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} 
SYLLABUS
THE COURSE OF LECTURES
PEINCIPLES AND PEACTICE  OF SUEGEEY,
Jr-
DELIVERED IN THE
JEFFERSON MEDICAL COLLEGE, PHILADELPHIA,
BY THOMAS D. MUTTER, M. D.
%-S*f3*
^
i>ie:RARY
        PHILADELPHIA:




BARRETT & JONES, PRINTERS, NO. 34 CARTER'S ALLEY.





              1847. 
 \^0
fAQSS
       Entered, according to Act of Congress, in the year 1S43, by

                  THOMAS D. MUTTER, M. D.

in the Clerk's Office of the District Court of the United States in and for the

                  Eastern District of Pennsylvania. 
/ 
 
NOTE.
  The classification adopted in my lectures differs materially from
that of any other surgeon, and its utility has been fully tested for
several years.   It will be perceived that I arrange all the subjects
comprised in the  course under six heads:
  1. Under the first, I include Inflammation, its products and
varieties, and  Wounds.
  2. Under the second, I  shall consider all the diseases  of the
different  tissues  and  organs,  commencing with the Bones, and
concluding with the Skin.
  3. Under the  third, the various affections of Regions may be
considered.
  4. The fourth division comprehends  all Tumours, whether
malignant or non-malignant.
  5. In the fifth, the Diseases peculiar to Females will be con-
sidered.
  6. In the sixth, /Imputation.
                                     Thomas D. Mutter.
                                           244 Walnut Street.
  Oct. 1, 1847. 
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SYLLABUS   OF    LECTURES.
                    INFLAMMATION.

  Definition.
  Liability of  tissues  to undergo inflammation.—Some more liable than
others.  Some  never attacked* t  Certain of the lower order of animals are sup-
posed to be exempt from this action.  Not as yet positively ascertained.
  Division or  classification.  First.—1. Acute.  2.  Chronic.  3. Latent.
  Second.—1.  Healthy.   2. Unhealthy.
  Third.—1. Adhesive.   2. (Edematous.   3. Erysipelatous.   4.  Gangrenous.
-r). Specific.  (Hunter's.)
  Fourth.—1.  Phlogosis.  2.  Epiphlogosis.   3. Metaphlogosis.  4. Hyperphlo-
gosis.   (Lobstein's.)
  Symftoms.—1.  Local.   2.  Sympathetic, general, or constitutional.
  (1.) Redness, heat, swelling, pain, throbbing, and an alteration or suspension
of the natural secretions of the part.   Although these symptoms are usually
present, inflammation may exist without their development.  Cite cases.
  (1.) Constitutional symptoms.
  Theories of inflammation.
  Effects on the blood.
  Terminations of inflammation.— 1. Resolution.  2  Delitescence.  ? Me-
tastasis.
  Effects or products.—1. Effusion of serum.   2. Effusion of lymph.  3. Ad-
h.esion.  4. Hardening.  5. Softening.  6  Atrophy.   7.  Hypertrophy.  8. Che-
mosis.  9.  Suppuration.   10.  Ulceration.   11.  Gangrene and mortification.
  Causes of inflammation—two classes.    1. Constitutional   2.  Local.
  First  Head, or  Constitutional —1.  Plethora.   2.  Local determinations.
3. Fever.   4.  Diathesis.  5. Disordered state of function.  6. Suppression of.
natural discharges.  7.  Atmospheric vicissitudes.
  Second Head, or Local.—1.  Those which produce palpable injury  to organi-
zation—as mechanical injuries of every kind—mineral irritants—heat, friction,
extreme cold, &c.
  2. Those which operate through the  sentient  extremities of the nerves.—as
concussion, pressure, constriction, irritating  substances, as mustard, cantha-
rides, &c.
  3. Fluids which produce a peculiar impression  and give rise to a specific
action or inflammation—as decomposed  animal matter, pus or  serum from
specific diseases.   The most familiar examples of the operation of  this class
are, dissecting  wounds, pustule maligne, and glanders.
  4.  Those which suddenly change  the natural feelings  of the  parts.  For
example, drawing off the water in  dropsy will cause inflammation of  the serous
cavity in which it has been collected. Peritonitis frequently comes on after the
delivery ; cystitis after the operation for stone, &c.
  Diagnosis.
  Prognosis. 
(   6   )
  Tre\tment.—Numerous indications are presented, most of which require to
be fulfilled in nearly every case.  They are  modified of course  by the pecu-
liarities of the attack, the age, and the strength of the patient, &c.
  1.  We must endeavor to remove the  cause.  An exception to this  rule is
occasionally met with in surgery, when  bullets, &c, lodge deeply.
  2.  We must diminish the action of the heart by nauseants, digitalis, general
and local abstraction of blood, by venesection, arteriotomy, scarification, cups,
and leeches.
  3.  We must reduce the sensibility of the part, and if possible cause constric-
tion of its vessels, by cold—ice, irrigation, immersion.
  4.  When cold fails to reduce sensibility, apply steam, fomentations, poultices,
warm water dressings,  immersion in warm water, &c.
  5.  We must restore  the secretions,  if possible,  by diaphoretics,  mercury,
iodine, warm baths, &c.
  6.  We must remove the original disease by counter-irritation, especially when
it becomes chronic.  For this we use irritating lotions, blisters, sinapisms, tart.
antim ,  croton oil, issues,  seatons, and moxas.
  7.  When the vessels are turgid, we must cause their contraction by astringent
lotions,  aided by scarifications, leeches,  &c.
  8.  We must also prevent the afflux of  blood into  the  part by  position, fric-
tions, and rest. Pressure, recommended  by some, is  generally a painful remedy,
except in chronic cases.
  9. -We must always bear in mind the  influence of  the  mind upon  the body,
and endeavor to  cheer up the patient by every possible means.
               PRODUCTS  OF INFLAMMATION.

                         I. SEROUS EFFUSION.
   1. Nature of this fluid.
   2. Kind of inflammation tisually producing it.
   3  Time requisite for its separation.
   4. Local phenomena.
   §. Effects upon parts containing it and those in their vicinity.
   6. Diagnosis.—May be confounded with dropsy arising from other causes.
   7. Diseases produced by serous effusion___Hydrocephalus, hydrophthalmia.
hydrocele of the neck, hydrothorax, hydropericardium, ascites, ovarian dropsy.
cedema, anasarca, skin bind of children, hydrocele of the tunica vaginalis  testis,
hydrarthus.
   8. Operations required to relieve these affections.
   rl.)  Paracentesis capitis, in hydrocephalus,  ,
   (2.)  Paracentesis oculi, in hydrophthalmia. jr^ Cx  '" '
   r3.)  Tracheotomy,  in cedema of the glottis.
   (4.)  Paracentesis colli,  in hydrocele of the neck,
   (5.)  Paracentesis thoracis, in hydrothorax and hydropericardium.
   '(].)  Paracentesis abdominis, in ascites and ovarian  dropsy.
   (7.)  Paracentesis scroti, in hydrocele of the  tunica vaginalis testis.
   (8.)  Paracentesis articuli, in hydrarthus.
   (9.)  Puncture of the skin, in cedema and anasarca. 
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(  7   )
              II.  EFFUSION OF COAGULABLE LYMPH.
   1. Nature of this fluid.
   2. Kind of inflammation producing its separation___Must not be too high or
we have pus ;  nor must it be of too low a grade.  There is evidently a secreting
point.
   3. Time required for its formation.                  m
   4. Tissues in which it is most liable to occur.           m
                             •           ...
   5. Effects upon the part into or upon which it is thrown.
  ' 6. Stages through which the lymph passes in its organization.    •
   7. Diseases resulting from this effusion.^— Hepatization of the lung; corneal
speck; various tumours; the hardness about boils and erysipelas; elephantiasis;
closure of the trachea in croup ;  strictures; adhesions; and strangulations.
   8. Operations required to relieve the effects---Extirpation ofvarious tumours ;
amputation of a  limb; tracheotomy  or bronchotomy in  croup; the different
operations for strictures ; separation of adhesions as in atresia vaginas; operation
for hernia.
                             III. ADHESION.
   Definition___The accidental or abnormal union  of parts, either separated
naturally or by some chance, from each other.
   Nature of this process___This product of inflammation, or according to some,
of irritation, is nothing more than the effusion of coagulable lymph under pecu-
liar circumstances.  When, for instance, a simple cut or wound unites, without
suppuration, the bond of union is either pure coagulable lymph or the fibrine of
the blood ; and it  is said to heal by adhesion, or by  << adhesive inflammation,"
or the  "first intention of Hunter.'''    Professor M'Cartney calls this process
" mediate union  by lymph," and  denies the existence of  inflammation in its
accomplishment.
   Theories in  relation, to this  process___Hunter's ; Thomson's ;  John Bell's ;
Maunoir's; Delpech's; Serre's; Duhamel's; those of the Physiological school, &c.
   Changes which talce place during the organization of the bond of union---
 1, Coagulation; 2,  change in color;  3,  formation  of vessels; 4, increase of
firmness ;  5, conversion into fibrous or cellular tissue.
   Process §f vascularization___Theories of Hunter. Duhamel, Clanny, Sir E.
Home, Gendrin, Laennec, &c.
   Appearance of cicatrix.
   Utility of this process.—Exhibited in the adhesion of wounds.  The attach-
ment of the lungs to the ribs  in pleurisy.   The cure of hydroceles, cysts, and
fistulrc.   The cure of wounds about the abdomen.   The arrestation of hemor-
rhages.   The restoration of parts entirely separated from the body.   And the
success of plastic  surgery.
                            PLASTIC  SURGERY.
   Definition.
   Synonymes___Autoplastic  surgery; anaplastic  surgery;  animal grafting;
chirurgia curtorum per insitionem ; morioplasty ; heteroplasty ; taliacotian ope-
ration, &c.
   History.
   Indications for the employment of plastic surgery.
   Circumstances which favor the success of the operation.
   Circumstances which forbid its employment. 
(   8   )
    Result of these operations.—1.  Favorable.   2.  Unfavorable.
    Treatment after a plastic operation.
    Classification___Several general groups.   1.  Operation intended  to  restore
 parts either entirely or partially separated from their original connection.
    2. Operations intended to restore lost organs by a process similar to vege-
 table grafting, and hence called the "operation by transplantation.'"  The new
 flap is here entire|y detached from its original position.
    3. The operation by " transposition;" the flap is here  left attached by a pe-
 dicle, and. is  taken from parts either in the  vicinity or at some distance from
 the seat of disease.
    Under each of  these general heads are  ranged the  different special methods
 of performing  the different plastic operations.   Under  the first, we have the
 operation after <flhcer, the removal of cicatrices, the loss of fingers, &c.  Under
 the second, the operations by "migration of the flap," "detachment and  migra-
 tion,'''' &c.  Under the third, the operations by "glissement du lambeau, or slid'
 ing the flap," "Roulement, or rolling the flap," "inversion of the flap," &c. &c.

                            PLASTIC OPERATIONS.                        J
   Each of these takes its name from the part to be restored.
     1. Cranioplasty, or restoration  of the soft parts and bones of the head.
     2. Otoplasty, or restoration of the ear.
     3. Rhinoplasty, or restoration of the nose.
     4. Blephereplasty, or restoration of the lids.
     5. Keratoplasty, or restoration of the cornea.
     6. Cheiloplasty, or restoration of the lips.
     7. Genioplasty, or restoration of the cheeks.
     8. Staphyloplasty, or closure of the soft palate.
     9. Palatoplasty, or closure  of the palatine vault.
    10. Bronchoplasty, or closure of  the larynx or trachea.
    11. Urethroplasty, or restoration of the  urethra.
    12. Oscheoplasty, or restoration  of the scrotum.
    13. Cystoplasty, or restoration of the bladder.
   14. Enteroplasty, or restoration  of a bowel,
   15. Elytroplasty,  or restoration  of  the vagina in vesico-vaginal, or recto-
vaginal fistula.
   16. Plastic operations for the restoration of  parts about the thorax and abdo-
men.
   17. Plastic operations after the removal of cicatrices.
   18. Plastic operation for the cure of hernia.

                             IV. HARDENING.
  Definition.
  Causes.—Besides inflammation, it may result from natural causes, or  it may
be produced by simple congestion ; undue accumulation in the cavities of organs ■
hypertrophy;  loss of the fluids of an organ; interstitial deposits, and the .presence
of unorganized masses,  as tubercles,  &c.
  Manner in which inflammation produces  hardening.
  Tissues liable.
  Effect on organs.
  Treatment. 
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(   9   )
               V. SOFTENING, OR RAMOLLISSEMENT.
  Definition.
  Causes.—Usually from inflammation.   May result from defective nutrition;
disease of arteries; want of proper food ; altered qualities of the  blood, &c. ;
the solvent qualities of the  gastric juice.
  Tissues liable to it.
  Effects on organs.
  Treatment.
                             VI. ATROPHY.
  Definition.
  Causes.—Besides inflammation, it may result from a law of nature, as in the
wasting of the thymus gland ; an arrest of the nutritive process before birth ;
from a state of inaction;  loss of nervous  power ; pressure ; diseases of various
kinds.
  Division.—Partial and general.
  Effect on hulk of organs---May exist  without any positive loss of size, as in
eccentric atrophy of the heart, &c.
  Effect on function of organs.
   Tissues most liable to be  attacked.
   Treatment.
                          VII.  HYPERTROPHY.
  Definition.
  Causes.—More active nutrition in a part, dependent often on inflammation;
but also the result of other  causes—as exercise ; vicarious function;  excessive
or unusual exertion  in the involuntary muscles.   It may also be congenital.
Certain  climates and trades also predispose to its occurrence.   Castration  and
excision of the ovaries will cause hypertrophy.
  Division.—Partial or  general.
  Effect on bulk of organs.—May exist without positive enlargement.   Cite
examples of this.
  Effect on function of organs.
   Tissues most liable.
   Treatment.                ,
                            VIII.  CHEMOSIS.
   Definition.
   Causes.—Acute inflammation.
   Symptoms.
   Tissues most liable.
   Prognosis.
   Treatment.
                        v IX.  SUPPURATIpN,       .-/. .>_ ,.  /■'..-
             A      r   , * _. ,   \     i.-i t   ■ ■-* '- ' l                    ^
  Definition./.,      [A  ^  , '.  , v A ■■  ;    ,*■  f% /,£>■■<'  vi^,v /''   ■■-■■•■
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but without foundation.   The inflammation must not run too high, for here, as
in the  secrAions, there is a " secreting or rather suppurating point," above or
below whicPpus will not be formed.
  Situations in which it is formed.—1. Upon exposed inflamed  surfaces, as
the skin, mucous membrane, &c.
  2. Upon unexposed surfaces, as serous membranes, cellular membrane, &c.;
here called << purulent effusion." 
(   io   )
  3.  On Granulations.
  4.  In a sac, to which we apply the term abscess.
  5.  It may be diffused through the whole substance of an organ
  Time required for  its occurrence.—Varies  from thirty-five minutes up to
several hours, or weeks.
  Symptoms.—1. Local.   2.  Constitutional.
  Theories relative to the formation of pus.—Numerous.  Those of Hippocrates
and Galen, Boerhaave, Hoffman,  Stuart, Hunter, Simpson,  Morgan,  Gendrin,
Carswell,  Gulliver, Donne, Andral, and  Gerber, explained.
  Usual change in tissue before pus is formed.— Puogenic membrane of Hunter.
New gland of Simpson ;  not always present; usually exists in abscess.
  pus,—Two kinds ;  healthy or laudable and unhealthy.
  1.  Physical properties of healthy pus.—Colour,  smell,  consistence, taste,
specific gravity.
  Microscopic examination of—Two parts,  solid and fluid.   Solid composed
of pus globules,  and pus molecules.  Difference  between these and globules of
blood.
  Chemical analysis of.
  Tendency to putrefaction.
  2.  Several kinds of unhealthy pus.—(1.) Ichorous pus.   (2.) Sanious pus.
(3.) Creamy pus.  (4.) Curdy pus.  (5.) Slimy pus. (6.) Serous pus. (7.) Sordes.
(S.) Malignant pus.   (9.)  Contagious pus.
  Character of pits modified by cause and surfaces secreting it.
  Action of pus on the surface secreting it.
  Diagnosis.—May be confounded with mucus.  The various tests examined.
Also with tuberculous matter.
  Prognosis.—Depends on extent and location of deposite, &c.
   Treatment.—General principles laid down.  Modified by  circumstances.
   1. Local remedies.  2. Constitutional.

                                 ABSCESS.
   Definition.—A  collection  of pus in  an accidental or preternatural  cavity.
When pus is collected in a natural cavity, it is cj$lled an "effusion."
   Causes.—Always the result of  inflammation;  theory of Dehaen  no longer
maintained.
   Classification___1.  Old arrangement into "acute or hot,"  and  " cold or
chronic," noUjnger retained.A ' ■  ' '  ' ? :' '
   2. Abscess of debility, or asthenic abscess.
   3. Purule?it deposit,  or abscess by congestion.
   4. Metastatic abscess, t^-v.  «<»-ttA-
   Some writers make a much greater variety, based upon cause, tissue, or organ
 involved, &c.
    Changes which take place in the tissues from, the period of inflammation to
 that of suppuration.
    Changes that take place after this---Divided by some into  threejstages: 1st.
 deposite of pus in the cells of the  part;  2d, maturity, or the  colle^ion of this
 fluid into one cavity ;  3d, resolution,  either by absorption of the pus,  or its
 evacuation by an  operation.
    Structure of an abscess___Depends on its character.   The puogenic mem-
 brane is usually, though not always, present. 
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(   11   )
  Uses or functions of the cysts.
  Mode of growth.
  Direction of growth.
  Progress of growth.—Slow or rapid.
  Termination.—In  resolution,  ulceration,  granulation and  adhesion;  or it
may become encysted.
  Effects of air when admitted into the cavity of an abscess.
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                            ASTHENIC  ABSCESS.
   Peculiarities of this form of abscess explained.
                       PURULENT DEPOSITE, ETC.
   Definition___An abscess which  differs from the ordinary forms in the cir-
cumstance of its pus not being originally formed  in  the  parts in which it is
found.   It is  hence sometimes  called symptomatic abscess.   Cite examples.
Why called abscess by congestion?
   Parts most liable to this form of abscess.
   Pathology.
   Character of the pus.
   Diagnosis.—Often obscure.
   Prognosis.—Usually unfavorable.
   Treatment.—Depends  somewhat on  circumstances.  Governed by general
principles.  To illustrate more clearly the proper treatment speak of that form
called Psoas abscess.
                           METASTATIC ABSCESS.
  Definition___An abscess that suddenly forms without any previous indication
of inflammatory action, and in parts distant from the point in which suppuration
has  originally  existed.   Hence it was supposed by some that the pus actually
changed its location, or that metastasis took  place.
  Location.—Usually in  the  viscera.   Sometimes they are  met  with  in the
cellular  tissue, muscles, joints, &c.   They generally select the largest viscera
and those most  highly organized.
  Number.___Varies from one to several.
  Exciting causes___Wounds, great surgical operations, injuries of the  head,
trivial wounds of veins in bad  constitutions,  delivery.
  Proximate cause.—A number of theories on this point;  supposed by some to
be  tubercles previously existing in  the organs attacked, and softened by the
general irritation of the system ;  by others, direct absorption of pjjs by the veins
or lymphatics, is considered the true cause ;  others again refer it to sympathy ;
but the doctrine now generally received, is that which  considers the true cause
 to  reside in inflammation of the venous capillary vessels or larger veins.
    Condition of the organ in which  or around which the abscess forms.
   Symptoms.—I.  Constitutional.  2. Local.  Both modified by the location of
the abscess.
   Diagnosis. —Obscure.
   Prognosis.—Generally unfavorable. 
(   12   )
    Treatment.— 1.  General remedies.   2. Local remedies.   Both modified by
 circumstances.
                            FISTULA,  OR SINUS.
    Definition.
    Causes.
    Symptoms.
    Pathology.
    Diagnosis.
    Prognosis.
    Treatment.
                              HECTIC FEVER.
    Definition.
    Causes.—1.  Constitutional.  2.  Local.
    Symptoms.—May be divided into  three groups :  1. Slight  febrile action,
 with  exacerbations  in  the evening.    2.  The  febrile  action is  continued.
 3.  Prostration indicated by perspiration, diarrhoea, marasmus, &c.
    Diagnosis.
    Prognosis. I
    Treatment.
                           X. ULCERATION.

