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LECTURES ON SURGERY.
   J. G. GILCHRIST, M. D.,

LECTURER ON SURGERY IN THE H0MO30PATHIC MEDICAL COLLEGE
      OF THE UNIVERSITY OF MICHIGAN.

                   . 5jA SUIS3 Hival r
*.  ^V
      ANN ARBOR:
JOHN MOORE, PUBLISHER AND BOOKSELLER.
         1877.- 
100
£H(A;
RAO::
Courier Steam Printing House, Ann Arbor, Mich. 
CORRESPONDENCE.
                                  Ann Arbor, Michigan,      1
                                             November 26, 1877. j
 Prof. ./. G.  Gilchrist, M. D. :
          Dear Sir,—As a committee representing the  students of the
 Homoeopathic College of the University of Michigan, we are instructed to
 ask from you the permission to publish your notes on Surgery.
     Kecognizing the great benefit  that must ensue from their use in a
 more tangible form, not only in  student  but in  professional  life, we
.earnestly request that you will furnish us a copy for publication.
         We have the honor to be,
              Very respectfully,
                     Your obedient, servants,
                             WILLIAM B. KNAPP,  M. D., ]
                             S. EUGENE WARNER,      ;•  Committer.
                             FRANK N. WHITE,
                               University of Michigan,       "|
                                           November 27th, 1877. )

 Wm. B. Knapp, M.D., F. A. White, and S. E. Warner:

         (rENTLEMEN,-It gives me  pleasure to be enabled to accede to
your request, for a copy of my notes  for publication.
     Thanking you for the compliment expressed in your note,
                           I remain,
                                  Truly yours,
                                              ,1. G. GILCHRIST
             I 
I
CONTENTS
                                                            Page..
      Preface    ________  -----   -------------   ----     - 1

   1.  Introductory_______________________________      -       '!

  II.  Inflammation    ______________________________          i

  III.  Erysipelas ..____________________________             *

  IV.  Suppuration  ...________________________________  -----   11

   V.  Pyaemia.            ______      __________-        ______ 12

  VI.  Ulceration....     _____            ____      -  ______— - 13

  VII.  Mortification     ........                              is

 VIII.  Instruments and  Appliances ....      ....   .  __  _       _  . 2<i

  IX. Anesthesia________  ...                          .  ._- ._   2o

   X.  Shock and Traumatism.  .__                ._  _____      22

  XI.  Injuries to Soft Parts   ____                            24

  XII.  Effects <>f Heat and Cold______  ____.....---  —.__     27

 XIII. Asphyxia ...              . ...    .                       2fi

 XIV. 'IVMiiiis...  _     ..              ...  .       ___   . ________30

  XV. Nerves                                    .    -  -  ____38

 XVI. Blood-Vessels  _______                     ..       _____43

 XVII. Muscles  and Tendons                     ____    ------47

XVIII.  Bones_______  ..._.                          ..   ______    4«

  XIX.  Joints                                     __    _______  TiT

   XX.  Nails                     .                               (H

  XXI.  Amputations                                        ____6t>

  XXII.  Head____ ..   ______         .             ____      ____«7

 XXIII.  Abdomen.....                     .        .____7(1
 XXIV.  Genito-Urtnary___   ___                                72

  XXV.  Chest                                                    SO 
IP^RT  FIRST.
GENERAL   DISEASES.
                I.   INTRODUCTORY.

     Surgery :  Corruption from Chirurgia :  " Work by hand."
     That department in medicine, which treats of morbid pro-
cesses chiefly characterized by objective phenomena, as well as all
those which demand mechanical or instrumental treatment.  The
practice  also •includes, cases of accident,  deformities resulting
therefrom, that are congenital, or the sequelae of disease.
     i.   Diagnosis "Theory of  disease:" Rests on  three  ele-
ments : (a) History  of case ; (b) symptoms  subjective, and (/)
symptoms objective.
     Age: Fracture  vs.  dislocation ;  cancrum  oris,  vs. lupus;
epithelioma, scrofulosis, vs. inflammation.
     Sex  : Thyroid body :  Hysteria.
     Occupation :  Phosphorus workers: tailors, housemaids, mi-
ners, etc.
     Social Condition: Married  or single :  abortions ; sexual
commerce.
     Habits : Prostitution, masturbation, drunkenness.
     Previous Diseases : Syphilis, struma ; cutaneous diseases.
     Hereditary Diseases : Cancer, phthisis,  syphilis, gout, in-
sanity, etc.
     Alleged Cause ; Mostly to injury; misrepresentation, wilfull,
and  ignorantly, e. g. Infantile gonorrhea, abortion, etc.
     Duration : Tumors, and malignancy ;  hernia, abscess.
     Course : Constitutional and local complications.
     Errors in  Diagnosis :  Frequent, often unavoidable.   Cases.
     2.  Semiology :  Interpretation of symptoms.
     (a) Subjective : sensation ; caution in accepting.
     (b)  Objective:  Visible; external surfaces, or  through spec-
ula.  First importance.
     Posture : Supine : Prostration ; serious injury.
     Bent forward : Abdominal lesions. 
4
A SYLLABUS OF LECTURES ON  SURGERY.
     Bent backward : Spinal trouble.
     Paraplegia:  Spinal lesions.
     Hemiplegia : Cerebral lesions.
     Paresis :  Local, spinal, or cerebral.
     Mobility of  parts : Fractures, spasms, luxations.
     Physiognomy : Pinched, peritonitis.
     Frowning, cerebral lesion.
     Compression of mouth, pelvic lesion.
     Expanded nostrils, thoracic.
     Nervous System :  Motion ;  coma ;  sensibility of parts.
     Pain :  Nervous, hysterical, neuralgic.
     Organs of special sense : Sight, hearing, etc.
     Respiration:  Dyspnoea.   Hyoid  lesions,  effusion, foreign
body,  etc.
     Circulation : Local  irregularities, sudden  cessation of pulse
in a part, venous enlargements, etc.
     Digestive Apparatus : Vomiting ;  gastric or cerebral.
     Urine: Litbiasis; Brights disease, or diabetes, forbids oper-
ations.
     Genitals : Sexual  functions;  epilepsy, brain lesion.
     Skin : Temperature, moisture, vital forces.
     Miscellaneous :  Cachexia,  etc.
     Physical Examination :
     Microscope :  Ophthalmascope ;  specula.
     Alterations in Form :  Hernia, hydrocele, fracture, etc.
         do       Color :  Bruise, gangrene, inflammation ; anae-
                          mia, asphyxia, etc.
         do       Volume  : Tumors, hypertrophy.
         do       Transparency : Hydrocele, cysts, etc.
         do       Consistency :  Emphysema, oedema, etc.
         do       Relations : Fractures, dislocations,  etc.
         do       Mobility : Fracture, dislocations,  anchylosis.
         do       Pulsation : Embolism, aneurism, etc.
         do       Sound: Thoracic effusion, aneurism.
         do       Smell:  Pus, gangrene, etc.
     Elicitation of crepitus.  Fractures, serous inflammations.
         do       Fluctuation : Abscess, effusions.
     Chemical Examinations : Little used ; liththiasis.

                II.  INFLAMMATION.

     Accompanies, preceeds, or follows all  morbid processes.
     Hypersemia:  physiological, or reparative.
     Inflammation :  pathological, or destructive,
     Objective : Redness, swelling.
     Subjective:  Heat, pain.
     Redness.—Not a fixed blotch ; receeds on pressure and re-
turns again.  Extravasation remains under pressure. 
A SYLLABUS OF LECTURES ON  SURGERY.           5
     Color:  Arterial, bright  red ;   active;  acute.    Venous,
dark;  passive;  chronic.   Modifications of  color dependant
upon shade formed by  union of red and the natural  color of
part.   Not alone diagnostic.
     Swelling :  Cause,  increase  in  blood; exudation; excited
growth.
     Serous or mucous surfaces, much effusion, equivalent to swell-
ing in solid parts.   Rigid organs,  as bones, no swelling.   Loose
textures, swelling and solidification, as hepatization of lungs.
     Exaggeration of natural secretions.
     Quality depends upon inter-arterial (or venous) pressure ;
when  moderate,  tvatery,  cedema;  greater,  albuminous, neo-
plasm ; extreme, sanguineous, from rupture of  vessels.
     Characters:  1.  Salts in larger  proportion  than  in pure
blood, e. g. chloride of sodium, and phosphates.   2.  Organic
forms, leucocytes or lymphoid corpuscles,  amoeboid properties,
always found, but sometimes few.
     Differences:  1. Fibrinous, diptheritic; 2. Pus, no coagula-
tion;  3. Serous, or watery ; 4. Sanguineous.
     Pain.— Cause : Nerve  disorganization,  stretching, or com-
pression  of fibrils.   Proportionate  to  intensity,  not extent.
Greater in  rigid tissues ; less in loose textures.   Insignificant on
free surfaces, as intestines, etc., (as in  cholera), when  extension
is on surface not in depth.
     Quality varies: Phlegmonoid, pulsative, tight-bound, feeling
of compression.   Surfaces,  as cuticular epithelium,  smarting,
pricking, or burning.  Ulcerating, a literal gnawing.  Oversensi-
tiveness to  external impressions, equivalent to  pain, e. g.   Eye,
light, (phosphenes) ;  Ear, abnormal sounds ; Post-faucial, bitter
taste;  Ante-faucial,  sweet  taste;   Mucous   surfaces,   reflex
motory phenomena.   Extension to some distance from point of
inflammation; as to arm in paronychia, etc.  Not  alone diagnos-
tic.
     Heat.—The  most  constant  symptom,  both  subjective and
objective.   Parts warmer in proportion to vascularity.   Inflamed
parts actively calorific  [Experiments.—Holmes,  I., 18 Simon],
1,  Point inflamed  warmer than the arterial blood supply;  2, Ve-
nous return current  warmer than afferent arterial;  3. Venous
current warmer than the opposite side.
     Increased vital effort, causes increased heat.   Temperature
of the blood generally raised in inflammation.
     Resume.
     Pain, or increased sensibility.
     Redness, or  "   blood supply.
     Swelling, or  "   secretion.
     Heat,  always.
     Neither pathognomonic singly. 
6
A syllabus  of lectures on surgery.
    First indication, functional abnormalities.  Secretions more
or less suppressed, followed by exaggeration.  Primary excitement,
secondary exhaustion.  Hotter blood,  first diagnostic value. Pro-
cess seems to extend by material contagion.
    Feverishness : Hot, or heat and chilliness.—Skin, lips, etc.,
dry.    Urine  less,  high  color.   Pulse quickened.    Restless.
Thirst.   Face flushed and anxious.  Sleepless.  Delirious.  Bow-
els inactive; dejections offensive.  Duration, etc.,  dependant
upon  extent of  inflammation.

    PATHOLOGY.

    Blood-Vessels.   Arteries :  Primary, contractions ;  Secon-
dary,  dilatation, and increase in size in all directions.
     Veins:  Ultimately  enlarged.   Primary,  circulation more
rapid  ; Secondary,  slower,  and ultimately  stasis.  All arteries
normally contract and dilate, but not to the same extent as in in-
flammation.
    Amount of blood not so much increased as volume passing
through from greater rapidity.
     Causes: Vaso-motor excitement.
    Direct stimulus, constriction of vessels and  capillary anae-
mia.   Reflex through sensory nerves, produces dilatation and hy-
permaemia.
    Blood  Changes.—Increase of fibrine and of colorless cor-
puscles.   Leucocytes having  amoeboid properties.   Escape of
leucocytes—(see  Holmes, V., p.  751).  Stasis, when complete,
not the only change in appearance—seems  entirely red  corpus-
cles packed together.
    Characteristics : Local  stasis,—transudation, and migration
of leucocytes.
    Tissue   Changes.—Influence on tissues of a  character to
increase cell life.   Permanent cells become leucocytes, by germi-
nation or  segmentation, living at the expense  of  the  tissues,
which they may ultimately  destroy.   Changes  due to  organiza-
tion of plasma.   Vide " Wounds."
    Characteristics in Inflammatory Process :  1. Pain.  2. Heat.
3. Swelling.  4.  Redness.   5.  Fever.  6.  Primary arterial con-
traction.   7. Secondary  arterial  dilatation.   8. Increase fibrine
in blood.   9. Increase in colorless corpuscles.  10. Local stasis.
11. Transudation.  12. Migration  of leucocytes.   12. Increase
of cell activity, and pseudo-growth.   14. Modification of func-
tion—Primary,  exaggerated.  Secondary, exhaustion.
    Terminations.—Resolution.    Suppuration.    Ulceration.
Mortification.   Neoplasma.

     CAUSES.
    1. Determining, or exciting.
    2. Predisposing, or maintaining. 
A SYLLABUS OF LECTURES ON  SURGERY.
7
     Determining :
                           Mechanical.

                           Chemical.
     2. Morbidproducts. Stone in bladder, stone in kidneys, stone
in salivary ducts, stone in lachrymal ducts.  Billiary concretions.
Retained  Putrefiable Excretions : Urine in paralysis. Faeces in
rectum.   Blood coagula, and  tubercles, when disorganizing {vide
Phthisis and Pycemia) Parts deprived of life :   Gangrene and se-
questra, acting as foreign matter.   Ergo,  both  mechanical and
chemical, dependant upon the stage.
     3.  Nervous Alterations.    5 th Nerve conjunctivitis, ulcera-
tion of cornea.
     Pneumo-gastric, pneumonia.  Sensory nerves protect against
many  external influences.  Sensory paralysis deprives  parts of
sensibility, and they cannot protect themselves;  e. g. Catheter-
ism prevents cystites in paralysis; air-tubes in pneumonia, etc.
     4.   Changes in  Blood.
     (a)  Deficiencies in elements,   (b)  Specific irritants in,
     a.   " Poor  blood"  causes inflammation in  many ways—
Textural starvation forms foci;  arterial occlusion ; slight textural
death.  Privation from nitrogenoids; not want of food but want
of elements e. g. potash.   Privations of poverty fill  all  these in-
dications, hence prevalence of inflammation among the  poor.
     b.  Irritants in Blood.    Ars'. produces gastritis, canth',
vesical troubles.  Such irritants must show their  presence  in the
products  of  inflammation.   Specific Poisons:   As syphilis or
gonorrhea.   Glands  swelling proves  the material character of
contagion.
     2.  Predisposing  Causes.
     1. Influences of Devitalizing Character: Lowering of tem-
perature :  Inanition of poverty : Inanition of  disease : Paralysis :
Old age :  Spinal lesions.
     2. Influences making one  more liable than another :  Syphilis,
past or present.  Gout,  past or present.  Also  forming differences
in kind.
     3. Tissues once  infla?ned, more liable to  take on the  same
process again.
     4. Rete?ition of Excretions:  Faeces.  Urine.  Also  the satu-
ration of  tissues with putrifiable substances, as above, will cause
either inflammation or tendency thereto.
     Treatment:
     Hygienic : Exclusion of  irritants and removal  of  cause  if
discoverable.
     Topical: Hot or cold ?
     Remedies: Aeon., Red, hot, shining, painful,  restless, worse
from warmth.
1.  From violence, 
8
A syllabus  of lectures on surgery.
    Antim c, Chronic, hot, very painful, glazed appearance.
    Apis m., (Edema: Stinging,  itching, or biting.
    Ars. alb., (Edematous, burning, dry, like parchment, rest-
less. Better from warmth.
    Bell,  Shining redness, swelling, great heat (pungent) throb-
bing.   Better from pressure, worse from touch.
    Calc.  carb.,  Chronic,  painless?   glandular  induration;
flabby, weak.
    Canth.,  Vesication ; extends on  surface, smarting like salt.
    Rhus tox.,  Vesicular, itching, smarting  worse on beginning
to move.
    Sulph, Chronic, of nearly all  kinds, skin scurfy, thick skin.

                  III.   ERYSIPELAS.

    Diffuse inflammation,  usually cutaneous or mucous surfaces :
rarely, if ever, attacking deeper tissues.   Mostly  in head  or face.
Common after operations.
    Always destructive ; purely pathological.
    i. Erythema.  2. Erysipelas.
    I.  Erythema :
    Simplex, fugax, circinatum, marginatum, papulatum, tuber-
culatum, nodosum.
    Simplex.  Epithelium—pinkish blush,  fading  on pressure,
returning intensified,  Capillary, desquamation.   Oval, tends to
coalesce:  no elevation ;  little increase  in  temperature—oedema
often as a cause.  5 to 14 days.
    {a) Acute, as above :  Action of sun, on the edges of  wounds
under water treatment;  gastric derangement
    (b)  Chronic.   Uncertain intervals:  from over-heating, etc.
    Fugax.  Ambulatory.   Females, (chlorotic) mostly on  the
chest.   Usual form of chronic.   Puis, typical remedy.
     Circinatum.   Same, except extends in circumferance fading
in center.  No elevation.   Has been seen to cover all trunk and
limbs successively.
    Sep., Sulph.   Typical  remedies.
    Marginatum.  Same, except elevation of margin and darker
color.
    Papulatum.  Papular modifying Simplex.
     Tuberculatum.   Tubercular modifying Simplex.
    Nodosum.   Wide difference;  more serious, quite regularly
oval, raised,  sensitive  to  touch, painful,  Anasmic cases.   Rheu-
matic females.   Color.  P. Bright red.  *S.  Many  changes, yel-
low, blue, like echymsis.   Shrink up and fall off.  Am., Lach.
Typical remedies.
    Nodosum,  circinatum  and  fugax,  show constitutional dis-
turbance ; others trifling. 
            A SYLLABUS OF LECTURES ON  SURGERY.          9

     Remedies.   Ars., burning.
     Apis., stinging burning.
     Ant c, stinging when touched; fine stinging.
     Arnica., tingling burning.
     Aur., hard  aching ; weight in part.
     Bell., bright red, in rays.
     Calc, itching heat, stinging, smarting, or stinging-burning
     Capsic, pungent stinging or smarting, dark.
     Canth., smarting as from salt, stranguary.
     Merc, ptyalism,  violent it:hing.
     Nux vom.,  burning, pricking like flea  bites,  skin  feels sore,
sensitive.
     Puis., itching, smarting when warm.
     Rhus tox., vesicular, corrosive itching.
     Sepia,, itching changes to burning, liver color.
     Sulph., formication, tingling, itching.
     II.   Erysipelas.   Invasion slow, at  times  rapid,  particu-
larly in epidemics.   Extent of primary fever does not foretell
gravity of case.
     First Indication.  Fever with pain and swelling  of  cervical
lymphatics. Q. E. D. Wounds,  edges become pale, flabby ;  when
united, fall asunder; granulations disappear;  pus  thin, ichorus or
ceases.
     Contagious? Epidemic.   Old Hospitals.   Inflammation,  all
tissues.  Erysipelas, cutaneous,  mucous and sub-cutaneous  conn'
tissue.
     1.  Simplex.  2.  (Edematous.   3.  Phlegmonous.
     1.   Simplex.   Typical.   Fever sometimes slight; agafn in-
tense.   (Edema more or less.  Scrotum face, etc.  Color termi-
nates abrubtly.   Surface not smooth as  looks.  Coalesce and
form bullae with   serum.  Itching   often  intolerable.    Pulse
quickened ;  ominous when quicker, intermittent and  thready
on 6th or 7th day.  Temperature high, proportion  to  fever and
inflammation.    Ominous above  1050.  Mental sphere  disturbed.
Delirious  at times;  not furious.   Urine,  albumen,  acid  reac-
tion, amorphous lithates, urea increased,   chlorides  dimin-
ished.   Serum tinged, billiary coloring matter.   Causes :  Excit-
ing ;  anything  that  will produce inflammation.  Predisposing,
blood changes not recognized, but thought to be,  by many,  actual
adulterations.    High  living and   low  living.   Termination :
Resolution, Desquamation, Suppuration,  Mortification.
     2.   GLdematous.   Preceded by simple ; broken-down consti-
tution.    Grave  symptoms.   Dangerous  form.   Low  vitality,
rather than intensity.   Great oedema ; almost anasarca.   Color
dark  or yellowish-red  fading  under  pressure.  Pain compara-
tively moderate.  Metastatic (E. Ambulans) fading in  one  place
and advancing  in  another.   Goes off ends of fingers and toes. 
IO          A SYLLABUS  OF'LECTURES  ON SURGERY.

Termination: Gangrene, suppuration, resolution.  Gangrene fore-
told by darker color, lividity  of skin.   Pus  ichorous  or serous;
often  followed  by  pyaemia.   No  limiting membrane.   Cicatri-
zation like burns, very irregular.
    3.  Phlegmonous.  Preceded by E. simplex often.   CEdem-
atous rarely.  Great gravity.  Three stages.   1st stage.—Skin very
dark;  pain  excessive or  increased.   Part  hard,  brawny   or
boggy.  No pitting.  Fever high; mind disordered.   2d stage.
—Skin pales on  pressure, slowly returning.   Rigors later.  Pit-
ting.   No  fluctuating.  Fever, pain, etc., abates.   3d stage.—
Skin doughy.  Urine heavily loaded with albumen.  Sordes on
lips and  teeth.   Mind  much  disordered.   Gangrene  of skin,
peeling off in long strips.  Subcutaneous parts more or less dis-
organized.  Pus  profuse.   Ichorous,  etc.,  mixed with debris.
Sometimes whole limb crippled or destroyed.   Points  of granu-
lation  to  be saved.  Termination :   Gangrene,  Suppuration,
Death, Resolution.Prognosis favorable : simple, uncomplicated,
surroundings favorable,  sporadic.   Guarded:  epidemic, phleg-
menous or oedematous with dropsy, preexisting organic disease of
liver,  kidney or heart during adynamic fever.  Long lasting and
pulse  keeps  quick  or  becomes  accelerated.  Metastasis rare.
Duration.—Simple  cases, 5 to  10 days.  Bad cases indefinite,
10  to  21 days or more.
    Treatment : When pus  forms let it out by free incisions.
Preventive in (Edematous  and  Phlegmonous.   Theories:  1.
Modified inflammatory excitation.   2. Typhus depression.  Pros-
tration  either case.  Hygienic.  No alcohol.  Cleanliness.  Ven-
tilation.   Sufficient  nourishment.  Avoid  unnecessary instru-
mental interference.
    Remedies :   Compare  Suppuration, Inflammation,  Pyaemia,
Gangrene, etc.
    Arsenic,  Rapid  prostration, exudation,  excessive thirst,
restless, diarrhoea, better from warm,  worse from  cold.  Septic
influences.
    Bell., Pungent heat—bright red ; rays,  follows lymphatics.
Light, motion, contact worse.
    Lach.,  Purplish color ; delirious on closing eyes.   Faintish-
ness, numbness, suppuration in spots, cheesy;  bullae, dark colored
serum.
     Rhus., Vesicular, intense; extends on  surface; great swell-
ing, stinging, smarting and burning.

     Sil,  Worst form ; extends in all directions.   Pus profuse,
bad smelling.  Profound vital derangements.
     Calend.  Promote  healing,   denuded  surface, and  lessen
suppuration. 
A SYLLABUS  OF LECTURES ON SURGERY.         II
                 IV.  SUPPURATION.

    Termination  of inflammation  in the  formation of  pus.
More intense and  rapid  inflammation,  short  of  congestion,
more profuse pus.
  Pus.   i.  Corpuscle.   Virchow.  Connective tissue cell.  Roki
tansky.   Blood  plasma.  Frey.   Lymphoid  corpuscle.  Cohn-
heim.   Leucoeyte.   Migratory leucocyte takes on a pseudo fatty
degeneration.
     2.  Liquor puris.   Serum  of  blood  in  all particulars.
Vascular ?   Extra  vascular,  or  both  characters.    Laudable,
creamy,   yellowish,  inodorous, neutral reaction.  Quite  rare.
Unhealthy, acrid, ichorous, corroding, serous, albuminous, curdy,
grumous.   Degeneration from standard mixedwith debris (Ichorae-
mia).  By compression, etc.,  contiguous tissues broken down
and liquified.   Sanguineous  effusions, at times  pus,  at  times
plastic formations, etc.   Why?
     Forms,  i.  Purulent secretions.   Luxuriation, reparative.  2.
Abscess:   acute,  chronic,  cold,  lymphatic,  diffused, emphys-
niatous or tympanic.
     Abscess acute.  Definition.  Pyogenetic membrane.  Diag-
nosis.   Palpatious for  fluid.  Trocar.  Exploring needle.   As-
pirator.   Rigors .change of pain.  Course  and Symptoms.   Pus
laudable ?    Cause,  exciting : Acute inflammations.   Predispos-
ing :   See inflammation.
     Chronic.   Strumous  or  cachectic.   Lymphatics.  Little
discoloration and pain ;  minimum  inflammation.  Unhealthy
pus;   thicker but imperfect (?) pyogneic membrane.  Concre-
tions.
     Diffused.   Rapid  inflammation.  Celluletis.   Erysipelas.
No limiting membrane.  No fluctuation.  No pointing.  Usually
gangrene.   Long sinuses.
     Tympanitic.   Modified  chronic.   Mucous  or   intestinal
regions.   Partly  filled with air.
     Terminations:  i.  Pointing;   sinus,  fistula.   2. Absorp-
tion.   Pointing,  by absorption of  intervening  tissues;  necro-
tic ; attenuation, etc. of blood vessels; long distances,  usually on
the nearest  surlace.
     Sinus.   Track  leading from  abscess, whether to  surface or
not.
     Fistula.  Track remaining open ; abnormal  communication
between two cavities, or natural cavity and surface, i. e., Recto
vaginal or anal fistula.
     Absorption.   Possible; vis  medicatrix naturae, or art.  Met-
hod, dry up; fatty metamorphosis, cheesey or cretaceous.  Use-
less. 
12          A SYLLABUS  OF LECTURES  ON SURGERY.

    Treatment.  Purulent secretions; preserve healthy charac-
ters.  Abscess ;  acute, evacuate.  Local  anesthesia.  Rhigohne.
Ether sprav.  Chronic; evacuate carefully, or promote  absorp-
tion.  Diffuse.   Evacuate  freely.  Sinuses slit up.  Fistula re-
cent,  pressure  and  proper remedies.   Chronic—destroy pyo-
genetic  membrane.
    Suppuration generally.  Remedies to  preserve or restore
laudable characters.
    Remedies.   Arnica., Hot, hard shining swelling after blows;
to avert suppuration.  Arsenic  Copious bloody corroding  or
ichorous;  watery;  smell  putrid.  Baryta  Carb.  Lymphatic;
old people. Pus scanty and curdy. Belladonna. Less pus than in-
flammation promised ; thick yellow.   Bryonia.   Pus brownish,
putrid or yellow.   Calc C.  Either copious or scanty,  yellow
and putrid, or white  like milk and thin. Lymphatics.  Calendula.
Laudable, too profuse.  Carbo Veg. Bloody, ichorous, corroding or
yellow.    Cham.   Corroding and scanty, thin.   China.  Wat-
ery,  ichorous,   putrid.  Coni.   Viscid,  putrid.   Graph.  Cor-
roding,   watery,  scanty, putrid.   Smells  like  herring  brine.
Hepar  Sulph.   Scanty, bloody,  corroding.   Smells  like  old
cheese.   [To hasten  suppuration and promote  healthy change in
most  cases].   Iodine.   Very   profuse; enormous.    Lycopod.
Bloody, corroding and putrid, whitish milky appearance.  Merc
Almost   any  color  and consistency,  but  scanty  or  corrod-
ing or acrid.  Phos.  Copious  and yellow.  Pulsatilla.   Copious
bloody, green, yellow or yellowish green.  Rhus Tox.   Copious
serous and corroding.  Silicia.   Copious  or scanty, brown and
gelatinous  or bloody, green,  grey, yellow,  thin  and  watery.
Putrid.   Sulphur.  Thin, blackish serum, of putrid smell.

