing the 
uterus & confining pat. to her back 


Continue with this treatment
[tonics] etc.
We are often called on when 
the diseases does not exist & we
find disease of [rectum] and vagina.
We do not find the uterus
pressing on the perinaeum
Use the pessary
Women of lax fibre & laborious women
as washerwomen are most
subject and often the disease has
made great progress before we 
are called the pessary will 
give effectual relief
This disease may be overlooked
& cause derangement of bowels
dyspepsia etc. & these complaints
only be prescribed. Prof B. has
known several cases of women confined
to the bed for years and the stomach
only prescribed to when the pessary 
has cured in a week
When the perinaeum is lacerated
the pessary cannot be used 


When the largest sized pessary is
required from extreme relaxation of 
vagina the oval pessary is best
Place the woman on the back
[enter] the pessary perpendicularly 
& after it is entered turn
Extreme prolapsus requires
a pessary with a handle [illegible]
in its place by a bandage
Pregnancy gives great inconvenience pessary not to be used
horizontal posture until the 
fundus rises
Retroversio uteri
Occurs generally between 3d and 4th mo.
fundus is in cavity of sacrum 
urine stopped in its passage
In passing up the hand we do not
find the os tincae & neck of uterus
Distinguished from polypus
which grows slowly & was gradual
in its symptoms
Growth of ovum prevented


Supposed to be caused by distention
of bladder with urine
Attempt reduction immediately
pay no attention to the
danger of producing abortion
First draw off the urine
Attempt reduction by the fingers
in the back part of the vagina
endeavouring to push up the 
fundus uteri. If we fail, place
pat. on hands & knees then introduce
a probang like inst. into the
rectum at the same time press 
with the left hand above the pubes
We may almost always succeed
Cases of failure are recorded 
[illegible] and it is recommended
to introduce a catheter & rupture
the membranes and draw off the
waters thus reducing the size of the 
uterus
Anteversio uteri
Can never be a formidable disease
& may always be remedied by change
of posture


Scrophulous enlargement of
uterus
Resembles schirrhus pain in 
neck back & loins etc.
large & less hard than true
schirrhus not extremely tender
Causes a resemblance of pregnancy
Sometimes the general health is
not much injured
Prof. B. has known a case of 
gradual enlargem. sympath action 
of breast & cessat. of menses
closely counterfeiting pregnancy
Prolapsus is very apt to 
occur with all its inconveniences
Prof. B. has known one case of 
this kind which continued 6 or 7 yrs
bed ridden unable to stand or 
walk cured by blue pill was
to bear 2 children blue pill 
is specific


Irritable uterus
The least touch cannot be borne
pat. cannot sit or stand even
lying merely palliates no relieves 
the pain. The slightest 
touch cannot be borne at the
pubes. Vagina natural os tuniae perhaps a little swollen
Rest cupping counterirr.
blisters hip bath conium & 
[illegible] narcotics blisters & 
setons (Well described by Dr
Gooch & only by him) Case related
Arsenicae
solution was the most successful
remedy & continued to be so
Diseases of ext. org. of [generatim]
phlegm. infl. of labia often occurs
to be treated with poultices frequently 
suppurates but the abscess [illegible]
[illegible] gives great pain discharges
fetid blood issues when an excis.
made 
Excoriations of labia
Soap & water ointm. of ox. zinc etc.



citrin oint. etc.
Warty excrescences not venereal
cured by nit. silver.
Dropsy of labia t pregnancy 
almost as large as the 
child’s head
Prusitus pudendi
very troublesome efflorescence
just within the labia intol. itch
may generally be cured by a wash
of nit. sil. or corr. sub.
[illegible] subj. to great elongation
but not with us
Imperforate hymen
Almost always congenital & discovered
by the nurse and will 
generally yield to pressure of a
probe If the knife is used be
very careful to keep a tent in or
a second operation will be needed 


Rupture of perinaeum
Occurs during labour
Keep the bowels open to prevent distention 
& irritation by passage of 
hardened feces It will generally 
heal up The hare lip operation 
is said always to have failed 
to cut by [palliatives]
Small vagina
may be caused by severe labours
& should be prevented after delivery
Introduce a dry sponge
after a few days a large one
Prolapsus vaginae
Astringents & a pessary


Cauliflower excrescence
Probably a fungus haematodis
vagina filled with a spongy soft tumour
bleeding at the slightest touch Disappears
at death
We cannot [illegible] by the touch
whether a tumour is malignant or benign
Hydatids are clustered vesicles
like a bunch of grapes Some call them
[illegible] They form in all parts of 
the uterus in the ovum & sometimes
the [illegible] itself produces [abortion]
It occurs only in those who have been pregnant
this last disease counterfeits pregnancy
hemorrhage comes on in an 
abortion pains resembling labour pains
etc. Treat as for hemorrh. & 
finally ergot might be useful to expel 
the hydatids
The ovaries are the seat of
scrofulous & other enlargements fecundity
is prevented
Ovarium Dropsy
Consequences in the [Graaffian] vesicle
with small tumours which gradually 
enlarge and as they enlarge, the matter 



becomes more limpid finally the
bulk may be as great as in ascites
from which it is distinguished by 
tumour more circumscribed & greater
thickness of integuments between
the liquid and your hand
Commences by pain & is near
the hip
Affects the health little except
from its bulk
Entirely out of the reach
of constitutional remedies.
Often there are several distinct
vesicles & upon making
one puncture we find the tum.
merely diminished & altered in size
Case Prof. B. drew off only 1 ½ pt
at the first tipping at the next tapping
immediately after 64 pounds
were evacuated
Remember that the coats
of the tumours are nearly as
thick as the walls of the gravid uterus
 


Cancer of uterus
Darting pains bearing down
pains in the groins General
health soon affected countenance
sallow etc.
Os uteri hardened & pressure
on it causes lancinating pain
Hard knotty tumours form about os 
uteri & in the vagina. Menstruation
irregular or substituted by 
hemorrhage.
Distinguished from scrofulous
enlargement by knottiness irregularity 
& hardness. Also cancer rarely 
comes on till after cessation of menses.
A. Cooper never saw a true
carcinoma under 36 years
Treat at first as if we had
mistaken the disease and prescribe
for scrofula. Afterwards palliate
give light nourishing food
keep bowels soluble. Attend to 
cleanliness discharge being intolerably 
fetid inject limewater
hip bath black wash. corr. sub.