   Definition.—Differently defined by different authors.   I adopt  that of Phil-
 lips :  " Ulceration  is that  product of  inflammation in which there is a loss of
 some  part of the body, which from some peculiarity, local ox general of the
 constitution, manifests no tendency to heal, so long as that particular condition
 exists."
   Distinction between wounds and ulcers.
   Predisposing or exciting causes of ulceration.— 1. Constitutional.  2. Looal.
   Proximate cause.—Difference of opinion among authors.   Hunter's  doctrine
 of "Ulcerative absorption" explained.   Difference between it and " progressive
 absorption."
   Liability of tissues  to  ulceration.—The most  highly organized,  are  most
 frequently attacked.   Some tissues  are exempt.
  Natural tendency  of ulceration.—When left to itself  it  generally extends.
 Sometimes it heals spontaneously.
   Effects of ulceration upon the part attacked, or upon  the constitution.
   Tissue forming the surface of an  ulcer.—Called a granulating surface.

                              GRANULATION.
   Nature  of granulations.—\, basis  or element of which they are formed;
 2,  size;  3, color;  4, shape;  5, temperature;  6, organization.   Guterboch's
 statement as to what enters into the  composition of a granulating suiface.
  Dependence 9f granulation upon  suppuration—Pus is supposed by some to
 be essential to the formation of granulations ;  by others this is doubted.   It is
 not found, for example, in ulcers of the cornea or  cartilage.

                             CICATRIZATION.
  Cicatrization, or the healing of granulating surfaces.
  Definition of a cicatrix—Tissue  by  which a  wound  or ulcer is united.   Ey
Delpechit  is called  the << inodular tissue."
  Difference between cicatrix and the tissue it unites. 
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(   13   )
   Modification---This  process is modified by a variety of circumstances ;  for
example—
   1. When it occurs  under a scab or crust of blood, the cicatrix  forms over
the whole surface, and is smooth and  pliant.
   2.  When it takes  place on a smooth, moist surface, as when a wound  heals
by the " modelling process of M'Cartney," the surface is smooth, and the cica-
trix a mere line.  L.   ' ■'- ■ ,*• -        ....    ,    .   .  , ' '
   3.  When  it forms  on granulations, the process usually commences at  the
edges of the ulcer, and the surface  is often irregular and prominent.
   4.  It is also much modified by the cause of  ulceration.  Those, for example,
produced by burns or scalds, are more irregular, have more extensive adhesions,
and cause more serious deformity,  than when they result from any other cause.
Specific ulcers usually produce a characteristic cicatrix.
   5.  The character of a cicatrix is also modified by the tissue in which it occurs.
   Structure of cicatrix.
   Profundity or depth.
   Force  with which it contracts during the process of formation. &"~*~ '*" f ""
   Circumstances which prevent or  retard cicatrization.         , .
   Nature of the tissue of the cicatrix. / ■  > '
   Power of resisting disease, and diseases peculiar to the cicatrix---Refer to
Sir C. Hawkins for an excellent paper on Cancer of Cicatrices.
   Form of cicatrix.    Dupuytren?s classification.
   Prognosis as to the result of operations___Depends on a variety of circum-
stances.   We must  take into  consideration—1st, the depth of the cicatrix).
2d, its age;  3d, its location; 4th,  its  extent;  5th, its peculiar character; 6th,
its vascularity ;  7th,  the condition of the parts in its vicinity; 8th, the health
of the patient.                                      ; .    . /  . '
   Treatment of cicatrices.—May be divided into—1.  That proper  during  the
formation of the cicatrix.   2d.  That required  after its  complete formation.
   Indications under first head___1. Remove  all  agents  calculated to  prevent
cicatrization.
   2.  Endeavour, as a  general rule, to  make the cicatrix as  small  as possible,
unless by so doing we interfere with some function.
   3.  Prevent the cicatrix being too small or too short, as in wounds about the
fingers, face, &c.
   4.  By caustics or the knife prevent fungous granulations.
   Indications under the second head.—1. Endeavour to  relax the  cicatrix  by
frictions, baths, extension, &c.
   2.  When  these means  fail, perform an operation.   The character of the ope-
ration is modified by circumstances.   To render  this  part of  the subject more
simple, the operation required in each form of cicatrix may be briefly referred to.
   (1.) In the narrow  cicatrix without extensive adhesions, divide the cicatrix,
extend it, and maintain it extended for some time.
   (2.) In the  prominent cicatrix, slice it off, or keep it down  with caustics, or
slough it out.
   (3.) In the cicatrix with extensive adhesions, cut out the cicatrix and fill up
the space with sound skin.  The practice  of Hildanus, Earle, &c, in these cases
explained.
  (4.) In contraction  of natural openings.  The operation of Dieffenbach, &c,
explained. 
(   14   )
   (5.) When an organ is entirely destroyed, the cicatrix must be removed, and
 a plastic operation performed.
                                 ULCERS.
   Definition.—Solution of continuity accompanied by the  secretion of pus  or
 other fluid—(Liston and S. Cooper.)   A granulating  surface secreting pus—
 (A. Cooper.)   This definition is objectionable, inasmuch as we may have secre-
tion of pus without granulations.   The definition  of  Liston and S. Cooper is
 better.
   Difference between ulceration and an ulcer.
   Classification---Difficult. The causes, the symptoms, and the parts attacked,
 have  each been taken as the basis of a classification.   That of Liston I prefer,
 as being most simple.   He makes six varieties of ulcer, and in this agrees with
 Sir E. Home.  Their classifications are almost identical.
   1.  The simple, healthy, or healing ulcer.
   2.  The weak or  sluggish ulcer.
   3.  The indolent ulcer.
   i.  The irritable ulcer.
   ■5.  The specific ulcer.
   6.  The varicose.
                              SIMPLE ULCER.
   Characteristics.
   Causes.
   Class of persons usually affected.
   Parts of the body attacked.
   Prognosis.
   Treatment.
                              WEAK ULCER.
   Characteristics.
   Causes.
   Class of persons usually affected
   Parts of the body usually attacked.
   Prognosis.
   Treatment.
                            INDOLENT ULCER.
   Characteristics.
   Causes.
   Class of persons usually affected.
   Parts of the body usually attacked.
   Prog?wsis.
   Treatment.
                           IRRITABLE ULCER.
   Characteristics.
   Causes.
   Class of persons usually affected.
   Parts of the body usually attacked.
   Prognosis.
   Treatment.
                            SPECIFIC ULCER.
   Characteristics.—Depend on cause.
   Causes___Cancer, scrofula, fungus, scorbutus, syphilis, &c. 
 
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(   15   )
   The peculiarities of these ulcers will be pointed out under the heads of their
respective causes.
                            VARICOSE  ULCER.
   Characteristics.
   Causes.
   Class of persons usually affected.
   Parts of the body usually attacked.
   Prognosis.
   Treatment.
               XI.  MORTIFICATION,  OR SPHACELUS.
   Definition.
   Difference between gangrene and  sphacelus.
   Classification.—-Several terms are employed to designate the different groups
of phenomena which  characterise mortification under different circumstances.
We have, for instance —
   1.  Hot, acute, traumatic, or inflammatory mortification.
   2.  Cold, or that which takes place without previous inflammation.
   3.  Humid, or that accompanied by the effusion of fluids.
   4.  Dry, or that in which little or no secretion or effusion occurs.   From the
fact of  its being chiefly confined to old persons it is often called "  Gangrene
Senilis."
   5.  Chronic, or that form  described  by Pott, as  attacking chiefly the ex-
tremities.
   6.  Hospital  gangrene. '•  '■  "
   7.  Epidemic gangrene.
   8.  Specific gangrene—example.  Malignast pustule.
   Causes.___Various.  It  must  be  recollected that mortification may result
from  many causes  besides  inflammation.  Nearly all of  these may be ranged
under four or five heads.
   1.  It may be  occasioned by any  cause  capable of producing a cessation, or
partial cessation, or even a feebleness of the circulation in  a part—as inflamma-
tion,  mechanical obstacles, debility,  ossification of arteries, &c.
   2.  By any cause which occasions violent mechanical or chemical changes in
the part, as  contusions, lacerations, heat,  cold, mineral  acids,  and caustic
alkalies.
   3.  By any which, in consequence of their poisonous properties, will produce
a deleterious influence upon the system at large, as the virus of rabid animajs,
and poisonous reptiles, and animal fluids the result of decomposition.
   4.  By any that will impair the  powers of nutrition or  furnish bad chyle.
High living, or bad food, certain articles of  food, (as ergot,) bad air,  bad  lodg-
ing, and certain trades by obliging individuals to deny themselves proper food,
air, and exercise, will all predispose to mortification, and  may produce it with-
out local injury.
   5.  By any that will  cause intense passions or emotions of  the mind.  (.See
Langenbeck.)
   Manner in which these various causes operate upon the parts attacked.
   Liability of tissues to mortification—some more liable  than others.
   Time required for the process  of  mortification to be completed---Depends on
circumstances.
   1.  It may take place very slowly. 
(   16   )
 . 2.  It may occur very rapidly.
  3.  It may be instantaneous.
  Symptoms___1. Constitutional.  2.  Local.
  Process of sloughing.—When in consequence  of our remedies or the vix
medicatrix naturae, the progress of mortification is checked, a distinct boundary
line is formed between the living and  the dead  tissue, and nature proceeds to
amputate, as it were, the portion which has lost its vitality, by a process termed
"sloughing," and where the bones  are concerned by << exfoliation,'''' the  chief
agent in the accomplishment of which was  called  by Hunter  "disjunctive
absorption."
  The different changes which take place in this process  described.
  The  period at which it occurs after mortification is completed  depends on
circumstances.   State what these are.   Condition of parts after the separation
of the slough, and their manner of healing.
  Prognosis.—The effect produced upon the system by the occurrence of morti-
fication depends on the part involved.   If the organ destroyed is one of import-
ance, or vital, the death of the animal is either instantaneous or speedy.  If, on
the other hand, the part  affected  is not essential to life,  sloughing takes place
and the individual recovers.  Sometimes, however, this process is so tedious,
and the parts destroyed so extensive, that death ensues in consequence  of  debi-
lity and hectic fever.   It is also modified by the kind of mortification present.
  Diagnosis___May be  confounded with other  discolorations  of the  skin.
Positive signs of mortification must always  be present before we pronounce
upon  the nature of the case.  We must always be careful to ascertain the depth
of the slough ; for the  skin alone  may  be affected, when  there is every appear-
ance of the whole limb being involved.
   Treatment.—To prove of any advantage, so  far as the affected part is con-
cerned, our remedies must be applied in the stage of gangrene.   They  are also
modified by the varieties of gangrene,  the general condition of  the patient, the
character of the cause, &c. We  may,  however, lay down certain general indi-
cations to be observed in the management of all cases.
   1. We must endeavor to apply such remedies as shall put a stop to the dis-
ease in the stage of gangrene.
   2.  We must endeavor to arrest the progress of mortification when once formed,
and at the same time lessen the violence of the local and general symptoms.
   3.  We must favor the separation of  the slough, and when nature is incompe-
tent to the task we must effect it  for her.
   a.  In obeying  the first general  indication, we must always take into  consi-
deration the cause of the attack, and remove it, if possible, at once.   If inflam-
mation is the cause, antiphlogistics, general as  well as local, are to be employed.
If strangulation, or the arrestationoi the circulation be the cause, the  stricture
must be divided by an operation,  or relaxed  by nauseants, &c.  When produced
by the binding of aponeurosis, or skin, as in carbuncle, free incisions are to be
made.  When intense  cold is the cause, the temperature of  the  part  must be
gradually increased, and the subsequent inflammation treated  on general princi-
ples,  &c.   The best local remedies as a general rule, in this stage, are  cold and
astringent lotions, or warm fomentations, water dressings, or poultices. Leeches
may also be occasionally employed.
   b.  In carrying out the second general indication, we must resort to both con-
stitutional and local means.  Tonics, as bark, wine, opium, a good  diet and 
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(   17   )
fresh air, will generally be required.   The local remedies are incisions, (to be
used only when the tissues bind, or fluids are infiltrated to some extent,) blisters, k
nit. argent., creosote, yeast or  carrot poultices, chloride of soda, pyroligneous
acid, and carbonated water.  Charcoal  and bark, once so highly esteemed, are
not much employed at present.
   c. The third general indication is answered by the application of warm dress-
ings and poultices; removing the loose sloughs with  the  scissors and forceps;
and by amputation.
   Period at which amputation should be resorted to___Depend on cause.  In
traumatic mortification remove the limb as soon as possible.  In all other cases
wait until the "red line of demarcation"  is formed.
   Point at which amputation should be performed.
   In this stage it is usually necessary to support the constitution of the patient.

   There  are  certain  kinds  of mortification  which,  from  their peculiarities,
deserve a separate notice.  The first  of these is

                              DRY GANGRENE.
   Definition.
   Synonymes___Gangrene senilis—gangrene of the rich.
   Persons most liable.—The old and dissipated.  Men are more frequently
attacked than females.
   Causes.—Divided by  Francois into two classes.
   1. Those which operate through the medium of the vascular system, as in-
flammation of the  vessels, formation of clots  in their cavities, obliteration of
vessels, ossification of arteries, diseases of the heart, diseases of the blood from
bad food, as ergotted grain, &c, and mechanical injuries which obliterate vessels.
   2. Those which produce their effect  in consequence of either local or general
debility of the nervous system, as palsy,  old age, and the excessive debility of
certain  diseases,  particularly phthisis pulmonalis.
   Symptoms.—1. Constitutional.   2.  Local.  When  ergot is the cause,  the
attack may commence with  convulsions of the limbs and vertigo, or it may
begin with the usual local symptoms of dry gangrene from other causes. The
former was called by Linnaeus " convulsio cerealis," and by Wepfer, « convul-
sio ab ustaligine."   The latter, « necrosis ustilaginea," by Sauvages.
   Prognosis.—Usually unfavorable.
   Diagnosis___May be imitated by  malingerers.
   Pathology___Still a matter of dispute.  Cite the different views of Delpech
Cruveilhier, Dupuytren, Thuillier, Tessier, &c.
   Treatment.—1. Constitutional.   2.  Local.

                          INFANTILE  GANGRENE.
   Definition.                                                        "«•
   Persons liable.
   Parts usually attacked.
   Causes.—Question of its  contagiousness.
   Symptoms.
   Prognosis.
   Diagnosis.
   Treatment.
2 
(   18   )
                       CHRONIC MORTIFICATION7.
   Definitions.
   Persons most liable.
   Causes.
   Symptoms.
   Prognosis.
   Diagnosis.
   Treatment.
                         HOSPITAL  GANGRENE.
   Definition.
   Synonymes.—Phagedena gangrenae ;  putrid or malignant ulcer;  hospital
sore;  gangrena  contagiosa.
   Causes.
   Symptoms.
   Prognosis.
   Diagnosis.
   Pathology.
   Treatment.
                  MALIGNANT  PUSTULE OR CHARBON.
   Definition.
   Causes.
   Symptoms.
   Prognosis.
   Diagnosis.
   Treatment.
              VARIETIES OF INFLAMMATION.
                             ERYSIPELAS.
   Definition___A peculiar form of inflammation attacking the skin and mucous
membranes, taking its name from two Greek words which signify red and skin.
It is also called St.  Anthony's fiie.
   Division.—Almost every writer has given his own classification.  I adopt
that of Mr. Lawrence.  He makes four  varieties :—1.  Erythema.   2. Simple
Erysipelas.  3. GSdematous-Erysipelas.  4. Phlegmonous Erysipelas.
   The " erysipelas ambulans vel erraticum" of La Motte, and the << universal
erysipelas" of Hoffman and others, being mere modifications of one form  or the
other of the varieties made by Lawrence, should not be considered as peculiar
forms of the complaint.  The division into idiopathic and symptomatic may be
retained.
   Symptoms___Vary in the different forms.
   Seat of the  disease.—Commencing on the surface of the skin, it gradually
becomes  more profound until it involves in some  cases the subjacent cellular
and other tissues.
   Question of its contagiousness.—Still a disputed point.  For my own part I
believe that it is not.  It may be epidemic.
   Causes.—Predisposing—constitutional and local. 
 