                      V.   PYEMIA.

     Syn: Purulent infection.
     Analogue :  Typhus fever (?)
     Pyaemia vs. surgical fever.
     Condition, toxaemia, septicaemia.
     Theories:   Suppurative  phlebites;   denied,  by  Callender
(Holmes, I, 268).   Embolism, soften, etc.   Lymphatic  absorp-
tion.   Septic introduction in some way.
     Admissions:  Through cut veins.  Patulous vessels  (puerp-
eral)  : natural passages :  Medium of flies :  Air.
      Characteristics: Low fever : pyogenic tendency; after oper-
ation, great exhaustion,  haemorrhge,  po^t-parturient.   Healthy
pus inocuous,  in  blood.  Some of the  products  of decomposi-
tion.
     Symptoms : Rigors :  persistent,  regular or irregular.  Ichor-
 ous metamorphosis.   Premonitions as in Erysipelas.  Apathy or
 mild delirium.  Muddy complexion.   Urine diminished.  Pulse 
A SYLLABUS  OF LECTURES  ON SURGERY.          13
weak, rapid, irregular, jerking,  compressible.  Sordes on teeth.
Tongue,  brown.   Sweet, nauseous breath.   Dry  skin, towards
fatal close, clammy.  Skin  brown, tawny.   Eyes dull, lifeless.
Temperature mostly lowered, rarely above  104.   No thirst; no
wants  of any  kind.   Rapid emaciation.  Bed  sores, profound
adynamia.   Abscess in various places.   Blood: Pus cells, fibrine
disorganized, loss of contractility.
     Special symptoms, as different  organs  invaded : Vomiting,
cough, diarrhoea, coma, etc.
     After operation appears after second day.
     Duration: a few days to many weeks.
     Pathology :
     Emboli.  1.  Pus cell encapsulated  by fibrine, form nucleus.
2. Fibrine,  lost contractility, encloses a large amount of serum :
nucleus.   Emboli forms  as  an effect.  Arrested by: Diminishing
calibre of vessel.   Increasing size of clot.  At one of the valves,
or at bifurcation.  Sometimes adheres at point of  formation.
     Center organized, periphery  soft;  particles detached, forms
new nucleus. ' Parent mass  grows until arrested.
     Vein occluded,  distal side  disintegrates  first;  new nucleus.
Partly occluded, oldest portion, center, breaks up first.
     Results:  Engorgement at points of arrest.   Serous  exuda-
tion, arrested  nutrition, molecular disintegration, suppuration
(Ichorrhasmia).
     Each new abscess, new point of origin ; successive embolus,
nucleus.   Healthy body, no such result; product of disease.
     Ergo :  If pus does not circulate and form in  blood, morbid
changes  in this fluid at fault.
     Treatment : Vide  Typhus fever.
     Remedies: Ars., Lach., Sil.,  Rhus.

                  VI.  ULCERATION.

     A   termination  of  inflammation.  Similar  to  gangrene;
necrotic, molecular disintegration.
     Open sore, discharging pus, ichorous in  proportion to activ-
ity-                          ...
     Abrasion,  removal  of epithelium.  Ulceration,  removal of
proper vascular tissue.
     Location.  1.  Mucous tissue.  2.   Cutaneous, particularly
lower extremities.
     Idiopathic: Symptomatic :  Specific  Shape  and characteris-
tics, peculiar and pathognomonic.  Either may be traumatic.
     Causes : 1. Predisposing or  maintaining.  (Erichsen)  De-
ranged assimilation, e. g., (1)  Deposition normal,  absorption too
active.   (2)  Absorption   normal,  deposition  deficient.   (3)
Elimination of spoiled,  dead matter. 
14
A SYLLABUS OF LECTURES ON SURGERY.
     2.  Exciting or  immediate:  i.  Inflammatory action.  2.
Wounds and injuries.   3.  Devitalization from  pressure, or other
vascular impediments.  3. Action of fire or corrosive substances.
     Women :  Habits  of life predisposing.
     Old age:  Senile changes; atheromatous, calcareous, etc.
     Poverty :  Squalor, inanition, etc.  " Safety vents."   Cure vs
suppression.
     Classification :
     Idiopathic: Simple;  Weak; Indolent;  Inflamed.
     Symptomatic :  Sloughing;  Varicose ;   Irritable;   Haemor-
rhagic.
     Specific:  Scorbutic;   Strumous;  Cancerous;  Syphilitic;
Mercurial; Lupous.   (Vide special sections).
     Simple:   Typical ;  circular, oval, shallow,  healthy   pus,
healthy granulations.   Heals readily.   Remedy, Calend.
     Weak: Simple, mal-treated.  Granulations flabby, large, jelly-
like; pus thin, watery, suppressed.   Edges pale, elevated.
     Remedy,  Sempervivum Tect.
     Inflamed: Maltraeated, stimulating.   Granulations  large,
firm, sometimes destroyed.   Pus  thick, offensive, blood streaked.
Edges raised,  much inflamed, also surrounding parts.  Painful,
sensitive.
     Remedies, Ars., Bell., Puis., Merc
     Indolent: Chronic.   Primary, or bad treatment.  Granula-
tions' firm, small, wanting.  Pus absent, or thin and bad-smelling.
Edges elevated, hard,  irregular,  ragged, skin indurated, discol-
ored, firmly  adherent to bone; covered with  scabs or scales.
Painless,  without sensation;  "old men's sores;"  on leg below
knee.  Remedies :  Baryta C, Graph., Sil.
     Sloughing:  Primary, or succeeds "inflamed."  Granula-
tions diappear.  Edges become  sharp cut and  discolored.  Pus
becomes  ichorous and putrid. Base  grayish.  Painful; extends
rapidly;   much  fever and  general  disturbance.  Rem:  Ars.,
Merc, Lach.,  Nit. ac, Sulphur, ac
     Irritable:  Women,  nervous,  billious,  middle life;  small.
Edges irregular,  flat.   Granulations  absent.  Base, tough,  gray
slough.   Pus thin, acrid.  Painful, excessive; sensitive.   Rem.:
Asafi, Bell., Merc, Cham., Sep.
     Varicose: Not incurable.  As  other varieties.  Anamnesis
and  appearance of surrounding parts  distinctive.  Rupture of
venous pouch  not cause.   Modified  nutrition,  from venous de-
rangement.  Varix must often  be cured  first.  Rents.: Ham.
Nux. V., Lach., Sulph.
     Hemorrhagic: Women:  Amenorrhoae:  Oozes  blood  at
catamenia.  Similar to irritable.  Purple color, small  circular
painful, sensitive.   Common "safety  vent."   Discharges  vari-
ous.   Rems.:  Ars., Carbo. V., Phos., Sil., Sulph. 
                    A  SYLLABUS OF  LECTURES ON SURGERY.          15

             Treatment:  Topical  forbidden.   Strapping;  Rest;  Ele-
        vation of member.  Prognosis.   Heals from center,  bad. From
        periphery, good.
             First  result,  when curative:   Edges  flatten  down,  pain
        lessened, pus becomes laudable, slough detached, itching or bit-
        ing may succeed pain.
             Remedies.
             Acid Mur.,  Foetid, scurfy, itching, stinging; stinging when
        touched.   Pus foetid, scanty.
             Acid Nit.,  Sensitive,  pricking like  splinters or  pieces of
        glass.   Mercury  or Syphilis.  Pus foetid, not profuse.
             Acid Phos., Painless, chronic ;  little  feeling.   Pus  dirty
        color, foetid.
             Acid Sulph.,  Corrosive burning,  biting   Pus corrosive.
        (Haemorrhage).
             Ambra Gris.: Painless, chronic; worse every spring.   Pus
        grayish, salty ichor.
             Ammo Carb., Flat, putrid ; pungent sensation.   Pus white
        and putrid.
             Antimon Cr., Fistulous, deep; spongy,  exuberant granula-
        tions; sore pain.   Pus scanty.
             Argent Met., Boring  pain.  Pus copious, bloody, gelatin-
        ous, yellow or corrosive.
             Arnica.  Jerking, bluish, bleeds easily, indurated, swollen ;
        shocks, tenseness.  Pus bloody or gelatinous.
             Arsenic:  Burning interior, felt while sleeping.   Base  like
        lard, or  black-blue,  bleeds  slightly on  bandaging.  Spreading,
        skin purple color.  Pus copious, bloody,  ichorous, putrid  and
        corrosive.
        Assafcetida:  Violent  pain, pain  changes character on  touching.
        Pus copious.
             Aurum:  Mercurial, deep, fistulous, swollen,  painful.   Pus
        yellow, foetid.
             Brryta C:  As if burnt; indurated, scabby, painless, swollen,
        tenseness.  Pus wanting, or scanty and  gelatinous.
             Belladonna: Burning  on  touching;  black crust in base;
        deep,  scabby ;  cutting  pain.   Painless,  though much inflamed.
        Painful, acute, throbbing.   Pus scanty,  bloody and ichorous.
             Byronia:  Itching,  burning,  scabby, inflamed;  stinging
        when moving ;  throbbing.   Pus scanty, brown.
             Calcarea  C.:  Scrofulous.  High,  florid granulations; pu-
        trid, little pain.   Pus scanty, albuminous.
             Calendula:   Excessive  suppuration  in  otherwise  healthy
        ulcer.
             Cautharis:  Smarting and stinging.   Pus copious,  inodor-
•        ous, sometimes bloody. 
           16          A SYLLABUS  OF LECTURES  ON SURGERY.

                Carbo Veg.:  Once cured, breaks out again, and  instead  of
           pus,  emits bloody lymph;  surrounding part hard;  burning as
           from a coal.  Pus scanty,  brownish,  foetid, cadaverous swell-
           ing,  sanious.
                Causticum: Bleeding blisters  on surrounding skin, boring
           burning ; pain as if burnt, pustules around.   Swollen  tense feel-
           ing.  Pus thin as  water, corroding, greenish or gray,  sometimes
           bloody or yellow.
                Cham:   Hitherto   painless,  suddenly   painful—creeping
           in ulcer, sensitiveness to touch.
                Chelidon: Old, putrid, spreading, deep fistulous.
                Ci:ina:  Boring,  painful sensitiveness;  beating  pain when
           moving;  foetid, flat, and gangrenous.   Pus bloody,  foetid and
           ichorous.
                Clematis E :  Burning, creeping, jerking, throbbing, shoot-
           ing  when touched.   Scabby deep,  indurated.   Pus  scanty.
t           Serous, yellow, acrid.
                Conium: Pains waken  at  night.   Bleeding.   Edges black,
           creeping,  tension,  indurated, fistulous,  livid skin.  Pus foetid
           and watery, ichorous.
               Cupr. Met :  Old; contracted feeling in skin.   Hard, in-
           flamed, jerking.  Pus scanty, corroding.
              Dulcam: Insensible, hard,  painless, swollen.  Pus yellow,
           scanty.
               Euphorb : Old, torpid, fistulous;  lancinating, turn black,
           Biting.  Pus, sanious.
               Graphites:  Exuberant granulations, crusty,  hard,  itching,
           sore.  Pus bloody, watery, acrid, putrid, like  herring brine.
              Hepar S:  Mercurial, jagged, smarting, surrounded  by pus-
           tules.  Pus any character ; like old cheese.
              Hyoscyamus:  Inflamed, surrounding skin  vermillion  red-
           ness ; large pustules around.
              Iodium : Hard, painless, spongy, swollen, feeling of tense-
          ness.  Pus excessively copious, bloody and corroding, or thin,
           watery and yellow.
              Kali  Bich:  Dry, oval, as if punched  out; overhanging
          edges, bright red areola,  hard base.   Extended in depth.  Pus
          scanty.
              Kali  Carb:  Gnawing, bleeding, burning, boring,  corrod-
          ing.   Pus copious, bloody, ichorous.
              Lachesis : Extends rapidly, small ulcers in areola  coalesce ;
          ragged  edges,  dark mottled areola;  burning when touched!
          Pus scanty.
              Lycop: Fistulous,  hard, red  shining, inverted edges • itch-
          ing at night when touched ;  surrounded   by papillae.   Pus copi-
          ous, albuminous, or sanious, gray, yellow, acrid. 
A SYLLABUS OF LECTURES ON  SURGERY.          17
     Mercurius;   Spreading  superficially.   Spongy,   readily
bleeding,  exquisitely painful, sensitive to  touch, bluish,  livid,
hard, ragged, elevated edges.  Pus anything but laudable.
     Mezereum :   Burning,  or excoriated.   Pus scanty  or sup-
pressed.
     Natrum C:  Burning,  pricking,  pulsating.   Pus  acrid,
putrid, yellow.
     Natrum Jf: Superficial, red, angry looking,  smarting, sur-
rounded by  vesicles.  No pus.
     Nux  Vom :  Raised  pale red edges,  pain as  being beaten,
burning, as if burnt.  Pus greenish, corroding.
     Petroleum :  Fistulous rapidly spreading, spongy, pain  prick-
ing ; deep, flat.   Pus scanty, acrid, watery.
     Pulsatilla:  Flat, putrid, carious, fistulous, edges hard ; sur-
rounded by  papillae.  Pus copious, bloody, green, albuminous or
yellow.
     Rhus Tox :  Small vesicles,  turn to putrid,  spreading, gan-
grenous ulcers.   Pus sanious, acrid.
     Secale:  Become black, bleeding  easily; painless.  Pus pu-
trid.
     Sempervivum :  Immense jelly-like granulations.  Pus scanty,
thin, colorless.
     Sepia :  Blisters around; deep, crusty,  flat,  painless,  fistu-
lous.  Edges high,  swollen.  Pain as if burnt, jerking,  itching,
pricking, tearing or painless.  Pus all characters, mostly  viscid
and copious.
     Silicea:  Extend in  depth ;  fistulous,  painful,  sensitive.
Pus almost any character, mostly copious, brown and watery.
     Sulphur: Readily bleeding, surrounded by  pimples, ragged
edges, oedematous swelling, reddish brown  discoloration  of skin.
Pus thick, yellow and foetid, or thin and foetid.
     Thuja :  Indurated edges ; raised, ragged edges, surrounded
by pustules ; deep, burning, fistulous ;  exuberant granulations.
Pus yellow.
     Tartar Emet.:  Deeply  penetrating,  malignant, broad, sur-
rounded by  black  pustules, breaking down and forming ulcers.
Pus foetid  and sanious.
     Adjuvants :  Dry earth : Galvanism.
     Operations.  Niissbaum : Incision  to  fascia around, then
lint, firm bandage;  2d day re-dress, water dressing {A. H.  Obs.
XL, p.  315.)
     Cell-grafting, aided by mild galvanic action: Silver plate to
ulcer and  zinc   plate on  skin ;   wire eight inches  long;  and
leather and vinegar under zinc.  (Helmuth, page 498).   Plastic
operations, rarely successful.
       2 
i8
A SYLLABUS OF LECTURES ON SURGERY.
               VII.  MORTIFICATION.
     Syn.: Gangrene.
     Death of a part as a  whole,  i. e.  opposed  to  molecular.
Sphacelus soft  parts.   Acute.  Hot, humid.   Chronic.  Cold,
dry.  Traumatic. Idiopathic.
     Diagnosis.    Ecchymosis  vs.  gangrene.   Color.  Previous
condition.  Cessation or change of pain.  Slough.   Temperature
lowered.  Internal organs suspected.
     Causes: i.  Predisposing.  2. Exciting.
     1.  Circulatoty.   Cardiac insufficiency.   Arterial  degener-
ations.  Senility.  Drugs, as Secale,  etc.  Exhausting  diseases.
Inervation.
     2.  Circulatory.  Any  interruption  of  circulation.  Liga-
ture.  Bandaging.   Tumours,  etc.  Embolism. Specific poisons.
     Prognogsis javorable, surface or part small.  Rapid  progress.
More or less pain, particularly surrounding.   Moist.  Moderate
inflammation.   Young people.  Traumatic.
     Unfavorable.  Progress slow.  Dry.   Intense inflammation
or none.  Old people.   Debilitated.
     Treatment.  Favor detachment of slough.   Preserve tem-
perature.  Amputation,  when progress  is  stayed.  Line  of  de-
markation forms.  Traumatic cases.   Frost bite.
     Ars., Lach., Secale particularly indicated.

     GANGRENEOUS  DISEASES.

     Bed Sores.
     Sloughing ulcers in bed ridden people.   At times  late, oth-
ers early.  Extent.   Seat not dependant on  vascularity.
     Causes.  Predisposing.    Low  vitality.   Brown-Sequard,
shows that it is spinal irritation, with local and general  anaemia.
Exciting causes.   Pressure long continued.
     Treatment.   Preventive.—Dry bed,  constant  change  of
soiled clothing.
     Hygienic.  Cleanliness in all respects.  Air-bags and pillows.
Tubs of water under the bed.
     No caustics or irritants.  Cell-grafting.   Galvanism.
     Phagad^ena :   Syn.: Hospital gangrene.
     Rare in civil practice  old hospitals common, attacks wounds,
and open sores.   Rapid, destructive inflammation
     Symptoms:  Points of soft gray slough  ; ulceration extends
m  all directions.   Surrounding  skin oedematous, livid, circular
form,  edges everted and sharp  cut.   Grayish-green  tenacious
slough, sways  to and fro, cannot be  removed.  Discharge dirty
yellow, green, or brown.  At times slight bleeding.  Pain  burn 
            A-SYLLABUS OF lectures on surgery.          19

ing, stinging, lancinating.   Fcetor; all tissues destroyed, blood-
vessels resist longest.   Irritative fever : sometimes pyaemia.
    Blackadder (Erichsen, p. 362) vesicles, bloody ichor, hot
stinging ;  breaks, and shows deep, spreading ulcers.
    Treatment.   Cleanliness.   Ventillation.   Some authors,
chloride of zinc, followed by carbolic acid paste.  Mild poultice
for separation of slough. Ars., Sulph. ac, Tart. Em.  Amputa-
tion ?
     Carbuncle.  Syn.: Anthrax.
    Debilitated people, aged, posterior surfaces, (back of neck).
Inflammation, swelling, pain, one  to  six inches diameter.   Flat,
circular, dusky red, slightly raised.  Becomes darker, separate at
edges,  fissures ; thin, scanty, bad smelling pus.
    Constitutional symptoms, severe.  Bad cases  death.
    Treatment:  Incision.  Caustic potash.  Ars., Bell., Lach.
    Boils.  Syn.: Furuncle.   Abscess nucleata.
    About hair follicles. Inflameslowly,suppurateslowly. "Core."
Gastric derangements.  Robust health.   Critical, in fevers, and
eruptive diseases. Sometimes premonitory. No assignable causes;
prick,  scratch.
    Diff.  Diag.   Carbuncle: Little pus, large slough.   Boil:
Small slough,  much  pus.
     Treatment: Am, said to  abort.   Lancing brings out a
crop.   Hep., Hastens suppuration.   Sulph., expels core.

    Felon.  Syn.:  Paronychia.  Whitlow.
     Peculiar suppurating  disease  about  the  ends of the fingers,
sometimes toes, rarely elsewhere.
     Four varieties :   1. Simple suppuration around root of the
nail.   2d.  In  cellular tissues,  tips of fingers.  3. Beneath the
fascia.   4. True whitlow, beneath deep fascia or periosteum.
    Pain  increases from first to  fourth.   Suppuration slow.
     Destruction from nail  in first  to  whole  finger or hand in
fourth.  Resulting deformity often great.   Tenderness for years.
     Causes:  Obscure.   Washerwoman, or  those  working  in
water,  particularly hot water.
    Treatment :  Open early, and freely.
    Aborted:  Hot water.  Strong lye. Iris Vers.  Skin of boiled
egg, which aggravates at first.  (Helmuth's Surg.,  p.  488.)  Nit.
Ac, Hep., Merc.
    Remedies,  in Gangrenous diseases.
    Arnica: Hot, hard, shining swelling, with pricking  in the
skin.
    Arsenic : Great  weakness  and emaciation ;  deep, burning
pains, with oedema.   Foetid, watery, burning diarrhaea.
    Aurum: Very sensitive to cold, with suicidal  melancholy. 
20
A SYLLABUS OF  LECTURES ON SURGERY.
     Belladonna: Fiery  redness  of skin,  painful, sensitive  to
touch ;  better from pressure.
     CfotalHor :  Fainting, tremulous; haemorrhagic.
     Hepat S : To hasten suppuration.
     Iris Vers : Has  aborted  felons,  when  the  fresh plant, all
parts, has been bruised and bound on the part.
     Lachesis:  Gangrenous blisters; livid or mottled  skin.
     Nitric Acid: Felons with feeling of splinter.
     Ranunculus B : Cuticular gangrene, with large blister.
     Secale Cor :  Senile, painless gangrene.   Internal gangrene.
     Tartar Emet :   Sloughing  phagedaena.    Large pustules,
breaking down and forming ulcers.

VIII.   INSTRUMENTS   AND  APPLIANCES.

     Selection of cases.   Compact (Parker's)  for general use.
Handles, ebony.  Care of instruments,  washing, etc.
     Pocket cases.  Use, and necessities.
     Knives :  Catlins, Amputating,  Scalpel,  Bistouries,  Ten-
otomes.
     Forceps  : Dissecting, Artery, Needle.  Bone ;  Straight, El-
bow, Curved, Right-angled, Gnawing.
     Scissors  : Straight, Curved,  Elbow.
     Needles.  Probes.
     Saws : Amputating.  Finger. Interosseous.  Chain.  Hey's.
Trephine.
     Special instruments, under proper heading.
     Straps :  Heat.  Wet.  Application and removal.
     Poultice : Objects and preparation.
     Lint: Pledget, dossils, tent, pellets.
     Compresses :  Ordinary, graduated, pyramidal, cribriform.
     Bandaging : Permanent, vide " Fractures."  Temporary :
Material, selvage, and seams.  Single-head ; Double-head.  Scul-
tetus, spica, recurrent.  " Maltese cross."

                  IX.  ANESTHESIA.

     Deff.: Without feeling.  Insensibility to pain, and  suspen-
sion of  motor and sensory phenomena.
     History :  i. Nitrous oxide gas.  2.  Sulphuric  Ether   -i
Chloric Ether.   4. Chloroform.   5. Local anesthesia.   6  Bi-
chloride of Methylene.
     1. Nitrous  Oxide:  Sir Humphy Davy, 1800.   (Chemiral
Researches, p. 556).  Dr. Horace Wells, Conn.,  1844  In Den?
istry.  (" Statement" Dr. Morton, p. 42).         ^4"        l~
     2.  Sulphuric Ether:  Caleb Bentley Mathews  M D
(Hommopathist/)  in a pamphlet  published  1824.   (Hvt^JL
Surg., p.  73-)   DR-  Sam'l Woolston, (Med. andSurg^^ 
            a syllabus of lectures on SURGERY.          21

May  27,  1870,)  ether  with morphine,  for  dentistry,  1836.
Refers to ad' in  Nat. Intelligencer for June, 1836.   (Helmuth,
p. 72).
    Prof. W. T.  G.  Morton, Boston,  Mass.,  Sept. 30,  1846.
Mass. Gen'l Hospital—(Vide "Statement," etc.,  p. 45).
    3.  Chloric Ether: Mr. Lawrence,  St.  Bartholomew Hosp.,
1847.   (Snow.  Anesthetics, p. 20).
    4.   Chloroform:  Sir J. Y. Simpson, 1847, at suggestion of
Mr. Waldie, Apoth.  Hall,  Liverpool.   (Snow. Anesthetics,  also
pamphlet by Sir J. Y.  S).
    5.  Local Anesthesia.   Freezing mixture, salt and snow, very
early period.  Rhigolene spray, by  Dr.  Bigelow,  Boston,  about
1864.   Ether spray, Carbolic acid.
    6.  Bichloride of Methylene :  Dr. Spencer Wells, in ovarioto-
my.   Little used in this country,  or by other than Dr. Wells.
    Chloroform  : Per-chloride  of Formyl.   Chlorine and for-
mic acid.  Sp. G. 1.480.   Many methods of preparation ;  result
the same.
     Tests of Purity :  Squibbs best. Neutral reaction.  For oils :
Sulph. ac,  rubbing on hand, dropping  on paper.   For alcohol:
Drop in water, milky if present.   For ether : Inflammable.
    Preparation of patient: Omit last meal, remove constriction
from throat, etc., avoid pressure on chest or abdomen.
    Administration :  Napkin superior to an inhaler ; about 1 dr.
at a dose, 5 per cent, of air.
    Symptoms:  Three stages :  1st. Temporary  irritation to mu-
cous surfaces.   2.  Nervous excitement.   3. Complete relaxation
and  insensibility.
    Pathology : Suspension of nerve function, at centers, in cer-
tain  order.   1st. Brain, failure in sensation, etc.   2d. Cerebro
spinal  axis, with perfect relaxation.   Respiration and cardiac ac-
tion remain intact.
    Prefer to Ether:  More speedy, continuous, and milder se-
quelae.  A stimulant, hence primary operations safely performed
with it.  (Lister, HolmesY., 482).
    Dangers:  Coma; Paralysis  of  brain ; too  rapidly  given.
Syncope : Paralysis of  heart;  an  over-dose.   Asphyxia :  Want
of atmospheric air.
    Mortality':  Since its introduction, more serious cases under-
taken.  Every year adds to number of grave accidents, extended
and rapid travel, etc.  Apparent increase in  surgical death rate.
     What is  cause  of death ?  (Lister; Holmes Surg. V.,  p.
480 et seq).
     1.  Arrest of breathing, from careless administration, oftener
than cardiac paralysis.  Watch breathing more than pulse.
     2.  Over-dose, direct sedative ; death  from causes distinct
from organic cardiac disease ; in latter  case, chloroform an ele-
ment  of safety. 
22
A SYLLABUS  OF LECTURES  ON SURGERY.
    3. From insufficient anaesthesia, and consequent intensity of
shock. Most fatal cases, trivial operations, dentistry, etc.  Shock
produces, through vagus and sympathetic, cardiac paralysis.   In
heart  diseases, produce full anaesthesia as a  means of protection.
    Narcosis:  Suspend administration ; lower the head ; seize
tongue and draw  it forcibly  out; tickling  fauces: Faradaism :
Amyl. nitrate:  Cold water: vide "asphyxia."
    Sequelce:   Vomiting :  Headache :  Sleepless.    Encourage
sleep.
    Sulphuric Ether :  Formula—Alcohol, o jv ; sulph. acid,
o j ;  potassa, dr. vj ;  aqua dis. f oz. iij.   Distill and re-distill, un-
til anhydrous, Sp. G. 0.732.
    Preperation of patient as  in  chloroform.   Perfect safety;
needs  no  air, particularly.  Symptoms  the  same.   Longer  in
coming on.   Sequelae more troublesome,  Ipec, for  the vomit-
ing.   Nux V., for the headache.
    Other Agents :  Of doubtful utility ; seldom employed.
    A. C. E.   1.  2. 3.  Harley's formulae in uraemia.