3 grs to 1 pt of limewater
Nit. sil. very useful
Chloride of lime for the fetor
[restorat???] discharges by ac. lead, sul.
zinc etc. injected
Opiates
Diuretics especially those which render
the urine bland e.g. uva ursi
gaultheria etc.
Polypus of uterus
Frequent discharges which exhaust
the patient. Hence necessity of manual
examination. Where we cannot
relieve frequently returning discharges
we ought to suspect polypus.
Generally in the cavity of uterus
After it protrudes into the vagina
we can feel it. If attached to the 
neck of the uterus the neck will 
be found passing directly in the 
direction of the uterus
Sometime they are attached to the
ext. surf. of uterus or to vagina 


more common in women who have
borne children But met with in others
They may exist a long time without
being discoverable
Frequently very small tumours
seem to have more effect than large
ones causing more or worse hemorrhages.
They may be large & 
give no inconvenience except by 
bulk & pressure on the bladder
& rectum
There is danger when the tumour
is attached to the fundus it may bring 
it down & produce partial inversion 
Vary from the size of a walnut
to that of a child’s head with a neck
as large as the wrist Case
Other diseases may be mistaken
for polypus. Prolapsus uteri is distinguished 
by the presence of os tunicae
by its sensibility & by its growing
larger from below upwards by 
relief being given when it is pushed
up a polypus causing uneasiness 


when pushed up history of case also
Gooch’s rule always to supply 
a ligature to a tumor with a neck 
is a good one
Sometimes their removal
results from the stricture upon 
the neck by the os tunicae
The ligature is the best mode
of removing them. Prof. B. prefers
the common double cannula
to any of its more complicated substitutes
For a larger tumour the [ring]
probe is the best instrument
If you get away as much as ¾ of
the tumour the rest will disappear
You will know if you have included
the neck of the uterus by the extreme
pain produced










Retention of Menses
Retention is the want Suppression is
the interruption Treatment of both is 
much the same We are to prescribe
however to constitution and symptoms
Either of them is rather the effect than 
the cause of disease
The [cutam.] will sometimes cease
at 25 and often between 30 & 40. They 
may continue also beyond 50 years
Suppression & retention are
usually from want of action 	
Want of expression of countenance
and eyes whiteness of tongue scurvy
as it is called
This form is relieved by tonics
and astringents Lime water is 
much used & is called tonic. Alternate
alkalies with astringents as gum, [illegible],
[illegible] etc. A convenient form is pills
of the extracts with molasses And 
also [iron] & formerly myrrh
was called deobstruent and much 




used in form of Jenkins’ pills
& the myrrh mixture (Griffith’s & [illegible]
Rx
In the worst cases in country practice geranium [illegible]
or statici or agrimonial (which resembles
contrayerva) or cornus can always
be found in the country Lime water can
be made sulph. zinc you will carry 
about you. Add also aromatics as fennel,
dill etc. mints [pyenanthin??]
Generally when you have obviated
the cachetic morbid actions of the constitution 
uterus will take on its own healthy 
natural action. If however the catam.
do not return use emmenagogues
R. sulph. zinc gr i sang. gr. i aloes gr i
[illegible] guaicum table sp. & tinct canth. So much 
guaiacum as not to operate as a cath.
& 20 gtts tinct canth. 2 or 3 times a day
Another disease
Symptoms pain in the side about
an inch above the anterior sup.
spin. proc. inquietude sleeplessness




upon enquiry you will find the discharge
paler or watery or less in quantity material it is unhealthy
Stimulate the spine with tart. emet
oint. or canth. from the neck down 
along the spine. You will generally 
find upon pressure some of the vertebrae
tender. Then give after [irritant]
guaiacum, myrrh. Cathartics
seem to increase the cachery of the 
system. Of course avoid costiveness
Bleed in small quantities if necessary 
in retention or supp. Remember
however that the system does not suffer 
from want of evacuation Ligatures
will do better often than bleeding applied
just before the time for the return of the
catamenia
Sometimes the bowels become
loaded from torpor & inactivity
etc. Prof. I. has no doubt that bleeding
at the lungs and hectic after arise
from this cause. Use repeated
any free injections to wash out the
bowels. Exercise & amusement in 
the open air will do much Injection 



([Dr Savemens]) may be somewhat of a
substitute for exercise. The shower
bath is a good thing & our old remedy
Young women are seldom subject
to dis. of the uterus. Yet young 
women of of strumous habit, in whom 
there is [tineae] is relaxed have prolapsus from 
jumping off a horse etc.
Symptoms pain down the thigh
a sense of drawing down of the stomach
& of the bowels sinking at the stomach
dyspeptic symptoms
Prof. I has known unmarried
women bed rid from this cause, feeling
as if the bowels would come out
if they attempted to rise The os tineae 
is relaxed and there is a tendency to spasmodic
action there. In young women
pessaries do not seem to do well
there is more or less spasmodic action
I have made them with a handle & 
used a T bandage but no with much 
success. Sea bathing has been beneficial.
Elastic gum pessaries are 
best & have cured. Silver ones are 



good. Sponges are used but are
too rough & absorbing the secretions
smell bad & if changed every day
irritate too much. Ivory pessaries
Pessaries are proper when there is 
no disease excepting relaxation
When there is prolapsus you do not
feel the os tineae & the neck distinctly, but
you feel the relaxed and enlarged os tineae
& perhaps the uterus in an oblique position
In such cases we use astringents, as oak
bark etc. but sulph. zinc is better
Keep the bowels open and give aromatics
R. magn zfs or zii chalk. zfs cubebs
zfs carb. soda zfs grana paradisi zjj
a teaspoonful 2 or 3 times a day is often
enough. If there is likelihood
of the liver’s being affected give blue pill
Prof. I. doubt the existence of the 
cauliflower excrescence. HE has seen
relaxed os tineae with its veins varicose
Various diseases are called
cancer. If you find the os tineae
hard & enlarged & unequally & you 


find tumours in the vagina the disease
will certainly prove fatal. You may 
give conium astringents irritate
the sacrum etc. but with no good effect
Sometimes the tumours are fatty
 A phagedenic ulcer affects
the uterus eating away the os tineae
carb. & phosph. ferri have been 
declared specifics
Another disease enlargement of uterus, pain
in it discharge like leucorrhea
perhaps catamenia excessive Os tineae
enlarged also. This terminates in 
medullary cancer of some [writers]
Apply alum to the os tineae astringent
give metallic tonics & narcotics & 
silver pill
There are diseases of the uterus
in which polypi, deciduous membranes
dropsy etc.