 
                                (    19   )

  Prognosis.—Depends on location and extent—the health  and conditiou of
the  patient.
  Diagnosis.—May be confounded with common phlegmon.
  Treatment.—Varies somewhat with the kind of erysipelas.  May be divided
into—1. Constitutional.   2. Local.
  Being essentially inflammatory, antiphlogistic remedies are required in the
first stage.   Emetics are  often  useful.  In  phlegmonous  and oedematous ery-
sipelas,  when  sloughing occurs,  it often becomes necessary to support the con-
stitution.
  The local remedies are very numerous.  1st, cold ; 2d,  leeching; 3d, scarifi-
cations ; 4th, incisions ; 5th, blisters ;  6th, argent, nit. as applied by Davidson,
or after the method of Higginbottom ;  7th, tinct. of iodine ;  8th, British oil;
9th,  ungt. hyd. mit. ; 10th, dry powders; 11th, compression, as recommended
by Velpeau and Bretonneau.  Examination of the value of these different agents.
                        ANTHRAX,  OR.  CARBUNCLE.
  Definition.—A  deep-seated,  circumscribed inflammation  of  the  skin  and
cellular tissue, characterized by  its hardness, peculiar  burning pain, and termi-
nation in gangrene.
   Varieties.—Benign and malignant.
   Causes.—Constitutional and local.
   Symptoms.—Vary with stage.
   Diagnosis.—Pustule maligne may be mistaken for it; also, common furuncle,
and erysipelas.
  Prognosis.—Depends on location and general health of patient.
   Termination.
   Treatment.—Varies with stage.
                          FURUNCULUS OR  BOIL.
   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Termination.
   Treatment.
                          PERNIO,  OR CHILBLAIN.
   Definition.—Specific inflammation.   The result of cold.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.—Divided into that proper in the early stages, and that required
after vesication and ulceration have taken place.
                               FROST-BITE.
  Definition.—A form of inflammation the result of the application of intense
cold to any  part of the body.
  Symptoms.—Constitutional and local.
  Diagnosis.
  Prognosis.
   Treatment.—Varies with degree, location and stage. 
(   20   )
                                  BURNS.

   Definition.
   Causes.
   Classification.—Hildanus, Boyer, Thompson, and others, make three kinds :
   1.  Superficial, involving merely the outer surface of the skin, and terminating
always in resolution.
   2.  Vesicular, or ulcerated, in which the cuticle is raised into blisters.
   3.  Sloughing, in which the  cutis is destroyed either  immediately or subse-
quently,  and forms either a " soft slough or hard eschar."
   This classification being simple is the one most generally adopted, but that of
Dupuytren is much more scientific; being based as it is upon the nature of the
textures and organs involved.   In this, six varieties  or degrees are made.
   1.  Erethema, or superficial phlogosis of the skin without vesicles.
   2.  Inflammation of the skin,  with detachment of the cuticle and formation of
vesicles.
   3.  Destruction of the corpus papillare, and rete mucosum.
   4.  Complete disorganization of the cutis down to  the cellular tissue.
   5.  Conversion of all the superficial textures and muscles into eschars.
   6.  Carbonization of the whole thickness of the burnt part.
   Symptoms.—Vary with the degree of violence with which the causes pro-
ducing them have operated.   Divided into—1.  Constitutional.   2.  Local.
   Diagnosis.—May be confounded with erysipelas.
   Prognosis.—Deduced from extent, depth, and situation; age and constitu-
tion of the patient; and the character of the cause.
   Periods of danger.—According to Dupuytren there are four :
   1.  The stage of irritation, or the period of the first shock on the system.
   2.  The stage of inflammation.
   3.  The stage of suppuration.
   4.  The stage of exhaustion or hectic.
   Post mortem.
   Treatment.—Varies with the degree, &c.
   In the first and second degree, we must endeavor, by both constitutional and
local measures, to prevent inflammation or limit its  extension, and relieve pain.
Should there be no chill, the best topical applications, at first, are cooling refri-
gerant lotions; should fever supervene, low diet, venesection, topical  bleedings,
and cooling medicines, must be administered;  and to allay  pain, it is proper to
give  anodynes.
   When the patient  is cool or prostrated, wait for  reaction or promote it, and
in the mean time cover the burnt part with raw cotton.
   When reaction  takes place, then resort to the antiphlogistic system
   When vesicles  form, and suppuration takes place, apply, instead of the cold
the linimentum aquae calcis,  or a mild poultice.
   The vesicles should  always be punctured with a needle, and the  fluid thus
evacuated.
   The cuticle must not  be removed.
   In the third and fourth degrees, the same general rules are to be observed.
   Where the pus collects under the slough, free incisions are to be  made and
poultices applied until the slough is detached, or until healthy granulations form. 
 
 
(   21   )
   In  the fifth and sixth degrees, the patient  is generally prostrated, and we
have to resort at once to stimulants.   Some  advise local stimulants, or "the
calefacient treatment;" but as the parts are nearly if not entirely destroyed, and
must be detached by sloughing, it  is  best to  apply warm poultices at once.
During the detachment of the slough, the patient's strength must be supported.
   The ulcers resulting from the detachment  of the slough are generally indo-
lent, and must be treated on general principles.
   Where a limb is entirely destroyed, amputation must be resorted to as soon
as reaction takes place.
   Local treatment during cicatrization to prevent deformity.
   Local treatment of the deformities arising from the unfavorable cicatrization
of burns.

                 SCORBUTIC  INFLAMMATION, OR SCURVY.
   Definition.
   Causes.
   Symptoms.
   Pathology.
   Prognosis.
   Diagnosis.
   Treatment.

               SCROFULOUS INFLAMMATION,  OR  SCROFULA.
   Definition.
   Synonymes.
   Tissues most liable to be attacked.
   Age at which the disease usually manifests itself.
   Causes___1. Hereditary.  2. Accidental.
   Characteristics of the "scrofulous diathesis."
   Symptoms___1. Constitutional.  2. Local.  Both are modified by the organ
or organs attacked.
   Diagnosis.
   Prognosis.
   Pathology.
   Treatment___1. Local.  2. Constitutional. 
(  22   )
                         WOUNDS.

  Definition.—A  recent  solution of continuity in the soft parts suddenly
occasioned.by external causes, and attended at first by more or less hemorrhage.
—(Cooper.)
  Objections to this usually accepted definition.—A wound may be pro-
duced by violent action of the muscles alone; and by the protrusion of a frag-
ment of bone.   We may also have a wound occurring in bone.
  Classification of wounds.
  First division—Is based upon the nature of the instrument inflicting the
wound.  Thus we have incised, punctured, lacerated,  contused  and gun-shot
wounds.
  Second division—Is based upon the introduction of some venomous, morbid,
or putrid matter, into the wounded part.   Hence we have poisoned, specific,
and dissecting wounds.
  Third division—Is based on the regions or parts involved.  Thus we have
wounds of the head, face, chest,  abdomen, &c.
  Fourth division___Wounds are also divided into the simple and complicated.
  Dangers of  wounds.—These depend on—1st, the  size, or the  extent of
injury;  2d, the weakness or strength of the parts involved ; 3d, the importance
of the organ ;  4th, the size of the bloodvessels involved ; 5th,  the kind of vessel
rartery or vein); 6th, the diathesis of patient; 7th, the  age of patient.
  Causes  of death.—1st, hemorrhage;  2d, tetanus; 3d,  traumatic  fever;
4th, erysipelas; 5th, hectic fever; 6th, gangrene;  7th,  metastatic abscess.
  Process  of healing.—Until recently, only two methods  described : union
by the first intention, and union by granulation, or the second intention.  Pro-
fessor M'Cartney has established the existence of tw©  others, and we  may;
therefore, make four different processes of union, viz :
  1. Immediate union.
  2. Mediate  union by lymph or blood, or union by the first intention.
  3. Union by the modelling process.
  4. Mediate by granulation, or by the second intention of Hunter.
  Objections to McCartney's  views.
  Mode of organization of the lymph and blood.
  Difference between Hunter and McCartney relative to the  necessary
presence of inflammation in the healing of all wounds.
  Comparative advantages of the different modes of union.
  First and second  should generally be  attempted ; because when either  takes
place, we save  time and pain, and obtain a strong and generally but slightly
deformed cicatrix.
  State  the objections urged by many of the  French authors and others against
these two modes of union in large wounds.
  Circumstances preventing union by the immediate or mediate  processes.
—Divided into—1, constitutional; 2, local. 
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(  23   )
   First, or constitutional.
   I.  Bad habit of body.
   2.  Diseases of various kinds.
   3.  Simple fever.
   4.  Vitiated atmosphere in hospitals, &c.
   5.  Epidemic influences.
   Second or local.
   1.  Atmospheric  air.
   2.  Foreign bodies lodged in the wound.
   3.  Large coagula of blood.
   4.  Laceration or severe contusion of the parts.
   5.  Faulty dressings.
   Character of the tissue by which wounds are united.—Already alluded
 to.   It is a singular fact, that with the exception of bone, all tissues unite by a
 substance different  from themselves.
   The different classes of wounds may next be considered; and first of

V                       ■  INCISED WOUNDS.
   Definition.
   Extent and direction.—Always to be regarded.
   Characteristics.—Pain, gaping, hemorrhage.
   The pain is owing to lesion of the nerves;  the gaping to the ordinary elasti-
 city and contractility of the parts, and also to the situation of the wound.  The
 hemorrhage proceeds from a wound of an artery, or vein, or both, and  its cha-
 racter  is  modified accordingly.  State  these modifications.  Its  activity is
 dependent upon the character of the wound, and the size of the vessel.
   Prognosis.
    Treatment.—General indications.
   1. Arrest of hemorrhage.
   2. Remove foreign bodies.
   3. Approximate and retain the sides of the wound in contact.
   4. Prevent or subdue inflammation.
   5. Protect the wound from injury by appropriate dressings.
   First indication.—Hemorrhage may be arrested either by an effort of nature,
 or by the assistance of the surgeon.   Explain the process by which the bleed-
 ing is spontaneously arrested.   We are not to wait for this, however, but must
 resort to the various agents afforded by our science.   These are numerous, and
 are to be modified  or varied according to circumstances.
    1. When the vessel is deep and beyond our  reach,—as  in wounds  of chest,
 abdomen, &c___our best remedies  are bleeding, digitalis, cold, rest,  low diet,
 and positive quietude of mind.
    2.  When the vessel is accessible, we may resort to
    a. The ligature.
    b. Torsion.
    c. Machure.
    d. Refoulement, or reduplication.
    e. Compression.
   /. Refrigerants. 
(   24   )
   g. Styptics.
   h. Suture.
   i.  Plugging.
   j.  Seton.
   k. Acupuncture.
   I.  Electro-puncture.
   The most important of these agents is the
                                LIGATURE.
   History.—Mentioned by Celsus;  but not  generally employed until the time
of Pare.
   Effect on an artery.
   Effect on a vein.
   Changes which take place in the blood contained in the vessel.
   Changes which take place in the vessel itself.
   Manner in which the ligature is discharged.
   Cause of danger when the ligature comes away.
   Time required for the obliteration of the vessel.        t          .  Z.y     k>   - ij
   Materials of which ligatures are usually made,  t* ''' '
   Shape and size of ligature.
   Mode of tying the ligature.
   Method of applying a ligature.—Depends on the location of the vessel.
   1.  When the vessel opens on a surface, as  in the wounds of amputation, &c.
we require a tenaculum, or artery forceps.
   2.  When the vessel is deep-seated, or when we wish  to cast a ligature in the
course of a vessel, as in aneurism, we may use the various aneurismal needles,
or a bent probe.   Objections to the needles.   In all large wounds it is well to
apply a ligature to both ends of the vessel.   Why ?
   Subcutaneous ligature. <\x..^,\^ i  ,"  ,                                    ' ^-*"
   Ligature d'attente, or ligature of reserve.  <v^ ^r-  V^ L-x   .  ''■'■■
   Scarpa's ligature.
   Ligat7cre and section of the vessel.
   Temporary ligatures.
                                TORSION.
   Definition.
   History.
   Arteries to which it is considered applicable.
   Mode of performance.
   Objections to its employment.
                                MACHURE.
   Definition.
   History.
  Arteries to which it  is considered applicable.
   Mode of performance.
   Objections.
                      REFOULEMENT, OR INVERSION.
  Definition.   -
  History.   &Q '  :  "  c'
  Arteries to which it is considered applicable.
  Mode of performance.
   Objections. 
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(   25   )
                              COMPRESSION.
   Importance.—Useful either as a temporary or permanent agent.
   Points upon which it may be applied.—Either directly upon the  bleeding
surface, or  at some distance from it.
   Class of wounds in which it is most useful___Wounds of extremities, or ovei
bones or firm tissues.
   Agents of compression.—1st, compresses; 2d, rollers;  3d, hand of assistant;
4th, tourniquet; 5th, garot; 6th, tissue itself.

                              REFRIGERANTS.

   Cases to which they are applicable.
   Agents usually em-ployed.—Cold air, cold water, ice, &c.

                       STYPTICS  AND ABSORBENTS.
   Cases to which they are applicable.
   Agents  usually employed___Salts of the metals, kreosote,  sponge, agaric,
lint, cobweb, dry powders, &c.

                         CAUTERY  AND  CAUSTICS.
   Cases to which they are applicable.
   Heat at which the cautery should  be applied.
   Agents employed.—Metallic bodies of different shapes,  mineral acids, argent.
nit., &c.

                                 SUTURE.
   Mode of application.
   Cases to which it is applicable.
                               PLUGGING.
   Cases to which it is applicable.
   Manner of applying it.—Speak of Sana's proposition to  " plug the artery"
in ordinary hemorrhage.

                                 SETON.
   Mode of application, &c.

                              ACUPUNCTURE.
   Mode of application, &c.
                           ELECTRO-PUNCTURE.
   Mode of application, &c.
   Manner  in which the circulation is carried on in a limb, after the obliteration
of a large artery.
   Second indication___Having arrested the hemorrhage, the next indication is
to remove foreign bodies.
   Character of these, generally speaking.   Should coagulated  blood  be  consi-
dered a foreign body ?
   Manner  of removing these bodies.
   Third indication.—The next indication is to bring the sides of the woimd in
contactahd retain them in this position. 
(   26   )
  Agents employed to fulfil this indication.  1. Position. 2. Sutures of different
kinds.   3.  Adhesive straps.  4. The rollers.  5. Splints
   Fourth indication.—Protecting the wound from injury is the next indication.
   Agents  employed to fulfil this  indication.  Much more  simple at present
than formerly.   The lighter the dressing the better, when we wish  union by
the first intention.   Cold water dressing.  When union by the second intention
of Hunter is desired, the best top dressing is the << warm water dressing," or
poultice.
   Fifth indication___To fulfil this indication, antiphlogistics, both general and
local, are usually required.

                        LACERATED  WOUNDS.
   Definition.
   Causes.'
   Characteristics. £> .■ '  ' <    .,••-_.' '.*"''    ,
        »"   . AA  /■»■ t ,  ■  ' < .  . ^<-   '
   Prognisis.', ', '>',A*A/>A'■  .«. ■
   Treatment.—General  indications.
   1.  Arrest the hemorrhage  when it exists.
   2.  Attempt, if possible, union by the  "immediate or mediate" processes.
Mode of dressing to accomplish this.   Irrigation and water dressings.
   3.  When suppuration  takes place,  promote  the  secretion by a poultice, or
warm water dressing.
   4.  Keep down inflammation at first, but when suppuration is profuse, support
the constitution.
   5.  When the extremities are, involved, the question of amputation may occur,
                      /-<  '-.-'■ ■ A-  -  .; c,. '  v •     .  ■   .
                        .  CONTUSED WOUNDS.
   Definition.
   Causes.
   Characteristics.
   Prognosis.
   Terminations.
   Treatment___General indications.
   1.  When the contusion is complicated with a wound of the integuments, close
the latter as soon as the  hemorrhage (where it exists)  is  arrested, and  foreign
bodies removed.
   2.  Keep down inflammation by antiphlogistics, both local and general. Dress
lightly, &c.
   3.  In severe contusions,  it is often necessary, at first to  stimulate the patient,
but this should only be done when the  prostration is  great.
   4.  After the inflammation  becomes chronic, or when the blood is not readily
absorbed, use stimulating frictions,  bandages, &c.

                        PUNCTURED  WOUNDS.
   Definition.
   Causes.
   Characteristics.
   Prognosis.
   Treatment.—General  indication. 
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«H                                PENETRATING WOUNDS.   <  rT   w t ,v, /- ,» ,  «  p»,./•■''•»'-

r"            Definition.**" ^ '  **'   " '   '    "                                           .    <


              Characteristics.,'       ' «''"'*"/"   A '     >*-,>-... ■>  ,'  •'»■    £i <-<■ <•  * '
y<f(^>  .Prognosis.      7           ,                     A^v^i^v^ . -/ — v*~- •* —
'A: /         f IWmerc*.—General  indications.  fl-TA-v)  6 JA£jA^    ^ //7 ^   ,   ■ .'K^
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■>, /  A- A                "     POISONED  WOUNDS.
N. '                                       ~}                    ,,,  ((   „7,  J„„  ■.  * v.
y.      ^^  Definition.       y t.*+*~>*  •»'


          ,     Characteristics. '                                                                    \
        ^*"    Prognosis.
        tj     Treatment___Depends on the character of the cause.
               1. When they  are produced by the stings of insects, the remedies are—cold
             applications, volatile alkali, saline  solutions to  the  part  affected; and occfc-
     V-/    sionally bleeding, diet, and purgatives are required.
               2. When they  are produced by the bites of  venomous or rabid animals the
             remedies are aligature above the wound, excision of the part, cupping or suction i\y 'JK I «■*. v
             of the wound, caustics,  poultices, and often constitutional remedies, according
             to the condition of the patient.
               3. Dissecting wounds are best treated by suction, caustics, leeches, a blister
             above the wound, a poultice or  cold to the part, and constitutional remedies ac-

■ftf.           cording to circumstances.

*,*                                                   ^A,<-x„x.x!A^ k.*t**rh*":  **


wix              Definition.«, A»- A"/** ^ ^  ,V^V*-?  if A , U *>«.* »  A* '•* ♦ '' '< > >'■' '   " ;Tt'-'
/) i.              Causes.                              •             ,        ,                        ,.
A,.              Time of appearance after the reception of the in jury.''*> ?l - -  -■ *    ^      ,
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 U*:            /Pathology.   ,      ^_ -     . .      '         ,  ,  /                                 ^*
mXi              Prognosis.    /            /                 /                                *  ,
jfeii              Diagnosis.             •   '---,'      \.,     ,  /^..'. / -£> <T/a -3 4  * ' *  ''   v^v  '
                Treatment. 0  «*t ~-^*-  *^** '"*  " *"                          '   /  ''          ;,  .


                                      GUN-SHOT WOUNDS.

      /*f'*"-   i                 ^. '     -.    .       *v-  ^ Ay-~'  '3 /ua/i-^-vzA-.
        %j ?   J  Definition. A-j/t-'f  *" * ''  "' / "        £       ft   /

J?      ,  !  ^ ^ITarteriM.         ..   ,.,.,_. .  jl ,'-. .• •  •  f         y  S?S^ *>  «<' f^ ^
        i •■*>>-  Characteristics.—Constitutional  and local.                 /   ,-, /:„,  V( .

      v<  1  ->  TF»«^wo.?»^* —HovY produced.* *-/'/'/*•.>__
      V  ^  '^^^ Chin-shot wounds usually contain foreign bodies.