        X.   SHOCK AND TRAUMATISM.

    Shock :  After injury ; nervous  depression ; physical pros-
tration.
    Symptoms : Face pale ; hands and feet cold ; clammy  perspi-
ration, often only on the head, face, or  chest; relaxed sphincters,
in extreme cases; pulse small, weak, fluttering;  mental disturb-
ance shown  in face  and  incoherent  speech.   Intensity, usuallv,
dependant upon extent of injury ;  at  other  times quite the  re-
verse.  Shock alone, sometimes kill; e. g. death  on  the gallows.
Bad cases : Appearance of  collapse or great loss of blood.
    Diminished Temperature : Fall of  more  than one  degree is
ominous.   Wagstaff,  cases  of   operation   fatal  fall   3.7;  not
fatal 0.3.  (Helmuth, p. 573).
    Primary or Immediate—Secondary or Remote.   Rally well •
days, or weeks after worst symptoms of shock ; often  fatal; per-
sons of strong constitutions, vigorous minds, disguise or  repress
it, until weakened by confinement, etc., break down all at once.
Treat all causes from the beginning, so as to  ward off the shock.'
No lesion to account for death.  Case of Prof Gross.  Died 6tli
or 7th day.—(Med. Chir. Rev. V., 949).
     Operation during shock.  Civil practice, secondary • mili-
tary practice, primary.   Intermediate  bad  in either.   Military
more cases of remote shock.                                 •y'
     Treatment:  1.  Moral.  2.  Medicinal.    Moral, reassuring
words, or scolding.  Caution in nervous cases.
     Medicinal: No stimulants, except  rarely. 
            A SYLLABUS  OF LECTURES  ON SURGERY.          23

    Remedies:   Arnica.   Wants  head  low;  diarrhoea;  dizzy
with nausea.
     Caftiph.: Great  coldness with  hot breath ;  hands and  feet
tremble on raising them ;  tongue  trembles.
     Opium : Coma.  Blue face ;  rouses  when spoken to loudly,
for a moment; stertor.
     Veratr:  Cold  as ice, breath  cold; weakness  great;  dis-
torted  face ;  terror.  Other remedies may be needed, but rarely.
     Traumatic Fever: Syn.,  Surgical  fever.   Some authors
confound it with pyaemia or septic  poisoning.  Febrile reaction
from shock.  Any degree of intensity, even of Typhoid charac-
ter, depending upon condition of the patient.    In private prac-
tice of little moment.
     Traumatic Delirium :
     May accompany fever or not.
     1.  Co-existent with shock, of a low, muttering character;
apathy.   More violent as reaction comes on.   2.  With reaction,
mild or otherwise as fever is high or low.
     First form :  Nervous, excitable persons, cachectic or broken
down,  or drunkards.  In  drunkards, resembles mania-potu,  and
a very bad symptom.  Second form  : The most  common and of
less moment.
     Treatment : As in Shock, also the following :
     Aeon., Lamentations, anguish, despair; thinks  is going to
die ; fainting on rising up.
     Bell., Shining, sparkling eyes ;  red  face ; beating arteries  ;
merry  ; melancholly ; furious ;  tries to escape; wants head high  ;
burning heat with moisture or steaming heat.
     Bry., Delirium about days business; faint and sick  sitting
up ; dark, bloated  face.
     Cup.  ac,  Absent  minded ;  staring; fixed, sunken  eyes;
cold sweat;  distorted, pale, deathly face.
     Hell., Taciturn, sighing, pale  face ; cannot think ; general
sweat.
     Hyos., Indomitable rage; wants  to  go  naked; red, spark-
ling, staring, distorted eyes ; blue face.
     Ign., Quarrelsome ;  laughing and crying almost in the same
breath ;  impatient.
     Lach.,  Sad;  loathing of   life;  suspicious  and  peevish;
moaning and complaining ; skin  shriveled and lived ; nose, ears
and forehead cold.
     Stram., Furious rage ; bites; talkative; convulsions  ; swol-
len red face; fear ;  staring, somnolent eyes;  spasms from light
or glistening objects. 
24
A SYLLABUS  OF LECTURES  ON SURGERY.
        XI.   INJURIES  OF SOFT  PARTS.

     i.  Contusions.   2.  Wounds.   3.  Surgical  Incision.
Contusions.  Syn.,  Bruise :  Pressure between two blunt bodies,
a squeeze. Shock.  Pain : Nerve injury and stretching from swell-
ing.  Swelling : Effusion of serum or blood.  Discolored (ecchy-
mosis)—effused  blood.   Three degrees : 1.  Small subcutaneous
lesion and serous effusion.  2. Rupture of vessels,  large or small,
and some destruction of tissue.   3.  Pulpification, subcutaneous,
without lesion of integument.   Injuries to nerves may  cause par-
alysis, and rupture of arteries  may endanger life or  limb.  Ter-
minations.—Resolution ; resorption ;  suppuration; ulceration ;
gangrene and neo-plasma.
     Treatment :  No incision.
     Remedies :  May be used locally.
     Arnica  : In nearly all cases.  Haemorrhagic effusions pre-
ponderates over serous.   Swelling firm.
     Conium: Serous effusions  preponderates.   Boggy swelling,
or hard and  heavy, like a  stone.
     Hammamelis : Haemorrhagic  effusion largely ; the  parts look
like  a  bladder, soft and fluctuating.
     Wounds :  Solution of continuity;  separation of parts, with
cutting, bruising, piercing,  or tearing weapons or instruments.
Six forms or varieties :  1. Incised.  2. Lacerated. 3.  Contused.
4. Punctured.  5.  Poisoned.   6.  Gun-shot.  (7. Subcutaneous.)
     Incised : Caused by sharp,  cutting instruments.   Import-
ance, on extent, and structures implicated.   Simple and Compli-
cated.
     Special  Phenomena:   Gaping, depends  upon direction  of
wounds in relation to direction of fibres.  Haemorrhage usually
free.  Pain:  Smarting,  aching, or throbbing, to which succeeds
a simple stiffness.
     Treatment :
     Arrest of Hemorrhage.
     1.  Compression: by tourniquet,  Esmarch's  bandage, com-
pressors, (digital  or mechanical), flexion,  accupresure, Spanish
windlass.
     2.  Occlusion : Ligatures, (silk or cat-gut,)  in continuity  or
at cut end.   Torsion.
     3. Styptics  : Per sulph. Ferri., Erigeron., Sulph. cupric.
     Ensure good scar ; cleansing ; no rubbing ;  closing ■ coap-
tation.
     Sutures : Interrupted ;  Continuous ; Quilled ; Wire • Hair-
lip-pins.  Straps:  Retained as long  as  useful.   No  lotions sal-
ves, or water constantly.  Staph.:  for first dressing, and all'sub-
sequent dressing.  Internally also. 
             A SYLLABUS  OF LECTURES ON SURGERY.          25

     Lacerated :  Torn, as by belting of machinery, etc.   Hae-
 morrhage usually insignificant.  Ex.:  arm torn out.  Some anaes-
 thesia, for a time, pain  moderate ; tetanus ; secondary haemor-
 rhage ; amputation.
     Treatment : Same  as incised, but never  convert into in-
 cised or cut off points or ragged portions.  Use Calendula in same
 manner as above.   Hypericp?rf  for soreness.
     Contused :  Blunt instrument; contusion of fourth degree,
 with cutaneous wound  added.  Haemorrhage  moderate,  as in
 "lacerated."  Anesthesia, then  pain,  aching.   Sloughing  of
 edges.  Extensive, as railroad injuries, much shock.
     First dressing, adhesive  strips only.   Second, suture,  as in
 other cases.
     Arnica, typical remedy.
     Punctured :  Stab :  sharp point, dull  edge.   Dangerous,
 when large cavity  opened.  Tetanus frequent in all cases.   Blunt
 ins\rument, as nail, more danger of tetanus than when sharp, as
 sword,  awl,  bayonet, etc.   Paget.   (Holmes, Surg. I., 646)
 says; Fibres crushed, purulent discharge, death  of tissues, septic
 absorption.   Little haemorrhage.   Pain, severe ; aching.
     Tratment :  Sucking the wound ;  removes foreign material,
 and approximates the sides.  When large, tents, to heal from the
 bottom.   When small, collodion, to seal up.  Never enlarge the
 opening.
     Led Pal. : Best remedy; extreme coldness.
     Hyperic : Soreness.
     Strata.:  Jerking of muscles.
     White-bean.   (A. M. Cushing, Med. Inv., XL, 184).
     Poisoned:  Any variety, usually  punctured, with  introduc-
 tion of venom or poison.   Weapons : Bites and stings, rabid and
 poisonous animals  and reptiles.
     Symptoms : Depends upon  agent.  Snake or animal poisons,
 disorganization of the blood.   Other agents  peculiar symptoms.
 In general, swelling, discoloration, pain,  and some alteration in
 blood.  Mental symptoms vary with agent.
     Treatment:  In all varieties, sucking a  useful procedure.
     Insects and Bee stings:  Swelling, smarting, and  redness.
 Use Ammo., Apis., Mud.
     Scorpions and Centipedes : Tobacco locally.
     Snake bites :  Some rapid ;  some slow.   Time of year  to be
 considered ;  also distance of spring and part  bitten.  Symptoms
 vary.  Usually swelling, discoloration, mental abberation,  and
 nervous excitement.   Sloughing, secondarily.
     Higgins (Ophidians) :  Gall  of serpent ix.  Heat,  direct
 or radiated.   Excision.   Alcohol?  Ligature.
     Hydrophobia :  Real or imaginary ?  Symptoms :  Generally
after cicatrization.  Shooting  pains premonitory.  1.  Muscular. 
 26          A SYLLABUS OF LECTURES ON  SURGERY.

 2. Hyperesthesia.   3. Mental  agitation.   Pain on swallowing,
 particularly fluids, u catching"  in breathing.   All senses acute;
 sensitiveness to contact and drafts of  air.   Mental agitation, bit-
 ing, frenzy, tetanic spasms, froth at the mouth.
     Treatment :  Prophylactic, as  well as curative.  Avoid cur-
 rents of air, running about and noise.  Also sight of liquids.
     Bell: Preeminently fearful.
     Hyos : Chiefly combative.
     Stram.:  Continuousness.
     Lach. : On being touched.
     Xanthium Spin :  Before frenzy.   (Gryzmal, Kriva.   Hahn
 m.,xil, P. 530.)
     Hydrophobic cases, frequently cured ; always a doubt about
 etiology in such cases.
     Dissecting wounds :  Post mortem, soon after death.   Pecul-
 iar poison, not specific inocculation ;  or pyaemia.
     Sucking, heat, etc., as needed.   Strong nitric acid.  Ars.,
 main remedy, with reference to septic condition.
     Gun-Shot :  Literally  from any explosive forces.  Practically
 missiles from fire-arms.   Injury modified by  (a) Form of missile.
 1. Spherical.   2.  Conical.  3.  Irregular.   Direct shot, direct
 from gun, produces compound fracture.   Indirect, glancing, or
 after passing through  other objects, simple fracture often.
      Pistol balls:  Shot; Wadding;  Gun-caps;  simple powder.
      (b) Degree of Velocity:  More  rapid  motion, more penetra-
 tion ; less motion, more wide-spread  destruction.
     Symptoms:  As modified  above.   Shock, according to cir-
 cumstances.  Pain, tissues involved.  Bleeding,  secondary or
 primary.   Secondary from  sloughing of cut ends  of vessels, or
 continuity from bruise.  Lodgment of ball, depends upon veloc-
 ity.   Wound of entrance,  edges inverted  and margins either de-
 vitalized  or burnt. Sometimes triangular  flaps.  Wound of exit,
 edges everted, or fat pushed out.  When high speed wound of en-
 trance smaller than missile ; of exit  larger.   Slow speed, of en-
 trance larger than ball and discolored ; of exit, large ragged.
      Ball  split:  deflected ;  fall out.    Constitutional  symptoms
  severe ; pus profuse ;  much sloughing.
      Causes of death:  Immediate,  Wounding  of blood vessels,
  nerve centers, profound shock, wounding  of vital  organs.   Re-
  mote, Tyaemia, tetanus, hectic,  erysipelas.  Tenacity of  life.
      Treatment: Shock (videarticle  "Shock").   Hemorrhage,
 precautionary.   Probing,  finger  or  Nekton's probe: caution—
. Extraction forceps, Thomassin's,  or dressing.  By counter-punc-
  ture.   Hermetically seal.
      Remedies : As the symptoms arise.
      Surgical Incisions :  Edge of knife away from skin. Always
  incised.  Forms:  Linear,  crucial,  elliptical, crescentic.  Trans-
  fixion.   U. H. T., etc. 
             a syllabus of lectures on  surgery.         27

     Healing of Wounds.
     Largely relegated to Histology.  Remedies much assist pro-
cess.   Open wounds,  nucleated  cells.   Subcutaneous nucleated
blastema ;  fibres.  Four methods.
     1.  Immediate union.  2. First intention, or primary union.
3. Second intention, or granulation.  4. Under a scab.   Paget
adds:  5.  Union of two granulating  surfaces.  (Holmes, I, 32.)
     1.   Immediate  Union.  Exact coaptation, clean cuts, imme-
diate adhesion,  no  plasma thrown  out or needed.   " Process of
negations."
     2.   First Intention.  Period of rest.  Hyperaemia  (not In-
flammation) ; effusion of lymph, ceasing when enough is obtained.
Blood  retards.   How  disposed  of:  Absorbed;  ejected ;  pus.
Inflammation retards or prevents union.   Appearance of lymph
to the eye.   None in the substance of part, only on  the cut sur-
face.  Vascularity, loops form, and unite.  Time required in pro-
cess dependent  upon tissue and extent of wound.
     3.   Second Intention.  Wounds  left  open.   Whitish  film,
full of lymphoid corpuscles.   Blood-vessels project into points of
exudation,  which  become   ruddy  granulations.   Granulations
(min. anat.),  lymphoid cells heaped  together without regularity.
Little, if any, intercellular substance. Blood-vessels end in loops
on apex of granulations.  Healthy  process, profuse laudable pus.
Any defect indicated by morbid character of  pus.
     4.   Under a Scab.  Most natural form ; almost universal in
animals.   Difficult  to  excite or  study in  man.  Crust formed,
inspissated  lymph and blood coagula.  Integument forms without
granulation.  Process similar to third form, but less  pus.  Little
contraction, as no granulations.   Formation of connective tissue,
which in  time takes on the characteristics of  the  tissue  of the
part.  Ultimately, sometimes in  years,  scar  disappears  entirely,
and  deep attachments become also loosened.  Healing sometimes
fails, due to disease, old age, anaemia from  hemorrhages.   Some-
times takes on ulceration.  Scars may be weak, depressed,  con-
tracting, thick  and elevated.  (Vide Am. Horn.  Obs. XIV, p.
297.)   May be dissected out in bad cases.
     Remedies :  Aid process,   e. g.: Am., absorption of  blood.
Led., or Hyperic,  corrects  innervation.   Calentt., modifies pus
genesis.  Staph., lessens or prevents inflammation.

   XII.   EFFECTS OF  HEAT  AND COLD.

     Heat :  Destroys tissue, never revitalized.  Bums, dry heat;
Scalds,  moist heat.  Pain most intense.  Indications: Healing,
prevent deformity,  modify or remove visceral lesions, support
strength, etc.   Effects : In  rising  scale  from  water to  molten
metals. 
28
A SYLLABUS OF LECTURES ON  SURGERY.
     Five degrees :  To be recognized, to inaugurate appropriate
treatment:
     i.   Simple inflammation, or erythema.  Sometimes formid-
able, from extensive surface, as flashing from gases or explosions.
Shock; brain lesions  from serous effusion, to relieve vascular
excitement.
     Urtica  Urens.,  relieves pain.  ' Nit. Silver., strong solution,
painted on,  relieves pain instantly.
     2.   Blistering  of  Skin :  Vessels  relieved, by pouring  out
serum.   Never open blister;  protect from injury,  and air.  Pain
as above.
     3.   Charring of  Skin:  Certain  sloughing.  Pain  greater
when not extending through  whole substance of skin.  Visceral
lesions common.   Hasten slough ;  Calend. to ulcer.   Pain, etc.,
as above.
     4.   Charring of Skin and Soft Parts:  Aggravation of above.
     5.   Complete  Carbonization &f Whole Part: Rarely calls for
treatment, on account of fatality,  unless small limb.  Amputa-
tion, early.
     Causes: Gaseous,  or other explosions; sun  heat;  molten
metals;  spontaneous (?) combustion.
     Symptoms:  Three stages:  1st. Collapse: Pain, shock, heat,
then chilliness, quick pulse, thirst and dry mouth.  2d.  Reaction :
Inflammatory; constipation, vomiting, diarrhea,  bloody.   Duo-
denal ulceration.  Sloughing; bleeding.   3d. Exhaustion : Local
conditions prominent.   Suddenly fatal.   Intestinal lesions.
     Cause of Death :  Shock; exhaustion; pyaemia;  erysipelas;
tetanus ; cerebral, thoracic or abdominal complications.
     Prognosis : Extent, reaction,  habit of patient, age, locality.
     Scalds : As burns ; devitalization, without charring.
     Treatment:  Pain, as above.  Dressings, essential; light,
exclusion of air, unirritating ;  chalk, or  flour, and white  of egg.
Care in removal.  Carb. soda., white lead ; linseed oil, and lime
water, etc.   Scarring ;  results, and treatment.
     Cold :

     Similar to heat.  Effects same, except 5th degree.  Parts of
low vascularity.   Sudden cold ;  ecchymosis. Gradual cold ;  first
redness, then white.  Dry cold, less  severe.  Moist  cold, 'more
speedy in effects.
     Frost-Bite: Immediate effects.  May be followed by slough-
ing, or  ulceration.  Tingling,  weight,  numbness, then  loss of
sensibility and  color.   Treat in  open air,  or unheated  room
Cover with  snow,  until  parts  are pliable; then  friction  with
snow,  cold  water.   Pam on reaction,  Carbo. Veg., or Arsen  Re
action  hastened,  strong black coffee.   Gangrene  develoDed"
amputation  early.                                         F  '
     Chilblains, (Pernio) : Secondary, chronic inflammation, itch- 
            A SYLLABUS OF LECTURES ON SURGERY.          29

ing, burning, stinging, in warm, moist weather.  Mur. Ac, top-
ically,  in  recent cases.  Puis., Fragaria  Vesca., Worse from
warmth.  Chronic cases: Agaric,  Ante,  Apis., A?s., Rhus.,
Sulph.  (Compare "Asphyxia.")

                  XIII.  ASPHYXIA.

     Asphyxia, "without pulse" :  Heart beats long after respira-
tion ceases.   Apncea, " without breath."  Difficulty in suspend-
ing  breathing.    Apparent  death :  want of  oxygen, as well as
obstructed respiration.
     Causes: (Holmes V. 887.)   i.  Mechanical,   (a)  Accident.
External and Internal,   (b)  Disease, Ext. and Int.  2. Absence
of oxygen.  3.  Inhalation of toxic gases—chemical effect added.
     Symptoms :   Chest, fullness, oppression.
     Head:   Fullness, giddiness, ringing in the ears, flashes of
light.    Dreams, then coma and convulsions.
     Heart: First accelerated-, then slower and labored. Between
last  inspiration  and  cessation of  pulsations, from two to four
minutes.
     Face:  Anxious.    Eyes protruding and  staring, blue lips,
sanguinolent or frothy mucus.
     Sphincters:   Relaxed;  involuntary micturition and defeca-
tion.  Also  emissions of semen, with or without erections.  Vari-
ations with  reference  to cause.    Diagnosis usually  easy from
history, but attempts to deceive frequent.
     Post mortem:  External:  Lips, blue,  frothy mucus; (also
in epilepsy and heart-disease).
     Tongue:  Swollen,  and  bears marks of  teeth.
     Eyelids:   Half open.  Pupils  dilated.
     Countenance :  Placid ;  at times livid.
     Skin :  Pale ; at times discolored in spots.  Cases of violence
—marks of  cord,  finger  marks, dislocation of tracheal  cartilages,
fracture of hyoid bone, laceration, etc. Hanging, when cut down
within  a  few moments, no marks of rope.   When hung living,
after a half hour, deep furrow, looking somewhat  seared.  When
dead, simple groove.   Rigor mortis early.
     Internal.    Gases,  opposite effect,  e. g.,  sulph.  hydro.,
muscles intense dirty black.   Carbonic ac,  vermilion.
     Brain.   Anaemia sooner or later when  head has been raised
from beginning ;  when low, venous engorgment.
     Blood.  Usually fluid.  Right  heart full;  left either flaccid
or filled with dark venous blood.   Venous congestion in most of
the viscera.
     Lungs.   In drowning, more or less water and floating sub-
stance.  Rapidly absorbed, if some respiration particularly.
     Prognosis good  when respiration  has  not been suspended
over ten minutes.   Unfavorable after a longer time. 
3°
A SYLLABUS  OF LECTURES  ON SURGERY.
     Treatment:   i.  Alternate compression of abdomen and
 thorax, to imitate respiration.   2. Silvester's method:   Inspi-
 ration,  arms  brought up over the sides of  the  head, until the
 elbows  nearly touch  each other, slowly.   Expiration, restoring
 them to the side of the chest, and gently pressing upon it.  Head
 and shoulders to  be elevated, to make thorax prominent.  3. Mar-
 shall Hall :  Treat the  patient instantly, on  the spot. — Send for
 medical aid. — To clear the throat, place the patient gently on the
 face, with one wrist under the  forehead. — To excite respiration,
 turn slightly on side, and apply irritant  to the nostrils, and dash
 cold water on the face, previously rubbed briskly until  it is warm.
 —If no success, replace the patient on his face. — Turn the body
 gently but completely  on the side, and a little beyond, and then on
 the face, alternately ;  repeating fifteen times in a minute, only. —
 When  the prone position is resumed make  equable but efficient
pressure along the spine. — Rub the limbs  upwards, with firm
pressure. — Replace  the  patient's  wet  clothing  by  dry. —
 Meantime, let  cold water  be dashed briskly on the surface  pre-
 viously  rubbed dry and warm.
     Remedies useless,  owing to suspension of assimilation, etc.
     Common cases.  1. Newly born.  Any of the methods above
 mentioned.   Alternate raising from and  restoring to supine posi-
 tion.  Electricity;  bath, etc.   2. Noxious gases.   Chloroform
 (vide Anesthesia).    Friction;   fresh air.    3.  Strangulation.
 Look for cause.  Food in the glottis, etc.  Tumors,  fracture, etc.
 4. Drowning.   Nausea  afterwards, Ipec   Hering and  others.
 Lach. or Solan, mam.    5.  Cold.   Remove  to unheated  room  ;
 cover with snow,  renewing it as it runs off (or cold water ;  salt
 and water had better be avoided).   When the limbs become
 pliable  remove all  clothing, brisk friction.    Pain on return of
 consciousness,  Carbo. veg or Ars.   Also give black coffee, without
 milk.   6.  Lightning.    Not apnoea properly but  may be con-
 sidered at this place.   Effects:    1. No marks.   2. Vesication,
 burning or charing.   3.  Tearing, etc.   (Holmes).   Burying in
 the earth with face exposed and turned toward the sun, and cold
 water dashed in the face.