Dysmenorrhoea
Occurs in persons with some deranged
state of the viscera catamenia comes
on with pain in the back limbs
much unequal excitement head hot
sometimes neuralgic pains Patient
will frequently throw off a deciduous
membrane
Dewees recommended
guaiacum (tinct) & allspice called
Dewees tinct. but it is better to give
the guaiacum by itself and the allspice
if needed Give 5 to 11 gr
camph. repeat every hour until’
you have given a z If you can
keep this on the stomach it will generally 
cure I have given also camphor 
& magnesia 20 gr of each
by mistake she took double the dose
became weak but after a few
hours recovered regular catamenia
Other narcotics may be used but camphor
has been long recommended. Deobstruents
also as sanguinaria may 
be used. Hyoscyamus is better then 


opium or conium
Equalize excitement by irritants
& drafts warm bath etc.
Other articles are ipecac
wild ipecac ([illegible])
External irritants are burgundy pitch
plaster on the sacrum
Sometimes there is a sallow
countenance, atony etc. then support
the patient
Incipient cases of diseased
ovaria the os tineae is spongy and 
flattened These diseases of ovaria
are very various but are called
dropsy & cancer Curable at
first by a course of blue pill, moderate
stimulants, aromatics, absorbents
(for acidity) and deobstruents
in general. I have kept patients under
the use of blue pill and even for a year
occasionally [illegible] it for 2 or 3 yrs
I gave also a compound powder
of alkalies, aromatics and columbo
and kept the patient also under conium


but I find hyoscyamus equal in its 
deobstruent effects even while it is
far superior in its narcotic effects
while it does not like opium produce
constipation & torpor of al. can.
Polypus of uterus
It may exist without unpleasant
symptoms. They do not always bleed
but at the time of catamenia hemorrhage 
is apt to occur. In the 
bleeding kind it may come down
and project beyond the vulva
At the time of the catam. there will 
be pain in hips & back & extending
down the thighs cat. profuse & finally 
terminating in a watery discharge
If the astringents as nutmeg, geranium
and best ac. pl. with op.
given both locally & by the mouth
do not relieve, we may examine
for polypus. There will be a dragging
sense in the uterus etc. Examine & you
will at about an inch & a half you 
will meet with a tumour which you 
will distinguish from a prolapsed uterus


by the absence of the os tinaea &
by feeling a tapering tumour its
neck being embraced by the os
tineae Its surface being smooth & 
delicate. Generally the neck will 
be too high up to be felt.
Retroversion
Well described by J. Hunter in the
London Observations
The trifling complaints spoke of
by Dewees do not deserve to be
considered Retroversion is
when the uterus is carried back down
into the perineum the os tineae is
carried back & up
Symptoms uneasiness constipation 
retention of feces & urine
vomiting, hysteria etc.
Introduce the finger into the vagina
about an inch up you find a resistance
on all sides you carry the finger back
along the prominence and you find a
tumour in the perinaeum and you find
no os tineae but by changing the position 


of the patient say erect or upon hands
& knees you are able to feel partially 
the os tineae The orifice of the urethra
is also drawn up, because the bladder
is drawn up & you do not readily 
find it and cannot readily introduce
the catheter Introduce a small
elastic catheter & draw off the urine
when great relief is obtained
Evacuate the bowels by injections
John Hunter recommended puncturing
the uterus drawing of the waters & producing
abortion
Restore the uterus by placing
patient on hands & knees & introduce a
probang with a ball about an inch in 
diameter covered with lard introduce
the left finger into the vagina
Pass the probang gradually up the 
rectum & let it act upon the fundus of the
uterus so as to push it back in the way it
came down assisting with the left two
fingers. Use the catheter for some days
after and give injection per anum
After the child rises above the pubis there 
is no further danger


# Found in bex humida, convulsiva etc.
# Very large and strong in the 
“dead rattle”


Stethoscope
Continued from the 1st vol. M.M. 1832 & 3
2nd Mucous [rhoncus] occasioned
by the passage of the air through sputa forming
bubbles which produce the sound by their
bursting. The epithets are very large, middling or small
according to the size of the bubbles also
abundant or rare according to the number 
of them. # Found also in haemoptysys
though then there is an indication 
of greater fluidity the bubbles being more
frequent. This originates from the large tubes 
Tracheal rhoncus is also mucous
and may often heard very loud by the steth. when 
not audible to the unassisted ear #
These two the crepitant and mucous
are called moist rhonci
3d Sonorous rh. a flat dull
sound resembling the cooing of a dove
or the large strings of a violincello The 
causes are not known The indications
also unknowns. The sound varies very 
much. resembles the varieties of sound
produced by blowing the nose



4th Sibilant rhon or a dry sharp
whistling sound sometimes
resembles the chirping of a ground bird
pathogn. of asthma
In sonorous rh. but one sound is heard
but in this there are heard a great many 
almost persuading one sometimes
that the chest is filled with young birds
This rhoncus is from small tubes
The former (sonorous) is from one small
tube. This sibiliant may may be caused by a thickening of the [illegible] membrane
5th Crackling rhoncus proceed
emphysema pulmonum (an unnatural
inflation of the lungs at first an unnatural
inflation of the air cells
ultimately the cells burst and the 
connecting cell mem. is inflated
in dissection the pleura may often 
be seen elevated In another
variety the air is effused into the
cell mem. between the lobules of the
lungs) In vesicular emphysema
this rhoncus is not always found
but in the interlobular emphysema 
it is very manifest


The sound is a crackling one, like the
burning of hemlock leaves or like blow
into a dry bladder. Sounds as if air was
entering dried lungs
6th Some authors add the cavernous
found when there are cavities, formed
from tubercles, or from gangrene or from 
abscesses Tubercular excavations
generally contain some fluid, which 
gives rise to a gurgling sound. We
have likewise the term “amphoric resonance
or atricular buzzing, which 
is caused by the communication of the 
cavern by a small orifice resembles
the sound made by blowing into a large
vial When there is no fluid
we have the cavernous respiration
of which the amphoric is a variety
Some make this a variety of the mucous ronchus
Some persons breathe so 
feebly that it will be advisable
to request the patient to make a full & 
quick respiration Otherwise he may 
not notice an engorgement which the 


ordinary painful & cautious respiration
may not slow and he
may suppose a part to be completely
obstructed which which will be [illegible] to be not [illegible] upon
a full & quick respiration
It will also be useful
probably to the patient to make occasionally 
a free respiration especially 
in the commencement & in 
the resolution of pneumonitis (N.B.
when pneum. is going off we hear
the crepitus caused by the air beginning 
to reenter the cells)
Also in incipient adhesions of the
pleura, we may make use of the
same means. Dr H.’s own case
He felt a sense of tearing
Emphysema will only 