      V ^    ^Pathology of the wound.
     Ai.  J     "* Prognosis.                                          ,      ,
     "  *    -  2V«t«e»*--Several indications. Modified by nature of wound.
       1   • .   -  1. Attend to  general condition of patient at the time the wound is received.
    1 "*     -.2. Arrest the hemorrhage where it exists.

      +   '    -  3. Examine wound.
     k" 'A A "• 4  Remove foreign bodies,  if possible.  ,      , .
      I  AAV.  y      ...:.^.iic*i         •   y-^^'-^  ,-;,<-.•'
r~ a

  \
A.

 
(   28   )
  5. Dress the wound.  Cold applications should first be tried, and if these fail
to afford relief, apply warm or hot.
  6. Guard against secondary hemorrhage.
  7. Prevent the formation of pus.
  S. Prevent inflammation if necessary by antiphlogistics.
  9. Support the general health,  if necessary after suppuration is established.
 10. Heal sinuses.
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■ - ,r / 
SECOND  DIVISION, OR DISEASES  OF  THE

                          TISSUES.


               I. DISEASES OF THE BONES.

   General Remarks.
   Bones most liable to disease.
   Causes  of Disease.
   Effects on Constitution.
   Classification___All diseases of the bones may be ranged under three heads.
   1. The  non-malignant diseases.
   2. The  malignant diseases.
   3. Wounds and fractures of bones, and their occasional results.
   First head, or non-malignant diseases.
   a.  Neuralgia.
   b.  Atrophy.
   c.  Hypertrophy.
   d.  Osteitis.
   e.  Abscess.
   /.  Ulceration.
   g.  Necrosis.
   h.  Mollities ossium.
   i.  Fragilitas ossium.
   j.  Rachitis.
   k.  Tubercle  in bone.
   I.  Osseous aneurism.
   m. Exostosis.
   n. Hydatid encysted tumor.
   o.  Serous encisted tumor, or spina  ventosa.
    Second head, or malignant diseases.
    a. Osteo-sarcoma.
    b. Medullary sarcoma.
    c. Fibrous sarcoma.
    d. Fungus Hematodes.
    e. Melanosis.
                             First Head.
                          I. NEURALGIA.
    Diagnosis.
    Causes.
    Symptoms.
    Prognosis.
    Diagnosis.
    Treatment. 
*
                                (   30   )

                        II. ATROPHY  OF  BONE.
   Definition.
   Varieties.
   Causes___1, diseases of various kinds ;  2, retardation of structural growth ;
 3, old age.
   Effect upon the strength of the bone.
   Appearance of the bone.
   Analysis of atrophied bone.
   Treatment.
                          III.  HYPERTROPHY.
   Definition.
   Varieties.
   Causes___1, exercise; 2, excessive nutrition in  different bones;  3, inflam-
 mation ;  4, degeneration of soft deposits  upon bone, the result  of  periosteal
 inflammation.
   Effect upon the strength of the bone.
   Symptoms.
   Appearance of bone.
   Treatment.
                             IV. OSTEITIS.
   Definition.
   Question of its possible occurrence.
   Varieties.—1. Acute.  2. Chronic.
   Persons most liable.
   Bones most frequently attacked.
   Causes.—1. Constitutional.   2. Local.
   Symptoms.
   Diagnosis.—May be confounded most readily with periostitis and endostitis.
   Prognosis.
   Terminations.—Resolution, atrophy, hypertrophy, suppuration, ulceration,
mortification.
   Dissection.
   Treatment.—Depends on variety of  inflammation, its intensity, and the bone
attacked,   The remedies required may be either general or local, or both com-
bined.
                        V. ABSCESS IN BONE.
   Location of matter.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.
              VI.  CARIES,  OR ULCERATION  IN BONE.
  Defiyiition.
  Confusion among authors as to its precise nature.
  Bones  most liable to be involved. 
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                                (   31   )

   Varieties.—Simple, syphilitic, strumous, malignant, &c.
   Causes.— 1. Constitutional.   2.  Local.   The seat of the disease,  when
constitutional causes operate in  its  production, is modified very much by the
character of the cause.
   Symptoms.—Constitutional and local.  Modified by the cause, stage, location,
and extent of the disease.   Usually three stages.
   Diagnosis.
   Prognosis___Often confounded with osteitis, periostitis, endostitis, necrosis.
   Dissection.
   Chemical analysis.
   Treatment.—Both constitutional and local remedies will usually be required,
and these must be modified to suit the  stage, intensity, and cause of the disease.
In the first stage, antiphlogistics are usually required.  In the  second stage,
emollients or stimulants, to  change the  character of the ulcer, are  generally
employed.  In the third, we must either cut out the diseased bone, destroy its
vitality, or remove the limb.
   The cause must always be removed, if possible ; and if  specific in its cha-
racter, specific remedies or alteratives are to be employed.

                              VII. NECROSIS.

   Definition.
    Confusion among authors as to its precise character.  Louis was the first to
 describe it accurately.                             ^     ,
   Bones most liable. '■  '  '  / " "                        { '
    Causes.—I.  Constitutional.  2  Local.  Most of these operate through the
 medium of the periosteum, either internal or external.   Some effect the bone
 primarily.
   Remarks in reference to the influence of the periosteum.
    Varieties.—1. External.  2. Internal.   3.  Complete.
   Symptoms.— Constitutional and  local.   Often obscure.  We  have usually
 three distinct stages  in  the progress of the disease.
    1.  The inflammatory stage.
    2.  The stage of suppuration and detachment.           .;
    3.  The stage of reparation.     ^
    In external or superficial necrosis, the local symptoms, in the first stage, are
 a dull or acute  pain, soon succeeded  by a flattish tumour, in which fluctuation
 is after a time observed.  The skin next  changes its color, ulcerates, and  pu3
 is discharged.  There is always more or less fever.
    In the  second  stage, the swelling  diminishes  in  size, the bone is felt bare,
 rough, or smooth, according to the nature of the action preceding its death, often
 rings when struck, and when we can see it is either whiter or darker than natu-
 ral.   The pus discharged  is either laudable or unhealthy.  There  is sometimes
 inflammatory fever in this  stage,  but often we  have  hectic.   The  bone is
 gradually loosened and detached by a process termed "exfoliation," which is
 very analogous to sloughing of the soft parts.
    In the third  stage,  the local  symptoms become  milder, the constitution im-
 proves, and the new bone is formed.
    In internal or complete necrosis, all  the symptoms are more severe ; and in 
                                (   32   )

 the second stage, the swelling does not diminish in size so much as in external
 necrosis.
   Process of separation described.
   Manner in which the sequestrum or dead bone is disposed of.—Depends upon
 its being external,  internal or complete.
   Process of reparation described.—Varies in the different kinds of necrosis.
   Character of the new bone and its various stages of organization.
   Cloaca.—How formed, shape, &c.
   Prognosis.
   Diagnosis.
   Treatment.—General indications.
   1.  Remove the causes.
   2.  Palliate the symptoms.
   3.  Remove the dead bone after its detachment, and sometimes detach it with
our instruments.
   4.  Treat the limb, where the entire shaft of the bone has  been destroyed, as
you would a fracture of the same part, until the new bone is sufficiently firm.

                      VIII. MOLLITIES OSSIUM..

   Definition.
   Causes.
   Persons most liable to be attacked.
   Symptoms.
   Prognosis.
   Diagnosis.
   Pathology.
   Treatment.

                      IX. FRAGILITAS OSSIUM.

   Definition.
   Causes.
  Persons most liable to be attacked.
   Symptoms.
   Prognosis.
  Diagnosis.
   Pathology.
   Treatment.

                           X. RACHITIS.

  Definition.
  Causes.
  Persons most liable to be attacked.
  Symptoms.
  Diagnosis.
  Prognosis.
  Pathology.
  Treatment.             " 
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(   33   )
                       XI. TUBERCLE  IN  BONE.

   Varieties.—1.  Encysted tubercle.  2.  Tubercular infiltration.
   Characteristics of first form, or encysted tubercle.
   Effects on surrounding parts.
   Similarity between encysted tubercle in bone, and tubercle in other tissues.—
Sn bone, as in the lungs, &c, the crude tubercle proceeds  from the semi-trans-
parent gray granulation, of Laennec and others.
   Process of reparation after softening of the tubercle.
   Tubercular pouches.
   Results of these collections___1. They may be absorbed. 2. They may cause
suppuration and ulceration  in the bone.   3. They may serve as the nidus of
new tubercles.
   Stages in the development and maturation of encysted tubercle.
   1.  Semi-transparent gray granulations.
   2.  Crude, opaque, encysted tubercle.
   3.  Bony excavation, loss of substance in the bone.
   4.  Evacuation of the tubercular cavity.
   5.  Hypertrophy of the cyst, obliteration of the cavity, recovery, (Nelaton.)
   Characteristics of  second form, or tubercular infiltration.—This may exist
alone, or in connection with the other variety. It usually presents two different
conditions.
   1.  Semi-transparent infiltration.
   2.  Puriform or opaque infiltration.
   Difference between the two.
   Effects  on surrotmding parts.—Invariably  causes necrosis of  the part
attacked, and also produces purulent infiltration.  It may also occasion tuber-
cular  cysts, caries, &c.
   Process of reparation after the bone is affected or destroyed.
   Stages in the development and termination of this form of tubercle.
   1.  Semi-transparent gray infiltration.
   2.  Interstitial hypertrophy of the ttony tissue, or ivory degeneration.
   3.  Puriform infiltration.         •
   4. Necrosis of the infiltrated portion.
   5.  Sequestration—foreign body—(Nelaton.)
   Diagnosis of tubercle in bone.
   Prognosis.
   Seat of the disease.
   Persons most liable.
   Diseases produced by these tubercular deposits.
   1. Certain forms of diseased spine.
   2.  Certain forms of white swelling.
   3. Certain diseases of the smaller joints.
   -1.  Certain diseases of the inner ear.
                                                   Aa^  '/v y-
                      XII. OSSEOUS ANEURISM.  A.      / . /  ■
        . .   T»               ,,/*.* •*%      i x -. V         '
  Definition A* *,<.■'-
   History. A 'w
   Causes. I
        3 
                                  (   34   )

_  Persons most Halle, fin r^*^ A> • <*■ * ' - '   "*»»^-«.«  ,-y'l-   V
Location.
a
   Symptoms.                     \».
   Effects on adjacent parts.  t                                       %t
   Diagnosis.   -.. , ,  . »w ,-/« -«  '  " •- ^   *"-•  "
   Prognosis,  i w-f  t.»t«» »
   Dissection.            z    # f
   Treatment,  ^i^^  *  ^'*      ^ .  «-*»<»-  •     *"   "-

          XIII.  EXOSTOSIS, OR SIMPLE BONY TUMOURS.

   Definition.
   Classification.
   1. Those which originate in the periosteum, or sub-periosteal cellular tissue,
and may be  termed external, periosteal, or peripheral.
   2. Those which originate in the substance of the bone, or in its cavity, and
may be called  internal or parenchymatous.
   3. The cartilaginous*.  £■ - ■       St. •  ■    . ■  *
   4. The ivory-like.  hlW-tx. Ui  1* d-. .
   5. General  Exo.ttosis involving the  entire bone. <■*■ *'*•'*•   "~*n
   C. Partial Exostosis, when the disease is confined to a portion of the bone.
   Mode of development of the periosteal tumours.
   JMode of development of the parenchymatous tumours.
   Liability.—Some bones more frequently attacked than others.
   Number of tumours.                 11   ,   \  .
   o-    ,A      c.o-*>-<*,  -v.v~*-U- US- *-u  ,
   Size of tumour. \s^               ,    .,»
   Color of tumour. fuAzU  c * <■*  Qj  K"'U "
   Form of tumour.
   Causes of disease.
   Symptoms.—Vary  with the cattse, structure, and shape of tumour, its loca-
tion, and the rapidity  with which it grows:
   Effects on adjacent parts.             '>
   Diagnosis.
   Prog>iosis.
   Terminations.—1.  Resolution.  2. Conversion into other tissues. 3. Necrosis
4. Suppuration.
   Treatment.—1. Medical.  2. Surgical.

          XIV.  HYDATID  ENCYSTED TUMOUR  OF EONE.

   Definition.
   Causes.
   Part of tin bone most liable to  be attacked.
   Effect upon the lone.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.  # A~-»-v v- A*- ;   A!.* - K 
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(  35   )
                    XV. SEROUS ENCYSTED TUMOUR OF BONE.
            Definition.                                                             (
     ,       Syuonymes---Spina ventosa, fibro-cellular tumour,  wind ball, &c.        *A&  ':•" *''--"■.-
   aL**+l- 'Causes.<t-t-^*^£-/-  >':   .  -t-^e..-,. ■   f'-A   <^ fx\w  i^'i-^^.■•- '-> >>v-*'■-^.
            Part of the bone most liable to be attacked. 1yA^> £-x-»-Y ox^^, y f^^ y     ( v^ ,
            Usual situation of the tumour.                                    C
            Effect upon the bone.                                     ?l\   f  .   A    ,

            Symptoms.  lA^ &**"«■ *~~ ' v"^   '  Y
            Diag7iosis.                                       S."
            Prognosis.    ^    ^,                   7  .'^ ., ^.V /^AA    .-
            Dissection.   y£t "J          ^ y;  j y ■ \ «. a.- <             Hk ,'■ a^-f     r„
            Treatment.—-Depends upon the  size and location of the tumour,  and the        ,C  "
         na|ure of its contents.  Several general methods.                        tr.x _       >T
          %1. Puncturing or simply opening the tumour..  I" fAy l """ft*""                       ?   A
            2. Puncture followed by seton.             ~  '  '~~                               A  A
            3. PuMture followed by stimulating fluids.    t                                   ,v
            4. Removal of the semi-solid contents of the tumour, and pressure.                ,  ,^J
            5. Removal of the tumour, or amputation of the limb when it occurs on an           r.
         extremity.


                                     Second Head,

                                XVI. OSTEO-SARCOMA."**-* ^A-.y-.-  - ~A-'

            Definition.
            Causes.—1.  Constitutional.  2. Local. /VWC<*vc>)
                                            x. .  ,K  ' Y \  **'  f M.        / ' llx   I  ■  x xx f
y          Bones mosp frequently attac7ced.  -c<  ■£-•*    <- J /Z-x- -•*»-v•« - ^y  '    ■„.::.....
          j  Age at'xuhicli it generally occurs.  "■  ~ X"^T *£+**■"'£■-: <*--■*■    t
         >  Symptoms.   ■ "■ .  ~fei            . «- /»••», p. ft^'tt^**" (^^ r   *AA'
          ^■Diagnosis.     j y*             "**,**.-^    <-  *-v**^
      ••     Prognosis.    '                  "                                                \
            Dissection.                                                                      J
            Treatment.—Removal.  Amputate at a joint if possible. </  . ^  ©..«*■•*»■   <£,? /^A  '   \
 ^U*.,,xrl\..    i{^AAAtAAA   ^        '   -'■     -&.-^"*--- C*r&A7Z*~~  J
 A>~   '• ^v •"■« ^ '           XVII. MEDULLARY SARCOMA.
            For the  characteristics of this disease, see " Cancer."                                I y
                                                                                            K'
                              XVIII. FIBROUS SARCOMA.                               V^

            For the characteristics of this disease, see chapter on diseases of the << Fibrous            j
         Tissue."

                              XIX.  FUNGUS HEMATODES.

            For the characteristics of this disease, see << Cancer."

                                    XX.   MELANOSIS,
            For the  characteristics of this disease, see « Cancer.1' 
(   36   )
                               Third  Head.

                        XXI.  WOUNDS OF BONE.
    Definition.
    Causes.
    Bones most usually involved.
    Characteristics of wounds in bone.
    Prognosis.
    Diagnosis.
    Process of union.
    Treatment.