                    XIV.  TUMORS.

     A rising or prominence in some part of the body, developed
 and sustained  by some morbific cause.
     Solid:  diffused;  encysted.   Cystic.  Sessile or pedunculated
 I. Benign.   II. Semi-malignant;   III.  Malignant.  Anatomical
 characters :    Benign,  homologous;  semi-malignant,  compound  ■
 malignant, heterologous.   Age.    Growing.-  Increase rapidly  •
 innocent.   Mature:   Increase slower ;  innocent or semi-maliV-
 nant.   Decline :  Increase slow or moderate ; malignant   Sex  • 
A SYLLABUS  OF LECTURES  ON SURGERY.
31
Women present more cases, particularly about the genitals. Men,
more varieties, particularly cutaneous.
    Diagnosis :   Tumors from hernia, and hypertrophy.  Phan-
tom tumors ; muscular contractions, disappear under chloroform.
Pulsating tumors; differentiate from  aneurism.
     Causes,  i. External:  Effect of pressure  as bursa ; deeper   »
irritation, bone spiculae, etc., excite morbid action; largely hyper-
nutrition.   2.  Internal:   Nervous influences ;  repair  and assim-
ilation abnormalities.   Summary:    i. Morbid cell production
(quantity, quality or both), to repair loss.   2. From  exaggeration
of function.   3.  Senile involution.    Recurrence:   1. Continu-
ity (benign).   2.  Migration  and  transplantation  (semi-malig-
nant).  3. Constitutional reproduction (malignant).
    Treatment :    General  and Instrumental.    Medicinal to
improve general condition, and  cures tumors secondarily,

     I.  BENIGN TUMORS.

     Syn.: Non-malignant;  innocent.  Tendency to perfection of
growth; enduring.   Usually single ;  have  been found secondary,
by dispersion of fragment.  Seldom recur : extinct action ; hy-
perplastic tendency may be re-excited by  removal;  obscurity of
symptoms mask secondary deposits ; portions  of growing tissues
remain.   Do not implicate contiguous structures.   Do not cause
death, unless : 1. They compress important parts;  2.  From im-
mense size and weight; 3  Destroy bony  parts; 4.  By degenera-
tion (after frequent removal).
     Structure: Normal  elements in  excess;  sort of tumor-like
hypertrophy.  Redundancy;  luxuriation.
     Growth : Generally rapid,  or irregular.
     Types:  1. Cystic;  2. Atheroma;  3. Warts, (condyloma);
4. Sarcoma;  5. Lipoma, (steatoma) ; 6.  Adenoma; 7. Fibrous;
8. Glandular; 9. Polypoid  (myxoma).
     1.  Cysts:  Simple;  multiple.   Serous;  mucoid; hcemato-
ma.    Natural:  Duct  occluded, or hypersecretion of contents.
Type, ranula.  Artificial: Limiting membrane;  cystic or fluid
degeneration.  Type,  some ovarian cysts.
     All tissues : single or  many;  size varying; contents, any
consistency or color ; grows rapidly, usually ; terminates, absorp-
tion, suppuration, ulceration,  rupture and  resorption.
     Treatment :  Complete  extirpation ; scalping;  injection ;
compression ; electrolysis.
     Remedies : Apis., Am.,  Ars., Bell., Calc, Coloc,  Graph.,
Lye, Plat., Podoph., Puis., Rhod., Rhus., Sep., Sil., Sulph.
     2.  Atheroma : (Sebaceous).  Natural cysts, mostly on head ;
usually in  numbers.  Size,  from marble to  orange.   Contents
pappy', or all consistencies; all colors.  Grows slowly; suddenly
rapid.   Termination : Suppuration ; large, intractable ulcer, high 
 32          A SVLLABUS OE  LECTURES ON SURGERY.

 rounded edges.  Horns, anywhere—spiral, brownish color,  any
 size; a few lines to nine inches.
     Diagnosis: Fungus of cranium, of dura-mater, hernia cere-
 bri, or other forms of tumor.
     Treatment : Excision,  complete.
     Remedies : Baryta C, Lach., Sil., Sep., Sulph.
     3.  (a).  Warts: Syn.: Verruca.
     Hypertrophy of  papillae ;  hard, horny, soft.  Lobulated  (see
 warts).   Epidermis dipping  down  between  papillae.  Smooth,
 pedunculated, or sessile.  Mostly on hands.  Vascular, loops in
 apex.  Pain absent, or trifling.  Cause, unknown; local  irrita-
 tion.  May develop epithelioma.
     Treatment : Pedunculated, snipped off.  Nitric ac. to base.
 Sessile, nitric or acetic ac.  Galvano-cautery.
     Remedies : Often cure:  Calc, once a day for  a  week, then
 Thuja., topical as well.
     Nit. ac, Soft warts;  thin epidermis.
     Sep., Large, hard warts.
     Calc. c, Small, soft; great numbers.
     (b).  Condyloma: Syn.,  Mucous tubercle.   Hypertrophied
 papillae; soft;  mucous surfaces,  or borders; genitals.   Various
 forms, like warts.   Vascular, no pain, or  trifling.   Causes, ven-
 ereal, or dirty habits.
     Treatment: Excision;  Ecrasseur: Galvano-cautery.
     Remedies: Nit.ac, Elevated, cauliflower, exuberent; moist;
 sticking pain.
     Phosph., Large numbers  ; dry.   Vaginal.
     Thuja., Fan-shaped;  moist;  suppurating;  large.   Other
 remedies: vide "Warts."
     (c).  Cheloid: (Keloid):  Seems  semi-malignant.   Usually
 in cicatrices; often in ridges or welts.  Vascular; pink color;
 fibrous.   Recurs.
     Treatment : Excision rarely successful.
     Remedies : Vide  " warts" and  "condyloma."
     4.  Sarcoma :  (Abernethy) :   Usually classed semi-malig-
 nant.  "Fleshy," exaggeration of  natural elements:   rich  in
 large cells, at times little connective tissue.  Recurrent, increased
 malignancy.  Consistency, depends  upon  region;  usually firm,
 compressible, elastic ; often  an element  in compound  tumors.
 Found in every tissue, exaggerated morphology.  Growth rapid,
 large size.   Irregular  form,  often  lobulated; smooth,  circum-
 scribed.  Vascularity  high, recurs, resembles finally encephaloid.
 Cause: Excited cell proliferation or genesis.  Terminations, often
fatal after frequent recurrence, from exhaustion and haemorrhage.
Ulceration and sloughing.
     Treatment :  Removal complete.  Knife and  cautery.   Es-
march.   (Holmes I, 549.   Paget), Bromide potass., lar<re dose.
 No cases reported Homceopathically. 
A SYLLABUS  OF LECTURES ON SURGERY.
33
      Calc ?  Phos. ?  Lye. ?  Sulph. ?  Sil.  ?
      5.   Fatty:  (a) Lipoma: Fat cells in loose connective tissue,
 either  encysted  or  diffused.   Migratory ;  loose attachments;
 sometimes pendulous;  irregular in  form, smooth, symmetrical,
 or lobulated.  Soft and  doughy,  or granular in feel.  Growth
 slow.  Found in any  situation, even heart.   Vascularity low.
 Fain absent, except from nerve  pressure.  Cause, exciting, pres-
 sure.   Predisposing, alcohol, or corpulent habit.
      Termination:  Sometimes adhesion,  inflammatory changes,
 degeneration, absorption.   Little change for years.
      Treatment :  Excision preferable in all cases.
      Remedies : Baryta C, Calc, Sulph.
      V^b)  Steatoma : (Cholesteatoma): Dry,  white  fat, laminated,
 or cholesterine.   Encysted;  smooth; regular; firm feel.  Any
 tissue,  mostly sub-cutaneous.  Small size, slow growth, low vas-
 cularity,  pain insignificant or absent.  Termination and Treat-
 ment as Lipoma.
      6.   Adenoma:  Neo-plasma, resembling gland  tissue,  race-
 mose glands; either in  connection with, or  separated from, and
 encapsulated.  Solitary;  symmetrical in  form, and  firm, dense,
 inelastic.  Situated in any glandular region.   Growth  slow;
 small size.  Vascularity considerable.  Pain insignificant.
      Treatment :  Excision.
      Remedies: Graph., Phytol.,  Merc,  Calc. C, Sulph.   Fre-
 quently cured with remedies.
      7.   Fibrous: Various forms, with a  fibrous basis, as fibro-
 cellular, fibro-plastic, etc.  Compound frequently.  Single.  Cut
 into, appears white, glistening, ligamentous.   Irregularly rounded
 or oval;  smooth, movable, firm. On mucous surfaces cauliflower-
 like.   In most  tissues ;  oftener uterus, antrum, and parotid
 regions.  Growth slow, but may attain enormous  size.  Remain
 stationery for years, then grow  rapidly.  Vascularity consider-
 able.   Pain absent, or slight.
      Termination :■  Disintegrate ; oedematous ; sloughing of skin ;
 soften ; ichoraemia; immense fungus ;  bleeding easily.  Death
 from exhaustion :  Sometimes cachexia: Calcareous degeneration:
 Cystic degeneration.
     Treatment  : Excision.   Ecrasseur.  Galvano-cautery.
     Remedies : Calc. ph., Teucri.
     8.   Glandular: Any form of tumor implanted in, or grow-
 ing from, glands.  Lobular hypertrophy.  Often semi-malignant.
     9.  Polypi: Mucous hypertrophy; sub-mucous fibroid ; (myx-
 oma).  Pendulous ;  pedunculated ; pear-shaped; sessile.   Some-
 times malignant.  Rapid growth; large.   Any mucous passage.
 High vascularity.   Red or slate  colored.  Pain slight.
     Termination : Sloughing; degeneration ; very destructive to
bones by absorption.
      3 
34
A SYLLABUS  OF LECTURES ON SURGERY.
     Treatment :  Removal; evulsion ; ecrasseur ;  galvano cau-
tery.   Naso-pharyngal: extensive operation.  (Helmuth, p. 66.)

     II.  SEMI-MALIGNANT.

     Slower growth.   Large size.   Often  painful.   Frequently
returns.  Tendency to destroy  life.  May implicate near  parts.
Compound;  or heterologous.  Structure:  Normal  cellular  ele-
ments; misplaced deposition.  Recurrence: By transplantation ;
or remains of growing tissue.   Each return more malignant.
     Types:   i. Fibro-plastic.  2. Recurring-fibroid.   3. Enchon-
droma.   4. Epithelioma.
     1.   Fibro-plastic:  Syn.:  Myeloid.   Commonly painless;
elastic; smooth;  young people, in  connection with bones,  at
times in the interior.   May not recur.  Section shows translucent,
shining, bluish-green, gray, or  pink color.   Dotted  with brown
or red spots. Succulent; fluid yellow.  Cell elements  : Like foetal
cartilage.  Paget (p. 465).   1. Cells oval, lanceolate, elongated,
angular, caudate, granular.  Single nucleus and nucleoli.   2.  Free
nuclei assuming  cell  form.  3.  Most peculiar: Large,  round,
flask-shaped cells,  or masses of  cells, or thin discs; granular, two
to ten clear nuclei with nucleoli:  All these in dimly granular
substance.   Malignancy in proportion to succulency.
     Termination : Partially  ossify; cystic  degeneration;  simu-
lating colioid.
     Treatment :  Early and thorough extirpation.
     Remedies : Ars., Bry., Lach., Merc, Sil, Sulph.
     2.   Recurring-fibroid:  In  connection with bones, or close
proximity  thereto.  Grow rapidly, large,  painful.   Externally
appear like fatty tumors, but larger.  Recent specimens fragile,
lobulated ; varying in color—white, drab, or pale yellow.  Cell
elements, oat-shaped, elongated, caudate,  bifid termination.  De-
veloping into fibres.  No cachexia,  particularly when primary.
Recurrence with increased malignancy.
     Termination : Sloughing, exhaustion, death.
     Treatment:  When very  large, amputation.   Extirpation;
knife and cautery.
     Remedies: Very  few cases:  Phos., Calc, Sil., Graph.
     3.   Enehofidroma : Syn., Cartilaginous.  In connection with
bones, particularly heads of long bones.   Soft near  the  surface,
but hard on deep pressure.   Large, irregular,  nodulated,  some-
times elastic, not freely movable.   Cellular elements,  all grades
from cartilage to fat,  in cartilaginous stroma.  Resembles  cartil-
age of lower animals.
     Termination: Cystic; calcareous osseous, or fatty, degener-
ation.  Often two processes at the same time.
     Treatment :  Excision or amputation.   Sil., has cured sev-
eral cases.   Calc, recommended empirically. 
A SYLLABUS OF LECTURES ON SURGERY.
35
     4-  Epithelioma : Sometimes classed among  malignant tu-
 mors.  Firm,  hard,  sessile, or  pedunculated.   Any  location,
 usually near or on mucous surfaces.   Recurrence the rule.  Inter-
 nal proliferation of epithelium, displacing  and absorbing inter-
 vening tissue.   (Forchheimer, N. A. Jour. XXIV, 337.)  Closely
 packed epithelium.
      Termination: Ulceration, exhaustion.
     Treatment :  Excision the rule.
     Remedies : Acet.  ac. Arg. nit., Aur., Chelid,  Puis., Sulph.,
 Thuj.

     III.   MALIGNANT.

     Syn.:  Cancer. Carcinoma. Moderately rapid growth, greater
 in some forms. Recurrence. Implicate contiguous parts. Destroy
 life.   Produce cachexia.
     Cell elements: Multiplicity,  immature,  disintegrated,  and
 free nuclei.
     Course:  Mental  depression;  gastric derangement;  mal-
 assimilation; irregular cell-genesis.  Production of tumors, or
 degeneration of  existing growth.
     Characteristics: Succulency; excess of albumen ;  simulating
 embryonic or lower animal tissue.   Women ;  middle aged or old
 persons.
     Types: (Primary):   1. Scirrhus.   2.  Encephaloid.  (Sec-
 ondary) :   3.  Colloid.  4.  Melanosis.
     1.  Scirrhus:  Mostly  in mammary gland; any  glandular
 part.  (1).  Occult.  (2). Open.
     (1).   Occult: Hard,  craggy,  incompressible, immovable.
 Slow growth.  Single, or in numbers.   Skin  at  first loose, later
 firmly attached, brown, brawny; veins enlarged.  Glandular in-
 filtration.  Lancinating pain on handling. Sometimes compound,
 particularly with encephaloid.
     (2).   Open:  Softens, breaks down into  foul, foetid, rapidly
 destructive  ulcer.   Tough,  greenish-gray slough.   Increase of
 pain, almost constant.
     Recent specimen, creaks under the knife; looks  like cartil-
 age ; when dry, like horn.   Very succulent and soft after removal.
 (Walshe).   Laminated,  Fibrous lines running  through it.
     Recurrence:  By secondary deposit.  Colloid when visceral.
 Scirrhus when  glandular.   Ulceration when in cicatrix.   Second-
 ary Ulceration :  Pink eievation,  thin  covering, abraded apex,
 form ulcers  with  tough, yellowish  sloughs;  coalesce until whole
 scar broken down.   Connection with phthisis.  Duration of life.
     Termination :  Ulceration ; dispersion ; cachexia; death.  Oc-
 casionally, spontaneous cure by extrusion or resorption.
     Treatment  : Early thorough extirpation.   No  plasters or
caustics.   Injections of alcohol (Schwalbe).  Electrolysis? 
36          A SYLLABUS OF LECTURES  ON SURGERY.

     Remedies: Ars., Carbol.ac, Con., Carb.v.,  Graph., Lapis
alb.
     2.  Encephaloma : Syn., Fungous-Haematodes.   Any age ;
both sexes;  even animals in general.   Soft, compressible,  rapid
growth.  Skin covered with tortuous veins; at first  unattached,
then adherent;  changes color; gives way.   Sloughing;  enor-
mous fungous granulations; terrible  haemorrhage.   Rapid  ca-
chexia.   Secondary deposits,  sometimes  scirrhus ;   stratified,
tuberiform,  or  infiltrated.   Oftener in  eye,  mammae,  ends of
bones,  and testes.   In the Eye: Metallic lustre in fundus; canary
colored tumor;  absorption of contents; perforation of cornea,
and usual characters.   Recent specimen : Vascular, loose texture ;
stroma delicate  fibres: to  the  eye like brain mass,  or  boiled
potato.   Cell elements :  Caudate,  fusiform,  oat-shaped,  nucle-
ated, granular, compound,  bifid termination.
     Termination : Death from  exhaustion, or cachexia.
     Treatment:    Sometimes amputation;  rarely  excision.
Sharp spoon.
     Remedies: Ars., Lach., Phos., Carbol. ac,  Croc Sat., Crot
hor.
     3.   Colloid:  Syn.:  Gelatinous.  Alveolar.   Rarely seen as
an external tumor.   In connection with scirrhus.  Oftener sec-
ondary  visceral  deposit, stomach and ovary.   May resemble
compound cysts; cells filled jelly-like,  semi-transparent, yellow
substance, like honey.   Tumor hard,  small, rapid development.
     Termination :  Death from  exhaustion.
     Treatment :   Rarely removed, unless in combination with
other tumors.
     Remedies: Ars., Carbo v.,  Carbol. ac
     4.   Melanosis:  Rarely as a  tumor, part of  other forms.
Black  substance, opaque,  humid,  unctuous:  like  a  bronchial
gland.  From great density to inky  fluid.  Occurs (a) Tuberiform:
Serous  or adipose tissues;  from millet seed  to  orange in size.
(b) Punctiform:  Minute points or dots  in other tumors,   (c)
Stratiform :  Diffused, like adventitious membrane.
     Termination :  Softens, disintegrates, eliminated.   Spontan-
eous cure, rarely fatal.
     Treatment : WThen practical, extirpation.
     Remedies:  Carbol. ac, Sang.,  Ars., Lach.
     Summary :  Etiology made  out ?
     Benign : Normal cells; simple redundancy.
     Semi-Malignant: Normal cells, misplaced deposition.
     Malignant: Disintegrated, immature, misplaced cells'.
     All forms over-production.
     Special  forms of tumor, see 2d and 3d sections. 
            a syllabus  of lectures  on surgery.          37

     General Remedy Indications:

     Acetic ac, Reputed  solvent for cancer cells.  No records.
     Apis., Cystic tumors:  burning, stinging.
     Am.,  Mottled, ecchymosed appearance, with  aching pains.
     Arsen., Destructive  secondary ulceration.   Cachexia,  with
emaciation and burning pains.
     Baryta c, Indolent, painless, hard,  glandular, in  old  peo-
ple,  or drunkards.
     Bell.,  Painful, inflamed.
     Calcc.s Strumous cases ; takes cold easily; subject to indo-
lent, glandular swelling; lax fibre, and sweats easily, when sleep-
ing.
     Carbol. ac, Based on anti-septic properties.
     Com'., Stony hardness, with weight.
     Crocus s., Hemorrhagic, blood black, tar like, stringy.
     Coloc, Ovarian cysts, with  dysmennorrhoea;  billious vom-
iting ;  paroxysms of sharp, cutting pain.
     Galium.,  Clinical testimony in cancer of tongue.
     Graph., Sebaceous tumors, with much itching of neighbor-
ing skin, when warm.
     Hydrast.,  Many  cases  of cancer  reported.   Pricking in
part, on motion only.
     Lachesis., Skin of part mottled;  small ulcers  about tumor,
burning when  touched.
Lapis alb., Grauvogl  reports cases cured of scirrhus.
     Mur.  ac, Cancer of tongue (vide " mouth") with  blue
color of  parts.
     Nitric  ac, Bone tumors, or  other  forms,  in mercuralized
subjects.   Pricking pain.
     Phosph.,  Encephaloma; when fungous.
     Phytol., Glandular tumors, and lipoma reported cured.
     Plat., Moral symptoms, haughty,  etc.,  of first importance.
Squeezing pain.
     Puis., Cured sarcocele,
     Silic,  Semimaglignant and  cancer;  great itching  of
tumor.
     Sulph., Completes cure, arrested when partly cured by other
remedies.
     Teucrium., Nasal fibroids. 
FJ^^irr siEQOiisriD-
SYSTEMIC   DISEASES.
                   XV.  NERVES.

    Neuralgia :

    Irritation of nerve, functional; remittant or intermittant.
When chronic may  become neuritis, or softening,  or sclerosis,
but very rarely.  Extensive lesion with  little  pain, or  violent
pain with no lesion.
    Symptoms,   i.  Primary.   2. Reflex.
    Primary: Pain of all  varieties;  exaggerations  of function.
Principally motor nerves.
    Reflex : Motor nerves; twitching, or even spasms.   Modi-
fication  of  function.  Vaso-motor;  primarily pale skin, with
chilliness.  Secondarily, turgor, sweat, and increase of excre-
tions according to location  and severity.
    Treatment :  Almost  entirely with remedies.   Heat, cold
or pressure allowable.
    Remedies:   Aeon., Early  stages;  acute;  restless; much
febrile excitement.
    Apis., Burning, stinging ; pale, puffy swelling.
    Ars., Burning deep in part; felt while  asleep; better from
warmth.
    Bell, Comes  suddenly, and ceases  suddenly;  throbbing;
better from pressure.
    Bry.,  Pain expansive; dark color  of skin; worse on least
motion,  yet can't keep still.
    Bisth nitr.,  Excruciating pain relieved by cold  and  moving
about.
    Carbo v., Burning like a coal in the part;  flatulency.
    Cham., Wild and unruly ; wants relief at  once ; hot sweat
from pain.
    Chin.,  Least  touch aggravates;  pale and prostrated after
paroxysm.   Periodical attacks.
    Cedron., Unerring periodicity. 
A SYLLABUS OF LECTURES ON  SURGERY.
39
     Coff, Unendurable pain ;  uncontrollable even from slight
pain.  Cold water in mouth sometimes relieves.
     Coloc, Sharp,  cutting  or  lancinating;  the  least  motion
bring on paroxysm.
     Gels.,  Almost loss of control; like chorea.
     Hepar. Sulph.,  Better when part is well wrapped up.
     Iris  v., Pain attended  by  much  nausea and vomiting  of
sweetish mucous.
     Lyco.,  Perspires  at  every  motion;  constricted  feeling  in
part.
     Merc, Sweats  easily;  extends to periosteum.  Worse  in
bed  and in  damp weather.
     Mezer., Pains come like electric shocks with shuddering and
chilliness.
     Nux  Vom., Tearing  with  numbness;  dull  pain;  morose
and  irritable.
     Plat.,  Boring, squeezing pain.
     Puis.,  Pains  better  from cold, and worse  from warmth;
worse in the evening.
     Sepia., Jerking like electric shocks.
     Spig., Acute pain, better from very strong pressure.
     Zinc,  Burning,  quick  stitches,  and jerking; worse from
slightest touch.
     Neuritis :
     Inflammation.   Adults;  sanguineous robust subjects.
     i.  Acute.   2.  Chronic.  3. Idiopathic.  4. Traumatic.
     (1)   Acute: Typical.   Pain chief symptom ; continuous, or
slightly intermittent;  excited by pressure; relieved by pressure
on paroximal side.   Tearing, darting, lancinating, in  course of
nerve and branches.  Climax and decline gradual.   Remission
indicates resolution or death of  the nerve.  More or less paraly-
sis.  Nerves swollen, like a cord.   Sympathetic fever.
     Seat, neurilemma and connective tissue between the bun-
dles  ;  impaired nutrition.   Color  varies with vascularity, from
violet to deep red.
     Termination: Resolution.  Adhesions.   Softening.   Hard-
ening.  Suppuration.
     (2)   Chronic:  Same symptoms, less severity,  more  persist-
ent,  slower progression, paralysis often.
     (3)   Idiopathic: As above, from causes other than trauma, as
cold, wet. suppressed secretions.
     (4)   Traumatic:  Injuries of all  kinds,  particularly  contus-
ions  or lacerations.
           ["Acute.                 f Chronic.
            Periodic.       A7-   ...  J Continnr
Neuralgia ■{ n.„.:ii..t    Neuritis \ j
Periodic.       Ar    ...  I Continuous.
r>    -^        Neuritis < T .
Remittent.             ] Intermittent.
Irritative.              ^ Inflammatory. 
40          A SYLLABUS OF LECTURES ON SURGERY.
    Treatment :  Resection of nerve.  Re-amputation.
    Remedies.   Calend., In lacerated wounds.
    Hyper., Great soreness and sensitiveness, from trauma.
    Led. pal., Great coldness, subjective and objective
    Alii,  cep., Pains violent and continuous; neuralgia of the
stump.  [Helmuth, Stephen's Clinics,p. 103.]
    Ruta.g.,  In nerves that have been stretched, as in sprains.
    Stan., Pains reach climax slowly, and slowly recede ; better
from strong pressure against hard substance.   (Vide "Neural-
gia.")

    NEUROMA:  Syn., Painful tubercle.

    Tumor of, or  in connection  with a nerve.   Single  or multi-
ple.   Painful.   Vary in size.  1.  Nerve tissue, true neuroma.  2.
Neoplasma, either fibroid or fatty.
    First: Rupture or  a few fibres, which roll up and  form nu-
cleus.  Form a bulbous extremity to divided nerves.
    Second:  Primarily  fibrous, between  the  bundles separating
the fibres, which  become thicker in slow growth  and thinner
when rapid.
    Pain  greater when single.  Mostly upper extremities.   Wo-
men more liable.  Worse from change of weather, pressure, etc.
     Termination, Fatty degeneration  and  absorption ;  fibrous or
fibroid tumor ;  paralysis ; or even death.
    Treatment :   Excision.   Exsection of nerve.   Amputa-
tion.
    Allium cepa.,  5 gtt tr.,  four times a day, and  onion poultice
to part.   [Vide  Neuralgia and Neuritis.]

    Tetanus:
Powerful  spasmodic contraction  of voluntary muscles, long-con-
tinued and uncontrolable.  Tonic contractions with intermittent
spasms.   Trismus.  Opisthotonos.    Emprosthofonos.  ' Pleuros-
thotonos.   Idiopathic.  Traumatic, Acute, Chronic.
     Usually begins with Trismus, not always, nor  always suc-
ceeded  by other  forms.  Stiff jaw and tongue,  back  of neck;
sometimes violent  pains under the sternum.  Difficult mastication
and  deglutition.  Lower jaw  fixed.   Pain agonizing.   Muscles
hardened,  particularly abdominal, like a board.    Face  pale, dis-
torted.  Pulse rapid, irregular ;  breathing labored and hurried
during  spasm.   Spasms  violent,  throwing patient off  the  bed.
Consciousness retained; senses  morbidly acute ;  distress  from
dread  of  spasms.   Opisthotonos  quite  frequent.   Emprosthoto-
nos rarely seen.    Pleurosthotonos rare,  oftener  to  right  side.
Trismus very constant.
     Causes: (1)  Predisposing;  (2)  Exciting.
     (1) Predisposing. Age  10-30.  Mostly men ; changes of tem-
perature ;  equatorial; negroes.   (2) Exciting causes (a)  Periphe- 
             A SYLLABUS OF  LECTURES ON SURGERY.          41

ral; wounds  and injuries, particularly punctured and lacerated.
Exposure to  damp  or  cold ; to air in motion,  whether hot or
cold.   (b) Centric: Verminous; foreign bodies iu intestines;
suppression of secretions.
     Incubation  from a few hours to many days.   No constant
lesion ; occasionally some disorganization of spinal cord.  Char-
acteristic :  continuity of contractions, gradual development,  re-
tention of  consciousness.
     Prognosis.   Favorable, when very acute, rapid in develop-
ment, and  after the  fifth day.   Unfavorable, traumatic cases and
short incubation.
     Resembles Epilepsy, Rheumatism, Hydrophobia, Poisoning-
     Treatment :  Anesthesia.   Avoidance  of  currents of air,
noise, disturbance of patient, or holding  him.
     Remedies:  Centric.  Bell, Cicut., Nux. V, Gels., Stram.,
 Verat.,  Vir., Peripheral. Aeon.,  Angust., Hyperic
     Aeon., Premonitory stage,  when throat feels contracted.
     Angust., Pains terrific.
     Bell:  Symptoms established at once.
     Cicuta.,  Deadly paleness of face ; cold face, hands and feet;
foam at mouth ; trembling after paroxysms.
     Gels.,  Irritable ; cannot be spoken to.   Heat in  head, full-
ness in  face, and cold feet.
     Hydroc ac, Cyanotic appearance.
     Nux V., The typical drug.
     Stram., The contractions are not so severe, but the  clonic
spasms are violent.
     Veratr vir.,  Much used  in  tropical  countries.   Used  in re-
peated doses until relaxation occurs.

     PARALYSIS :

     Generic  term ;  loss of  motion or sensation from  nervous
insufficiencies.   Paresis: incomplete.    Hemiplegia:  one-sided,
from cerebrial lesion.  Paraplegia:  both sides  from spinal les-
ion.   Cerebral lesions,  mental aberations.  Spinal lesions, mind
unimpaired.   Causes.   Anything that deprives  nerve of  blood.
Structural  lesions  in continuity or at point of origin.  Six con-
ditions. (Raue.  Pathol, p. 524.)
     1.  Anesthesia of sensitive nerves.
     2.  Loss of consciousness :  e. g., sleep, coma.
     3.  Cerebral lesions.
     4.  Spinal ditto.
     5.  Ditto in continuity.
     6.  Anaemia  of  nerves.
     Treatment : Spinal lesions requires long  time, patience.
Faradaism.; Massage.  Stretching the nerve.   (Nussbaum N. A.
J. of Hom.  XXV. p.  232.) 
42          A SYLLABUS OF LECTURES ON  SURGERY.

    Remedies:  Aeon., Acute cases with formication.
    Alum met., Cannot walk in the dark.
    Anac,  Loss or imbecility of mind.
    Am.,  Cerebral or spinal effusions.
    Baryta c, General in old age, with palsy and loss of mem-
ory.
    Bell.,  Spinal hyperaemia.   Paralysis on one  side, spasms on
the other.
    Cocc,  In weak and  nervous people, subject to fainting and
palpitation of the heart.
    Dulc,  Part as cold as ice.
    Ign., After grief or great mental emotions.
    Nux V., In old age after fits  of anger.
    Olean.,  Long preceeded by vertigo.
    Picric ac, Progressive locomotar ataxia; limbs feel as if in
an elastic bandage.
    Plumb., Complete paralysis with atrophy.
    Secale.,  Rapid emaciation, relaxation  of sphincters.
    Stram.,  Paralysis  after spasms.  Paralysis on one  side and
spasms on  the other.