Patholog. cond. of the voice
1st Tracheophony or layrngoptony
2 Bronchophony 3d
4th Pectoriolquy
The two first are heard in health 
in limited portions of the chest however
The air of the lungs being in distinct
cells we have a compound medium
but when the lungs are hepatised or
hardened with tubercles So also if
one lung has been entirely destroyed
Case of a child foreign body in the
lung infl. supp. vom.  & prod. of pus
child recovered from the sound
the lung was considered healthy
afterwards a year after the child died
of scarlet fever & the lung was found wanting # 
When apart of a lung is solidified
we find a dull sound upon percussion 
we hear bronchial respiration & bronchophony


Introduction of the catheter
During labour the neck of the bladder 
is often much elongated, and you may 
have to pass the catheter directly upward
Next attend to the child
Be careful that the room is warm
that the child does not take cold
Keep a cloth warmed at the fire
against the birth of the child
The body of a new born child
should be cleansed of a white unctuous
substance, which resembles tar, by 
rubbing with lard and wiping with 
a soft cloth. Then the child, if vigorous 
may be washed with soap & water
Others, after rubbing off the 
lard, sprinkle over wheat flour or 
starch 




Aegophony or Haegophony
goat like tremulous, bleating
voice resounds through a thin stratum of fluid
Pathogn. of empyema
collection of [serum] (Pleuritis)
Commonly not distin. from 
bronchoph. by the inexperienced
It is like a kind of silvery voice vibrating
on the surface of the lungs. Apply 
the cylinder firmly on the chest the ear
to the stethos. lightly (if hard pressed on
it, it will sound like bronchoph.)
When the liquid is small, 
aegoph. will be heard only at the lower
portion of the lung But if we hear
the sound near the root of the lungs (between
the scapulae) we may conclude the 
collection to be large
In strongly marked cases it
may be distinguished by its shrill sharp
sound also by seeming like an echo
of the voice often also the seat of it
may shift with a change of position



Pectoriloquy
the resounding of the voice from within a 
cavity communicating with the tracheae
or bronchia Caused by softened tubercles,
by separation of gangrenous
[eschous] by abscesses formed in any way 
by openings into the mediastinum was perhaps
& perhaps also into the liver
Pathogn. principally of phthisis
In perfect pectoril. the voice
seems at the end of the steth. & often
seems louder In imperfect the voice
does not seem to traverse the whole length
of the instrum. or
Doubtful pectoril. sound slike
aegophog or is too obscure to be defined
In perfect. pect. an amphoric resonance
or cavernous rhoncus will accompany it
and there will be obscured in the
imperfect
If excavations exist in the 
lungs, they can generally be detected by 
the stethoscope & before the use of the
steth. they could not as there is often 


no pain in their region In some
few cases the information conveyed will 
be imperfect or doubtful, but the instrument
is valuable
Pectoril. is modif. by the nat. tone
of the voice clearer & more distinct
when the voice is high though perhaps
less loud. Hence the nat. resonance
of a sharp toned voice may be clearer
than a true pectoriliquy, in the axilla, for
instance, when the voice is grave. But
we can generally determine by comparing
the opposite sides of the chest
2nd modified by the size of the
cavity but then a cavity is large as  a 
pea! will render a true petoriliquy 
5 by the situation of the cavity if it
is deep in the substance, the pectoril.
will be far less clear than when it is
near the surface but when very 
near & with thin collapsing sides
we have only the veiled puff a
var. of cavernous rhonc.
4th by the  slope of the cavity
louder & clearer of sound & smooth very 


loud indeed when the cavity is lined with
a cartilag. sub. Ragged an obscure sound cavities yield
5 by the opening several fistulous
opening will much obscure the sound 
6 more distinct, when the cavity is perfectly
empty sometimes the cavity will be 
filled one day & empty another according
to the abundance & facility of expectoration
Hence, in general, pectoriloquy
indicates a cavity, but a cavity may not
give pect. still there may be other
sighs, as amphoric resonance


Signs given by resp. & voice
1st amphoric resonance & metallic
tinkling.
1st is like blowing into
a vial 2nd like striking a short
metallic cord, or a wine glass or 
tumbler. Both indicate a large
cavity with hard unyielding walls
& filled principally with air & communicating 
by a small orifice
Commonly cav.  resp. amph. res.
& met. tinkling are varieties of the 
cough & [speck.]
Auscultation of the cough
The phenomena are intermediate
between those of the voice & the respir.
Cavernous cough indicates excavations
& cav. rhonc. is made more manifest
by coughing
Also by requesting the patient to cough we
can obtain a full inspiration


1st Clavicular over the clavicle
2nd Infraclavicular from the clavicle to the 4th rib
3d [Mammary] 8th
4th Infram from 8th to cart
3 sternal regions
5 Superior sternal region
6 Middle
7 Inferior
8th Axillary reg. to the 4th rib
9th Lateral reg. fr 4th to 8
10 Inferior lateral reg fr 8th to [cartilage]
11th Acromial ac. proc. of scap
& above
12th Scrofular space of the scap.
Some make superior & inf. scap. reg.
separated by the spine
13 Interscep (2 of them
14 Inferior dorsal (2 of them)


Diseases
Pneumonitis more fatal than any other
acute disease. Infl. of lungs etc. vide Good
To be distinguished from bronchitis & 
pleuritis. Though it may be complicated
with one or both
3 stage 1st obstruction or engagement
2nd hepatization 3d purulent
infiltration
Engorgement is from blood
and serum the lung when cut will 
give a crepitus, & does not sink in water
resp. high small, accelerated, incomplete,
unequal, difficult commonly
cough & pain & expectoration (when no cough or pain 
called latent [illegible] then we must observe the 
respiration & use the stethoscope which 
gives the crepitous rhocus). The 
modification of the rhoncus gives the character
the fluid engorged (if bloody crepitant) if serum, subcrepitant.
Hepatization has the air cells entirely 
obstructed lung sark red sinks in 
water called also [carnification]
absence of vesic. resp. & [illegible] of bronchial
resp & bronchophony (if near the centre 
of the lungs


puerile respiration (produced by a preternaturally 
vigorous action of the healthy
part of the lungs) occurs in both stages
3d Purulent infiltration into the substance surface of 
the lung straw coloured. Lung humid
& soft fingers easily penetrate it 
softer if from serous engorgement generally 
accompanied at its commencement
by chills mucous rhoncus
Percussion gives no difference in the 
first stage of engorgement grows duller
decidedly dull after the stage of
hepat. commences In hepatization we have bronchphony & bronch. resp.
The three first stages are completed in 
from 6 to 8 days the first two in’
5 days But often the disease is irregular
and the regular course may be broken
up by medication You may find all 
the grades of healthy and morbid respiration
within 4 or 5 inches
After dust both lungs are found
affected for the disease is seldom fatal
when one lung only is affected. Respiration 
of one lung may be entirely gone and yet 