                   XXII.  FRACTURES IN GENERAL.
   Definition.
   Causes—l. Predisposing or  remote.   2.  Proximate or efficient.  The first
 class may  be subdivided into the local and general.
   (1.) The local predisposing causes  are—
   a.  The situation of a bone.                                       'i|f
   b.  The function of a bone.
   c.  Some local disease.
   The general predisposing causes are—
   a.  The diathesis of  the individual.
   b.  The disease of the individual.
   c.  The age.
   d.  The season of the year. , ■■■
   e.  Sex. y            ._}■'■'■        !'■  '
   (2 ) The efficient causes of fracture are—
   a.  Muscular action.
   b.  External violence, directly or indirectly applied.
   Bones most liable to fracture.   Refer to statistical tables.
   Classification of fractures.
   The first division is  based upon the relation of  the solution of continuity to
 the axis of the bone.  Thus we have—
   a.  Transverse fracture.
   b. Oblique or obtuse fracture.
   c. Longitudinal or parallel fracture. r   -
   The second division  is based upon the  appearance of the  fracture, which is
always modified by the kind of force producing the injury, and the bone involved.
Thus  we have—
   a. Fissures.
   b. Stellated fracture.
   c. Depressed or indented fracture.
   The third division is based upon the  displacements of the  fragments.   Thus
we have—
  a. Longitudinal displacement, or shortened  fracture.  •
  h. Lateral displacement, or displacement in the diameter of the bone.
  c Rotatory displacement, or displacement in the circumference of the bone.
  >'. Angular displacement, or displacement in the  direction of the bone.
  , Impacted fracture. 
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(   37   )
   Causes of displacement.
   1. External violence, either direct or indirect.
   2. Weight of the body  in falling.
   3. Weight of the limb.
   4. Muscular contraction.   Refer to Boyer's remarks on the influence of the
different sets of muscles attached to the fragments.   When the muscles are
paralyzed by the blow, there is often no displacement of the fragments.  Nor is
displacement invariably present, even when the muscles retain their power.
State the cause of this.
   The fourth division is based upon the degree of injury done to the parts around
the fracture, and to the bone itself.   Thus we have—   .        -»■■• ^
                                                        iyW4sz>
                           CU. ^ , xx„ V, c xxxx, „  ^ ^  ^ ^ D
a. Simple fracture.  A       CzTH-.                 *    <   i „   'D  & - ^
/>. Compound or open fracture. i^V*-**-*- *y "'        .,  •   A-  il, *-^->
;tA/-
  z. Complicated fracture.     ' >-"       '""',   ';      A            >  ,
  ''. Comminuted fracture. >..*'        Atrvv^-  «-, ^w^ <?  * Vw'v v
  Symptoms of fracture.—1. Rational or physiological.  2.  Sensible or phy-
sical.   First or rational signs.
   a.  Pain.   N
   b.  Numbness. zv%-v °"v '
   c.  Loss of voluntary motion.~
   d.  Occasional constitutional disturbance.
   These symptoms are never to be relied on, as they are present in other inju-
ries.  Second, or physical signs.                   <                A' ' ■'
   a.  Change in natural form of limb. V^A'A  A A -• •-• ■■  ■ -
   b. Unnatural mobility of the  part at the, seat of fracture.
   c Change in the length of the limb.
   d.  Crepitus.
   These  symptoms are more to be relied on; yet it must be recollected  that
change in the natural  form and  length of a limb  are present in luxations and
sprains, and  that crepitus  may be occasioned by inspissation of the synovial
fluid—the riding of  one bone upon  another in certain  luxations—sanguineous
tumours—the motion of tendons in  their sheaths, and emphysematous collec-
tions.   It may also be absent  in fracture, or very indistinct.  Lisfranc in  such
cases proposes the employment of the stethoscope in our examination.
   Diagnosis.—Fractures may  be confounded with—1. Luxations.  2.  Bent
bones.  3. Partial fracture.   4. Sprains.   State the characteristics of each.
   Prognosis.—Depends on a variety of circumstances.   It is modified, for ex-
ample by—
   a. The size of the bone.
   b.  The number of muscles attached to the fragments.
   r.  The seat of fracture.
   d. The relation of the bone to one of the great cavities.
   c  The extent of injury to the soft parts.
   /.  The character of the force producing the fracture.
   g. The direction of the fracture.
   h. The age  of the patient.
   i.  The health of the patient.
   j.  The season of the year.
   k. The extremity involved. 
(   38   )
    /. The existence of more than one fracture.
    m. The degree of injury to the bone broken.
    u. The existence of a luxation along with the fracture.
    The process of the reparation offractztres, or the formation of callus. —Two
 kinds of callus.
    a. Provisional, or that which serves the purpose of uniting the fragments for
 a time, and is then removed.
    b. Definitive, or that which unites the fragments permanently.
    There are several stages in the organization of callus which deserve attention.
 We have—
    1. The effusion of blood and lymph.
    2. The absorption of serum and the coloring matter of the blood, the inspis-
 sation of the lymph, and the  union of the soft parts.
    3. The conversion of the lymph into cartilage, which forms a distinct pin in
 the cavity of the bone, and a ring around the seat of fracture.
    4. Ossification of the cartilage in the spongy tissue of the bone.
    5. Ossification of the cartilage between the compact portion of the fragments.
    6. The removal of the provisional callus,  and the restoration of the cavity of
 the bone.
    Time required for the formation of  definitive callus.—Depends upon a va-
 riety of circumstances.  Usually in adults, and in  large  bones, from  eight  to
 twelve  months  are requisite  The limb,  however, is useful long before the
 process is completed.
    Agents concerned in the formation of callus.
    1. The periosteum.  Not essential, though highly important in the formation
 of bone.
    2. The vessels of the adjacent soft parts.
    3. The bone  itself.
   4. The internal periosteum.
    5. The absorbents which remove provisional callus and model the bone.
    Mode of union in flat bones.
    Strength of bones after the fracttire is cured.—They are sometimes stronger
 at others  weaker than  natural. The locatioH of the fracture as regards  the nu-
 tritious  arteries, and the activity of absorption, are the modifying agents here.
    Treatment.—General indications.
    1. The mode of moving patients in severe fractures from the spot at which
 the injury occurred, is a matter well deserving the attention of the surgeon.
   2. As there is usually displacement of the fragments, «  reduction" or setting
 will be required.   This may be effected by extension, counter-extension,  relaxa-
 tion of  the muscles, and coaptation.   We are often  resisted in the accomplish-
 ment of this indication by spasm of the muscles, binding of the soft parts, and
 binding of the bones---Mode of overcoming these difficulties explained.  Value
 of myodiatomy in these cases discussed.
   3.  To prevent a recurrence of the displacements, mechanical means must be
 applied, and the  part guarded against all motion.  This indication is occasioned
by  the employment of rest, favorable position, bandages, compresses, cushions,
and various apparatus or dressings.
  4.  As inflammatory symptoms  may supervene, measures  must be taken to
prevent  their occurrence. 
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(   39   )
  5. Spasm and pain often occur after dressing, and these symptoms must be
relieved by anodynes, cold or warm irrigation, sometimes by changing the dress-
ings, and occasionally by bloodletting.  Be careful, however, not to deplete too
mueh, as callus will not be formed unless a certain degree of excitement is al-
lowed to take place in the seat of fracture.
   6.  In applying the dressings be careful to protect parts  liable to pressure, or
that seem chafed or swollen, by straps, cushions, and proper position.
   7.  Carefully inspect the dressings  daily, but do not disturb them so long as
they are steady and properly adjusted.                 v
   8.  When phlyctanae form, carefully puncture them with a needle,  but do not
allow the cuticle to be removed.
   9.  Should superficial or deep-seated suppuration ensue,  it must be treated on
principles already laid down.                                                ^
   10.  During convalescence the patient requires strict attention in order to pie-  y">
vent the occurrence of "secondary fracture."
   11. After callus is formed, the parts, especially the joints,  remain  rigid.  '
The indication here is to relax this rigidity by friction, passive  motion,  wcAm  y
douche, vapour bath, electricity and galvanism.
   12. Finally,  set the fracture as soon as possible.  Do  not wait as some ad-
vise, until swelling and inflammation have occurred and subsided.
   General methods of treatment :
   1. That in which the limb is kept extended in the horizontal position.
   2. That in which it is maintained in the semiflexed position.
   3. That in which it is encased in some unyielding and permanent dressing,
as the « starch bandage," or plaster mould.  This dressing is  sometimes called
the n immovable apparatus.,"
   4. That in which the limb is  suspended.   This method is technically called
 .; hyponarthecia."   It originated with Sauter and Mayor.
   5  That in which the dressing is composed of handkerchiefs, variously folded.
 This method, from having been introduced by Mayor, is called « Mayor's hand-
 kerchief system."
    6. That in which the ordinary splints and bandages are employed.
    Review of these different methods.

                          COMPOUND FRACTURES.

    Definition.                                                    .
    Causes___1.  The  fragments of bone may  be driven through the skin.
    2.  The integuments may be wounded by the body causing  the fracture.
    3.  Sloughing may open the integuments.
    4  An abscess may form and open.
    5  Finally, pressure upon some projecting point may cause its ulceration.
    Dangers.—\.  Immediate shock to the system, from injury to the nerves, or
 from loss of blood.
    2. Inflammation and fever.
    3. Hectic fever.
    4. Tetanus.                                               .  .  .
    Question of amputation.-When called to a case of compound  fracture, «e
 are 'first to determine between the propriety of amputation, and an attempt to
 save the  limb.   No  fixed rules in regard  to this operation can be laid down,
 but we must take into consideration several points. 
                                (   40   )

   1.  The age of the patient.  A c       0
   2.  His constitution. A..Ji-^'-
   3.  His habits.   x-  y  -                                             /,
   4.  His position in society, a A *'l  :i ;'  f  /...., a«i ■■•<'• l,   ,/
   5.  His means of obtaining proper nursing, food, &c, during the treatment, if
we attempt to save the leg.                          i
   6.  The season of the year. -'■ ~1-'
   7.  Atmospheric peculiarities.
   Circumstances supposed to warrant amputation.
   1.  When the injury done to the soft  parts and  bones is such as to warrant
the impression that gangrene will inevitably ensue.    <
   2.  Where, along with the  fracture, a portion of the limb is torn off, as we
see in wounds inflicted by machinery, cannon shot,  &c.
   3.  Where the soft parts are extensively stripped off.
   4.  Where the fracture extends into a large joint.
   5.  Where the bone is broken in several places; and the soft parts extensively
injured.
   6.  Where the fracture is complicated with  laceration of large  bloodvessels
and nerves.
   Before resorting to amputation, even under these circumstances, weigh well
its dangers.
   Time at which amputation should be performed___Difference of opinion among
surgeons on this point; some preferring immediate, others secondary amputation.
It would appear from the reports that in civil practice the latter  method has
been  most successful, while in military, the  former is most to be relied on
Many  cases, however, admit of no delay, even  in  civil practice, and the sur-
geon must let experience determine the  course to be pursued.  Never  operate
until reaction to a certain degree has taken place.
   Treatment where it is determined to attempt the cure of the injury without
amputation.
   1.  When the injury of the soft parts is comparatively slight.  Here we must
close  the wound at once by straps, the  bandage, lint  soaked in  blood, or lint
covered with oil-silk ;  apply splints, or the proper dressings, and treat the case
like one of simple fracture.
   2.  When the injury of the  soft parts is  more extensive, and the bones pro-
trude and overlap, and cannot readily be reduced.   Here divide the soft parts,
pick away any loose  pieces of bone, and, if necessary, saw off the ends of the
bone.  Then apply a loose bandage of strips, place the limb on a pillow in  a
fracture box, or upon  a carved splint, and use irrigation with cold water if the
weather  is warm, or  if the accident  occur in winter, we may use  the warm
water dressing or a poultice.  It is in this form, also, that the bran dressing of
Dr. J. R. Barton is so useful.  Constitutional symptoms are to  be prescribed
for.
   3.  When, in spite of all our efforts to prevent it, profuse  suppuration takes
place, we must give free vent to the pus, and support the constitution.
   4.  After the subsidence of swelling, suppuration and severe pain, treat the
case like a simple fracture, with splints and  bandages.
   5.  Where our remedies fail to relieve, and mortification sets in, we must am-
putate if possible. 
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(   41   )
   Character of the callus in compound fracture and the agents employed hi its
formation.

                         COMPLICATED  FRACTURE.
   Definition.
   Causes___The fragments may be thrust through large vessels, or nerves, or
into joints;  or the force producing the fracture may cause their injury, or occa-
sion luxation.
  Dangers___1.  Immediate shock to the system from loss of blood, or injury
of the nerves.  2. .Sloughing from infiltration of blood and serum.   3.  Morti-
fication from  loss of nervous  influence.   4.  Permanent paralysis of the limb.
5. Phlebitis.  6.  Hectic fever.   7.  Tetanus.
   Question of amputation.—No general  rules can be laid down, but the circum-
stances already stated as modifying our treatment of compound fracture, should
always be taken  into consideration here.
   Treatment.—Varies with the complication.
   1.  Where we have profuse hemorrhage from a wounded vein.  Bleed, apply
cold,  and pressure, and afterwards frictions and pressure, to cause the absorption
of the blood ; occasionally a ligature will be required.  Be careful to prevent
phlebitis.
   2.  When we have hemorrhage from a large artery, characterized, where there
is no external wound, by  a tumour  pulsating at first, apply a ligature above the
tumour, and do not as a general rule open  the integuments  and seek  for the
artery as advised  by Boyer.  When the collection of blood  is so  great as to
threaten sloughing, then open the tumour, evacuate the blood and tie the vessels
When a wound in the integument exists, we may sometimes  dilate it, and thus
tie the artery above and below.
   3.  When a large nerve  is  torn  across, which is  manifested  by paralysis,
numbness, pain and spasm of the limb, we must bleed, place the part at rest,
apply leeches, cold or hot applications, and give anodynes.
   4. In comminuted fracture, complicated with  a wound in  the integuments
We must take away splinters, provided  they are not attached to the soft parts.
Close the wound and treat it like a bad compound fracture.  When the bone is
crushed to pieces, it will generally be proper to amputate.
   5.  When a luxation complicates the fracture, always protect the fracture by
some firm dressings, then reduce the luxation as speedily as possible, and after-
 wards set the fracture and treat it according to the rules laid down.
    6. When the fracture extends into a joint, we have to fear intense inflamma-
 tion, and must treat the case accordingly.
    7. When mortification takes place amputate.
    S. When tetanus supervenes treat it in the usual manner.

     IRREGULAR CALLUS,  OR FRACTURE  UNITING WITH  DEFORMITY.
   Causes.—Usually, neglect or bad treatment of  the case, or the wilfulness of
 the patient, are the immediate causes of deformity.
   Question of the propriety of interference in these cases.—Many points must
 be considered before the  operation  is undertaken.
   1.  The duration of the injury. *'■*'   '^ ' i
   2  The degree of functional  injury resulting from the deformity. 
(   42   )
  3. The practicability of relieving the deformity without endangering the life
of the patient.
  4. The size and location of the injury.
  5. The age of the patient.
  6. The health of the patient.
  7. The season of the year.
  S. The existence  or not of disease of the soft parts or of the bone itself.
  Means employed to remove the deformity.—These vary  with the duration of
the injury.
   1. Pressure and extension of the limb.—-When called to a badly set fracture,
within the first sixty days after its occurrence, or while the callus is yet yield-
ing, we may often succeed in restoring the limb by well regulated pressure and
extension of the limb.   Cases are reported by Dupuytren and others, in which
these measures  have succeeded  even after the lapse of the 120th day from the
receipt of the injury.
   2.  The seton —In these cases Wienhold proposes the introduction of a seton,
which by causing suppuration would break down the callus.
  3. Rupture of the callus.—If more than sixty or seventy days have elapsed
before we are called, as a general rule rupture of the  callus will prove more
useful than any attempts to mould it into proper shape.   This is an old operation,
and has been recently revived by CEsterlen, Richerand, Dupuytren and others,
   Cases to which it is applicable.
   Dangers of this  operation.
   Preparation of the patient.
   Mode  of rupturing the callus.
   After  treatment.
   1. Resection of Bone.—In cases of long standing, where the bones overlap, and
are  firmly bound to each other, pressure, the seton, and refracture will all fail to
afford relief, and we must then resort to " resection of the bones."
   Dangers of this operation.
  Preparation of the patient.
  Mode  of performing the  operation.
  After treatment.
   5. Removal of exuberant callus---When spiculae or ledges of bone are thrown
out around the seat of fracture, and interfere with the motion of its parts, or oc-
casion pain, we may, after waiting a few months  for the efforts of nature, cut
down upon them and remove them with the knife or saw.   (See cases of this de-
formity reported by Alcock, Velpeau, Dawson, and myself.)

             PSEUDARTHROSIS, FALSE JOINT,  OR NON-UNION.

   Definition.
   Frequency of the defect.
   Varieties.—1.  Where the fragments are united by soft callus.   2.  Where the
fragments are united by a ligamentous band or bands.   3. Where the fragments
are united by cellular tissue alone.   4. Where a sort of  joint is established.
The bones being rounded off, tipped with cartilage, covered by a synovial mem-
brane, and held  together by a capsular ligament.  Very rare.
   Causes.—1.  Constitutional.  2.  Local. 
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(   43   )
   First, or constitutional.
   a. Syphilis.
   b. Pregnancy and suckling.
   c Fevers of different kinds.
   d. Cancer.
   e. Fragilitas ossium.
   /. Scurvy.
   g. General impoverishment of the system.
   h. Paralysis.
   i. Deficient supply of arterial blood.
   A Advanced age.
   Second, or local.
   a. Frequent  motion of the fragments.
   b. Separation of the fragments.
   c Disease of the  fragments.  (*-•>.     &: ■  > ■ **»                         ,          ,. ^
   d. Interposition of foreign bodies  between the fragments.   J A'
   e. Tight bandaging. A p  '•■■.'■•                     t\, ■'• ■"• * '                ' v£a1
   f. The long continued use of cooling applications.^t^-vCU '- k« ■  ■'■•      ,--*, < . ,
   g. The too early use of a fractured limb.  ;                                               ;
   h. Division or stripping off of the  periosteum.                           ,     ;
   i. Want of cellular tissue. r >•<
   Symptoms]              '
   Diagnosis.
   Prognosis.
   Object of treatment.
   Treatment.—Various  methods have been introduced.   " N
   1. Simply keeping the parts  in splints for several months.
   2. Friction, o ..'ir-l -   ■    A                  A*"''
   3. Compression.
   4. The application of caustic alkali to the integuments over the seat of fracture. fj/'v
   '). The introduction of a heated canula between the bones. Proposed by Mayor. Yfr i->" *
   6. The seton—proposed by Dr. Physick. Modification of this agent by Rhynd.
   7. Escharotics applied to the ends of the bone. ->-tA~  fc*~£/<y.# -
   8. Removal of the extremities of  the fragments.
   9. Section of ligamentous union.
  10. Section of muscles attached to the fragments, coaptation, and friction or
pressure.   Proposed by Dieffenbach, in false joint of the olecranon, patella, &c.
  11. Acupuncture.
  12. Electricity.   ; { \ * <■ ■„*■ ,
  13. Blisters. Aiy*AA<t e,~^>-u
  14. The use of iodine or mercury.      -'"»■-• ,J l-~   *■'-■
  15.  The metallic ligature of Somme.                          \   t-            ,.a  A»
  16.  The actual cautery.  Employed by Kirkbride and others. ^T'".' n'  A ^
  17.  The introduction of ivory pegs—(Dieffenbach.)

                DIASTASIS  OR  SEPARATION OF EPIPHYSES.
   Definition.
   Age at which the  accident occurs___Varies  in different  individuals.   May
take place at any age previous to that at which the epiphyses become attached
by bone.  This generally occurs before  puberty. 
(  44   )
   Causes.—Violence or muscular contraction.
   Symptoms.--Obscure.   Unnatural mobility at the seat of the epiphysis is
the most important sign.
   Diagnosis.—May be confounded with fracture or luxatio?i.
   Prognosis.—The injury, if properly managed, rarely results in deformity;
if neglected, the person is almost sure to be crippled,
   Treatment.—Depends of course on the seat of the lesion.  The general indi-
cations are nearly the same with those laid down for our guidance in the treat-
ment of fracture.
               PARTICULAR  FRACTURES.

                       I. NASAL  BONES.
Liability.,  C-A-V> '-^••-■'V-/^*"
Causes A ■'-■AlSAAAP^y *&'<"*
(Arri
   Varieties. * *- A                    AA .-■',;.     -    •..*-*
   Complications.—Concussion of brain; emphysema;  injury of lachrymal
duct and canal;  fracture of cribriform  plate;  inflammation,  and caries  or
necrosis of the bone, '^yy^-  >   y txy-
   Symptoms.                         A/..^A,      ^'/a'      -, ' fk
   Diagnosis.,^y-iJ' ~  ,<        i     y~  .. /»'■",              '
 r  x__      .  V/ e-yy /'•' ■■■ •    •  ■ _   <x \ ,t <■., .,
   Prdgnosis. j                  '
   Treatment.