    INJURIES :

    Results depend  on size and importance of  the nerve.
    (i)  Contusions.   May  cause  neuritis, extravsaation, lacera-
tion, (partial or complete).  Secondary atrophy.
     (2)  Compression (or stretching)  may cause atrophy of mus-
cles and  paralysis ; numbness ; pain severe.
    (3)  Laceration, caused by reducing old fractures or disloca-
tions ; trauma generally.    Followed  by neuritis  neuroma, or
cure without complication.
     (4)  Ligature.   Causes great pain, neuritis, tetanus or death.
     (5)  Division. Paralysis, temporary or permanent ;  ultimate
incomplete reunion.  Large nerves may be divided, and function
may be continued by nerve on opposite side.  Incomplete  divis-
ion more disastrous.
     Primary results of nerve  lesions.    (Holmes  IV.,  p.  173.
Clarke).    i. Lowered temperature.   2. Cutaneous eruptions.
3.  Secretory  changes.   4. Periodical swelling  of  joints.   5.
Atrophy and contractions of muscles, with distortion  of joints.
     Remote consequences.  (Holmes  IV., p.  184 Brown-Se-
quard).   1.  Epilepsy.   2. Tetanus.   3. Hysteria.    4.  Cata-
lepsy.   5.  Progressive  Paralysis.   6. Anesthesia.   7. Loss  or
 modification of other special senses.
     Treatment : As in wounds in soft parts.
     Remedies., Am., Hyperic, Led. 
A SYLLABUS  OF LECTURES  ON SURGERY.          43
               XVI.   BLOOD VESSELS.

     Phlebitis :

     Inflammation of veins. Some authors state lining membranes
 of veins rarely inflames; and never suppurates.   (Holmes III., p.
 359).   All tissues inflame, ergo suppurate.
     Veins rarely originate morbid process.   Causes  i. Predis-
 posing.  2. Exciting, (i.) Enfeebled general condition ; increase
 of fibrin; thrombus. (2.) Wounds, contusion, ligatures. Insignifi-
 cant usually.  (1.) Adhesive.  (2.) Diffused.
     (1.) Adhesive   Usually traumatic ; destruction from lymph
 or thrombus ; suppuration.   Hard, knotty swelling at the valves;
 skin dark ; stiffness of limb, not much pain ;  tenderness ; oedema
 early.
     Termination.   Resolution, obliteration, perforation, abscess,
 or pyaemia.
     (2). Diffused:  Phlegmonous  inflammation.    Secondary.
 Pyaemia. In general:  Vein thickens, feels like a cord ; painful
 on pressure.   When deep veins, limb flexed, swollen, pain on ex-
 tension ; hot,  dry skin;  oedema.  Inflammation,  any  degree.
 Oftener superficial veins.
     Treatment: (See  "Pyemia") Aeon., Bell., Merc, Puis.,
 Rhus.

     Varix :

     Irregular enlargement of vein ;  pathological  or  physio-
 logical.  Enlargement  in  all directions,  tortuous.  Indicates
 atony;   in some  cases  hyperaemia.   Causes : Venous  obstruc-
 tions;  distension  and destruction of  valves.   Superficial veins,
 from lack of  support; as choroid, mesentery, spermatic cord, etc.
    Physiological: (Andral. Path.' Soc' Tr.' II,  p. 3.  1831.)
 Simple  dilatation,  tortuous or not.  Pathological: Enlargement;
 thinning of  walls.  Enlargement, with  thickening.   Enlarge-
 ment  at the valves,  without elongation;  minute orifices, with
 transudation.  Beginning at point of  union of deep and super-
 ficial veins; distal pressure  distends superficial branch.  Effect,
 separation  of valves ;  become  either adherent or  disappear.
 Chronic cases, walls and integument  thin.  Blood  in pouches
 generally fluid ;  if coagulates, may cause pyaemia or obliteration.
    Termination:  Extravasation; haematoma; ulceration; alarm-
ing haemorrhage.   Little pain, unless from pressure; little oedema.
    Treatment :  Remove  cause ; bandage ; ligation ; oblitera-
tion ;  galvanism.
    Remedies :  Ham., Aloes, Nux V..  Petr.,  Sulph. 
44
A SYLLABUS  OF LECTURES ON SURGERY.
     Arteritis :

     Inflammation of arteries.  Traumatic.  Idiopathic. Adhesive.
Diffusive.
     (i). Adhesive (limited):  Chronic.  Thickening; lymphatic
effusion ; embolism ; obliteration.  Resorption ; collateral cir-
culation ; gangrene.
     (2).  Diffuse :  Acute.  Erysipeloid ;  wide extent.   Resolu-
tion ; embolism; gangrene.
     Pain ; tenderness on pressure ;  coldness ; pulsation in jerks;
embolism ; pulsations cease slowly or rapidly;  lower tempera-
ture ; sometimes sudden pain ; gangrene.
     Treatment:  For embolus,  friction,  heat.   Aeon.,  Ars.,
Carb. v., Merc,  Bell.

     Fatty Degeneration :

     Rarely diagnosed in life.   Usually, old and feeble  persons.
With aneurism.
     Inner coat, white  streaks, becoming patches.   Middle coat,
cheesy and soft.  Outer coat, becomes thicker, finally degenerat-
ing.
     Results: Gangrene, embolism, etc.
     Treatment :  Constitutional, symptomatic.  Baryta, c.
     Calcification (erroneously, ossification) :
     Obscure  diagnosis:  middle life,  pulse weak  but  not ir-
regular ; arcus-senilis,  8etheromatous  deposits,  enlargement of
prostate.  Coronary arteries most  frequent.  Scmetimes in free
granules; again the whole artery an unyielding  tube.  Phos-
phate  of lime.  Senile  gangrene;  sloughing;  ulceration; or
functional  disturbances.   No  cases of cure, probably from ob-
scure diagnosis.

     Aneurism .■

     A sac or cyst, in  connection and communicating  with an
artery.   1. True: composed  of coats of vessel.   2. False : the
sac communicating with vessel.  Fusiform  or Tubular.   Saccu-
lated.   Dissecting.
     (1)  Fusiform:  Equal dilation of  all coats  from atony;
aorta ;  no necessary elongation.   Cause, local inflammation, etc.
Outer coat, thickened.  Middle, thin.   Inner, studded with de-
posits.   Coagula laminated.
     (2)  Sacculated:  Tumor-like;  most common form,  (a)
All the coats distended,   (b)  Middle through opening in artery.
(c) Inner through opening in others,  (d)  Outer through open-
ing in middle and inner, with  fusion of the torn  edges.
     Causes:  Trauma;  ulceration; secondary from other forms. 
A SYLLABUS  OF LECTURES  ON SURGERY.          45
     Results : Laminated coagula; rupture, accidental  or  spon-
taneous ; forms  false variety;  destruction of  bone; sometimes
spontaneous  cure.
     (3)   Dissecting: Internal coat give way, is dissected up for
some distance, and  (a)  opens  into  vessel lower down; septum
disappearing, and forms fusiform variety,  (b) Does not  open
again into vessel, and forms sacculated variety.
     Prognosis: Unfavorable;  constant menace to  life.
     Diagnosis : Tumor  over an artery, grows  rapidly  ; pulsat-
ing, purring, whistling, or blowing sound.  Painful on  pressure.
Symptoms dependent  on situation,  e. g.,  deep or superficial.
Pulsation dependent on extent of coagulation.  Differentiation
between  tumor and abscess.   Any artery, when traumatic.   Large
vessels of heart, when  idiopathic.
     Aneurism by Anastomosis (English syn. :  cirsoid aneuriem):
Analagous to varix in veins.
     Vessels  thin, pouched  and tortuous, but arterial pulsation
Superficial: Skin red, dark  red ; elastic or doughy  feel;  higher
temperature ;  distance from large trunks.   Large vessels running
in from various directions.  On  head mostly.   Blood  expelled,
returns by expansive beat.   More  of a thrill  than a pulsation.
Sound, blowing,  loud or soft.
     (b)   Aneurismalvarix: Communication between varicosed
vein and cirsoid aneurism.   Characters blended.
     Treatment: Object to cause  coagulation,  (i) Ligature:
Distal.   Proximal.  Double, on healthy coats.  (2) Pressure :
Continuous,  (mechanical or  digital).  Remittent.  Esmarch's
bandage  (Louisville Med. News, III., 12.  IV., 226).

     Malgaigne,  introduced  hair to cause coagula.  Langen-
bach, injection of ergot subcutaneously.  Per-sulph. ferri for like
purpose.   Galvanism (?).
     Remedies : To restore tonicity.
     Lycop., Hughes (Pharmacodynamics), one case cured ;  other
relieved.
     Gallic  ac,  Helmuth  (Clinics,  Stephens,  p.  153).   Case
cured.  Causes  coagulation, but induces neuralgia when  given
for lengthened period.
     Secale.,  Number of  cases reported.

     N^evus.  Syn.. Mother's  or birth-mark.

     Sometimes erectile or vascular tumors.  Local  hypertrophy
of  vascular  tissue.  Congenital mostly.   Oftener  on  face  or
neck; little  elevation.   Capillary.  Venous.  Arterial.
     (1)   Capillary: Increased  size and  number of capillaries.
More or  less circular, flat, bright red, slightly elevated; warmer
than  surrounding parts;  no pulsation.  Smart bleeding  when
wounded. 
46          A SYLLABUS OF LECTURES ON SURGERY.
      (2)  Arterial:  Aneurism by anastomosis :  firm, bright red,
  hot, pulsating.  Dangerous bleeding, when cut.
      (3)  Venous:  Always congenital.  Doughy, compressible,
  dark color.   Sometimes aneurismal varix.  Little increase heat;
  no pulsation.   Gush of blood, suddenly ceasing, when cut.
      Results :  Ulceration ;  coagulation (?) ; sloughing (?);  spon-
  taneous cure, very seldom.
      Treatment :  Strangulation ;  Pressure ;  Cautery;  Ligature
  of main vessel; Galvanism.
      Remedies: Acet. ac,  Ars., Borax., Iod., Lye, Sil., Sep.,
  Sulph.,  Thuja.

      Wounds  of  Blood Vessels.

      1.   Veins: Haemorrhage.   Syncope.   Pressure;  elevation
  of limb.  Styptics.  Ligature, but seldom.  Compression, spar-
  ingly used.   Acupressure.   (Simpson.)  i.  Integument, over
 vessel,   through skin.   2.  Parallel to vessel,  and  through  in
 tegument.  3. Under the vessel, and figure of  eight.
      Dangers:  From bleeding, repeated syncope.   From press-
 ure, devitalization.   From  cautery, secondary bleeding.  From
  ligature, phlebitis.
     2.   Arteries:  Haemorrhage.   Secondary,  from  bruising, or
 sloughing.  (Vide "  Wounds").
     Ligature :  Operation :  Expose sheath, on director through
 each  layer.   Open sheath ;  small opening.
     Special Vessels :  Mark course, ink, or mentally.
     Axilary :  V.inside.  N outside.   Centre, and little to front
 of space.
     Brachial:  V inside.   N outside upper half, inside lower
 half.   Inner edge of  biceps.
      Carotid:   Common.  V outside.   N between V and A.  In-
 ner edge sterno mastoid.
     Carotid: External.  V and N in front.   Same line con-
 tinued to ramus; vessel undemath the  muscle.
     Carotid: Internal.  V and  N  behind.  Same  line  vessel
 deep, behind external branch.
     Dorsalis pedis:  V and N outside.  Inner edge first meta-
 tarsal bone.
     Facial: Tortuous.   V changes frequently.   N crosses.   In
 the neck, midway between  angle of jaw and hyoid  bone.  On
jaw : Incision anterior edge of masseter.
     Femoral:  V inside.  N outside.   Center  of Pouparts liga-
 ment, inner edge of patela.
    Innominate : V and N to right.   Triangle from inner end of
 clavicle,  out two inches.  Ant. border sterno mastoid, two inches
 Vessel found readily,  very deep, on raising this flap. ' 
A SYLLABUS OF LECTURES ON SURGERY.
47
    Iliac:  Common.   Right side,  V inside.  Left side ; more
underneath.  In front: Line  midway from  umbilicus to pubis,
to middle  of Pouparts ligament.  Behind: Preferable.   From
point of last  floating rib to crista ilii.
    Iliac : External or Internal, same line, commencing two
inches lower  on  linea alba.
    Lingual: V underneath.  Crosses greater horn of hyoid.
     Occipital: V and N to left.   Tortuous.  Line expose vessel,
carried two inches,  in  same line, from post' edge of sterno mas-
toid.
    Popliteal:  V outside.   N inside.  Center of space.
    Peroneal:   V  and N both inside.   Inner  border of the
fibula.
    Plantar: External.  N inside.   Inner maleolus, to head of
metatarsal bone  of  the little toe.
    Plantar:  Internal.  N  inside.   One line  from center of
heel,  to tubercle of scaphoid bone.  Another from inner-malleo-
lus, to center of web between  two  first toes.   Shorter  triangle
mark course  of  vessel.
    Radial:  V on  both sides.   N outside  for upper half; under
lower  half.   Inner  edge of radius.
    Sub clavian : V below.  Lower  edge of  clavicle.
    Sup. Thyroid:  V and N cross and recross.  An inch above
and behind thyroid cartilage,  down  and back,  to lower edge of
cartilage.
     Temporal:  Vertical, half inch in front of ear.
     Tibial:  Anterior.  V. both sides, N. outside, outer edge  of
the tibia.
     Tibial:  Posterior.  V. both sides.  N. inside. Center of po-
pliteal space, to internal malleolus.   Under gastrocnemius and
soleus.
     Ulnar:  V.  both sides.   N.  inside.  Base of fourth metatar-
sal bone, to inner condyle of humerus.

       XVII.  MUSCLES  AND TENDONS.

    Rupture of Muscles and Tendons.

     i. Partial: Difficult to  detect.   Pain, particularly on mo-
tion.   Swelling, either effusion or extravasation.  Impaired func-
tion.   2. Complete: Deformity: wide retraction of extremities,
early ; later,  effusion, etc., masks the diagnosis.   Loss of power,
pain,  and shock. Rare, as bone will oftener yield before muscle.
Cause, a sudden, unexpected,  or forcible motion.
    Treatment:   Passive motion ;  position.   Aeon., Am., Ca-
lend. 
 48         A SYLLABUS of lectures on surgery.

     Strain :

     Violent twisting of joint, or part; injury confined to muscles
and   tendons.   (Not  sprain),  oftener  in ginglymoid  joints.
Blood-vessels occasionally ruptured.  Pain, swelling, discoleration,
varies.
     Treatment :  Alternate immersion  in  hot  and cold  water.
Rubber bandage.  Rhus., in most cases; Am., when much ec-
chymosis.

     Contractions and  Talipes.

     (i)  Transitory.  Spasmodic, from  centric  or peripheral irri-
tation ;  becoming (2) Permanent, from local inflammation, with
plastic effusion.   From accident, with misplaced tendonous at-
tachments. Or, congenital malformations.  Important to decide.
Anesthetics. When spasmodic, see "Tetanus," etc., for remedies.

     Talipes :  Muscles of leg and foot.   Single or double.  Ac-
quired or congenital   Permanent or transient.

     (1.) T Equinus:  Common form.   Heel  drawn up.   Mus-
cles  of calf.   (2.) T.  Varus:  Foot  turned in.   Peroneal, or
muscles of calf.   (3.)  T. Valgus : Turned outwards. Same mus-
cles  (?).  (4.)  Calcaneus: Walks  on heel, foot flexed.  Rare form.
Anterior tibial muscles.  Complication of above.
     Cause: Agglutination  of  muscular and  tendonous  fibres.
(Taylor: N. A. Jour, of  Horn. XXIII., p. 69).  Bauer. (Or-
thop1 Surg. p. 36).  Arrest of growth,  extending  foot to compen-
sate.   Affection  of cord,  or meninges,  or both :   particularly
lower dorsal and upper lumbar.   Paraplegia; sometimes talipes
coming on suddenly indicates a cure.   Mechanical injuries, with
muscular shortening.
     Treatment:  Mechanical,  uncongenital   cases,  mostly
paliation.   Maintain  good  position;  tenotomy; galvanism, or
Faradaism ; massage;  acupuncture.   Bauer:  (Ibid).   "  In or-
der to establish success, re-establish proper innervation,  promote
nutrition and development, and give tone to the muscles.
     Remedies: Depending  upon strictly symptomatic indica-
tions.
     Brucea, ant., Talipes varus.  (Hartmann).
     Pinus. syl., Talipes varus;  particularly "weak ankles."
     Contraction  of Tendons: Nat. m., Rhus tox., Ruta.,  Con.
Caust.
Cicatricial contractions:  Nit. ac., Sil. 
A SYLLABUS OF LECTURES  ON SURGERY.
49
                    XVIII.   BONES.
     Periostitis :

     Inflammation of periosteum.   Medicinal; Rheumatic ; Ven-
ereal ;  Traumatic ;  Idiopathic.  Acute and chronic differ little,
except intensity and persistance.
     Symptoms : Swelling  of part usually circumscribed;  hard-
ness (or  puffiness).   With or without redness.   Tenderness on
pressure and motion.  Pain.  Diagnosis:  Rheumatism, more per-
sistent  and pain deeper.    Osteitis, bone not enlarged ; often ac-
companies or precedes osteitis.  One form essential to the repair
of bone, e. g.  Hyperaemia.   Increased vascularity; thickening",
but soft and succulent;  effusion ; separation from  bone.  Perios-
teal functions not purely osteogenetic :  Felon : Necrosis.
     Treatment :  Remedies under osteites, chiefly Aeon.,  Aur.,
Baryta., Bell.,  Calc,  Con., Iod., Merc, Mezer., Nit. ac, Phos.,
Phos. ac, Sabina, Sil, Staph.,'Sulph.
     Osteitis.
     Inflammation of bone.  Acute : Traumatic :  Chronic : Med-
icinal :  Idiopathic.
     (i.) Acute:  Rare.  Pain deep, boring or gnawing;  contin-
uous ;  on motion, pressure, weather changes.  Swelling of part
and  some redness of skin.  Bone swells, but soft.   Heads of long
bones  mostly.  Result: Caries,  suppuration, osteoporosis.
     (2)  Chronic : Same, except elongation, hard swelling of the
bone, slower progress ;  pain less but more constant.
     Result: Caries, exostosis.
     Treatment :  Mostly medicinal.
     Aeon., as usual.
     Ars.,  Burning pain,—like an ulcer,—boring.
     Asafi, Acute pain, changes to other kinds of pain on touch-
ing or  pressure.  Intermittent, like a plug, as from a  shock.
     Aurum.  Burning stitches ;  gnawing; excited by touch.
     Baryta c, In old persons, chronic cases.  Scrofulous.
     Bell., Extreme sensitiveness,  dread of being touched  or
jarred.
     Calc. c, Chronic; scrofulous; hard, bloated abdomen.
     Iodine. Proceeding to suppuration, whi;h is very profuse.
     Merc V.,  Pain as if broken,  and usual symptoms.
     Nitric ac, Mercurial cases.  Pricking pain, etc.
     Phos. ac,  Feeling, as  if bone scraped with a knife.
     Silicea. Threatening  caries, with  thin brownish, unhealthy
suppuration.
     Suppuration of Bone.  Syn.,  Osteopyelitis.
     Cancellous structure ;  Medulary canal. From osteitis or after
amputation.  Deep pain;  swelling and  oedema  of  part; skin
       4 
50          A  SYLLABUS OF .LECTURES ON  SURGERY.

glazed, shining ;  Pulsation, remission, with tenderness on  pres-
sure.  Pus thin, unhealthy.  Result, Caries or  pyaemia.
    Treatment :  Evacuation with trephine or bone drill.
    Remedies : lod., Merc. V, Sil.
    Caries.
    Ulceration,  removal of outer  laminae.   More or  less cir-
cular.  Caries, granular  disintegration.  Commences  in  interior
of bone ;  particularly  heads of long bones or  cancellous  por-
tion.  Increased vascularity, swelling in part affected; abscess;
sinus;  unhealthy pus;  debris.   Not  easily recognized until fis-
tula forms.   Probe reveals  roughness of surface, which  crushes
under pressure.
    Constitutional symptoms light or severe ; extensive deform-
ity from muscular contraction ; even  fracture.
    Results : Death.   Deformity  from irregular  repair.
    Treatment :  Resection : Gouge  and chisel.   Splints, etc.
    Remedies : Angustura : Easily angered from slight cause.
    Aurum: Caries of nasal  bones,  fetid odor;  great  melan-
choly.
    Calc,  C, Scrofulous persons.  Sweating  of  head,  hands,
and feet.   Coldness.
    China., Great weakness and profuse suppuration.
    Fluoric Ac,  Syphilitic caries.
    Merc. V.,  Constant bone pains, particularly at night. Sweat
easily, no relief.
    Ruta G., Pains as if broken  or  sprained ; the skin erysipe-
latous.
    Silicea: First importance.   Fistula; brownish, thin  pus, ex-
coriating and offensive.
    Also: Hep., Nit.  Ac, Lye

    Resection :
    Objects :  Save limbs;  save life;  and preserve   symmetry.
Remove all visibly diseased portions of the bone  ; entire thick-
ness ;  remove completely unimportant bones.
    Question of amputation.   Functions  of the  part.   Extent
of injury  or disease.   Constitutional condition.  Facilities for
treatment.
    Complete resection of joints to be preferred.   Sub-periosteal
operation  to be  preferred.  Restoration  of Bone :  Prof. J. B.
Wood removed lower  jaw.  Three years afterwards patient died.
Perfect new jaw.   Only specimen in  museum.   (Louisville Med.
News, III, p. 8.)
    Instruments:  Scalpel; retractors; raspatory;  chain  saw,
and key-hole saw; lion-jaw forceps ;  bone forceps ;  artery for-
ceps ; needles, etc.  Gouges, chisels, etc.
    Incisions:  Avoid  blood-vessels,  tendons,  nerves,  etc.  and
disfigurement.  Dressing:   Extension;  passive motion, etc'. 
             A SYLLABUS OF LECTURES ON SURGERY.          51

     Treatment of Wound in Soft Parts: Arnica, Staph.. Hyper-
 ic  Of Bone:  Calc. phos.,  Symphyt.
     Special: Sup.Maxillary: Dieffenbach's, Fergusson's, Lis-
 ton's.
     Inf. Maxillary,  half at a time.   Danger of tongue  falling
 back.   Secure glossi muscles for new attachment.
     Clavicle: Formidable;  time no object.  Mott : 4 hours, 40
 ligatures.  Knife  close  to  the  bone;  handle  to  be used more
 than edge.   Linear incision.
     Scapula : Incision  depends on circumstances.   Sub-clavian
 artery compressed, on account of sub-scapular haemorrhage.
     Shoulder:  U incision, or linear.
     Humerus :  Linear incision.
     Elbow : Linear ;  posterior.
     Fore arm : Most  convenient method of incision.
     Wrist:  Complete.   Liston's method.
     Fingers : Rarely called  for.   Linear incision.
     Hips:  T, U, A, incision,  or linear.
     Femur: As humerus.
     Knee:  Transverse;  H or U incision.
     Leg: As fore-arm.
     Ankle:  Two  lateral incisions.
     Oscalcis:  Most convenient incision ; less extensive removal
 better.
     Astragalus: Most convenient incision.
     Toes : Little  used.   As  fingers.
     Necrosis :
     Analogous  to gangrene.  Caries, molecular death.  Nectosis,
 death as a whole.
     Compact portion  :  Symptoms similar to caries.  Probe elicits
 hard, metallic sensation.  Double process both in caries and ne-
 crosis :  i. e., destruction and repair.   Calus deposited with more
 regularity in necrosis.   Clocae: Sequestrum : Exfoliation.
     Causes: " Mal-nutrition "  sequelae to osteitis, etc.  Dimin-
 ished or obstructed blood  supply,  as loss of periosteum.   Ca-
 chexia ;  medicinal poisoning.
     Treatment :  Removal of sequestrum when loose.  Excision.
     Remedies:  Compare "Carles."   Aurum.,  Phos., Silicea.,
 Merc.   In early stages perhaps Bell, Bry., Calc, Lye, etc.
     Treatment largely preventive.
     Hypertrophy :
     General: No increase of elements  singly ;  simple exagger-
ation in weight,  size, density, etc. Hyper-nutrition.   Often physi-
ological.
     Partial: Tumor-like. Resembles, and may be  considered,
exostosis, etc.
     When general, no treatment required.
     Partial, see "Exostosis,"  " Ostco Sarcoma." 
£2
A SYLLABUS  OF LECTURES  ON SURGERY.
     Rachitis :
     Western continent. Poverty. "English Disease." Bones soft;
 cartilaginous :  bend easily, with consequent  great deformity.
 Commences in legs ; cancellous structure enlarged ; serous (red)
 infiltration.  Head  large ;  open fontanels ;  weak ; sickly ;   ca-
 chectic-looking.   Urine  loaded with salts of lime.   Diarrhoea.
 Recovery, with deformity.   Death,  from "marasmus."   Or-
 ganic elements in excess (normal). Inorganic, diminished.  Cause :
 Obscure.  Not hereditary.   " Mal-assimilation."   Bauer (Ortho-
pedic Surgery, p.  213) :   Poor, inadequate  nourishment ;  and
 damp atmosphere, as in laundries.  Excess of lactic acid.  (Vir-
 CHOW.)  Paget (Surg. Pathol.) :  Fatty degeneration.
     Treatment:  Avoid  "physiological."
     Remedies: Cod-liver  Oil in ix at ten.
     Bell., Squinting; dilated pupils ; protruding abdomen.
     Calc. C, Slow dentition;  open fontanels;  sweat  head,
 face, etc.
     Calc. Phos.,  Similar  to  Calc  C. ;  whitish  diarrhoea; ex-
 treme emaciation.
     Natrum Mur.:  Emaciation, particularly of  thighs.   Com-
 pare remedies for diarrhoea, marasmus, etc.
     Osteo-Malacia :  Syn., Mollities Ossium.
     Adult rachitis.   Women,  particularly  after  child-birth.
 Earthy salts in urine.  Fatty deposit to repair loss.  Two forms,
 (Paget's  Surg. Path., 109.)  Senile:  Accidental  or acquired.
     Senile: Form of fatty degeneration, with atrophy.
     Acquired:  Fatty degeneration,  without atrophic  essentials.
 1. Pliable.  2. Friable.   Former like rachitis.   Latter, not  fra-
 gility, but breaks down under pressure into oily mass.
     Symptoms:  As  in rachitis.  Wandering  rheumatic  pains.
 Urinary deposits.   Bones dark colored and oily.
     Treatment :  As rachitis.   Very rare.  No cases of cure on
 record.
     Fragilitas Ossium :
     Old age—either sex.   Loss of organic elements ; increase of
 inorganic.   Associated  calcification of  arteries ;  obliteration of
 arteries.   " Mal-nutrition."
     Symptoms.-  No prodroma  recognized.  Frequent fracture,
 and  general calcification.   (Malgaigne's case.)   Bones dry and
 porous.
     Treatment :  Unsatisfactory.  Palliative : Symphytum.
     Exostosis :
     Original meaning.  Modern, ivory or hard form.   Smooth ;
 round ; hard.  Flat bones, mostly ; particularly frontal.   Excess
 of inorganic elements.  Often  derived from periosteum and soft
 parts.  No assignable cause.  Exciting cause, injury.  Diagnosis,
 easy, when on external surface.   Rarely  on internal. 
            A syllabus of lectures on  surgery.         53

    Treatment:  Excision.
    Remedies: See "Osteosarcoma," as well as "Tumors"
    Osteo-Sarcoma :

    Soft or  cancellous structure.   Ends  of long bones chiefly.
Large;  circumscribed; nodular;  irregular; broad  attachment.
Structure :  Outer laminae  of bone pushed out;  multiplication
or enlargement of  cellular structure.  Vascular.  Grows rapidly.
Recurs.   Causes death  by exhaustion.  Sometimes forms bone
cyst, spina-ventosa.
    Treatment :  Excision.  Amputation.
    Remedies : Arnica: Red, hot, shining swelling of the part.
Bruised, lame sensation.
    Ars., Pain  like the gnawing of rats in the bone, or  screw-
ing a gimlet in.
    Aurum: Painfulness of bone at night; bones  sensitive and
painful to the  touch.  Boring pain in  tumors ;  increased when
touched.
    Hecla lava: Osteo-sarcoma, particularly  of the jaws.  Ar-
rests growth, but not proved curative.
    Mezer.,  Pains severe ; burning pain.   Pressure  aggravates.
Skin of part brown and dry, surrounded by reddish blue.
    Phos., Shining, painless, uninflamed tumor,
    Silicea:  Cases proceeding to suppurate, with  characteristic
pus, etc.
    Other remedies may be needed in the  beginning, or to com-
plete a cure: Bell., Con., Hep., Nit. Ac,  Merc, Sulph.
Disease.	Aye.	Sex.	Structure. Involved.	Elements.		Results.	Morbid Process.
				Organ.	Inorg.		
Osteitis:	All.	All.	Cancellous.	Inc.	Dec.	Suppur-	Inflamma-
Acute,						ation.	tion.
Chronic	do	do	All.	Dec.	Inc.	Exostosis	do Molecular
Caries .._	do	M. ?	Cancellous.	Inc.	Dec.		disintegra-tion.
Necrosis	do	All.	Compact.	Dec.	Inc.	Exfolia-tion.	Gangrene.
Hyper-	do	do	do	N.	N.		Hyper-nutri-
trophy.							tion. Fatty degen-eration.
Rachitis .	Child	do	Cancellous.	Inc.	Dec.	Deform-ity.	Mal-assirniia-tion.
Osteo-	Ad.	Fein.	do	Inc.	Dec.	do	do
Malacia							Senile invol-ution.
Fragilitas	Old.	All.	All.	Dec.	Inc.	Fracture	Mal-assim.
Ossi—_ Exostosis..	All.	do	Compact.	Dec.	Inc.	Necro- "| sis. {	Luxuriation.
Osteo-sarcoma	do	do	Cancellous.	Dec.	Inc.	Death : [	Mal-assimila-
						Sup. j	tion.
 