the health be pretty good apparently 
Dr H. has often known one lung completely 
hepatized within 36 or 48 hours,
and within 6 or 8 hours find the
disease entirely transferred to the other
lung
Commonly one lung
undergoes resolution
& then the other is affected
Sometimes however both lungs
are engorged and then of course
a fatal suffocation occurs Especially 
is this the case in pneum. notha
vide Good
Case in which death occurred in an hour
another in 3 hours Such cases
hardly deserve the name of pneumonitis
(inc. inf.) but no definite line can
be drawn between them.
The older writers speak of termination 
in abscesses or gangrene
the matter is disputed.
The truth is a regular circumscribed
cavity containing pus is not found
Proper abscesses occur from tubercles
Occasionally a gangrenous abscess occurs
In such cases we have cavernous



rhoncus
By careful medication & good
nursing, resolution may generally be
brought bout this may occur in 
either of the three stages 
Resolution is effected sometimes effected
in a few hours days and week may 
be required
Stethoscope says all well frequently 
when resolution has commenced from hepatization,
when the general symptoms 
show no mitigation first we hear
crepitation etc. etc.
Resolutions of purulent infiltration
Case related pulse slower than it
ought to be owing to cerebral aff. coma etc.
Rx tinct. sang. zi tinct. cinch. comp.
z8 tablespoonful every ½ hour
In the winter of 1831 & 2 we had
pneumonitis oedematosa In the previous winter
we had a pneumonitis which afforded no stethoscopic
sign the disease was rheumatic & yielded 
to actaea alone. There were all the ordinary 
appearances and progress of pneumonitis, viz
diff. resp. bloody expect. etc. 


In the pneumonitis of 31 & 2 we had
no crepitous rhonchus but a sub crepitous rh.
yet the disease went through the 
regular stages and there was even an
uncommon tendency to suppuration. Some
cases however were mere oedema of the lungs
This according to Lacunec is very rarely 
an idiopathic disease It commonly occurs
as a hydropic. disease of cachectic
habits. Good knew but little of it
he thought it could not be distinguished from 
hydrops thoracis It can readily be distinguished
however by the stethoscope
Dr Hooker thinks the disease has often 
been overlooked. When edema of the lung
has been found after death, it has too 
exclusively been attributed to effusion just
before death. To be sure the effusion
is liable to shift or disappear suddenly 
but we find the same thing in 
edema of the limbs. Within the last 18 mo.
we have had such cases of shifting from 
the limbs thence to the head thence to 
the lungs etc.


Dr Hooker thinks that ½ of our fatal
cases of disease terminated in hydrocephalus
Instead of 30 or 40 according to the bills
of mortality, he thinks we may say at least
130. The intellect was not in general materially 
affected
[Lae???]’s account of edema of the lungs
is not a good one. The pathog. signs are
progressive dullness upon percussion & 
sub crepitous rhoncus His subcrepit. rho is
rather a super crepitous rho caused by fluid in large bronchiae
in [illegible] cases.
Haemoptysis
Called also pulmonary apoplexy IT
is an effusion of blood into the substance
Stethoscope shows a crepitus
rhon
Hydrops thoracis
Good says the only decisive indication
is a fluctuation but this can scarcely 
ever be observed
Percussion gives a dull sound
Haegophony exists in the first stage q.v. In the advanced
stages no respiration can be observed 
A very rare idiopathic disease


Empyema detected
in a similar manner
Pleuritis
Acute pain difficulty of lying on
the affected side (yet when adhesions exist
the weight of the lung renders it more
painful to lie on the opposite side
There is bloody sputum & cough
But effusion of serum generally takes
place & then we have haegiophony
Frequently the effusion becomes concrete
& tough and hard, perhaps cartilaginous
Laennec has observed a contraction of
that side of the chest (in the young the
lung of that side not growing so fast)
Pleuorpneumitis
Pleuralgia a rheumatic aff. of
the intercostal muscles relieved by 
opium, actaea or some narcotic
Stethoscope shows no signs of pneumonitis
hence valuable, negatively 


Emphysema
1st Pulmonary or vesicular emphys. 2nd
Interlobular emph.
The first is an effusion which causes
larger & larger globules
The second generally gives oblong or
triangular collections of air
The crackling (crepitant) rhonchus
indicates this especially the 2nd
Caused generally some obstruction 
of one or more of the bronchial vessels
The case of the child who had never spoken 
loud (in Broadway) exhibited emphysema
of the lungs. Tumours & croup
have the same effect. Hepatization or
tubercular degeneration or some [illegible]
of a part of the lungs may cause an emphysema 
of other portions. This is one of the most
common causes. Yet the p.m. ex. shows
emphysema we do not necessarily find
that the stethoscope has given indication
Symptoms are hurried and laboured
respiration lips livid, from 
want of decarbonization of the blood
Easily out of breath etc.


Stethoscopic signs of it are obscure the
respiratory sound is said to be feebler
The sound of percussion is clearer however
Little has been known of this disease until 
of late years
Pneumo thorax
Pneumato thorax might be called
emphysema thoracis. Not distinctly 
described by Good It is a collection 
of air in the cavity of the pleura 
First memoir on the subject by [Itard]
1803? May be caused by a 
wound of the thorax by a communication
between the bronchiae & the cavity of the
pleura by putrefaction and extrication 
of gas
More or less inf. will be apt
to be caused.
Percussion gives a remarkably clear sound 
steth. gives not resp. sound on the affected
side on the opposite side the respiratory
sound will be clearer than natural
If there is a communication between the 


cavity of the pleura & the bronchiae we
have amphoric resonance & occasionally 
upon coughing or speaking, the metallic tinkling
This affection is commonly complicated
with presence of fluid. Inflammation 
caused by the air will be apt to produce
fluid. In this variety we may make
use of what is called the Hippocratic succession
Concretions of the lungs
We find them bony or cartilaginous or chalky
in p.m. exam. especially in old cases
of phthisis. Laennec thinks they are
tubercles which have been cured.
Black pulmonary matter upon 
the surface is found more abundantly 
after pulmonary diseases and phthisis
but found more or less where there had been
no pulmonary disease. Laennec thinks
it more abundant in blacksmiths
Bex. dyspnoea want investigating.
Good’s dyspn. includes 4 or 5
distinct diseases. Sometimes we have 


a sibilant rhoncus. Sometimes it
is caused by emphysema of the lungs.
Phthisis
most of the recent French writers restrict
the term to tubercular phthisis
Cullen considered it a sequel of haemoptysis.
but the latter might with
more propriety be considered a sequel
of the former. Haemoptysis rarely
leads to phthisis.
Good has P.  catarrhiulis P apostematosa
& P. tubercularis. Apostemes,
with excavations, very rarely 
exist, in the lungs, as has now been 
ascertained
P.m. ex. in Paris show that ulceration 
of the bronchial membrane is
(almost) always connected with tubercles
the question is which is the primary 
disease. The French think the 
latter is the primary disease
Of tubercular phthisis
Tubercles are small tumours (tuber)