                         II.  MALAR  BONES.

   Liability.—This accident is very rare.
   Causes.
   Varieties.
   Complications.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.
III. SUPERIOR MAXILLARY BONES.
Liability.
Causes.
Complications.
Diagnosis.
Prognosis.
Symptoms.
Treatment. 
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                             (   45   )

                  IV. INFERIOR MAXILLARY.
          <rt   A                            ■  •■ *■
Liability.
Causes, y  *'1             .'•'•"
Parts most liable to fracture,  »-v~ *-w-v /v*'w/>-
Varieties.
Complications.            *■  r3"tJf ' ^v-   S
Symptoms of each of the fractures of this bone.
Diagnosis.
Prognosis.
Treatment—Depends on the seat of fracture. - ^ £>~

                        V.  OS  HYOIDES.
Liability.
Causes.
Varieties.
Complications.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
x- ,/vn^'.- £ - ■>-•■ -
r> /, ^vt-Ct-0
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VI. THYROID  CARTILAGE
Liability.
Causes.
Varieties.
Co mplicatio n s.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
VII. STERNUM.
V £
U.  f v •
Liability.         .
Causes. A!'x c v -^ <- •  '■ r  '


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         /           ,. ,     VIII.  RIBS. V <*-■ >'• - *'    </ '"' ^ ' A f „'"
UamUyA-'    '   A'vA-   ,.,Un_tA   '•-  •**—  ^
2£i&£ most frequently broken,  /mi
Parts of the bone most liable to fracture.
Causes.—External violence.  Muscular contraction, as  in coughing,
Varieties. 
                                            j                                      *<- *x <£^ .

frxA          X    .  AA*~   '-   '    (   46   )

                 Complications.—Hemoptysis, emphysema,  pleuritis, empyema.
                 Symptoms.
                 Diagnosis.
                 Prognosis.
                 Treatment.

                                         IX. CLAVICLE.

                 Liability.__Its shape, size, texture, exposed situation, and function, render
              this bone very liable to fracture.
                 Parts usually broken.
                 Causes.—Direct or indirect violence.
                 Varieties.—Complete, incomplete, simple,  &c.
                 Complications.—Paralysis of arm, injury of axillary plexus and vessels. (Earle.)
                 Symptoms.
                 Diagnosis.
                 Prognosis.
                 Treatment___Various dressings employed to carry out the three indications
              of  Dessault.   1.  Desault's bandage.  2. Boyer's bandage.   3. Mayor's hand-
              kerchiefs.    4.   Fox's  apparatus.   5.  Brown's  bandage.   6.  Dr. Reynell
              Coates' bandage.    7. Hiester's dressing.   8.  Sir A.  Cooper's.

                       y  lCf^.q        X. SCAPULA.

                 Liability___Its site and mobility protect it  in a great measure from fracture.
                 Parts most  liable to fracture.—1.  Acromion process.   2. Inferior  angle.
              3.  Body of the bone.  4. The coracoid process.  5. The spine.   6. The neck
                 Causes.
                 Varieties.
                 Complications.
                 Symptoms___Depend on part broken.
                 Diagnosis___Depends on part broken.
                 Prognosis.—Depends on part broken.
                 Treatment___Varies with the seat of injury.
                   I  ■
            A "J"'    "  a  A \ „     * XJ. HUMERUS. _                   .     .
                 Liability—According to Longsdale, fractures of this bone are proportionately
              less frequent than is usually supposed—about one-sixteenth of all fractures.
                 Ages at which it usually occurs___Childhood and old age.
                 Parts of the bone liable to fracture —1. The bead.  2.  The anatomical neck.
              3.  The surgical neck.  4.  The epiphysis.   5. The shaft.   6. The condyles.
                 Causes___Muscular contraction, direct and indirect violence.
                 Varieties.
■^      ' AC_A   • ■  /H..A-,    /.'   7t-w--«>  --^W,   ^
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   A/^\^.
a. . >-»-Y( ~*^ a>x-<yx. 
(  47   )
Diagnosis.
Prognosis.
Treatment.
Liability.
Causes.
Variety.
Sigfis.
Diagnosis.
Prognosis.
Treatment.
ANATOMICAL  NECK.
 SURGICAL NECK.
.AA
f—
k
— ^  &■-
     Liability.  AAyr—i^ -«-
     Causes.
     Variety.
     Signs.
     Diagnosis. ^-"vy.- ,A
     Prognosis. >   *^    A* A A
        °      4<s--f~ v-«. * Srfy_
     Treatments ^_.  ex.-..  Af>*r.--
^^AAY-x^xf^  ^y.Y-A.-'f-.[  Am
  y                  SEPARATION OF THE EPIPHYSES.
f-.--.-f_y
AT-;-
_y,y
A  7'V
lYfl'<>'■< AXA

s}£
gy\-\-^n, vx. ~r-^x*3 i (Ty^y^s
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          A

v*-«

S   Liability.  -
    Causes. ^«vf- <^   ^A*,*, *®«-X4<A  ^ r.^, £r  A"
    Variety,  l^. * ft0-1^,*^ CY-   > Stfetf «W  >  JWK^v.  &J
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    Diagnosis,  k (),■
Ow.  ft-*-
17-
c/W

/U
Treatment.
SHAFT ABOVE INSERTION OF DELTOID.
Liability.
Causes.
Variety.
Signs.
Diagnosis.
Prognosis.
Treatment-
Liability.
Causes.
Variety _
Signs.
Diagnosis.
Prognosis.
Treatment.
SHAFT AT  ITS  MIDDLE. 
Liability.
Causes.
Variety.
Signs.
Diagnosis.
Prognosis.
Treatmen/t.
(   48   )
SHAFT  ABOVE  CONDYLES.
CONDYLES.
   Liability.
   Causes.
   Variety.
   Symptoms.
   Diagtiosis.
   Prognosis.
   Treatment.

                 XII. BONES OF THE FORE-ARM.

   Liability.___More  frequently  broken than the humerus — oHe-fifth of all
fractures.
   Bones involved.—One or both may be broken.  The radius is most liable,
from its connexion with the wrist.
   Causes.
   Varieties.
1      H^
 7c4a
BOTH BONES.
A  C
K-Cy* 4,
Ax   A,
   Parts generally bro-cen.    *                        ^  < A> A -  ^tV
   Causes.   >t ^y/^yA^*^^  A'4<v   T'    , '  .    }v\JZW* *• ~
 ,AL*ty-   U^.f-  ^   V       2'h^rAA^
   Symptoms   ^^A*    '  '       ,.vf,    l\ &~ ^-'   &&&*****M'1
   _Dt«°-«0«S.                                 ^         .  y.     i jr l\
(■   Prognosis, ■yyxi'w Lc. v ."A  '  'A-,'                         A
   Treatment.A^"     C*X\j  Kv^y  -
             /a**, oyLAA  )x„t)%iy
                    FRACTURE OF  RADIUS ALONE.
Vv7- 7cO
     Liability.—Very common.
     Causes.
     Variety.
     Parts usually broken.— Head, neck, shaft, or inferior extremity
     Symptoms of each.
     Diagnosis.
     Prognosis.
     Treatment.
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                               FRACTURE OF  ULNA  ALONE.
           Liability.
           Causes.
           Variety.
           Parts  usually bro&en.—Shaft,  extremities,  coronoid  process,  olecranon
         process.
           Signs of each.
           Diagnosis.
           Prognosis.
           Treatment.

 *         A        '/A*        XIII.  CARPAL .BONES. Y,y  ^         .     >  .    t.„ v;f /
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           Varieties.fin  pf~  ^  **X   Ai~«.  a. V-A k>w^/< {*■*-tn * *-' ^ - "AAA
           Symptoms A SZ-*y.   Ct^xO-- A> -A e*-auJ*  ~~  a~v-» A  «  * *>- -i-i*»mJ" '.V/-&-0-X A.
            _ .      .  /^  Yixex.     -i    .-        *            '      .     i . <  ;   „.-,  f
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* ^   jL-4 <7 A-4:. .£     '  'XIA  METACARPAL BONES. ''  *2,,»-' «-%■«•- «-'  > C U**-
                                             ■  <  -    —- n AjAtf+la ■ \a & U ft. M»J
Liability.
Causes.
Varieties.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Liability.
Causes.
Varieties.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
XV.  PHALANGEAL BONES.
                                    XVI.  SACRUM.        ./    ■    ^ r'  _     £
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U k~^ Varieties.  ^X_ >, ■  y^_ fr ^ C-Y *     /
 1/         Symptoms A        A                        AS
<Hr-~~~-  —
Diagnosis.
Prognosis.
Treatment.
     4 
%^
                                       (   50   )

                                 XVII.  OS  COCCYGIS.
Sy^-'1 -■*•'-■"  -""A   At ■«- -                     O
           Liability. Agrz.  yV%,   -y-t.-j.--x. ■  > e-Y-*-^
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           Varieties.
           Symptoms.
           Diagnosis.
           Prognosis.
           Treatment.
A I-
A
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 A
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Liability.
Causes. r
                         -4
XVIII.  OS INNOMINATUM.
       - y>
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      b   '  /   Situation of fracture
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    ,          Symptoms.    ' ,»  s
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          " ' ': **• "r •*' * *XIX. FEMUR. ">"-«— > *V :^A^v^4«r-  4-*-^
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Importance oj"the fraot tires ofthis bone:             "T"^  ^U.  o^   if- ^-^vuM
Liability.
Causes.
Varieties.
Parts usually brolen.—Head, neck, trochanters, shaft, and condyles
            Xj\.         ~.  -     -* ,  >- *x-tx  .- . ■ X?
   *   A..  4f4?<
      ■fA.xt-0  l»**-*
FRACTURE OF,'THE HEAD.
 ..  Yt-x- ■*
     . L.
X   • -*va.
^
    7      © -.
Liability, r^ ^x. ,  t, t, c,^  , rX[ ^_  ,  ^»><. w, ^'U',S  .'
CaK5M.  ^ ^.o^.^ .fV. »1-  ^^ ^^  ,c.x ,y  ^.  /f#t  //^
Varieties.Vy-, )\  FVl f^ .,,Lifr  , e*\. '-jh-  i  f, , 1 .  A
IF "^ 'y
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Symptoms. ..,  ^7"AA'f,  ~ -^ "^ \vv^< ■> A.'   A.   ,v t^'U.^
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     Prognosis. &yy\ t■ «\x   .  f'ow^.^.
     Treatment. '          f-l^e^  <-4^__ i, ^ ^tK
       •          < ^-<. •     &, -      _     f   ,
^■■»v>       <?» *     ,  rfi  tv4th^ f   ^. ex.-.
     ■  FRACTURE OF  THE  CERVIX WITHIN  THE  CAPSULAR  LIGAMENT
li f        ■ «-  c-4 *  I ■            .*>t>4  w^ '■ , ,*«  a»V.'-
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t    Causes.           v..         '"     '" <• v ' *  :          A
• »-»-4j




  Z'  ' -

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Sex piost liable.
Varieties.
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'  ' Diagiwsis.
:  .,* +
 ■ <•• -•   z
,  A/A-/
4
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  Treatment.   u  '' ^ p-

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(   51   )
    FRACTURE OF THE CERVIX WITHOUT THE CAPSULAR LIGAMENT. OR PARTLY
£X  . >,..L  ,..,           WITHIN AND TARTLY WITHOUT.
z^-
  Liability.     :y
  Causes. ^ ' ' ' '"  :  ;  ■ ■ n r    •
  Age most liable.
  Varieties.   ^   , .. ,   A   ,   t-U'l x..   X   * '
  Symptoms.  - --jL^^g-e  y ,. ± ._ »....
  Diagnosis ."^r  *X"7  '  '  '  '  A"<  '.'  — A •        '  •
     °    .   .„lM-.tU,4   :,   r          ,    ^v-^-vA
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,. Treatment. .         ,  gj^ ^^..zv... £ h.x,.$  >*A  -1

                   FRACTURE OF THE TROCHANTERS.

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  Treatment-.&-<**yk  A* -  «
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       FRACTURE OF  THE SHAFT .TUST'BELOW  TROCHANTERS/
fir ■
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"^Ac           •  . A- '  ^FRACTURE OF  THE SHAFT. ^
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Prognosis.-^ r-. <~
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^  -/'n-.r  t  ^:              1*
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FRACTURE OF THE CONDYLES.
Liability. (A\  *A .  ^ .A ,A<-   f >-• '  ,'      A'
Causes.  ■'-■■■'■
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                                   (   52  )

                                XX. PATELLA.
                  fy.  Ar-t,  .    •/•■  =/-7/
           Liability';    A       (           4
           CX;.5f,s.


           Diagnosis.                        (
           PrO^"?J05l5.


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           Pro^


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XXII.  BONES  OF THE FOOT,
Liability.
Causes.
Varieties.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
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                                  (   53   )
Liability.
Causes.
Varieties.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
FRACTURE OF OS CALCIS.
• 
(   54   )
     2.  DISEASES  AND  INJURIES OF THE  JOINTS.


  General Remarks.
  Joints 3iost liable to disease.
  Causes of disease
  Effects  on constitution.
  Classification.—All  the  diseases of the joints may be ranged under nine
heads.
  1. Diseases originating in the soft parts, either intra oi ?a:^a-articular.
  2. Diseases originating in the hard tissues of a joint.
  3. Affections which may be considered  as products  or terminations of dis-
eased action.
  •i. Malignant diseases of the joints.
  5. Wounds.
  ti. Sprains.
  7. Dislocations.
  S. Congenital luxation.
  !). Diseases of the  bursas  mucosas.
  First head.
  a. Synovitis—acute and  chronic.
  h.  Hydrops articuli.
  <•.  Abscess.
  A Elongation of ligaments
  e.  Inflammation of ligaments.
  f.  Fleshy tumours of the synovial membranes.
  g. Loose  cartilages in the joints.
  h. Certain forms of white swelling.
  i.  Coxalgia, or hip disease.
  j.  Neuralgia.
  k. Inflammation of the  cellular tissue.
  Second head.
  a. Certain forms of white swelling.
  b.  Certain forms of coxalgia.
  Third head.
  ■i.  Hypertrophy of articular cartilage.
  b.  Atrophy of articular cartilage.
  c.  Eburnation of articular cartilage.
  d.  Softening of articular cartilage.
  e.  Ulceration of articular cartilage.
6 
 
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                              (   55   )

/. Reparation of articular cartilage after wounds, &c.
g. Alteration in the form of the head and neck of the long bones.
h. Collections of blood in a joint.
i. Chalkey concretions in a joint.
j. Anchylosis.
                              First Head.

                             I.  SYNOVITIS.

   Definition.
   Causes.—1.  Constitutional.  2. Local.                (> x.     .   f«
   First, or constitutional.—Rheumatism, gout, gonorrhoea,  parturition, preg-
nancy, checked leucorrhcea, catheterism.
   Second, or local___Blows, strains,  mechanical injuries of all kinds,  foreign
bodies in the joints, wounds.
   Symptoms___Pain on the slightest motion ; swelling, redness, heat, and ten-
derness of the  skin;  fluctuation; displacement of any loose  bone or cartilage
about the joint; and constitutional disturbance,  r^- AtA*^ A* Y" '  "*
  Diagnosis.—May be confounded with inflamed bursas, but scarcely with any
thing else.
   Prognosis.—Varies.   When but one joint is affected—when the cause is
local—when the inflammation runs  high—it may terminate in ulceration or
degeneration of the synovial membranes, ulceration of the cartilages  and bones,
necrosis, the loss of the joint, or even the life of the patient.   Under other cir-
cumstances, the prognosis is rather favourable.
   Dissection.
   Treatment.—General indications.   1. Remove the  cause.   2. Subdue the in-
flammation by general and  local  antiphlogistic remedies.   3. Employ  specific
remedies when  the cause is specific.   4.  Prevent anchylosis.
         II. HYDROPS  ARTICULI,  OR HYDRARTHUS

Definition.,       *%    \__ •

SymptomsA ^&  *-/■_^ ^ A *
         *-i^t   ^OCU^O  y  fTr-
eatises.  /y-"r                .f    ,       V
           Diagnosis. ^t-V-£*-*-»"«-«F-v u  ,       ,        j , >   __        >,          .  -x
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           Dissection. ' )  /,', U v O  £i>b~Xt+>\-  l&*4- ^ « A f^ J^~   ]
           Treatment. ^   ^. ^>. . /,'*.'_.  lj A .  ^A  *//f7  -^-  v '

           «*.'**->.*- VX^III-ABSCESSA^ "*" *<*  ,** *~>  ^Af!

7   ""*""' Causes. ->-*■ A t-i -V -.  W   x tC~.--+~ *\  ; * v •,-■ *•£- U **'fl  **  ' -y<y~
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^-A- DiagnosisA^-A .. ..  4  / "    A-~ 4 *< < •  ^ 4 *<" '" *<?'►. • >
A/ ZK    Prognosis. —  V *-£* 'A~Z .-»-*.  /*-A£   <r  /K, /A'» \A'(\^  ^ l'«"-^
 X-  ^    Dissection.   h  4  A,. ,,-?..'   r A  A  A\.4 ^-   'jf./AvJ*
Treatment. 
(   56   )
             IV.  ELONGATION  OF  LIGAMENTS.           .  ,
                                                              y
Causes, ^/tw^ i\,<.  ■L^ -flfrl^t-y   -.r  nv/i     , X  * ' ^
Symptoms'.  ] r» 's ;
Diagnosis. ^* > * >&

V. INFLAMMATION OF LIGAMENTS.
Prognosis.
Dissection.
Treatment.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

     VI. FLESHY TUMOURS OF  THE  SYNOVIAL MEMBRANE.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                VII.  CARTILAGES IN  THE  JOINTS.

   Definition and history.
   Joints most liable---The ginglymoidal, especially the knee, elbow and jaw
   Condition in the joint.—Loose or attached.,       ,
   Size.—Varies. Vi -v     *,  p^r*."~to <j w^. */■ /     '  '  "
   Consistence___Varies.
   Structure---Scarcely organized.
   Number.—Varies.
   Mode of formation---Different explanations.   Those of  Pare, Monro,
Eilangen, Hunter, Cooper, and Brodie, referred to.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.—Two general methods.   1. Compression.  2.  Extraction.  Re-
lative value of the  two.  Dangers of extraction referred to,  and the different
operations, especially that of Goyraud and Syme, explained.

         VIII.  WHITE SWELLING, OR FUNGUS ARTICULI.

   Definition.
   Confusion in relation to the precise meaning of the term.
   Brodie's classification.—According to Sir Benj. Brodie, all the cases of white
swelling may he referred to one of four different lesions.   1. Simple inflamma-
tion of the synovial membrane.   2. Gelatinous degeneration of the synovial
membrane.   3.  Ulceration of the cartilages.  4. Ulceration of the bone.
   Ages most liable.
   Joints most liable. 