54
A SYLLABUS  OF LECTURES  ON SURGERY.
     Fractures:

     Literally, a break. Technically, a broken bone.
     Causes: i. Predisposing.   2. Exciting.
     (1).  Morbid process.  Age.   Season.   Sex. •>     ■  t   ^jj^ha,-^
     (2).  Direct injury.   Muscular contraction.ct  ■ aJ-,:li"'  '
     Varieties:   Simple.   Compound.  Comminuted.  Compli-
cated.   Ununited.   Complete, and  Separation of  Epiphysis.
Incomplete.  Transverse  (En  Rave).  Oblique (Bee  de flute).
Longitudinal.   Impacted.   Perforating.  Stellate.   Depressed.

     Semeiology : Deformity, absent in impacted.  Mobility, pre-
ternatural ; absent in impacted, and of flat bones.  Pain.  Crep-
itus, absent in impacted and depressed, or of flat bones generally.
Diagnosis: From contusions ; dislocations.
     Repair: Rarely perfect  symmetry.  Dependent upon de-
gree of displacement and impaction, etc.  Similar to soft parts:
i. e., Immediate union ;  First  intention ; Analagous to granula-
tion.    Provisional  callus.  Sometimes permanent.  Definitive
callus ;  more solid  than bone.  Reparative material comes  from
ends of bones,  soft  parts, etc., plasma. Removal of  provisional
callus.   Effect  of disease on  permanency,   Scorbutis,  Syphilis,
etc.  Overlapping of fragments ; bridge forms.
     General Treatment:  1.  Reduction.  2.* Retention.  Mini-
mum use of splints. Silicate, plaster, starch bandage.  Improvised
dressings.  Pasteboard, etc.   Position of  muscles.  Weight and
pulley ; bran-bags.   3. Complicated  and compound ;  first  heal
other lesions.   4. Ununited; seton, friction,  ivory pegs, resec-
tion.   Ruta., Calc. phos.
     Remedies:  Symphyt.  Ruta.
     Special Fractures :  (1). Head:  Flat bones.   From  torn
muscles :  Trephining.  Am., to raise  fragment.   Direct force.
Contra-coup.   Firm bandage.   Cephalic  trouble, see "Diseases
of Head."
     (2). Face:  Nasal.   Rapidity of union.   Catheter and fin-
gers to  reduce.  Lead  mould, or  pledgets  of lint for reten-
tion.   Malar:  Usually violent direct blow.   Concussion   fre-
quent ;  extensive  injury  to  other bones  and  joints  Difficult
reduction :  sometimes allowed to remain.    Sup. Maxillary :
Concussion, often more of a luxation.   Reduction difficult.   Line
of teeth irregular.  Wiring  of the teeth.   Gutta-percha  splint.
May need incision to reduce.   Inf. Maxillary .- Line of fracture
rarely transverse.   Line of teeth :  pain on motion, upon pressure
inwards  upon  both  rami.  Wiring  of teeth: moulded  splint.
Ramus:  Difficult retention.   Same  treatment.   Zygoma:  Out-
ward displacement usual.   When inwards, reduce by chewing on
stick, through action of temporal.   Whole face driven  in, Mal-
gaigne's case. 
a syllabus  of lectures  on surgery.
55
     (3).   Hyoid: Rare.  Direct violence.  Great pain, dyspnoea,
etc.   Rest and adhesive straps.
     (4)-   Spine : Usually crushed.  Paraplegia or death, accord-
ing to region.  Rest and adhesive straps ; usually fatal.
     (5).   Clavicle : Arm  supported by other hand.   Fox's ap-
paratus, and modifications.  Inner portion sometimes tilted up :
needs a compress in addition.  Figure of eight bandage.
     (6).   Sternum : Compress. Figure of eight  bandage around
the shoulder to  keep well back.   Usually extensive thoracic in-
jury.   Emphysema common.
     (7).   Ribs:  Squeezing force :  great violence required.  Ob-
lique.   Thoracic injury.  Adhesive strips around chest.
     (8).   Scapula:  (a). Acromion, or neck.   Simulate disloca-
tion or fracture of humerus.  On raising head of humerus,  de-
formity remains, or little improved.   Can place hand on opposite
shoulder,   (b).  Coronoid, bring elbow forward ;  fix  by  firm
body-bandage ; sling to forearm,   (c). Body, difficult to detect;
firm body-bmdage.  Fox's dressing, modified by body-bandage,
is useful in all three.
     (9).   Arm : (a).  Condyles : Bandage,   (b). Shaft: Simple
extension,  and  straight splint,  (c). Surgical,   neck: Simulate
dislocation,  but freedom  of  motion differentiates.   Body band-
age ;  sling for forearm ; weight to elbow,  (d).  Head:  Usually
gun-shot.   Firm  bandage, with  axillary pad.   Simple  sling  in
many cases.
     (10).   Forearm:  (a). Head of radius :  Rare. Difficult ex-
tension.   Flex arm ;  double splint,   (b). Shaft : Displacement
dependent on location, whether above or below attachment of
biceps or pronators.   Arms supinated, and straight splint.'  (c).
Colles fracture : Lower extremity  of radius.  Deformity great.
Hands  turned  outward ;  great  pain.  Lower  fragment turned
backward.   Hand flexed,  in  " pistol "  or Bond's splint.  Com-
press,   (d).  Ulna :  Little displacement.  Double splint,   (e).
Olecranon :  Usually detected easily.   Compress and  firm band-
age ;  arm  extended,   (f)  Coronoid : Very rare. Strong flexion
and angular splints,   (g),  Both Bones : Easily detected ; semi-
pronation, flexion  of arm,  angular splints.
     (11).   Carpus:    Usually comminuted.    Semi-pronation :
Hand extended.  Passive  motion.
     (12).  Metacarpus and Phalanges :  As other long bones.
     (13).  Inominate:   Crushing  or  squeezing,  often fatal.
Haematuria, and pelvic complications.   Firm bandage and rest.
     (14).  Femur:   (a) Neck, Inter-capsular;  Extra-capsular.
(1). Predisposing cause, age.  (2). Exciting  cause, fall  on knee or
foot.    Muscular action, upward force.  Capsule partially torn.
Oblique  impaction.    Shortening,  less in  beginning,  or absent.
Crepitus, absent or indistinct.   Careful manipulation  to avoid
dangerous displacement.   Eversion of foot; in rare cases, inver- 
56          a syllabus  of lectures on surgery.
sion.  Trochanter, less prominent.   Motion usually impossible ;
painful.
    Prognosis :   Ligamentous union ;  often.
    Extra  Capsular or  Trochanteric, involving trochanter or
not.   Injury directlv to  trochanter  at times, seldom ; falls  on
foot or knee.  Impaction  the rule.   Trochanter seems driven in.
Eversion of foot usually.   Crepitus, when no impaction.   Mobil-
ity, when no  impaction, otherwise easily moved  by others, but
not by patient.  Shortening, either primary or secondary. Diff.
diagnosis:   (Hamilton, Fractures and Dislocations,  page 379).

         Inter-capsular.                Extra-capsular.
Slight violence.                   Greater violence.
Fall on foot or knee.              Fall on trochanter.
Over fifty years of age.            Often  under fifty years of  age.
More frequent females.            Frequency not  established.
Pain, less and  deeper.             Pain, etc., greater, superficial.
Shortening at  first, less or more.   At first greater.
Later, greater.                    Later, less.
Trochanter  turns on a relatively   Shorter radius.
  longer radius.
Three or four months before res-   From six to eight weeks.
  toration, if at all.
No enlargement of  trochanter   Trochanter enlarged.
  after recovery.
Progressive wasting of limb for   Natural strength and size.
  months after recovery.
Excessive halting.  Hip motion   Slight halt.  Hip motion  nat-
  as from a wooden leg.             ural.

     (b).   Partly in  neck, partly in  trochanter.    Similar symp-
toms.    Long splint;  absolute rest.  (c).  Shaft.  Direct blow.
Middle   third, oblique the  rule ; great obliquity, so that frag-
ments  cannot  support each other.    Shortening, eversion, and
common symptoms.  Recovery with shortening the rule.   Danger
from  perineal bands.    Double  inclined plane.   Long splint.
Weight and pulley, immovable  dressing,   (d).  Condyles.  Rare,
Bandage.  Passive motion.                                  ^
     (15). Patella : Transverse ; vertical,very rare ;  comminutea ;
wide gap.  Special bandage.  Leg extended and elevated.   Lyg-
anentous union.
     (16).  Tibia :   Direct   force.    Little  displacement unless
oblique,  from  direct violence.   Sloughing of skin.   Fracture of
fibula also  the  rule.     Weight and  pulley.   Fracture box or
double-inclined  plane.
     (17). Fibula:  Direct injury or twist of foot.  Displacement
inwards of lower fragment.   Turns foot same as in Talipes varus.
Straight  splint. 
            A  SYLLABUS OF LECTURES ON  SURGERY.          57

     (18). Both bones of leg. Direct force, oftener compound. As
in tibia alone.
     (19). Tarsus (a) Astragalus :    Usually with dislocation of
ankle.   Crepitus only sympt.  Constant with displacement;  heel
shortened or flattened.    Easy position  Combat  inflammation ;
passive motion,  (b). Calcaneum.  Direct force.   Easy diagno-
sis.   Flex  leg.   Slipper, bandage on thigh, and connection to
heel of slipper.  Foot extended.  (c).  Other bones as of astra-
galus.
     (20). Metatarsal send Phalanges :  Vide bones of  hand.

                     XIX.   JOINTS.

     Synovitis:   Inflammation  of synovia.    Traumatic,  stiu-
mous,  medicinal, idiopathic.    Primary :   All symptoms of in-
flammation of joint.   Secondary:  Swelling, fluctuation.  Later,
swelling becomes boggy, doughy.   Hydrarthrosis.   Membrane
thicker, rough, crepitus, pain of varying  intensity.  Results, sup-
puration  with  fistulous abscess;  anchylosis.    Knee oftener
affected.
     Treatment :   Elastic bandaging ;  aspiration ; free evacua-
tion of pus ;  rest.
     Remedies :   Bell.   Bubbling as from  drops of water,  with
cutting and drawing pain.
     Calc c:   Chronic ; scrofulous.  Debilitated persons.
     Caust:   Stiffness,  bruised,  tearing,  sticking, numbness.
Worse in evening.
     Ledum .   Much effusion ;  coldness.
     Merc :   Aching  in  bones ;  syphilitic cases ;  much sweat
with no relief.
     Lycop:  Feeling of constriction, with  slight swelling.
     Kali c:  Aching; dread of open air;  takes cold  easily.
     Rhus  t.:   Rigidity  of joints;   sticking pains;  typhoid
tendency.
     Sepia: Jerking, sticking ; where tendons have been violently
strained.
   -.Sil:   Chronic cases with destructive processes.
  W
     Arthritis:  Syn.:   Gout.   Podagra;   feet.    Gonagra;
knee*.   'Chifagra;  hand.    Periodical articular inflammation.
Masculine ;   over thirty years of age.    Hereditary disposition ;
excess of nitrogenous food, and indolent habits.
     (1). Acute:   Pain, excessive ;   worse on least jar and  at
night.  Swelling uniform, no fluctuation (vs. Synovitis); doughy,
boggy.   Sometimes abscess.   Spontaneous  luxation.
     (2). Cnronic:   Same symptoms frequently occurring.   De-
posit in  joints  urate of soda  and  potash.   Nodosities (tophi). 
58          A SYLLABUS OF LECTURES ON SURGERY.

Swelling  remains after attacks, each time  larger.   Sometimes
abscess, or anchylosis.
     (3).   Ambulans:    Metastatic.   To stomach, heart, brain.
Often fatal.  History essential to diagnosis.
     (4).   Chronic rheumatic.   Not gout;   scrofulous.    Worst
features of both diseases.
     (5).   Idiopathic.    Inflammation  of joint.    (See  " syno-
vitis").
     Treatment :  Absolute rest;  change of diet.   Exercise ;
early medication.
     Remedies:   For most part as in rheumatism.   Acute  cases :
Aeon.,  Bry.,   Rhus.,  Colch.    Chronic:    Caust., Calc, Lye,
Sulph.,  Thuja., Ant. c, Caust.
     Anchylosis :   Immobility of joint.    Partial, or ligamen-
tous.  Complete, or osseous.
     Causes :   Long-continued inflammation ;  fractures ;  disloca-
tions ; gout.     Mercurialization ;  Syphilis;  or any destructive
process.    False anchylosis, muscular  contractions, ligamentous
attachments.    Pain on  motion  in  incomplete  form ;  no pain
when complete.  Congenital, or congenital absence of joints.
     Treatment :  Mostly mechanical.   Not a disease.   Tenot-
omy ;  brismentforce;  exsection ;   to alter  faulty position, or
establish new joint.  Caution in old cases, from shortened  nerves
and  blood  vessels.  Caution in  young people, from separation of
epiphyses.
     Coxalgia :  Syn.   Morbus coxarius ;  coxarthrocace ;  hip
disease.  Children and young persons.  Scrofulous.   Sometimes
due to trauma with no prodroma.  Unilateral ; rarely cured spon-
taneously.  Three stages.
     First  Stage.   Limps;  easily tired ;  pain slight in  knee;
sleep disturbed ;  at times jerking  in knee or affected limb ;  4io
objective symptoms. Pain next  extends upwards and downwards,
tendo Achillis, being very painful.    Apart from struma general
health good.    Pressure on  trochanter, or striking sole of foot
with leg extended, will cause pain in hip.
     Second Stage.  Pain more  local;  some  little in the  knee;
more continuous and  severe;  nates flatten ;  crural  fold  disap-
pears ; muscles atrophy; leg longer; foot everted or invertjjd.
Health impaired ;  sleepless ; night fever; night  sweats ;  emaci-
ation ; fretful  and peevish.                               *
     Third Stage.   Suppuration in joint; joint  destroyed; foot
turned in  or  out; leg lengthened  or shortened.   Increase  of
pain ;  cannot  bear  any motion ;  deep  throbbing ; swelling of
hip ; oedema of parts ; veins turgid and  enlarged ; rigors ; high
fever;  copious sweat;  discharge of pus.
     Results:  Anchylosis;  continuation  of  morbid   process
elsewhere; death. 
            A  SYLLABUS OF LECTURES ON  SURGERY.          59

     Hysterical: Sex;  age ; no objective symptoms ; no pain on
pressure on trochanters, etc.; pain never wakes from sleep, butmay
keep awake.
     Treatment :   ist  Stage.  Rest,  even after apparent cure.
2d Stage.  Aspiration or puncturing of joint sometimes  gives re-
lief.
     Remedies :  Bell, or Merc, in first stages.
     Coloc, Sharp  cutting pains ; as if held in iron hand.
     Calc. c, Scrofulous subjects;  urine loaded with urates.
     Rhus,  t.,  Rheumatic symptoms; tension  and stiffness  of
muscles.  Also Sulph., Lye, Stram., and others.
     Enlarged  Burs^e.   Oftener   on  the foot.   Inflamed;
hypersecretion.  Soft, compressible.   Organized and hard later.
Painful, particularly after  irritation.
     Treatment :   Remove  cause.   Extirpation  when large.
Ars., Ant.  c, Apis,, Puis., Sil., Sulph.
     Ganglions.  Simple, Compound.  Syn.   Weeping  Sinew.
     (i) Simple.   Cysts in connection with tendons.   Mostly in
region  of wrist.   Smooth, globular, elastic, movable,  painless.
Contents clear  serum.   Size from pea to cherry.
     (2) Compound.   Distension of  sheath of tendons  irregular
in form, of great size.
     Cause : Strains, pressure, or rubbing.
     Treatment :   Rupture.   Compression.  Section.  Calc  c,
Sil.,  Apis., Ruta.,  Rhus.
     False  Cartilages.  May  be fragment of  articular cartil-
ages  or new formations.   Varying size, shape  and  consistency.
Float about; attached by  a long pedicle.   Often in knee.
     Treatment :  Favor attachment.  Excision.
     Wounds  of  Joints,  Serious  in proportion to  size and
proximity  to trunk.   Anchylosis; suppuration;  destruction  of
joint.   Incised   wounds least  dangerous;   punctured  greater.
When lacerated, with great injury to joint, amputation may  be
called for.
     Treat as wounds of other soft parts.
     Sprain. Actual sub-luxation.   Pain  on motion  excessive.
Swelling considerable, more or less discolored.   Heat not always
great.   Possible rupture  of  blood-vessels.  Ginglymoid joints
oftener  affected.
     Treatment :  Rest;  cool applications.  Arnica, Favor re-
sorption of  blood.  Rhus., Ruta (vide "Strains").
     Dislocations.  Syn.: Luxation.   Displacement of two  or
more bones entering into  the composition of a joint.
     Simple.  Compound. Complicated.   Complete.   Partial.
Recent.  Ancient.   Primary.  Secondary.
     Causes Predisposing:  Age,  oftener in middle  life.  Feeble
constitutions; lax  fibre ; paralysis. 
6o
A SYLLABUS  OF LECTURES ON SURGERY.
    Exciting: External violence,  direct or indirect.  Muscular
action, spontaneous or spasmodic.   Ball-and-socket joints most
frequent.
    Symptoms :  Rigidity;  no crepitus ; when reduced remains
in place  without support  as  a rule; pain;  swelling; discolora-
tion.   Limb oftener shortened, sometimes lengthened.  Natural
axis with socket  always changed.   Injury to  joint of varying de-
grees ; ligament  stretched  or  torn.  When unreduced, old socket
fills up, new one often formed.  All parts  more  or less atrophi-
ed.  Ancient cases artery sometimes torn in reduction.   Joint
never completely restored.
    Treatment:  Reduction  early;  manipulation  preferred.
Anesthesia.  Extension;  manual force;  pulleys;  clove-hitch;
Spanish windlass.  Retention  as in fractures.   Am., Ruta., Rhus.
    Hamilton (Fractures, p. 499): Warning against  attempt-
ing treatment without complete knowledge.
    Special Dislocations.
    1.  Lower  Jaw:  Single, unilateral.  Double, bilateral.
    (a) Double:  Women  oftener.   Direct  muscular action;
mouth open;  immobility;  salivation; pain; depression ante-
rior to auditory canal; inarticulate speaking.   Unreduced, grad-
ual restoration of form, speech, etc.,  but jaw advanced.
    Reduction:  1. Wood between molars and upward pressure.
2. Thumb  on molars  pressing  down,  fingers pressing up.   3.
Gradual forcible  pressure of chin upwards (Ravaton).  4. Fur-
ther  depress  chin, then push  backwards  (Hippocrates).   5.
Reduce one side at a time.  Anesthetics in every method.
    Double-headed bandage;  passive  motion  after  the first
week.
    (b) Single:   Same  symptoms.   Chin directed  to  opposite
side (Fracture of  condyle, chin  to  injured  side).   Same treat-
ment.
    2.  Spine :  Rare without fracture.  Falls on feet  or  head ;
twisted spine; spontaneous, from  disease.   Fixedness  (fracture
mobility).  Not  as fatal as fracture, but needs prompt reduction.
Paralysis, temporary or permanent.
    3.  Ribs :   Rare.   From vertebra:,  reduced by  pressure.
From cartilages,  pressure;  splint over three spaces for retention.
    4.  Clavicle : (a) Forward from sternum :  Force on point
of the shoulder ; sudden muscular effort.  Plainly seen ■  shoul-
der falls a little back ;  head inclined to the  same side ;  embar-
assed movement  of arm.   Has been  taken for a tumor;  tumor
taken  for luxation.  Hitherto,  treatment a failure; reduction
easy,  retention seems impossible.   Draw the  shoulders back.
     (b)  Upwards on sternum : Same difficulties ;  very rare.
     (c)  Backwards:  Crushing force or direct injury.   Pressure
on trachea, causes dyspnoea.  Easy reduction, easier retention. 
            A SYLLABUS OF LECTURES  ON SURGERY.          61

     (d)  Acromial end upwards:  Force on  point  of shoulder.
Shoulder depressed ; cannot raise the  arm at right angle.  Re-
duction ; pressure, pulling shoulders back, pad in the  axilla, arm
for a lever.  Impossible (?) retention.
     (e) Acromial end downward: Rare.  Force on top of clav-
icle.  Reduction, draw shoulders back  and outwards.  Retention
easier.
     4.  Shoulder :  (a)  Downwards  (axillary) .• Force direct
on upper end and outer surface; falls on  the  hand,  or elbow.
Subacromial depression ;  elbow out from the body ; inability to
put  hand on the  opposite  shoulder.  Perfect  restoration only
after months.  Reduction: i. Elevate the arm, and  pull in the
same axis.   2. Draw the arm out,  at right angles,  or beyond;
traction, with pressure down on the top of scapula.   3.  Heel in
in the axilla, and traction.   4.  Knee in  the axilla and pressure
on scapula.  5.  Pulleys.
     (b) Fortvard (sub clavicular:  sub-coracoid) :  As above, in
all essentials.
     (c) Backwards (subspinous) :  Same  as above; arm carrried
to  the  front,  and  head of bone felt  under spine of scapula.
Treatment essentially  the same.
     6.  Elbow  : Head of radius :  (a) Forwards :  Fall  on pos-
terior face  of  radial  head ; on  hand, arm extended and pro-
nated ;  extreme pronation.   Head  felt  in new position;  arm
inclines outward ; pronoted;  flexed.  Old cases, unnatural ex-
tension.  Reduction often impossible.  Extension  in direction
of flexion, and pressing head of bone  with thumbs.  Never ex-
tend the arms for some weeks (Retention usually fails), nor forci-
bly  extend  for  months.  Right angled  splint, compresses and
roller.
     (b) Backwards: Blow  or fall on front of radius ;  violent
supination ;  twisting in machinery.   Head felt back of condyle ;
arm flexed and pronated;  supination impossible.  Arm  inclined
outwards;  Extension,  forcible supination,  and  pressure with
fingers.
     (c)  Ulna:  (a) Backwards:  Falls on  the hand; blow on
upper part of arm.   Olecranon  prominent:  Flexion;  painful
or  impossible  extension.  Pressure on ulnar nerve gives much
pain.  Extension; pressure on olecranon ;  forcible flexion.
     (d) Both bones: Backwards: Fall on  the hand ;  blow on
the arm; forced flexion.  Coronoid  in olecranon fossa;  slightly
flexed ;  pronation;  great swelling;   flexion painful, gives in-
creased  prominence to the olecranon.  Reduce by  knee in the
elbow.  Guarded diagnosis.
     (e)  Outwards:   (Radial  side).  Often  partial.   Blow on
the inner side of forearm ; Secondary  upon  backward luxation.
Forearm flexed; pronated; great and characteristic  deformity. 
62          A SYLLABUS OF  LECTURES ON SURGERY.
  Reduction easy;  knee  in the  elbow,  extension,  supination,
  pressure.
      (f)  Inwards :  (Ulnar side).  Much  more  rare.  Fall on
  hand or forearm; blow  on the  outside  upper,  or inside lower
  part of  forearm ;  twisting.   Radius occupies ulnar trochlear.
  Ulnar nerve often contused.  Flexion ;  forcibly pronated.  Diffi-
  cult reduction; modifications of the above.
      (g)  Forwards:  Supposed  impossible  without fracture.
  Great violence;  forcible  flexion  or extension; twisted.   Right
  angled or  acute; strong supination.   Reduced  by flexion  and
  extension.
      7.   Wrist: Very rare; most autopsies show  fracture.
      (a) Backward:  Fall  on palm of the hand.  Abrupt rising of
 ends of the bones, greater than in  fracture.  Reduce  by exten-
 sion in straight line,  with rocking motion.
      (b) Forwards:  Same considerations ; more rare.
      (c)  Ulna.   Backwards : From extreme forcible pronation.
 Hand more or less pronated ;  head  of bone  felt  and  seen ;  fin-
 gers, hand  and  arm slightly  flexed.  Reduction easy;  strong
 supination and pushing bone in place.
     (d)  Ulna,  forwards.  Rare.   Cause,  extreme supination.
 Flexing hand, and pushing bone in place.
     (e)  Carpal bones (among  themselves).  Very rare;  gener-
 ally backwards.   Reduction easy (?).  Retention easy.  Danger
 of severe inflammation and  anchylosis.
     8.   Hand,   (a)   Metacarpals (from  Carpals.)  Thumb of-
 tener.  Symptoms usually clear.  Reduction by extension and
 pressure.
     (b) Phalanges (backwards  or forwards).  Easy diagnosis ;
 usually  at an angle.    Flexion, extension  and flexion  for  re-
 duction.  Sometimes  tenotomy required.   Extension  made by
 clove-hitch, Levis' instrument,  or  Indian puzzle.
     (c) Forward.  As above,  reversed  manipulations;  i.  e.
 forced flexion, extension, and then straightening the finger.
     9. Thigh. Four  directions, mainly.   Dorsum  ilii; Ishiatic :
Foramen thryroidean : Pubic.