They commence greyish bout the size
of a grain of mustard (miliary tubercles)
Colour deeper in adults
In examinations we may find not more
than a dozen tubercles or thousands 
Tubercles are found also in other parts
of the body particularly upon the intestines
and in the liver, spleen. etc.
When they become large they first soften
internally then discharge. “Crude
tubercle” collections of non-discharging
tubercles
Tubercles may exist at a very
early age 2 or 3 years. They may be
inherited in infancy. Case of a child of 
3 months. They have been found in 
the fetus 
No one symptom is constantly 
met with in phthisis. Cough, expectoration,
pain etc. may be absent. It is 
doubtful whether the tubercles and ulcerations 
of themselves cause pain.
In this disease the physical signs
generally come too late.


When suppuration and excavation occur
we have mucous rhonchus cavernous
rhonchus and pectoriloquy q.v.
Curability Those who make
the least pretensions do as well as any 
The disease may mitigate and apparently 
cease in summer & revive again
in the winter
It is difficult to get leave to 
examine the bodies of drunkards
There is no doubt that confirmed
phthisis is occasionally cured as shown 
by steth. & p.m. examinations
Affections of the heart
No part of the body is subject to a greater
variety of affections Corvisart
produced the first valuable work
An enlarged heart will be indicated 
by percussion though the pericardium distended with water will give
the same sound
Manual examination is better
Place your hand over the heart & judge
of the regularity etc.


But the steth. is still better & also
shows new phenom 
1st sounds
1 impulse or shock
3d extent of the chest over which the pulsations extend
4th rhythm
1st By the stethoscope we hear two 
sounds first duller & longer then a shorter
& sharper. The former is isochronous 
with the pulse
2nd an impulse on the ear is felt at the
time of the first sound. In children & 
thin chested persons the second may have
a slight impulse
3d extent generally small In fat persons
we have not more than an inch of extent
the extent is increased by high
living etc. & vice versa
4th rhythm i.e. order of succession now
receives much attention cannot be 
thoroughly explained as to its causes. Still
valuable indications may result from it
Laennec says the first sound is produced
by the systole of the ventricles the second


when the auricles contract then a 
period of repose so that ¼ of the
time is occupied by a state of repose
In 1828 Mr. Turner maintained that
the auricles contracted first and was
followed so immediately by that of the
ventricles so that both together cause the
first long dull sound Mr. Turner
also thinks the second sound made by the
beating of the heart (in a diastole) again
inst. the pericardium. Many other
hypotheses have been advanced since
We must conclude Laennec’s hypothesis
to be unfounded. A later hypothesis
supposed the dilation caused the sounds
Another supposes the sound caused 
by the striking together of the sides of the 
ventricles but then the ventricles are
never empty
[Refutation] of Corrigan and Haycraft
Dr Hope has published lately a large octavo
volume on this subject.
1st the auricle contracts so immediately
before the ventricles as to make but one 
sound


2nd the extent of the auricular contraction 
is very small & incomplete
3d the ventricular contraction is the cause
of the impulse & coincides with the pulse
at the wrist
4th the impulse is made by the apex of 
the heart
5th the ventricular
6th the ventricles do not [illegible] themselves
7th
8 after the diastole the ventricles remain
apparen
1st sound caused by systol 2nd by the
diastole of the ventricle
Rhythm 1st auric. syst. 2nd ventric.
sys
3d v. [illegible]
4 v. repose towards the termination of
which auricles begin to contract
Dr Hope attributes the sound to the
agitation of the blood in the ventricles
Dr Hope attributes one sound to the
active dilatation of the heart [illegible]
or elastic



1st mot. auric systole
2nd immediately followed by ventricular
systole & 1st sound
Dr H. thinks the 1st sound produced
by the closure of the auricular vent. valves
& the second by those of the arteries
The sudden arrest of the regurgitation
causes the sounds
The sound occurs at the times of 
the closure of the valves
[illegible] of the sound is such as
might be expected from the striking together
of the valves & the sudden check
of the regurgitation hence the second 
sound is like the lapping of a dog or 
the snapping of a whip
The second sound (by the auric. vent. valv.)
is more gradual as it should be also
the sound is more dull
Dr Hook thinks the first sound
is caused by more than one circumstance
The impulse also is caused (he thinks) by 


the apex of the heart and also by an internal
abrupt succussion caused probably 
by the auricular vent. valves and the
reaction of the chordae tendinae colum.
[illegible] etc. upon the whole mass of the
arterial valve
Dr H. thinks Dr Hope’s account
of the order of the action of the heart is the
tone one
Hence the first sound 
is heard lower down than the first opposite
the apex of the heart the sound
being conducted by the dense contracting
ventricle & coinciding with the impulse
The first sound
1st Hypertrophy of the heart muscle
larger than natural contracts
slower & stronger Impulse stronger less sudden sound
more prolonged less sharp because
the valves close less suddenly 


2nd Dilatation of heart muscle
thinner hence contract more
rapidly but less strongly So too 
the sounds become preternaturally 
abrupt, loud & sharp
In a high degree of hypertrophy
the sound is scarcely perceptible
3d Contraction of the orifices
of the heart
We have the bellows the rasp
serrate & thin whizzing murmurs all varieties
of the same Caused generally by 
diminution of size of cardiac orifices
but often by regurgitations (perhaps
more frequently The murmur 
may exist before death for months & yet
p.m. ex. show no disease of heart
It is observed that in arteries
It is heard in the arteries of the placenta
Slight derangement however may exist about
the valves and not be detected by 
dissection e.g. relaxation of the chord. tend.
It is found that excessive depletion causes
the bellows murmur from this cause or 
a similar one. Dilatation of the heart will 