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(   57   )
  Causes.—Constitutional and local.
  Symptoms___Vary with the form of lesion.   Three groups may be made.
  Diagnosis___Highly important to distinguish one from the other.,
  Prognosis.—Varies, but generally ft is^nfaKquraJjle. .  ,.,,_   uux yx.
  Terminations.—Resolutionfanchylosis, suppuration, alteration of all the tis.
sues of the joint, necrosis, the loss  of  the joint or limb, or  the life of the
patient.
  Dissection.—Depends  on the stage at which it is made, and the form of the
disease.
  Treatment.—Differs somewhat in each variety, but there are certain general
indications that will answer for all.   The remedies are of course both constitu-
tional and local.
   General indications in the first stage of the disease---1. Keep the  part at
rest by splints and  position.   2.  Employ general and local antiphlogistics if
inflammation runs high.   3.  Prevent contraction of the limb.
   General indications in the second stage—1. Counter irritation should be em-
ployed.   2. Pressure as recommended by Scott  is  often  useful.   3. Employ
alteratives to  suit the diathesis.   4.  Keep the joint at rest, while  the patient is
allowed^if possible, access to the fresh air.   Crutches and sling,  &c.  5. Sup-
port the strength if prostration should supervene.  T.' Prevent anchylosis.
   General indications in the third stage---1.  Support the  general health.   2.
Never open the abscess unless we are forced so to do by peculiar circumstances.
3. Poultice the part after the abscess opens.  4. Keep the joint in a  splint.  5. It
is often essential to obtain anchylosis, to save the life of the patient.  6. When
all our remedies  fail, and the patient  is sinking, amputate or excise the joint.

                   IX. COXALGIA, OR HIP  DISEASE.

    Definition. CfUj. t+^\ x- u'/ v-^A„, ■i.-w-AX «-* £ll ■ t...A•■  -?  A<fX  J Av "
    Persons most liable___Children  of  a scrofulous  habit,  from  thVee to fdur
 years of age,  or from seven to fourteen.   May occur in adults.
    Causes.—1.  Constitutional.   2.  Local.
    First, or constitutional___Scrofula,  atmospheric changes,  rheumatism, re-
 pelled eruptions.
    Seco?id or  local.—Mechanical injuries of every kind.
    Symptoms.—May be divided into  four groups.   1.  Those which characterize
 the period of apparent elongation of the limb, with slight  pain in the knee and
 lameness, &c. &c.  2.  Those which  belong to the period of shortening of the
 limb, with pain in the hip itself, &c.  &c.   3.  Those which  characterize the
 period of suppuration and ulceration  in the joint.   4. Those which indicate con-
 valescence.   The causes of elongation and shortening in the  first  and second
 stages explained.
    Diagnosis.—May be confounded  with—
    a. Fracture of the cervix femoris.
    b. Luxation of the caput femoris.
    c. Congenital luxation.
    d. Rheumatism.
    e. Chronic inflammation of the upper third of the femur.
    /. Sciatica.
    g. Psoas abscess. 
(   58   )
   Prognosis.—May be stated to be generally unfavourable.
   Dissection.—The appearance on dissection depends upon the stage and pro-
gress of the disease.
   Pathology.—Much diversity of opinion on this point.   State my own views.
   Treatment.—General  indications.   1.  Rest  and  the antiphlogistic system
throughout the first stage.  2. Place the limb in a splint of such construction
as shall maintain  the  limb as nearly in its natural position as possible, so that
when resolution cannot be obtained, and false joint or anchylosis must be brought
about, the patient may still retain its use.  Speak of Physick's and  Humbei A
method of practice.   3.  Attend to the diathesis. 4. Apply counter  irritants.
5. Support the health when this support is indicated.  6. Evacuate pus when it
is formed in large quantities, poultice, and support the health.   7. When reso-
lution cannot be obtained, endeavor to form a false joint, or establish anchylosis,
S. After inflammation has subsided, and the limb remains  shortened from mus-
cular contraction, it is often useful to employ Humbert's method of reduction
Point out the dangers  of  this practice, as well  as  its advantages.   9. Protect
the limb for some time  after the cure has been established.  10.  When the
limb is shortened or deformed, apply some apparatus  by which the patient will
be enabled to walk with comfort.

                            X. NEURALGIA.

   Definition.
   Persons usually attacked.
   Cazises.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.  L"--                    -.     .    '   •

XI.  INFLAMMATION  OF  THE  CELLULAR TISSUE EXTERIOR TO
                              THE JOINT.

   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                             Second  Head.

            I. CERTAIN FORMS  OF WHITE SWELLING.

  For the characteristics of these  forms, refer to what has already been given
under the first head.

                II.  CERTAIN FORMS OF COXALGIA.

   For the characteristics of these forms, refer to what has already been said
under the  first division. 
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                          (   59   )

                        Third  Head.

   I. HYPERTROPHY OF THE  ARTICULAR  CARTILAGES.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.

     II.  ATROPHY OF THE  ARTICULAR  CARTILAGES.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.

   III. EBURNATION  OF  THE  ARTICULAR CARTILAGES.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment-

     IV.  SOFTENING OF THE  ARTICULAR  CARTILAGES.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.                                            ,

    V. ULCERATION  OF  THE  ARTICULAR CARTILAGES.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

VI  REPARATION OF  THE ARTICULAR  CARTILAGE  AF'
                 WOUNDS AND FRACTURES.

Describe this process. 
^
                               (   60   )

  VII.  ALTERATION IN  THE  FORM OF THE HEAD AND NECK
                       OF  THE LONG  BONES.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

 VIII. COLLECTIONS  OF BLOOD  IN THE CAVITY OF  A JOINT.

   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

     IX.  CHALKEY  CONCRETIONS IN  AND  AROUND JOINTS.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.         *
   Treatment.             -

\\^  \ V V j —          x. ANCHYLOSIS, (tr+wtl*- 9 /"  SuC^t)]
   Definition.  w'; Wn-  ■ '         *  Av
   Classification.—1. Partial  or local.
<"Wv r>vv
2.  General or universal.         ;       «.   j  .  TjA
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      Causes---Most of the  causes operate by keeping  the  parts motionless, or
    nearly so, for a length of time.   For example : diseases of various kinds, tumours,
    fractures, dislocations, simple rest, cicatrices, injuries of tendons and muscles!
    paralysis of one set of muscles, contraction of  faseia,  &c; others operate
    under all circumstances, as old age, chronic rheumatism or gout.   Sometimes
    it is a protective effort of nature, as seen in curvatures of the spine, anchylosis
    of diseased joints, &c.
      Liability.—Ginglymoid joints are  more  frequently thus affected than  the
    orbicular.  Why ? dir-. J\A+ f^'jAi *. <*?< A<       t i~x ^
      Symptoms.—Depend on the variety of anchylosis.
      Diagnosis---Cannot  be confounded  with any other affection.   There is
    often much difficulty, however, in the distinguishing one form  from another.
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    the duration of the case—the age and health of the patient—the joint involved,  &c.
      Dissection.—Varies with the kind of anchylosis.
      Treatment.—In true anchylosis we can only relieve the patient by establishim- 
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(  61   )
a false joint, or straightening  the limb by cutting out a plug of bone, as per-
formed by Dr. J. R. Barton.   Never excise the joint, nor amputate the limb,
as advised by some ;  nor should we attempt Louvrier's operation.
  In false anchylosis, the treatment is modified by the cause of stiffness.  The
agents usually employed are passive motion, frictions, electricity, galvanism,
vapour bath, the screw, division of tendons, fascia  and  muscles, excision of
cicatrices, and some contrivance to take the place of paralysed muscles, as advised
by Sir C. Bell.   The comparative merit and dangers of these means explained.


                            Fourth  Head.

                      MALIGNANT DISEASES.

   The joints are liable to be attacked with malignant diseases of various kinds,
 but especially with  malignant exostosis, medullary sarcoma and fungus hema-
 todes. For the characteristics of these diseases, as well as their treatment, see
 chapter on  " Tumours."

                              Fifth  Head.

                        WOUNDS OF  JOINTS.  v.,,  -      .  .X ,^ <?  v-vww-.  7

 ^Division.  *a <'"*«- ' '*■  ' m*. «-*- ^    *-} f~  <   ""---$> ""
   Causes.
   Symptoms.—Vary with the character of the wound.
   Diagnosis—Generally, there is no difficulty in deciding upon the character
 of the wound at once.  Punctured wounds may be confounded with wounds of
 the bursa? mucosae^_^_
   Prognosis:-—Depends on the joint injured, the, character of  the wound, the
 age and health of the patient,  the season of the AAA and the possibility of
 obtaining the proper remedy.  ;   >"-"A''   <S"
   Dangers.—Inflammation, tetanus, caries, and  necrosis.
    Dissection.—The appearances on dissection depend upon the stage of the
 disease, at which the examination is made.
   Treatment.—Divided into—1.  Constitutional.   2. Local.  The  remedies
 must be modified to suit;  the peculiarities of Jhe case.......    tv.,  £ tat, /*♦ ^.W^A'A
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  A~1,A(.  V**^* W rt?£,  Sixth  Head. 0'wjvl.■ «x }■ aA-v^-~-  Aj  « "~4_/~

                                 SPRAINS.                                ^;
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Prognosis.'  -'--^ s
Results or effects  of the injury.
 Treatment.

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(   62   )
                             Seventh  Head.

                 ,   /v>    DISLOCATIONS    X  ^ti*^L .^A^A

   DefinitionSZAx /-z "■ J*_* -Wv tzwt/-  ' ' iA*       f"1 '   A
   Causes.—1.  Predisposing or remote.   2.  Proximate or efficient.   The first
 class may be subdivided into the local and general.
   (1.)  The local predisposing causes are—
   a. Preternatural length of the ligaments of a joint, (see Stanley,)     , jg
   b. Peculiar congenital  conformation of the joint. l^A^izr ?4   ~  f ♦'^v ('
!  * The*" form of the joint.   /     .* >    ■
   d. Paralysis of the muscles around the joint
   e. Disease of the constituent tissues of a joint.
   /. Hydrops articuli.
   g. Tumours or earthy  deposites in or about the joints.
   h. Interstitial change in the articulating surfaces.
   The general predisposing causes are—
   a. Preternatural laxity of the entire ligamentous system, (see Delpech.)
   b. The age.   Dislocations are rare in the  very young or very old.
   (2.) Local or external causes.
   a. External violence.
   b. Muscular action.
   Joints most liable to luxation___The ball  and socket joints, from the charac-
 ter of their articulating surfaces; the weakness of their  ligaments; and their
 subjection to the influence of a larger number of muscles, are more frequently
 dislocated than the ginAymoid.
   Classification of dislocations..—The first division is based upon the definitive
 position of the head of the bone.  Thus  we have—
   a. Primitive luxation.
   b. Consecutive luxation.
   The second degree is based upon the degree of displacement.   Thus we have.:
'' '^Complete luxation.  N*Cfe *  uj  A  (A 4,'   Cv;.-fcv» ;      < Wn   -■ -<-.••
   b. Incomplete luxation, or sub-luxation.
   The third division is based upon the duration of the accident.   Thus we have :
   a. Recent luxation.            «                    ,
   b. Old luxation, fct'lt  . aAL, #.  (  -,.'•/   1 •;. t t*V   i
   The fourth division is based upon the degree of injury  inflicted upon the ad-
jacent soft parts or the bones themselves.  Thus we have—
   a. Simple luxation.
   b.  Compound luxation.
   c.  Complicated luxation.
   Symptoms of luxation.   1. Rational or Physiological.  2. Sensible or physical.
   First, or rational.
   a. Pain.
   b.  Numbness or paralysis in limb.
   c.  Loss of motion.
   d. Constitutional disturbance.
   Second or physical.
   a. Change in the entire form  of the limb.
   b.  Change in the  natural length of the limb. 
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(   63   )
     c. Unnatural rigidity of the limb.
     d The disappearance of preternatural enlargement of the natural prominences
  of the joint.
     e. The appearance of unnatural cavities about the joints.
     /. The  appearance of a tumour (formed by the  head of the  bone)  in the
  vicinity of the joint.
     Diag?i0sis---Dislocations  may be confounded with__
     1st. Fractures.
     2d.  Sprains.
     3d.  Bent bone;.
     Prognosis---Depends on a variety of circumstances.  It  is  modified,  for ex-
  ample, by—
     a. The joint involved.
     b. The degree  of displacement.
     c. The duration  of the injury.
 /   d. The degree  of injury sustained by,the soft parts of bones. ■*"'* i«v'r-«^v  A   -
f*^'AAThe constitution of the  jAtient. f ;   ft  "*■ X A     {? .yk i+,**-t*.*.  4.£jy,\
     f. The direction taken by  the head of the bone.      wA*-*.  «vw vvv-^vtrA? <■
     Dissection---Appearances depend on the duration of the injury, and the tis-
  sues upon which  the  head of the bone  rests___State the usual appearance in
  recent and old luxations.
     Treatment.—General indications.
     1. The  general condition  of the  patient demands our first attention, and be-
  fore we attempt to relieve the injury he must be  placed in as comfortable a
  position as possible, his  fears calmed, and reaction to a certain  degree estab-
  lished.   It is sometimes well  to deviate from the last direction, for should the
  patient faint from pain merely,  his muscles are  in the most favorable condition
  for our attempts at reductiou.
     2. As there is always displacement, << reduction''' will be  required.   This
  may be accomplished, in many cases, by the employment of mechanical means
  alone, but often constitutional agents are required.
     The mechanical means are—
     a. Extension.                                 ,                            ,
     b. Counter extension.                         .    yt        __ _ _ s  |„  ,Al  y ti
     c. Change in the position of  the  different bones.—To  accomplish these ob-
  jects we employ the hands of assistants, bands, rollers, the pullies, and various
  apparatus for overcoming  muscular resistance---The forces must  be  applied
  steadily and slowly, they must  also be equal, and generally  in the line of dis-
  placement.—Muscular resistance is often  overcome  by directing  the patient's
  mind from the  set of muscles  concerned  in the accident---We must also select
  the part  upon  which  our extending  and counter  exte?idi?ig  bands are to be
  placed.   Difference among surgeons  on this point---The obstacles to reduction
  by mechanical  means alone are—
     1. Muscular contraction.
    2.  The degree of laceration of the soft parts
    3.  The shape of the joint. /Vwt*-. ;
    4.  The locking of the bones.
    5.  The existence of adhesions.
    6.  The interposition of tendons or ligaments
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   The constitutional remedies employed, are intended chiefly to pro luce pros-
tration, so that all muscular resistance is destroyed; and the most efficient are :
   a.  Bloodletting.                        '    • '
   b.  Hot bath.
   c.  Tart. Antim. et Potassae.  '                '    "
   d.  Fumes of tobacco, or injections of its infusion.
   /.  Intoxication.           -
   Value of Myodiatoiny in difficult cases  discussed.—Also  the  propriety of
attempting the reduction of old luxations considered.
  "3.  From the partial paralysis of the muscles, and laceration of the ligaments,
it is essential to apply some mechanical means to prevent the recurrence of the
luxation.—The usual  dressings for fractures of the  same  bones  may be em-
ployed, for a week or two  after  the reduction of the accident.
   4.  As inflammatory symptoms may supervene, measures must be taken to
prevent their  occurrence,  and should they occur in spite of our efforts to the
contrary, the antiphlogistic system in all its details must be employed.
   5.  For the rigidity, which, in almost every case, is the result of the disloca-
tion, the remedies already  mentioned as applicable to the same  difficulty coming
on after fractures, may be  had recourse to.
   6  When complicated with fracture, always recollect to dress both injuries
before you leave the patient, and also to adopt  the plan of treatment already
indicated under the head of fractures.

          COMPOUND AND COMPLICATED LUXATIONS.

   After  the reduction of  the bones, the treatment in these injuries is identi-
cal  with  that  advised in cases of compound and complicated fractures___It is,
therefore, needless to  repeat  it  here---The remarks relative to the dangers,
and question of amputation, in the latter class of accidents, apply very well to
the former.
                PARTICULAR LUXATIONS.

                   I. INFERIOR MAXILLARY.
                       0 k -. -  A A   ,-,   ,    ; -  .
^JfAi'atomy of the joint.          '  ' A -  ■•''
Liability.—This accident is common.
Causes.—1.  Predisposing. 2.  Proximate.
(1.)  Age, sex, and preternatural elongation of the processus vaginalis. /
Variety.    >       !         • -   , >          •  .               .
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment. 
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    (   65   )
II.  SUB-LUXATION OF THE LOWER JAW. ,      .
Symptoin^y^^  _         ,   LyAL^.^  « il.U   t A   A-
Diagnosis.  »     *   r^i            Z t       ■        t       '
Prognosis A^^^  ^   ^"-^  ^   ^' "** * «*~ - - '
Dissection.
Treatment.
III.  OS HYOIDES.
Liability.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Anatomy of the articulations.
Liability.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
IV.  RIBS.
V.  STERNUM.
Liability.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
VI.
W*
CLAVICLE.
 y-L'*-v  ,y\ O- * <~~
   Anatomy of its articulations.
   Liability.__May be luxated at either extremity.   The scapular is most fre-
quently displaced.
   Direction of Displacement.—The sternal extremity may be displaced in
three  directions:—forwards, backwards, and  upwards.   The  scapular >?
usually thrown  upwards or downwards beneath the acromioc process.
        5 


*K
!*<-«"

Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissectio/i..
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
             (   66  )

I.  STERNAL EXTREMITY FORWARD-.
II.  STERNAL EXTREMITY  BACKWARDS.
V
III. STERNAL EXTREMITY UPWARDS.

u
<

Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
IV.  SCAPULAR EXTREMITY  UPWARDS.
V. SCAPULAR  EXTREMITY DOWNWARDS.
VII.  LUXATION OF THE INFERIOR ANGLE OF THE SCAPULA.
7 « 2 k	Causes. Symptoms
	Diagnosis
^ v	Prognosis
X	Dissection
>.	Treatment
■6 i " A	
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(   67   )
        VIII.  LUXATION OF THE HEAD OF THE HUMERUS.

   Anatomy of articulation.
   Liability.—Very great, from the small size of the articulating surface ;  the
weakness  of its ligaments;  the freedom of its motions ; its constant exposure ;
and from its subjection to the influence of several muscles.
   Direction of displacement.—Downwards, forwards,  backwards, and partially
upwards and forwards.  Displacement directly upwards, to any extent, cannot
occur without  fracture of the acromion.  Explain the intercostal and thoracic
luxations mentioned by Larrey and Percy.
                        I.  DOWNWARD LUXATION.