     (a) Dorsum Ilii : Force compelling,  or while in, extreme
abduction, with rotation ;  bone  driven up and back.   Remlar
incomplete rupture of Y ligament.   Irregular, complete rupture
of ditto.                                               i
     Shortened;  adduction; rotation;  slightly flexed;  great toe
on  instep of sound foot; knee touches opposite thigh;  varies in
degree of deformity.   Body bent forward ; hip flatten ; trochan-
ter  depressed ; head of femur felt and seen.  Examine'standing
then in other positions.                                     °' 
A SYLLABUS  OF LECTURES  ON SURGERY.          6t,
          FRACTURE.
Crepitus.
Mobility.
Eversion of foot.
         dislocation.
No crepitus.
Immobility.
Inversion of foot (?).
Shoitened little, or none at all.    More shortening
Able to walk some distance.
Advanced life.
Cannot bear weight on foot.
Middle life.
    Prognosis, good in recent cases; little crippling in ancient
ones.
    Treatment :  Obstacles to reduction :  Muscular action ; re-
mains of capsular ligament; Y ligament; obturator internus ten-
don,  i. Manipulation.   2. Extension^   3. Combination of the
two.
    (1) Manipulation :  Flexion, adduction, rotation  outwards,
extension.  Knee  carried in direction of least  resistance.   No
anesthesia as a rule,  Fractures of neck  may  occur in ancient
cases or old people.
    (2) Extension:  Pulleys ;  tourniquet (Bloxams) ;  adjuster
(Jarvis); Spanish-windlass.   Foot in groin.  Fracture of shaft
may occur.   Counter extension.
    After reduction, knees on pillow  and tied together ; lying
on back ; hip gently rotated outwards.
    (b) Ischiatic : Primary : Secondary Upon iliac ; or become
iliac.  Cause, violence wheu leg  much advanced.  Really sciatic ;
leg extended, slips up in sciatic notch,  is  checked by  tendon of
obturator int.    Shortening:  flexion;  abduction:   rotation in-
wards :  thigh may be at right angles,  and across the body;  or
slightly  flexed.   Head of  bone felt.  Flexion moderate, difficult
detection.  (Syme.)   Arching of lumbar spine,  particularly when
leg extended.
    Treatment :  Manipulation ;  may transfer  to  thyroidean.
Same as dorsal, disengaging head from tendon.  Extension more
at right angles.
    (c) Thyroidean.   Cause: Violence when thigh is abducted.
Abducted ; lengthened;  body bent  forward :  flexed :  toes point
forward, eversion  or inversion; hip flattened:  long  abductors
felt tense;  trochanter depressed  : head of bone felt.   Lengthen-
ing, vs fracture.   Ileo-femoral (Y) ligament, chief obstacle.
    Treatment :  Manipulation, extension in easiest direction of
motion.  Lift head of bone by towel and  assistant.   Extension,
lateral (Cooper).
    (d)  Pubic.   Cause, violence, thrown backward.  Shortened ;
abducted;  flexed; rotated outwards:  trochanter lost; head  of
bone  felt.
    Treatment :  Reduction easy.   Rotate upwards, pressure of 
64          A SYLLABUS  OF LECTURES ON SURGERY.
hand on head of bone, or, adduct forcibly, rotate outwards, flex-
ion, and extension.   Extension slightly downwards.
    10. Patella,   (a)  Outwards:  Muscular action ;  twisting
the leg ; blows.  Knee broader ; leg bent; felt easy ; great pain.
Reduction easy,  straighten  leg to relax tendon.    Easy reproduc-
tion.
    (b) Inwards:  Same symptoms  and  treatment.    Less fre-
quent.
    n.  Knee.  Exceedingly  rare.  Severe wrenching  or ex-
treme violence.   Complete, or incomplete; rather oftener.
    (a) Backwards:  Felt in popliteal space; much  pain; de-
pression in front; may be  shortening;  extreme extension, or an-
terior flexion ; varies greatly.
    Treatment: Recent  or incomplete, manipulation in direc-
tion of least resistance ; or forced flexion, pressure,  and  exten-
sion.  When complete may need  extension also.
    (b) Forwards : Reverse of. former, same treatment.  Popli-
teal artery may  be torn or  compressed.
    (c) Outwards :  Symptoms obvious.   Same  principles.
    (d) Inwards : The same.
    (e) Sub-luxation: (Semi-lunar cartilages).   Sudden, great
pain; loss of power;  immobility.   (Transient;  one attack pre-
disposing to others).
    12.  Ankle.  Four directions,  often fracture also. Hamil-
ton ; tibial  dislocations.   Boyer, of the foot.   Terms reversed.
Adopt the latter.
    (a) Outwards :  Fall on foot inclined outwards.  Astragalus
tilted up.  Foot abducted, sole outward.  Pain very great.   Easy
detection.  Reduction easy, forcible  abduction, or flex leg, exten-
sion and pressure.
    (b) Inwards :  Same; reversed.
    (c) Backwards: Force with violent extension.  Malleolus
broken.  Foot shorter, heel  longer; toes down,  heels up.  Ex-
tensor tendons well defined.   Flex leg, extension  with  pressure :
when nearly reduced, forcibly flex foot.  Sometimes difficult re-
tention.
    (d) Forwards: Rare.   Symptoms marked.  Foot longer;
heel shorter.  Treatment,  same  principles.
    13.  Tarsal:  Vide  "Carpal."
    14.  Metatarsal: Vide " Metacarpal."
    15.  Phalangyal.: Vide "Fingers."

                      XX.  NAILS.

    Malformation.   i.  Arrest of development;  little  to  be
done.   2. Irregular repair;  promise of at least  partial success.
Alterations in any  form:  elongation, shortening,  thickening, etc.
All cases considered either hypertrophy or atrophy. 
A syllabus  of lectures  on surgery.
65
     (a)  Hypertrophy:   Nail  thickens;  laminae  heaped  up;
 shorter;  sometimes larger,  talon-like ;  roughened;  loses shining
 appearance ; splits longitudinally.  All the nails, or of one ex-
 tremity alone.
     Treatment : Unsatisfactory when  matrix is injured.  Graph..
 Calc, Alum., Sil., Sulph.
     (b) Atrophy:  Oftener toes.   Rougher,  dull appearance,
 thick, short, laminated; on  trimming  them, they split  off in
 laminae.   Ultimately disappear,  without inflammation  during
 whole progress of case.  Specific taint, or senile involution.
     Treatment :  Entirely  medicinal;  rarely  presented  for
 treatment;  occurring as a symptom.
     Nails break, peel off, split readily : Alum ,  Curare.,  Merc,
 Sep., Sil, Squil., Sulph.   Fall off, without inflammation.  Ant. c,
 Ars., Hell., Merc, Secale, Sep., Squill., Thuja.  (Lilienthal.
 Skin Dis., p. 164).
     Onychia.   Inflammation of matrix, and parts in connection
 with nails.  On hands mostly.
     (a)  Simple.   Usually traumatic; little moment.
     (b) Malignant.  Syphilitic, strumous, etc.   Children under
 ten ; rare disease.  Inflammation in corner ; nail rolls up, shows
 foul ulcers ; pus offensive;  end of fingers bulbous,  loss of bone;
 imperfect repair ; recurrance.   Rarely cured spontaneously.
     Treatment: Traumatic: Am., Fluor, ac.  Other cases, de-
 pending upon,  dyscrasia : Hep., Lach., Sil., Sulph.. Calc, Bufo.
     In-growing Toe nails.
     Cause.   Tuberculosis;  cutting nail square;  ill-fitting  shoes.
 Ulceration, with fungous granulations.  Nail may pierce toe com-
 pletely.   Resembles,  in fact, onychia.
     Treatment : Mechanical.  Remove mechanical cause : trim
 nail; remove thin  shaving  from root to tip, once a day; draw
 parts away with straps ;  pellets of  lint in ulcers; removal of nail;
per-sulferri., to granulations.   Sil., Nit. ac, Merc.
     General  Therapeutics.
     Alum.  Discharges  copiously, gelatinous;  tenacious,  flesh-
 colored.
     Antim. c,  Skin of part hard, horny, callous.
     Arn., Onychia from injuries.
     Bufo.,  Phlegmonous inflammations;  lymphatics affected;
 pain runs in streaks up the arms.
     Fluoric ac,  Empirically used.
     Graph., Thickening, little elongation.
     Hep. s., Syphilitic or murcurial cases.
     Lach.,  Livid appearance, with  threatened  destruction of
finger.
     Merc,  Syphilitic cases.
     Sil.,  Smells offensively;  thin  pus ;  extends  to bones.
             5 
66
A SYLLABUS  OF LECTURES  ON SURGERY.
              XXI.   AMPUTATIONS.

    Indications:  Extensive injury;  large  tumor of bone ;  indi-
vidual  judgment to decide.  Rarely for disease ; if so, above a
joint.
     Objects : Save as much of part  as  possible; fitting artificial
limb;  nourishment of stump.   Point of election.
    Instruments:  Knives;  amputating,  scalpels, interosseous.
Cloth retractor.  Saw, finger or butchers.  Bone-forceps.  Artery-
forceps or tenaculum.
    Assistants:   Four.   Tourniquet:  Esmarch's bandage, or
compression.
    Methods :  Transfixion;  without  inward;  double, single,
or  skin  flaps;   oblique  (fanciful);   circular;   Teales,   rec-
tangular flaps, lateral incisions, length of  half the circumference
of part.
    Dressing:  Sutures;  straps;  recurrent  bandage;  maltese
cross.
    Treatment :  Position,  easy, and to relax muscles.  Temper-
ature, even.  Remedies :  Aeon., Staph., Bell., Am.
    Special Amputations :
    Fingers; Rarely leave  first  phalanx alone.  Second  and
third fingers may be  removed  at middle of metatarsus.   Thumb
to be kept, if possible.
    Hand: Thumb to be kept, if possible.
     Wrist: Point of election, lower third of arm.
    Forearm : Skin  flaps, to avoid muscular tension.
    Elbow : Single flap.
     A?m: Double flap.
    Shoulder: Assistant to follow and secure artery,   (i)  Lis-
franc  : External  flap (of*  deltoid) by  transfixion; knife  over
caput,  followed by assistant, for inner  flap.   (2) Larrey :  Lat-
eral flaps.
     Toes: As fingers.
    Foot:  (t) Hey  : Metatarsus,  from tarsus.   (2)  Chopart :
Leaves astragalus  and calcis.   (3)  Pirogoff:  Remove  ends of
leg bones, articular face -of calcis ; turn latter up against former.
(4) Syme : Close above the  malleoli.   Preferable to others.
    Leg: Teale's preferable.
    Knee:  Carden : Through condyles of femur.
     Thigh : Point of election, lower  third.   Flaps, antero-pos-
terior, lateral, or of  skin.  Circular.
     Hip : As in  shoulder.  Assistant to follow knife  for artery.
Abdominal aorta, or iliac, to be compressed. 
:p.A-:R/r third.
REGIONAL   DISEASES.
                    XXII.  HEAD.

    Compression of The  Brain :

    Suspension, or modification of function,  from pressure on
the brain.  Causes :  Depressed fracture, effusion of blood, serum,
or  pus;  tumors;  foreign  bodies.  Prognosis: Dependent  upon
cause; traumatic most favorable.   Cold face, clammy perspira-
tion,  "pumping" of larynx, stertor, frothing at mouth ; pupils
dilated or contracted, but immovable.
    Treatment : Evacuation of fluids, when detected. Trephine
for depression ; careful over sinuses.  Instruments: Razor; scal-
pel; trephine; guide; brush; HEY'ssaw; raspatory;  elevator.
Remedies: Am., Restores  tonicity of membranes, and elevates
loose depressions.  Other remedies, see "Shock."
    Concussion  of  the Brain:  "Stunning."
    Causes: Fall  ; blow ;  jar ; molecular derangement.  From
slight laceration to complete  fluidificalion.
    Prognosis: Good in mild cases.  With  much  disorganiza-
tion, more grave.  May produce compression from haemorrhage.
    Diagnosis :  Much resembles  shock and thrombosis.  Two
groups :   i. Primary. Coma -f- or —.   Answers,  when spoken
to loudly, but relapses again.  Pulse weak ; relaxed sphincters;
muscles relaxed ;  cold surface ;  dilated and immovable pupils.
    2.  Secondary. Reaction. Warm ;  conscious; fever; delir-
ium ;  vomiting ; running into encephalitis.
    Treatment:  Mostly medicinal. Am., Opi.,Veratr., Camph.
Vide " General Indications " and  "Shock."
    Irritation of the Brain :
    Condition short of inflammation.
    Causes : Laceration  of the  brain; consequent on concus-
sion.                       .
    Pre^nosis : Guarded, particularly with laceration. 
68          A SYLLABUS OF LECTURES ON  SURGERY.

    Symptoms : Semi-conscious.  Answers questions, but peevish,
irritable, unobservant.  Curling and twisting about.  Frowning.
Pain evident on fixing attention.   At times convulsed ; at others
delirious, shouting, etc.   Pulse slow, feeble.  Skin cool.  Face
pale.   No signs of inflammation.
    Treatment : Medicinal  solely.
    Remedies:  Compare "Shock."  Chiefly Apis., Am.,Lach.,
Con., Stram.
    Encephalitis (Traumatica) :

    Inflammation of the brain.
     Causes :  Any of the preceding conditions.
    Prognosis : Guarded.
    Diagnosis : Difficult differentiation ;  chiefly signs of inflam-
mation pronounced.
    Symptoms : Coma or delirium.  Face and eyes red and full.
Beating and throbbing in temples and carotids. Holds head with
the hand.  Pain severe, but not sharp and acute.
    Treatment : Medicinal  solely.
    Remedies: Aeon., Bell., Glon., Hyos., Stram.

    Differential Diagnosis :
Compression.	Concussion.	Irritation.	Encephalitis.
Pupils immova-ble, either dilated or contracted. Coma and stertor.	Dilated and im-movable. Coma. Answers when spoken to loudly.	Twists and curls about. Answers questions peevishly if at all. No inflam-mation.	Evident inflam-mation. Holds the head with hands.
    General Indications :
    Aeon., Ordinary primary febrile symptoms.
    Apis., Single, sharp,  shrill  scream,  sleeping  or waking.
Bores the  head in the pillow.
    Arn., Will not answer questions; giddiness  when  moving
or rising.
    Bell,  Will not talk, or fast  talking; vessels in  head and
neck enlarged.  Violent headache, fiery eyes, and red face; bor-
ing the head in pillow.   Holds the head in the hands.
     Camph., Deadly cold,  with hot breath.
     Glon., Fullness in the  head, as if  the brain were expanding,
as if it were moving in waves.  Pulsating pain.
    Hyos , No wants except thirst; pulsations  so  violent that
the head shakes ;  the head is shaken, or drawn to one  side, with
loss of consciousness, and  red,  sparkling eyes.  Contortion of
the eyes ;  distorted, bluish face, and mouth wide open.
     Opium. Complete  loss of sense and  motion, with relaxed 
            A  SYLLABUS OF LECTURES ON  SURGERY.         69

muscles; eyes half open, and turned up ; face bloated, and dark
red ; stertorous  inspiration.
    Stram., Loquacious delirium ;  staring, glistening eyes; anx-
iety and fear, expressed in the countenance ; distortion of mouth.
    Wounds  of Brain :
    Not necessarily fatal.  Oftener from  fracture,  concussion,
gun-shot injuries. Wounds of pons or medulla most fatal; recov-
ery in any case rarely complete.  Extract the missile, if it can
readily be  done ;  give free  exit to  discharges.  Symptoms of
compression indicate effusion.   Keep down inflammation, and
treat external wounds on general principles; treat symptoms as
they arise.
    Heknia Cerebri :
    Protrusion of brain  substance  from opening in the skull.
Oftener traumatic ;  rare cases congenital.
    Prognosis : Good when small, and general health fair.  Fun-
gus of varying size, pulsating syncronously  with arteries, covered
by meninges ; soon disorganizes and  fluidifies.  Primarily, little
cerebral irritation ;  later,  coma, strabismus, death.
    Treatment:  Shave off; compress, close wound.
    Fungous of the Dura  Mater :
    Tumor from dura mater.
     Cause: Unknown ; excited by  long-lasting  meningitis or
injury.
    Diagnosis:  Difficult; mixed  with compression, irritation,
hernia-cerebri, etc.   After perforation, soft mass ; can be pushed
back into the cranium, causing faintness and nausea.   Diplopia,
syncope, deafness, etc.
    Treatment : Extirpation.  Remedies have never cured.
    Fungous of Cranium :
    Soft tumors of skull, like atheroma.  Usually ulcerates and
sloughs out.  Skin discolored.   Cannot be pushed  back.   No
cerebral disturbance.
     Injuries of Head :
     1.   Scalp.   Contusion: Rarely calls for more t^ian Am., or
Ham.   May be fracture and depression, without  wound of skin.
Tendency  to diffuse inflammation and suppuration.
     Wounds :  Of all kinds ; to be treated as elsewhere.  Lacer-
ated most  common.
     2.   Skull:  Fracture, direct, or contra-coup.   Stellate, de-
pressed, longitudinal,  or separation of sutures.  May be fracture
of inner table, whilst the  outer remains intact, forming exostosis,
or suppuration, epilepsy,  etc. 
70          A SYLLABUS OF  LECTURES ON SURGERY.


    XXIII.   ABDOMEN AND  INTESTINES.

    Contusions :
    ist Degree : Confined to parietes ; any degree of contusion.
(Vide  " Wounds.")
    2d Degree : Force extends to  viscera, and may be  paresis,
or  molecular  derangement, short  of  actual  laceration.  Rare
accident.
    Diagnosis:  Difficult; functional suppression,  derangement,
or  reflex  action ;  e. g.,  vomiting, suppression  of urine,  etc.
Weight, but little pain : Arn.,  particularly when there is  some
haemorrhage.   Con., when no blood, and  feeling of weight pre-
dominates.
    2,d Degree : Laceration of viscera, with or without lesion of
integument.
    Diagnosis :  Obscure ; kidney crushed, and no signs  of acci-
dent.   (Erichsen.)  Usually  symptoms of haemorrhage, which
may be told by excretions, as urine, in kidney cases ;  faeces, in
intestinal or gastric, etc.   Shock, considerable.  Functional dis-
turbances, as in 2d Degree.
    Treatment :  Unsatisfactory.  Left largely to nature.   Pre-
vent unnecessary motion.  Am., often useful;  irrespective of de-
gree.
    Wounds :
    Penet?'ating.  Non -penetrating.
    Latter as other wounds.
    Penetrating :   Serious,  from injury  to viscera.   Peritonitis
oftener follows, in recent cases  subdued by  Aeon.   Intestinal
wounds, when small, left alone ; larger, close  with cat-gut, and
returned to abdomen. Visceral lesions, according to special indi-
cations, bleeding, etc.  Suppuration may ensue.  Early opening ;
prevent admission  to peritoneal cavity.
    Gun-shot injuries,  vide  " Wounds."
    Rupture of  Bladder :
    Usually when full.  Collapse.   Severe burning pain ; inabil-
ity  to urinate, or only bloody water.  Result,  peritonitis, exten-
sive sloughing, suppuration, pyaemia.
    Treatment :  Retention of catheter.  Incision, as in peri-
neal lithotomy.  Arn.
    Foreign  Bodies in  Bladder :
    Frequently found ;  large list.   Must  be  extracted early, or
may become encrusted  with  salts and require lithotomy.
    Laceration of Urethra :
    From direct violence.  Disastrous results : Perineal  abscess,
and fistula.  Treat as rupture of bladder, and preserve  the pa- 
            A SYLLABUS OF LECTURES ON SURGERY.          71

tei?iCy ?f the canaL Sometimes very extensive sloughing.  Hyperic,
will often overcome  irritation, causing retention.
    Remedies:
    Arnica : Contusions, with  extravasation of blood.
    Arsenic :  Resulting in gangrene.  Great prostration.  Burn-
ing, changing to coldness.
    Belladonna :  Distended, but neither  hard nor painful abdo-
men.   Transverse colon distended.
    Bryonia : Bitter taste in mouth. Stools dry, as if burned.
Cannot make the least movement, on account of pain,  yet can-
not keep still.
     Canth : Violent vesical inflammation, with strangury.
     Cham : Peritonitis, with great impatience and irritability.
     Coffea :  Peritonitis, with exaggeration of sufferings.
     Coloc :  Sharp, cutting pains ; bending double.
    Lach.,  Visceral gangrene, with  profound vital depression.
    Nux Vom.,  Pressing, contractive pains, as consequent upon
abdominial  lesions.
     Opium. Paralysis of intestines,  or bladder, from concussion.

     Hernia :

     Protrusion  of viscera from any cavity, natural or artificial
outlet.  Technically, abdominal  region: Enterocele:  Intestine
alone.  Epiplocele: Omentum alone.  Entero epiplocele: Both toge-
ther.   Reducible,  can be returned.  Ireducible, cannot be pushed
back.   Inguinal: (a) Direct: Through external abdominal ring,
or any point internal to epigastric artery, (b) Indirect: (oblique):
Through both rings, occupying inguinal canal.  Femoral (or cru-
ral):  Through  crural ring.  Ischiatic:  Through ischiatic  notch.
Umbilical:  At umbilicus ; mostly children.   Pudendal, Scrotal,
etc.;  variety of inguinal.  Ventral: Through  any part of ab-
dominal walls  where no normal opening  exists.   Acute,  when
recent;  Chronic,  when  of  long  standing.  Cause,  (i)  Excit-
ing: Injuries of all  kinds :  sudden  and forcible diminution  in
capacity of abdomen, as strains, etc.  (2) Predisposing: Abnor-
mal  elongation  of mesentery, acquired  or congenital.  Patency
of vaginal  process,  from late(?) descent  of  the testes.  Symp-
toms :   Tumor  suddenly appearing ; elastic,  painless (?) disap-
pearing at night, re-appearing  in the morning.   Any  size; few
constitutional symptoms.
     1.  Reducible:   Readily returned, gurgling sound, in entero-
cele ;  sucking noise  in epiplocele.
     Treatment : Retained  by well-fitting truss, flat-pad.   Rem-
edies,  in recent cases : Nux  Vom.,  Lycop.,  Calc,  according  to
symptoms.  Operation for radical cure.  Invagination  of canal,
retained by sutures.
     2.  Irreducible;  Cannot be returned.   Plastic  adhesions;
spasmodic constriction  of neck of  sack; inflation of knuckle 
72          A SYLLABUS  OF LECTURES  ON SURGERY.
with air.  Primary, in recent cases.  Secondary, from accidental
injury,  from  truss-pad,  etc., of old  reducible.  Sudden pain,
heat,  discoloration of tumor.   Later,  vomiting, stercoraceous.
Result,  in gangrene, artificial anus, or death.
    Treatment:   (a)  Taxis:  By  manipulation; draw gently
down, with fingers in upper loop, and push up with base of hand.
Abdomen relaxed by  position, thighs, in femoral and inguinal, to
be flexed and adducted.   Failing this, anesthesia; inversion of
patient.  Injection of molasses, air, or generation of free gas.
    Remedies: Nux  Vom., Plumb.,  or Opi., Aeon.,, to relieve
soreness from handling in taxis.   Aspiration.
    Instumental: Scalpel, director, Coopers hernia-knife.  Open
integument, and layers, fascia by fascia; if possible  divide con-
striction without opening sac.   Gangrene of  intestine ;  remove,
attach free extemity to wound for artificial anus ; later, close this
by second operation.
    Intestinal Obstructions.  Syn.: Intussusception.   From
accident, or morbid processes.
    Acute:  i. Portion of intestine strangulated in  aperture in
mesentery.   2.  Invagination.  3.  Twisting   of  intestine.   4.
Plastic exudation.   5. Spasmodic constriction ; direct  or  reflex
irritation.
    Diagnosis:  Difficult.  Local pain, constipation,  vomiting
becoming stercoraceous.   Distension  of  abdomen,  rolling of
wind, mental disturbance, prostration.   Sudden attack.
    Treatment :  Free  gas; injection of air.  Remedies as in
hernia.
     Chronic: Caused in two ways.   1. Scirrhus  of the bowel.
2. Pressure of neighboring morbid growths;  at times from  plas-
tic changes from acute form, slowly developed, increasing consti-
pation.
    Result:  Gangrene and death, or sloughing  with recovery.
    Prognosis:  Guarded in acute case, unfavorable  in  chronic.
    Treatment :  Varies with cause.  Little to be done.