Cause bellows murmur produced by 
imperfect closure of valves
A murmur rarely supercedes
the second sound the arterial valves
are rarely completely ossified
Simple dilatation of heart
Walls thin heart weakened in action
palpitation but (according to the general law) acts
quicker pulse quick feeble respiration
labored edema of extremities livid
& pale & leaden skin these are affections 
symptomatic of the general affection
If the left cavities are dilated
& the right healthy the lungs are
oppressed edema etc.
If the right sides of heart are diluted
the left continuing healthy, we have edema
of extremities congestion in grain etc.
a pathogn. [symptom] is swelling of jugular
veins. (N.B. pulsation of jugular
is produced by imperfection of the [illegible]
valves manual examination 


shows a dilated heart but not clearly 
which side is affected
Auscultat. gives a feebler impulse & shorter
sharper & clearer sound the extent
of the sounds is increased even extending
into clavicular & axillary & acromial
region
Generally both sides are diluted
but commonly one side more than another
The early stages of dilat. can scarcely
be distinguished from nervous palpit. of
[illegible] etc. (apply stethoscope 
frequently to prevent patients being
alarmed and excited by it N.B. In fevers
steth. useful in conjunction with 
feeling pulse, gives more certain signs)
The bellows murmur is generally 
heard caused by imperfect closure
of ariculo-ventricular valves
Now laennec would lead the [illegible]
to suppose that increased clearness of 
sound attends dilatation But when
the dilat. is excessive the sound is obscured
or superseded by the rushing bellows
murmur



The stethoscope gives no signs of 
dilatation of the auricles (Laennec
was mistaken his work on the lings
is nearly a perfect one)
Hypertrophy
morbid increase of muscular
substance of heart with thickening of its
parietes Excessive growth
weight increased
1st [Chicentric], 2nd Eccentric & 3d
simple hypert.
1st Case the grown incroaches 
on the cavities & diminishes the cavity
Simple is growth outwards merely 
Excentric is dilated & grows thickened outwards
also (vide Bertin) Corvisart
was acquainted only with the last
The two former occur more frequently 
in children & are frequently
congenital (specimen exhibited of
a congenital concentric hypertrophy N.B.
the heart was larger than the childs fist
larger than natural walls enormously 
thick cavity almost obliterated)


N.B open foramen ovale is given
as a cause of such cases then probably 
the hypertrophy is the principal evil.
The for. ovale is generally open for 
3 weeks after birth
The child above was restless from 
birth hemorrhage from umbilical
arteries (caused by strong power of heart)
palpitation very strong great
effusion into cavity of pleura
(hemorrhagic pleurisy) Child
moaned all the while put its hand
to its head etc. right side of heart 
thicker hence effusions in lungs
Tendency to inflammation found
all over the body
The apoplectic habit especially 
predisposed to hypertrophy but
sometimes the sanguine & robust
have dilatation & the feeble & cachectic
have hypertrophy
Pulse in hypertrophy strong
& slow (strength of heart without 


quickness as above) If right side
is hypertrophied the lungs are affected
& [illegible] left is the head will be
affected with serous apoplexy.
Stethoscope gives a slow strong
dull prolonged heavy impulse & 
sound In the left ventricle about
the 5th & 6th ribs in right
about lower part of sternum
Excentric hypert.
by no means uncommon occurs in 
adults incredible size sometimes
Dr Duncan found one weighing 32 oz.
(nat. weight is about 10 oz.) 7 inches long
& f in. broad
Stethoscopic signs are a 
union of dilat. & of simple hyper.
impulse extensive sound sharper
& duller? (more obscure in
its signs)
Polypi
Coagulated lymph questioned whether
formed before death or at death more
generally supposed that they do form before death


Notes of Prof. Knights Lectures
copied principally from Mr. Osgood’s
notes
Curvature of spine
Polypi were very remarkable last 
winter during the hydropic diathes
specimen shown extending through 
as far as the radial artery
Stethoscope to fractures
gives a more distinct & precisely 
located sound
Stethoscope in pregnancy
Gives first the pulsat. & sound of the
fetal heart & the blowing pulsation
through the placenta (a bellows murmur
of the placental arteries which is synchronous
with the pulse of the woman
Both are audible to the stethoscope & to the
ear The stethoscope is preferable from 
considerations of convenience & delicacy
[illegible] sound not heard before 3 or 4th
month Fetal heart heard [illegible] afterwards towards
the end of pregnancy Twins are predicted thus!
Bellows murmur of iliac arteries easily distinguished
Fetal heart gives a double clik and then is silent period


Fracture of clavicle
Mistake often made in supposing
that the sternal end rises, & in endeavouring
consequently to keep it down.
It is the scapular portion which requires 
to be kept in place
Dislocation of last phalanx 
of thumb
Instead of vainly endeavouring
to make sufficient extension 
bend the phalanx back almost to a 
right angle thus get one edge to 
catch upon another & then reduce by 
the lever principle
Bending of the long bones in 
children
Prof. K. has met with frequent
instances of this in children a fracture 
perhaps on the convex side symptoms
distortion with stiffness etc.
Fracture near the head of the 
long bones of children, occurring 


in a part not ossified, yields no crepitus
Amputation of the last or third 
phalanges of the fingers or toes
When swollen your knife may slip
by the joint & cut into the soft cushion
of the ultimate extremity & deceive
you be on your guard
Os femoria
The books represent the neck as 
smaller & they then account for fracture
there But both circumference
& the diameter from above downwards
is in fact greater
The body of the bones may be 
destroyed by disease and the [illegible]
remain
Tibia
When you set a broken tibia bear in 
mind the natural lateral curvature
of its anterior edge
Ankle joint
Dislocation backwards and forwards on 
rare occurrence. [illegible] inw. [illegible] with 


fract. of int. [mall.] Disloc. outwards
generally accompanied with fract. of fib.
1/3 or ¼ [illegible] way upwards superior fragment
of fib. retaining its nat. position
Tarsus & metatarsus
Tarsal bones very rarely dislocated
except in the practice of nat. bone set.
Prof. K. has been informed on good
authority of one or two instances
In amput. foot at tarsus bear in 
mind the uneven line caused by the projection
backward of the second met. bone
or Near the articulation of the
fibula with the astralagus, and a little 
before if three is a small cavity between
the anterior ends of the astralagus
and os calcis which can be readily felt
through the integument This often almost 
[illegible] filled up in sprains, & often
mistaken for a dislocation of a tarsal bone
In amputating at the tarsus the
land marks are the projection of the 
internal cuneiform bone & the projection of the 
metat. bone of lit. toe The former has 