            XXIV.  GENITO-URINARY,

    Prostatitis :   Inflammation of the  prostate.  Rarely in-
flamed primarily; extension of process from  near parts.  Acute:
From trauma, calculi, and gonnorrhoea.  Deep, burning, throb-
ing pain, difficult urination, weight and stuffing in rectum, with
flatening  of  faeces.   Easily detected  with catheter and finger.
Chronic:  Same, slower  progress,   less violent.  Aeon.,  Apis.,
Puis., and Thuja.
    Prostatic Abscess:  Secondary  to prostatitis.   Symptoms
same  as elsewhere.   Danger of perineal fistula,  organic  urethral
stricture.  May  be  multiple or  single.  Early  evacuation ;  He-
par, to hasten process, Catheter or Bougie, to prevent  stricture. 
A SYLLABUS  OF LECTURES ON SURGERY.           73
      Prostatic Hypertrophy:  Senile;  inflammatory;  hyper-
 nutntion  from irritation,  e.  g.,  onanism,  or  sexual  excesses.
 complete or lobular.  Hard, when partial:  soft, when complete;
 size  vanes.  When  hard  is  more  than  simple hypertrophy.
 ^Ross,  Uri. Dis., 687).  Prostatic urethra sometimes dilated
 until it holds  two  or three  ounces  of urine.  Aur.,  Bary c,
 Calc, Carb. v.
      Prostatic Atrophy :  Rare;  contiuation of destructive mor-
 bid process, pressure calculi (Gross, ibid), Jod.
      Congenital absence,  even of blader; ureturs open  in  rec-
 tum, or vagina, or even pubes.
      Prostatic Tumors :  Any form ; oftener fibrous, scirrhus or
 encephaloid ; oftener lobular hypertrophy.   Symptoms as  in en-
 largement.   Proceeds from chronic irritation, leading to  irregu-
 lar or local  super-nutrition.  (Gross).
      Prostatic Calculi : Frequently found, embeded in gland ;
 in connection with calcareous degeneration of the aged.
      Remedies in diseases of the prostate :
     Aeon.,  Inflammatory acute cases, with stranguary,  heat  and
 pain in perineum.
     Apis.,  Burning, stinging in part, with purulent discharge.
     Bary.  c, Old persons with chronic hypertrophy.
     Bell,  High  inflammation, redness of external  parts, and
 pulsating pain.
      Calc,  Strumous, in the young.
      Carbo v,, Burning from a small point like from a coal.
     Jod.,  Atrophy in characteristic persons.
     Puis.,  Thick yellow-green discharge;  better from cold.
      Thuja.,  Sensation as if a drop  were  running through  the
 urethra.
     Perineal Abscess :   From trauma, prostatitis, proctitis  or
 periproctitis ; may open into urethra, bladder or cellular tissue or
 through the integument.   May result  in fistula,  either  rectal  or
 vesical.  Open  early,  to  avoid fistula.  When a  fistula  forms
 [Urinary]  and urethra is  open,  close  the  fistula  as  elsewhere.
 When  the urethra  is closed,  restore patency.
     Urethretis :   Non-specific   inflammation.   Primary, sec-
 ondary, extension  from cystitis,  etc.   Heat, painful urination,
 pain in urethra;  viscid mucous discharge, appears  in  last stage,
 sometimes absent, sometimes becomes chronic, with  slight dis-
 charge  for a long time, and alteration  in urethral  tissue.   Incu-
 bative  stage  absent ; little,  if any constitutional disturbance;
 local  irritation  slight;  inflammation begins deep in  urethra;
 mucous membrane  alone affected ;  glandular, vesical,  or prosta-
 tic irritation either precedes or comes on early.   Caused by cold,
 venereal excesses, local irritations, as from catheters, etc.
    Remedies : Aeon., Acute cases.  Bell,  Phlegmonous inflam-
mation.  Puis.,  Profuse greenish discharge.   Merc, Serous dis- 
74
A SYLLABUS OF LECTURES ON  SURGERY.
charge.   Ars.,  Dry  inflammation : promotes discharge.   Apis.,
Burning, stinging;  profuse ill-smelling discharge.
    Stricture  of  Urethra :   Spasmodic.  Organic.   Single.
Multiple.   Permeable.   Impermeable.
    (a)  Spasmodic:   From   local  irritation ;   hyperaesthesia.
Catheter gives elastic  resistance.  Any portion  of canal, even
whole  length.   Catheter at times  easily  introduced,  difficult
withdrawal.  Beer-drinkers; cold, or acid drinks.   Transient or
persistent.   Aeon.,  Acute  cases.  Bell,  Great sensitiveness to
touch,  but bears pressure.   Co if., Hypersensitive; exaggeration
of the sufferings.  Ign.:  Hysterical cases.   Hot hip baths.
    (b)  Organic: Firm, permanent constriction.  From injuries,
long-lasting  inflammations,   suppuration;   plastic   effusions
from  any  cause.  Established  gradually.   Catheter meets  firm
resistance.   May result in false passages, from occlusion, or even
fistula.   Bridles, thickening of walls, or plastic bands constricting.
    Treatment : Gradual dilatation.  Rapid dilatation.  Ure-
throtomy (a) External,  (b) Internal.   Electrolysis.
    Tumors of  Bladder; All kinds, oftener fungous  or poly-
poid.   Symptoms as in stone, even  to click, owing to  incrusta-
tion with salts.   Pain, weight in perineum, stoppage of stream
in urinating, blood in urine.
    Calculi :   Crystalization   of  urinary  salts,  (a)  Renal.
Form in  kidneys.   Uric  ac,   oxolate  of  lime, animal  mat-
ter. Ragged,  small.    Great  pain   in   passing   to   bladder,
along course  of  ureters.    Pod.,  Lye,  often   will  facilitate
this passage, but pain may be sufficient to call for anesthesia.
    (b)  Uretal calculi:  Arrested in ureter,  from  kidney.  Pain
in testes, and in course of ureter.   Kidney soon partakes in  irri-
tation, which may extend to other side.  Same treatment.
    (c)  Vesical: May be formed in the  bladder,  or come from
kidney.  Symptoms :  Itching of meatus ; weight in  perineum ;
rolling ;n bladder;  mucous in urine, even pus ; sudden stoppage
of stream in urinating ;  bloody  urine.   On using sound, elicits
the characteristic click.  Exceedingly difficult diagnosis.   Cases
with immense stones  and no symptoms ; others   with no stone,
and all the symptoms.   May become encysted,   thus modifying
some symptoms.
    (d)  Urethral calculi: Stone arrested  in urethra in passing
from bladder.
    Causes : Morbid processes  that  favor  the crystalization of
uric acid, or produces  it in  large  quantities.  Without  nucleus,
(Van Buren and Keyes, Gen.  Urin. Dis ), cannot crystalize at
normal heat of body.   Retention of urine,  favoring decomposi-
tion,  as  paralysis,  pouching of  bladder  in the   old,  prostatitis,
tumors or  hypertrophy of this gland ;  cystitis,  which  furnishes
ropy  pus for nucleus.   Nucleus  from extraneous substances, as
ball, bone  or clot  of blood.   Causes,  therefore,  operating at a
 distance from urinary tract.   " Mal-assimilation." 
Sjiedes of Calculi.
External Characters.
C/iemieal Composition.
Remarks.
        1

Lithic, or Uric.
Mti.berry
Form, flattened ova!.
«V. G., generally exceeds 1,500.
Color, brownish or fawn.
Surface, smooth.
Texture, laminated.
      3

Bonk-Earth.
TniPi.i:,
Color, dark brown.
Texture, harder than others.
■V. (r., from 1,-128 to 1,1)70.
Surface, studded with tubercles.

Color, pale brown or gray.
Surface, smooth and polished.
Structure, regularly laminated easily
  separating into concrete crusts.

Color, generally brilliant white.
Surface, uneven, studded with  shin-
  ning crystals, less  compact than
  No ;i.  Between its  lamina?, small
  cells, filled with  sparkling parti-
  cles.
It consists principally of lithic acid.
  When  treated with Nitric acid  a
  beautiful pink substance results.
  Is very slightly soluble  in water;
  abundantly so in pure alkalies.

It is oxalate of lime, and  is decom-
  posed in the flame of a spirit-lamp,
  swelling out into a white efflores-
  cence, which is quicklime.

Principally  phosphate of lime ; sol-
  uble in Muriatic acid
The prevailing species.  Surface
  sometimes occurs finely  tuber-
  culated.
Often  the  nuclei  of  the  other
  kinds.
These  include  some  varieties
  which are smooth, and pale-col-
  ored, like the hemp seed.
It  is  an  a m m o n i aco-magneisan
 Phosphate, generally mixed with
 Phosphate  of lime.  Pure alkalies
 decompose it, extracting its Am-
 monia.
This species attains a larger size
  than iinv of the others.
    5

Fr.siULE.
Color, grayish-white.
A  compound  of the two  foregoing   Very fusible, melting into a vitre-
 species.                             ous globule.
Cystic.
Very like the triple calculus, but is
  unstratilied, more  compact,  ami
  homogeneous.
Consists of Cystic oxide; under the
  blow-pipe it yields a peculiar fetid
  odor.  Soluble in acids or alkalies,
  even if they are full of Carbonic
  acid.
A rare species.
Al/l'KKNATlN(i,
Compound.
Its  section exhibits different con-
  centric lamina;.
Compounded  of several species al-
  ternating with each other.
No characteristic form.
The  ingredients are separable only
  be  chemical analysis. 
•J6           A SYLLABUS OF  LECTURES ON SURGERY.

    Treatment:  For lithiasis,  Picric ac,  Scilla., Phos., Lith.
carb., Lye often produce cure.  For small stones, in bladder,
Gettysburg water has expelled many, also dissolved them.  (Hel-
muth 1087).    Ethereal solution of per oxide of  Hydrogen a
dose, gtt xx. thrice daily. (N. E. Med. Gaz. VIII,  p. 43)> als0
solvent.   Galvanism, doubtful.
     Lithotripsy.   Thompson's lithotrite  best.  Crush stone, in
several sittings, and wash out debris.
    Lithotomy.    Best method.    Median  ; lateral;  bi-lateral ;
supra-pubic.   Lateral  best.   Instruments :  sound, staff, scalpel,
lithotomy knife (Ferguson),  forceps, scoop,  syringe.  Never
operate unless the stone is felt when patient is on the table.
     Catheterism :  Male-catheter.  Female.  Mode of introduc-
duction.  Caution about retained catheters  ; prefer frequent use.
     Gonnorrhcea.   Specific urethretis ; from venereal poison.
Infectious.   In the female,  inflammation of mucous  surfaces of
vagina, vulva, etc.   Three stages :
     (1) Incubation.  Three to  five days, or more.   Then  heat,
swelling,  itching of meatus ; a drop or two of pus  may squeeze
out.  Lasts two or three days.  Aeon., in this stage  will nearly
always abort it.
     (2) Acute inflammatory. Abundant discharge, muco-purulent,
yellow fluid, smelling badly;  painful urination ;  increased desire
to urinate ;  urethra swollen, feels like a cord ;  gradually extends
deeper, when weight and heat in perineum  and  anus, with com-
plication  of  prostate and bladder.   Whole  organ or part swollen
or inflamed ; puffy swelling of prepuce.   Chordee, pain, erection,
with distortion of penis, from unyielding  nature of urethral swell-
ing.  Usually lasts a fortnignt, when untreated.  Apis, will usually
cure the case promptly in this stage, cutting down the duration
to a few days..   Ars. Apis fails, and  the pain is more burning,
with  deficient  discharge.   Canth., Rhus.,  Merc, or Bell., may
be called for, particularly for the chordee.   Never use injections.
     (3)  Chronic inflammatory.   Diminished discharge, pain  and
irritation; discharge watery ; smarting  on urinating, for some-
time.   May continue for  months,  with  slight glairy  discharge.
(Gleet.)  Remedy, Sulph.  will cure many cases.
     Petros., Intense itching, biting in the  urethea.
urethretis.
Speedy establishment.
Begins deep in urethra.
Prostate, and  deep parts,  early
  implicated,  or preceding.
Sometimes no discharge.
Mucous surface alone affected.
Runs its  course  in five or  ten
  days.
GONNORRHCEA.
Incubative stage.
Begins at meatus.
Deep parts implicated later.

Always discharge.
Deeper structures implicated.
Runs a course of many weeks. 
A SYLLABUS  OF LECTURES  ON SURGERY.
77
     Salisbury's  Algoid  bodies, are not diagnostic; found  in
persons not affected.
     Sequela.  Rheumatism, often.   Accompaniments, ophthmal-
mia.  Modification.   Little discharge from intense inflammation
and  swelling of mucous lining.
     Syphilis.  Commencing  in  mucous  membrane of genitals,
usually, successively invading every tissue  of the body.  Commu-
nicated  in many ways.  Begins as ulcer secreting pus, which ap-
pears like  pus from  any  non-specific  sore.  Any age.   May  be
quicky developed, from abrasion, or slowly from absorption  by
mucous folicles.   May be  wiped  off, after deposit, before infec-
tion.  Some persons  cannot be infected.  A  local manifestation
of a general disease.
     i.  Primary,  (a)  Chancre.   Hard or soft ; dependant
upon activity of process,  and completeness of  inoculation (?).
Same virus ;  any  part of body; oftener genitals.  Hard.  (Indu-
rated : Infecting: Hunterian).   Pimple, itching, then vesicle,
pustule ; hard, dark crust, which, when removed, reveals ulcer.
Rounded or oval; sloping edges, high, hard.   Firmly adherent
gray lymph at base.   Quite dry.  About fifth day, induration  of
base and areola, like  gristle, slightly elastic, and feels like a for-
eign  body under  integument;  sometimes before chancre, again
lasts long after sore is healed ; less  on perpuce or loose textures.
Generally solitary.   Inoculates healthy persons, but  not those
having had hard chancre,  or  the  same  individual.  Incubation,
 10 days to weeks.
     Soft:  (Chancroid.   Non-infecting).   Less  regular form;
more frequent.   Multiple  often; coming on  simultaneously, or
from auto-inoculation.  Flat, soft,  uneven,  "worm-eaten,"  su-
perficial.  Sometimes indurated from irritating treatment.  Dis-
charge profuse, inoculable, to individual as well. Spreads rapidly.
Incubation short, even 48 hours.
     Infecting properties remain until granulations appear.  Hard
chancre protects  from  future attacks ; soft, no such immunity.
Both forms modified  by circumstances,  as phagedena, sloughing,
serpeginous, etc.
     Scars disappear in soft, and  simple  hard  ulcers; persistent
after large  sloughing.  Diagnosis usually easy ;  married persons
deny exposure ;  unmarried readily admit  it.  Microscope shows,
in infecting sore, epithelial cells  formed  and mature; soft ulcer,
either few, immature, or  imperfect, from rapidity of morbid  ac-
tion.  (Kidder.   Med. Report,  U. S. N, III, p.  14).
     (b) Bubo.:  Enlarged inguinal  glands, when specific, appear
at  end of second  or beginning of third week; follows either
 form, when inflammation not too high and destructive.  Always
with hard chancre, but pus not  auto-inoculable.  Same side as
chancre.  Both sexes ;  Men oftener.  Discharge, and leaves sore
like  the primary ulcer.  Modifications  as  ulcers;  remains  un- 
 78          A SYLLABUS  of lectures on surgery.

 changed for weeks or months, etc.   Suppuration supposed to in-
 dicate non-infection.
     2. Secondary.   From 5 to 8 weeks.   Skin, mucous surfaces.
 Worst form,  joined  with mercurialization.  Foretold.  (Gross I,
 311).   (1). Indurated sore.   (2). Soft if multiple or large extent.
 (3). Seat of  chancre.   (4). Duration of ulcer.   (5).  Patient's
 health.  (6).  Kind  of Treatment.   (7). Degree, etc., of in-
 flammation.   (8.) Idiocyncrasy, sometimes comes on before pri-
 mary ceases.   Inoculable in  non-syphihtics.  Some  days  before
 feels unwell,  fever.   Forms  on skin.  Exanthema;  Scaly; Vesi-
 cular; Pustular;  Tubucular; Papular.   Always chronic.   Cop-
 pery  color.   Mucous surface.    Erythema ; Tubercles ; Ulcers.
 (Refer to "Practice").   Allopecia tonsurans, and general.
     3.  Tertiary.   Six to eighteen months, or  even  many years.
 Visceral, or on skin ; mucous  membranes; Periosteum; Bones;
 Cartilage; Tendons; Testes; Gummata.  (Refer to " Practice"
 and preceding lectures).
     Treatment :  Local treatment hurtful and useless.  Primary.
 Promote suppuration of buboes, but do not open until ripe..
     Hard  chancre: Merc.  Cor., In  most cases specific.   Soft
 chancre :  Nit. ac, or other remedies as indicated in ulcers ;  par-
 ticularly Merc, cor.,  Kali, bich.,  Ars., Sulph. ac.
    Secondary.  Prominently, Jacaranda.   (Schlusler  A.  H.
 Z. 75.  182.   Also Med. Invest. V., 285.)   Merc,  Aur., Asafi,
 Nit. ac, Sulph., Thuja., as indicated by special symptoms.
     Tertiary.  Symptomatic entirely.
    Mercurialization added : Asafi, Aur., Hep.,  Nit. ac.
    Phimosis.  Elongation  of prepuce, with  narrowing  of ori-
 fice, sometimes adhesions to  glans.   Congenital,  or  acquired.
 Produces epilepsy, and other reflex phenomona.   (Prof. Jerne-
 gan.   A. H.  Obs. XI, 85).   May result from accident.
    Treatment: Circumscision.  Nick mucous membrane, and
 stitch it back to skin.
    Paraphimosis.   Opposite condition ; drawn back and can-
 not be replaced.  Usually acquired, accidental, and  acute.  Must
 be reduced by pressure on glans with thumbs, and drawing forward
 with fingers.   Sometimes need to be nicked with scalpel.   When
 much imflamed, reduced somewhat by cold applications.
    Balanitis.   Suppurative  inflammation   of prepuce  and
 glans, (erysipeloid ?).   Causes are manifold;  anything that sets
 up inflammation, in subjects favorable to this form  of development.
 Profuse discharge, much inflammation and swelling, without ap-
parent abrasion of integument.  Prepuce  may  be   enormously
swollen.  Bell., often cures promptly.  Other remedies as svmp-
toms arise.
    Orchitis.  Syn.  :  Hernia humoralis :  Blennorrhagic  epidi-
dymitis.   Swelling and hardness of testicle,  usually one-sided
red, hot, painful; pain extends up the spermatic cord; sometimes 
A syllabus of lectures on surgery.           79
scrotum ,s covered with small vesicles, drying up in scales.    Fe-
rL?a7  hjSh-  The testes may be inflamed alone, or compli-
 ,  "lb!.Slmila; Pro«*s in other near  tissues.   Mav proceed to
  2rat,on5 ^hen the pain will be unsupportable, and the whole
g a, d1 may be destroyed.   A button-like enlargement of the epi-
ddymus  may  remain after cure.   Cause: Trauma, cold,  sup-
pression of gonorrhoea or urethretis, use of injections, etc.
     treatment:.Support the  scrotum in a sling.   Cooling ap-
plication admissable.                                    6  v
     Remedies: Aeon., early stages; high fever.
     Aurum., In syphilis  or mercurial cases, with  great weight
and  aching  in part.
     Bell., High inflammation ; great dread of motion, or jarring
the  bed.                                           '    J     b
     Lach.,  Black blisters on scrotum.
     Mere,  Constant  aching  pain,  with  increase  of  suffering
from heat.
     Hydrocele.  Effusion of serum into tunica vaginalis.   Ex-
ternal, when in cellular tissue.   Acquired or congenital.  Large,
smooth,  non-inflammatory swelling of scrotum ;  fluctuation;
transmitted  light shows testicle at  back part of swelling.  May
resemble  hernia, but  does not disappear  on  lying down,  and
grows slowly.  Exploration to  settle diagnosis.  Fluid of light
straw color.
     Treatment : Evacuation  with  trocar and cannula, and in-
jection of some irritating substance  to  promote adhesion.   Re-
moval of a  small portion of sac ; electrolysis.  Old cases,  wall
thickened, obscures  the diagnosis.
     Remedies:   Sil.,  Particularly successful.   Also,  Graph.,
Puis., Rhod., Sulph., Apis., Arsen.
     Sarcoclle.   Chronic orchitis.   Testes enlarged, and under-
go various fo*rms of tumor degeneration, generally sarcomatous or
cancerous, some cases  fibrous.  Testicle is ultimately lost,  and
place supplied by new tissue.   Often of syphilitic origin.
     Treatment:   Castration, when complete. Puis,  and  Sil.
are credited with cures in the journals and  text-books.
     Varicocele.  A  varicosed condition of veins of scrotum
and  cord.   Soft, doughy, compressible swelling, knotted, une-
qual surface; larger below.  Tumor smaller on lying down. Feels
like  a mass  of worms, differentiating  from hernia.   Debility of
sexual sphere either  a cause or effect; often on  left  side.  Cause,
sexual excesses, constipation, impeding venous  flow, constriction
from pantaloons, etc., as well as general atony.
     Treatment : Elastic  bandage ;  obliteration  of veins,  by-
ligature;  (hair lip pins).   Care not  to  include spermatic  vesi-
cles, etc.
     Re?nedies:  Ham.,  Nux.   vom.,  Sulph.,  Puis.    Compare
"Varix." 
8o
A syllabus of  lectures on surgery.
    Hematocele.   Effusion of blood into scrotum,  or some of
the tunics,  from accident.  History serves to make out the diag-
nosis.   Decomposition  of blood may cause pyaemia, or suppura-
tion.   Remove by aspiration, or small  trocar, closing opening
with collodion.  Atnica, when tumor is small, may cause resorp-
tion.
                    XXV.   CHEST.

    Wounds :  Non penetrating:  As elsewhere.   Penetrating :
First importance ; implicates viscera.  By weapon and  fractured
ribs.  Five considerations.
    (i) Hemorrhage:  Usually internal; large vessels,  fatal.
Auricles of heart, or transverse  to  fibres, fatal.   Small coagula,
causing embolism.   Pulse falls ; surface anaemic and cold ; ring-
ing in ears; syncope;  oppression of chest;  labored, panting
breathing.  Anxious.  Vomiting of blood, if oesophagus wounded.
    Treatment : Body-bandage;  prevent motion.  Am., cause
resorption of effusion. Merc, prevents pyogenesis? No probing.
Hermetically seal wound.
    Concussion of Chest: May  produce death, from paralysis or
laceration of  viscera.  Symptoms as  in  haemorrhage;  can only
be suspected.
    (2) Emphysema:  Infiltration of air into cellular tissue;
often in thoracic region.   Wounds of larynx,  trachea, or lungs.
    Sub cutaneous :  Inter-lobular :
    Sub-cutaneous :  Enormous  swelling, pale color; crackling
on pressure.  (Edematous appearance, but no pitting.   May  be
reduced by firm, equable pressure, but fills up again.  May ter-
minate in gangrene or ulceration.
    Inter-lobular:  Rupture of  air cells.  Great oppression and
fullness in chest, as  m  congestion.  Symptoms of ast^ima;  may
simulate haemorrhage.  Death imminent from actual suffocation,
on account of expiration being imperfect.
    Treatment : Very difficult. Sub- Cuf form, firm bandaging ;
even incisions.  Inf-lob1,  pressure contra-indicated.  Ars., or
Kali C, may relieve.
    Arsen., When relief from sitting up, and warmth.
    Kali C,  Better from bending forward, as with head resting
on table.
    Moderate infiltration, may need no treatment.  Dieulafoy's
aspirator, may afford relief.  (Vide "Pneumatic Aspiration")
    (3) Pneumo-Thorax : Infiltration of air into pleura.  Simi-
lar in symptoms, etc., to emphysema.  Resonance on percussion,
but not so urgent or grave a condition.  Frequent aspiration, or
even, in bad cases, cannula retained.
    (4) Traumatic Pneumonia : Identical with idiopathic form.
Greater tendency to suppuration (?). Aeon., Merc, Sulph., or Arn. 
            A •-VLLAliUS Ol  LECTURES ON Sl.'KCKRY.          8l

     (5)  Empyema:  Collection  of  pus in thorax.   Succeeding
traumatic pneumonia, or thoracic haemorrhage.
     Diagnosis:  Obscure. Rely upon history of case, and  results
of auscultation as indicating presence of fluid.   Rigors.
     Pus unhealthy, mixed with debris, and rapidly breaks down
lungs,  and  may form   long  sinus, and  destruction of  bones.
Pyaemia.
     Treatment:  Kvacuate freely  and completely.  Paracentesis
thoracica, or aspiration.  No attempt to absorb:   Vide "Abscess." >
     Hypertrophy  of  Breast :
     Two forms: 1st. Hard, firm, elastic.  Little pain; or neural-
gia.   Prominent, smooth, shining.  Natural color.
     2d.  Breast doughy ; lobes separated ; sulci readily  found.
Unconnected  with chest.  Hangs clown ;  some cases (Erichsen)
as low as the knee.   Stretching  of skin, etc., simulates malignant
disease.
     Men and women alike subject. Any period between puberty
and  climacteric.  Both glands usually affected.
     Enlargement, in either case, may be lobular or entire. When
lobular may become malignant, or form  true  tumor.   Cautious
diagnosis.
     Treatment : Removal,  when  symptoms  of  degeneration
appear, or the size is great.
     Remedies:  Baryta C,  Past  climacteric: strumous; small,
but firm.
     Bell, Rapid growth ; much inflammation.  Tender to touch.
     Calcar.C.,  Struma.  Tendency to  suppuration.  Calcarea
subject.
     Conium., Heaviness, biting, as from fleas.   Aversion to soli-
tude, yet dislikes company.
     Iodine,  Swelling  hard and small; secondary  tendency to
atrophy.  Coarse hair,  skin, etc.
     Nitric Ac, In sycotic cases.  Splinter-like sensation in part.
     SiHcca., Moderately hard swelling, with intolerable itching.
Clammy feeling of  part.
     Tumors of Breast :
     Of all kinds.   Readily diagnosticated, except (?) from lobu-
lar hypertrophy.  Oftener,  Fibrous,  Fatty, Scirrhus, or Cystic.
     Fibrous:  As elsewhere.  Nodulated; not deeply attached ;
flushed skin.  Gland becomes absorbed,  but tumor still nodu-
lated,  from  impression  at start, growing  between lobes.  Hard,
compressible.   Nipple prominent or normal.  Sometimes discol-
ored skin, and ulceration.   May even  have  glandular  engorge-
ment in the axilla.   No cachexia.
     Fatty Tumors:  Difficult detection.  In sterile  women, past
climacteric.   Gland ultimately absorbed, or  undergoes  fatty
metamorphosis.
       6 
%2          A SYLLABUS OF  LECTURES ON SURGERY.
     Cystic Tumors:  From occlusion of milk duct.   Resemble
an abscess, heightened by appearance of discharge on  puncture.
Sometimes attain  immense  size.   Diagnosis easy:   Fluctuation
and exploration.
     Scirrhus: Common. May  be encephaloid,   or  colloid, or
compound.   (Rare.)  Stony  hardness; immobility; discolora-
tion  of skin; retraction of nipple.  Skin  adherent  ;  veins en-
larged ;  axillary  infiltration.   Cachexia;  anamnesis.   Mental
depression.
     Ulceration:  (Vide  "Tumors.") Sometimes tumor extruded
through ulcer.
       Non-Malignant.

Feel:  Moderately hard, nodu-
     lated,  irregular in  shape,
     lobed, not very distinctly
     circumscribed,  sometimes
     elastic in parts.
Mobility :   Considerable,  but
     occasionally there is a deep
     pedunculated attachment.
Skin :  Natural color  through-
     out, though  thin  and ex-
     panded,  with  the  tumor
     lying close beneath.  Only
     complicated  in  the  last
     stage of cystic sarcoma.
Nipple :  Uusually not retracted.
Veins : But little dilated.
Pain :  Often moderate, if severe
     continuous, of  a neuralgic
     character, much  increased
     by handling.
Axillary Glands :  Of  usual
     size, or  but  slightly en-
     larged ;  movable.   Lym-
     phatics not affected; supra-
     clavicular glands not affect-
     ed.
No constitutional infection.
         Malignant.

  Stony hardness, knobby, dis-
tinctly  circumscribed,  or else
somewhat square, and  occupy-
ing the whole of the substance
of the gland.
  At first considerable, but soon
becomes fixed.

  Early implicated ;   at first
dimpled,  then  red or  purple ;
in other cases brawny or leather-
like, so that it can not be pinch-
ed up into folds; or nodulated,
purple-red masses form in it.
  Usually retracted.
  Much dilated.
  Severe and lancinating, espe-
cially at night, after  handling,
and when the skin is implicated,
but not continuous.
  Enlarged, indurated,  and fix
ed;  indurated  mass stretching
into the axilla;  supra-clavicular
glands enlarged.
Cachexia as disease advances.
    Treatment:  Excision in all benign growths, or in malig-
nant before glandular infiltration.
    Other treatment, as in  "Tumors."   No escharotics.
    Note.—Diseases  of the  Eye, Eary Female  Genitals, etc,
belonging to other departments, have been omitted. 
* 
,ril> 
 

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