a bursa on its top which is liable to 
effusion and swelling from pressure as
of a boot cured by abstracting the pressure.
The project of metatarsal
bone of lit. toe often mistaken by 
patients for something wrong
Sprains of ankle joint
They are affections of the tendons of the librating muscles
& the affection is either an injury 
of the tendons themselves or a displacement
from the sheath of those of the
external libration muscles
Calf of the leg
Soreness, long continued, & lameness
caused probably by separation of muscular
fibres from tend. of [gastro???]
It has been attributed injury often [illegible]
of plantaris
Wrist hand fingers
Pus formed under the brachial aponeurosis
may point in the palm of the 
hand. The tendons of the fingers are


at first in one common sheath &
then the separate in order to go to the
several fingers. In labouring men
these separate tendons sometimes adhere
to their sheaths causing a curvation and
stiffness of the fingers and a prominence
under the skin when the finger is bent
tendon feeling rounder and harder 
than natural This is not mentioned in 
the books
Ear diseases of 
Always examine for cerumen in cases
of deafness, by throwing the suns rays
strongly into the ear. Deafness from 
this cause occurs oftenest in elderly 
people. The wax gradually accumulates,
but deafness does not occur
until the closure is complete
Sometimes there is a thin coating of cerumen 
over the membrane tymp. destroying 
the [shining] appearance which it 
shd present when healthy. The lining
cuticle of the ext. auditory canal, instead
of secreting cerumen may secrete 


pus without abrasion of surface
When the eustachian tube is closed
puncture the memb. tymp. in the 
lower and anterior part to avoid the
small bones not piercing so [illegible]
a quarter of an inch through
Insects in the ear will be destroyed
by tinct. camphor. Foreign bodies
may generally be removed by a 
scoop. Case a small stone closely 
fitting the cavity Col. Blake pushed
through a tube a piece of cotton dipped
in any alcoholic solution of shellac
when the alc. had evaporated 
the stone was readily drawn out by 
means of the fibres of cotton
Diseases of internal ear Ulceration 
may take place in the muc.
mem. of this part. If the small bones
are destroyed hearing will remain but 
if the labyrinth is destroyed, hearing is lost.’



Puncta Sachrymalia
The course through the superior [illegible]
is the most direct Exceedingly difficult
to introduce a probe through
the puncta half the time we do not 
pass the probe into the sac when we
think we do
Couching
Prof. Knight prefers the posterior
operation for depression 
The [lens] is always depressed
into the vitreous humour there is not 
room in the posterior chamber of the aqueous
humour. Be sure to have the
needle far enough behind to avoid
the ciliary body
Laceration of capsule of [lens]
is performed anteriorly & the aqueous
humours entering though the opening
made by laceration, absorbs
the lens


Foreign bodies in the nose
are generally in the lower sometimes
in the middle meatus
Tonsils or glandulae amygdalae
are between the palate half arches
are often enlarged Their [illegible]
orifices are occasionally filled
with a semi-purulent, or a curdy
matter which may give their surface
the appearance of an ulcerated
one.
Throat foreign bodies in 
Thee when in the aesophagus are either
at its upper extremity in the root of
half cul de sac formed by embrace
of the larynx by the lower end
of the pharynx & then they may be 
swept out by the finger & they 
are at the cardiac orifice of the 
stomach In the former case they 
may often be seen & if we introduce the
finger we must be careful not to mistake
the projecting horns of the os hyoides 
for foreign bodies


Prof. K. has known an ulcer to eat
through the fold of membrane which 
extends literally on both sides of the
epiglottis, so that the passage to the 
larynx could not be protected
death ensued
Fraenum Linguae
The gone is more bound down by 
this fold of the muc. mem. in some individuals
than in others. If it necessary
to divide it, let the incision be
made near the floor of the mouth, to avoid
the [illegible] arteries The small glandular
bodies seen under the membrane are only parts of the sublingual gland
Uvula
when enlarged may occasion a dangerous 
chronic cough. Its removal [shortening] has never
been followed by worse consequences
than a slight subsequent hoarseness


Venesection
The basilic vein is apt to be a rolling
vein. The cephalic is apt to be 
small and deep seated. The median
is most superficial &most
firmly fixed. In order to 
be sure of avoiding the brachial artery
feel for it. The position of the superficial nerve 
we cannot calculate on and no 
one is to blame for wounding it. Prof.
I is incredulous about the injurious consequences 
of wounding it. Avoid 
pricking the tendinous expansion of
the biceps infl. there will be troublesome
Flexors and Extensors
The extensors are the strongest but
the flexors of the legs are the shortest
so that they are completely at rest
only when the limbs are flexed because
we like and sit so much



Bursae mucosae
There is one on the anterior surface
of the patella & one on the olecranon.
There is one under the 
tendon of the rectus femoris which 
always communicates with the
knee joint. There is a corresponding
one below the joint which sometimes
is separate from it
Hip joint
There sometimes occurs after a fall 
or other injury an utter [illegible] of
this joint, with violent pain and 
soreness & requiring many weeks for 
recovery the cause of which is unknown
(acute infl. of Prof Hubbard?)
Some have thought this effect caused 
by bruise of synov. memb. cart. etc.
or by fract. without displacement
Prof. K. has had 2 cases 



Curvature of Spine
First symptom may be a slipping
of the [illegible] from the shoulder
or a projection of the lower angle
of one of the scapulae, mistaken for 
a tumour and sometimes poulticed
etc. for a long time one hip 
may project
The first curve causes a 
second compensating curve, to preserve
the balance of the body.
Examine for curvatures 
by means of a string stretched along 
the spinous processes. The place of the original
curve will generally be [illegible]
indicated
by tenderness or pressure
Cure by strengthening the muscles by 
exercise
Spina bifida
Congenita It has been proposed to 
puncture the tumour this may be
done by a small orifice but a fatal
infl. may ensue. If the tumour
communicates with the brain, pressure
on it will produce symptoms 
of pressure on the brain



Circumflex arteries
In opening [illegible] abscesses about the knee
or elbow joint you are very liable
to wound some one of the numerous
circumflex or recurrent branch hence
make a free incision that you may 
be able to tie an artery if necessary
Arteriotomy
is performed on the temporal art.
[Arterio] feel under the finger much 
larger and nearer the surface than 
they really are. The artery should
not be completely divided. It is 
different to hit it longitudinally
hence & make the incision 
obliquely
Local depletion
May be serviceable in local infl.
Case wound of the hand. The 
divided artery had regular periodical 
[illegible] of bleeding for a while
and then ceasing for a few hours. This
proves an independent local action 


Mem. Obtain the minutes of 
Prof. Knight’s case of partial dislocation
of a cervical vertebra








E. D North
snuff taker !!!!
5
obstetrics
& 
Diseases of women