   Causes.
   Symptoms,
   Diagtiosis.—May be confounded with fracture of cervix  scapulae, fracture
of the neck of humerus, bruises, paralysis of the muscles, and dislocation of the
biceps tendon. .
   Prognosis,  xtny-^x ■           -.yA^-h  A   fir-**** t?  f #*-*  ^
   Dissection.
   Complications.—Great swelling; emphysema; inflammation ;  paralysis of
muscles.
   Treatment.—General indications.
   a. Fix the scapula.
   b. Relax the museles.
   c Draw the head of the bone to  its cavity.
   General methods.
   a. Simple elevation of the arm.
   i. Lifting the head of the bone while the arm is abducted.
   c. Mothe's  plan, or rather, Mr. White's. A,"'■f;Jf^i **™%^\ H-~*"i
   d. Extension, with heel in the axilla.  ,yA>  A...A-7'  k<3*X
   e. Pullies and bands, v^  <? e—a-v f) U  ^^.A th. ^Uw.^/'fy/c*
   /■ Dorlnnivirr QrirwratlK nf Hiffprpnt Vnnrls. *■'                            4
  /. Reducing apparatus of different kinds.
  g. Myodiatomy. |^ fp^A-  "» <■- •  --"A
  It may be  necessary  to use constitutional remedies  in combination with
either of these plans.

                         II.  FORWARD  LUXATION.

  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Dissection.
  Complications.
  Treatment.__Reduce to the first, and then employ the measures already indi-
cated,
^tfWV 
(   68   )
                       III. BACKWARD  LUXATION.
   Cavses.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Co'.,; plications.
   Treatment—Reduce  to  the first, and then employ the measures already
pointed out as efficient in the reduction of the former.

                    IV. PARTIAL, OR SUBLUXATION.
   Co- i.ses.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.
               V. DISLOCATION  OF THE  BICEPS TENDONS.

   Causes.
   Sy mptoms.
   Di:gnosis.
   Prognosis.
   Dissection.
   Treatment.

              IX. LUXATION  AT THE ELBOW-JOINT
   Anatomy of the joint.
   Li ability.
   D..,-ection of displacement---Backwards and upwards of both bones ; lateral
of both bones ; forwards of both  bones ;  forwards of the head of the radius ;
backwards of the head of the radius;  imperfect  luxation of the head of the
radius; upwards of the superior extremity of the ulna.

            I.  BACKWARDS  AND UPWARDS OF  BOTH BONES.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Di s section.
   Treatment.

                     II.  LATERAL DISPLACEMENT.
   C- 'ses.
   S ■ mptoms.
   Diagnosis.
   Poognosis.
   L. ssection.
   T eatment. 
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(  69   )
                  III--  FORWAH.D  DISPLACEMENT.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Dissection.
 Treatment.
          IV.  FORWARDS OF THE HEAD OF THE RADIUS.
 Causes.      ,
 Symptoms. Fwfji«w»»
 Diag)iosis.
 Prognosis.
 Dissection.
 Treatment.
,   ^y ,  V. BACKWARDS OF THE HEAD OF THE RADIUS.'  x
 Causes.    ^*-^*"            A    |       ~~y'       vz) 44   4

 Diagnosis.v
yA/U~  t-U-A.-tiA,/.'—  Ma. /,*,*» y -  xu*<j.
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Treatment.  ' ^    ^
   , • -  A'' A    ^
    VI. IMPERFECT  LUXATioN  OF THE  EfEAD  OF THE  RADIUS
Prognosis.*.tr\ G„.**» -            .   y       .               %^   v /■#'(-*-**-■*•
Dissection. VlyixA  ',,yU.V4v>  \A*+Ab   <y            ^<-7..  .
       nt. A^    „,4>   k »  •  t..w  U, )
        A '       3> «"■  ' v  •  ■ yvvvv
       .  IMPERFECT LUXATioN OF TH
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                  4 «x-Z, JU-
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^.
   VII. LUXATION  OF THE SUPERIOR EXTREMITY OF THE ULNA.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
                X. LUXATION OF THE WRIST.
          . .  .  .    ~v\^ iXX**,  K tr^*"   °   -* *~
Anatomy  of joint.               <   \
Liability.
Direction  of displacement___Backwards, forwards, and laterally.
                         I. BACKWARDS.      •         ^f   „^<Tv~  ~

Symptoms. \jy^JJ (\   ^VvV? ff* C*-^v^—t-^~"V*- V ^ *"^-,k^-

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(  70   )
        r   !■*              II. FORWARDS.        1§       J       /,     «
 Causes.                                       &
 Symptoms.
 Diagnosis.
 Prognosis.
 Dissection.
 Treatment.

         j   v^            III. LATERAL.
 Cam. '- &A^-i>Ov>    & <A-^W r


 Prognosis.
 Dissection.
 Treatment.

     IV.  LUXATION OF  THE LOWER  EXTREMITY OF THE ULNA.

 Causes.
 Varieties.—Backwards and forwards.
 Symptoms of each.
 Diagnosis.
 Prognosis.
 Dissection.
 Treatment.

              XL LUXATION OF CARPAL BONES.

 Afiatomy of joint.
 Liability.
 Direction of displacement.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Dissection.
 Treatment.

          XII.  LUXATION OF METACARPAL BONES.

 Anatomy of these joints.
Liability .—The first is usually the only one displaced.
Direction of displacement.
 Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
 Treatment.
X \yx. 
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(  71   )
                 XIII.  LUXATION OF PHALANGES.
  Anatomy of these joints.
  Liability.—All may be luxated, but usually the  first of the thumb is most
liable.
  Direction of displacement.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Dissection.
  Treatment.—Difficulties to be overcome are, 1. Shape of the bone. 2. Bind-
ing of ligaments.   3. Interposition of anterior ligaments.  (Vidaland Pailleux^)
4. Interposition of sesamoid bones.  (Lawrie.)  5. Want of leverage.  Manner
of overcoming these difficulties explained.
                XIV.  LUXATION OF THE  SACRUM.
  Anatomy of the joint.   k,  J—w-*.       A  ■  v  *—■'*                    »  ,
  Liability.    4.  ^/^  ^  CA)  l-f   ^  ^«y  <r

  Symptoms.' "  <~    A          _            *. ,\ rt  _  2  Ay  'm e.  A*  '- o
  Diagnosis,;    .'        .   |        a,<,-/JU-0.~   ^L^'»   *—
   Prognosis.  ,       "    " %.    / '                       "
   Dissection/' ***"*$*-* * -  *
   Treatment.
            XV.  LUXATION OF THE OSSA  INNOMINATA.
   Liability.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.
         XVI. RELAXATION OF THE  PELVIC  SYMPHYSES. •
   _.,.,.                I            yyi_    A   d IF%.\ <-y ■■-  »* t.usu4.4  «•_>,«
   Liability. y}  .  .->   4  -' *-*•»  >  ^ *"   ''^  f*'*"v
   Causes.  , t.  /,. f^nx_A   ct /   ""l--*-"* '"   "'


   Prog'wo.si.s.

   Tzea£?ree»£.
                 XVII. LUXATION OF  THE FEMUR.
   Importance.  ^ <- v *•-*-  '*    ^■*■*/* * w * ** '
   Anatomy of the joint.,                              0»-~s
   Liability.          / '    ,
   Direction of displacement.—The head of the bone may be displaced «ji«ar(/<
 in tfo-M directions, and <fow»w««fr in three  directions, viz. :  upwards and for-
 wards upon the dorsum ilii; upwards and forwards upon the ossa pubis ; directly
 upwards ; downwards, and backwards in the upper ischiatic notch;  downwards
 and forwards into the foramen ovale ; directly downwards. 
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f-Wify'ti-v*-1  >          .   I.  UPWARDS  AND BACKWARDS.  O-^.'.VV^ ^ OUzHA tfty.
A  ^         ,,      (T^'d-t* r  X.X'.^
               Causes.      w ^    >■ ^.. v .           ,_^ ^

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               Prognosis, rv- ^p**""'              ^
               Dissection.
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               a.  Fix the pelvis.
               b.  Draw the head of the bone towards  its cavity.
               c  Make use of the different muscles to assist in the reduction.
               d.  Employ constitutional remedies to relax the muscles.
               General methods.
               a.  Bands and pallies.
               b.  Apparatus.
ON  THE  OSSA PUBIS.
^  \y  r  I ?i\*..y  n.  upwards  and  forwards <
              Cait&s.   UvVf *  b- 0 tA Y  ''•  f'*-\,A-
              Symptoms.
              Diagnosis.
              Prognosis.
              Dissection.
              Treatment___General indications are the same as in the first variety.   The
            general methods are also the same, but we must vary the direction of our forces.

                       .    III. DIRECTLY UPWARDS.   (VERY  RARE.)  ■
              Causes.  k~*  -^""-*--*----T*a^.  oAZC<         «l/l ...  i: v..' A -
              Symptoms.
              Diagnosis.
              Prognosis.
              Dissection.
              Treatment—The same indications to be observed as above, but  vary the
            direction of the forces  to suit the case.

H C*-  i-H-x. '           IV' VBACKWARDS  AND SLIGHTLY DOWNWARDS.         'JL      ')
■\      \     'cAseA\\-^-^  ^AwAtl    ?V<X^~<-          '   "<>/J   *Ajf
A  v-„   ,. i  ■„, SymptbmsA!x~*~^-*-  t/"-t^y«—-^ t*A^-.W*.  jet-'■•■-■  -
             ■Diagnosis.
              Prognosis.
              Dissection.
              Treatment.—General indications the same as above, but the direction of the
            forces must be varied.
        i  4 AA
Causes. v^y '  A
                      FORWARDS  AND  DOWNWARDS.              /   j_
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   Diagnosis.                          '
   Prognosis.
   Dis section.
   Treatment.—General indications still the same, but the process must  be
varied. 
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(  73   )
              VI. DIRECTLY DOWNWARDS.   (VERY RARE.)
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment—General indications  still the same, but we must modify our
forces to suit the case.
                    XVIII. LUXATION OF KNEE.
   Importance.
   Anatomy of the joint.
   Liability.
   Direction of displacement.—To render these luxations more clear to the
student  it will be well to consider those of each constituent of the joint, and
first of those of the

   YwU«.                    PATELLA.                 x,S, . A^. ^
   Varieties.—1.  Outwards;  2.  Inwards;  3. On its axis; 4. Upwards;  5.A
Downwards. '^ftvA^W iA   . . A  ~y^  ^  #1&$>-*%.'cxA.  ,« i^m-m'^ ■
   Causes of each.
   Symptoms of each.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.
              II. LUXATION OF  THE HEAD  OF THE TIBIA.
   Varieties.—1. Backwards; 2. Forwards; 3. Outwards; 4. Inwards; 5 Sub-
luxation or twist.
   Causes.
   Symptoms of each.
   Diagnosis.    j   <  AZ                             _ £,-,. *-*>r*-  fi  -
   Prognc
   Dissection.
   Treatment.
            III.  INTERNAL DERANGEMENT OF  KNEE  JOINT.
   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.
           IV. SUBLUXATION FROM LENGTH OF LIGAMENTS.
   Causes.—Congenital or acquired.
  Symptoms.
   Diagnosis.
  Prognosis.
  Dissection.
   Treatment.
Tl ix-'f-   fiv(?  uUn^^aA* }A*a'  Cy h
>iosis.      (  //                               A,
wsis. H Ax. tf ,  or c e ^  ly^-j  * —y * -
* 
(  74   )
V. LUXATION OF  THE HEAD OF THE FIBULA.
Varieties.,   .          v
Causes. ^ f-*^^-^  L~ fy* t , -
Symptoms. A«/w tSl In. O. / o -
Diagnosis. ^-<lfx.l.  #   A Si.'I f )& A /
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XIX.  LUXATIONS OF THE ANKLE JOINT.
>4  /^
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             Importance. --, ^$ ,v\^f Jj /%^  £ „ £".*»fi  /«'
             Anatomy of the joint.        A                (■
             Liability.                                          ,
             Direction of displacement.—Inwards ;  Outwards ; Forwards ; Backwards

A-v  6. LA   n f'  v  '  -   f ..'x,. t.  / i_ INWARDS.                         /
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 LA          Causes.Y
             Complications.
             Symptoms.
             Diagnosis.
             Prognosis.
             Dissection.
             Treatment.
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Causes.
Vomphrations.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
III. FORWARDS.
IV.  BACKWARDS.
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(  75  )
XX.  LUXATION OF THE TARSAL BONES.

              I. ASTRAGALUS.
Causes.
Symptoms.
Diagnosis.
Prog7iosis.
Dissection.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
II. THE CUNEIFORM, ETC.
XXI.  LUXATION OF THE METATARSAL BONES.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
              Eighth Head.

XXII.  LUXATION OF THE PHALANGES.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Definition.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
CONGENITAL LUXATION. 
(  76   )
        III. DISEASES  OF  THE  FIBROUS SYSTEM.

   Some of the affections of this system have been included under the diseases of
the joints;  for example, Desmodia, and Desmectasis :  others belong more par-
ticularly to the practice of medicine than to surgery, as rheumatism, &c.  The
diseases usually considered as strictly surgical are—

                            I. PERIOSTITIS.
   Definition.
   Varieties.—1.  Acute.  2. Chronic.
   Causes.—1. Local.   2. Constitutional.
   First, or local:
   a. Contusions.
   b. Punctures.
   c Incisions.
   d. Extension of inflammation from diseased organs in the vicinity.
   Second, or constitutional:
   a. Syphilis.
   b. Excessive use of mercury.
   c. Scrofula.
   d. Cold.
   Symptoms.—1.  Local.  2. Constitutional.
   Diagnosis.—May be  confounded with ostitis, caries, necrosis, rheumatism,
or gout.
   Prognosis.—Varies in different cases.  Usually the cure  is tedious;  it may
nevertheless be considered a very curable disease.
   Dissection.—The  post-mortem  appearances  depend on  the intensity and
duration of the attack,
   Terminations.—Resolution, suppuration, effusion of lymph ; inflammation,
caries or necrosis of the subjacent bone; conversion of the membrane into car-
tilage or bone.
   Treatment.—The remedies  are divided into  general and local.   Both are
modified by the circumstances of the case.
   First, or general.
   1. Bloodletting.
   2. Active purgation.
   3. Low diet.
   4. Mercurials.
   5. Preparations  of iodine,  especially the iodide of potassium.
   6. Decoctions of the woods.
   Second, or local.
   1. Leeches.
   2. Free incisions.
   3. Poultices and fomentations.
   4. Blisters.
   5. Iodine, or mercurial frictions.
   6. Wool and oil-silk dressing. 
 
 
(  77   )
               II. PARONYCHIA, OR WHITLOW.
 Defi)iition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Terminations,
 Treatment.
                          III.  TYROMA.
 Definition.
 Varieties___Partial or general.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
  Termi?iations.
  Treatment.

                         IV.  CHONDROMA.
 Definition.
  Varieties.—Partial or general.
  Catises.
  Symptoms.
  Diagnosis.
  Prognosis.
  Terminations.
  Treatment.
            V.  OSSIFICATION OF THE PERIOSTEUM.
  Varieties___Partial or general.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

        VI.  MALIGNANT DISEASES  OF THE PERIOSTEUM.

  Like all other organized tissues, the periosteum  is liable to be attacked by
the various diseases termed malignant, the  characteristics of which have already
been or will be described under other  heads.

           VII.  WOUNDS OF FASCIA OR APONEUROSIS.

  Varieties of wounds.
  Symptoms.
  Diagnosis.

  TlrSr^^.-Inflammation,  sloughing, suppuration,  adhesions,  contrac-
tions.
  Treatment. 
(   78   )
                  VIII.  CONTRACTION  OF  FASCIA.

   The numerous fasciae and aponeuroses in different parts of the body, are all
 liable to undergo a chroiiic thickening and  contraction, from which results a
 variety  of deformities,  many of them very difficult  to  relieve,  and others
 entirely incurable. Ghidella and Froriep were among the first to describe these
 affections with any thing  like method or correctness, although the  disease was
 long  since spoken of by  the ancients, as  ^crispatura tendinum!"   Sir A.
 Cooper, Dupuytren, Goyraud, and most of  the  recent authorities in orthopedic
 surgery, have likewise carefully and correctly explained the nature of the defect,
 and also the most  appreved methods  of treatment.   We shall describe briefly
 the most important of the deformities resulting from this cause.

               I.  CONTRACTION OF  THE  FASCIA PALMARIS.
   Anatomy of the fascia of the palm of the hand.
   Deformity produced by the contraction of the fascia, or fibrous cords attached
 to its inferior margin.—(Dupuytren and Goyraud.)
   Fingers usually involved.
   Causes of the contraction.—1. Congenital.  2. Acquired: and according to
 Dupuytren, the defect is occasionally hereditary.
   Diagnosis.—May be confounded with retraction of the fingers dependent on
 other causes ; as contraction of the flexor tendons, cicatrices, &c.
   Prognosis___By no means in every case  favorable.   It  is, however, often
 susceptible of relief.
   Effects on the adjacent muscles, tendons and ligaments.
   Treatment.—Three  modes of treatment.  1. Mechanical extension. 2. Fric-
 tions.   3. Subcutaneous section, followed by mechanical extension.   The merits
 of these methods discussed.

                II.  CONTRACTION OF THE  FASCIA CUBITI.
   Anatomy of the part.
   Deformity produced by the contraction of the Fascia.
   Causes___1. Congenital.  2. Acquired.
   Diagnosis___May be confounded  with  contraction of the tendons  of  the
biceps and brachialis internus muscles, and inflammation  of the joint.
   Prognosis.
   Effects on the other constituents of the articulation.
   Treatment.—The  same general methods are applicable here, that are em-
ployed in the other fascial contractions.

             III.   CONTRACTION OF  THE  FASCIA PLANTARIS.
   Anatomy of the  sole of the foot.
   Deformity produced by the contraction of the fascia.
   Causes.—1. Congenital.  2. Acquired.
   Diagnosis.—May be mistaken for  common talapes equinus.
   Prognosis.
   Effects on  the tarsal and metatarsal articulations.
   Treatment.—The same general methods that are required in contraction of
the other fascia. 
 
 
(  79  )
        IV. CONTRACTION OF THE FASCIA  LATA AT THE KNEE.

  Anatomy of the joint.
  Deformity produced by the contraction of the fascia.
  Causes___1. Congenital.  2. Acquired.
  Diagnosis.—May be confounded with contractions of the tendons and mus-
cles, and also inflammation of the joint.
  Prognosis.
  Effects on the articulation.
  Treatment___The same general methods hold good here.
     IV.  DISEASES OF  THE BURS/E MUCOSiE.

                I. WOUNDS OF THE BURSzE.

Varieties.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

            II. INFLAMMATION OF THE BURS.E.

Causes.
Symptoms.
Diag)iosis.
Prognosis.
Treatment.

                III. ABSCESS  OF THE BURS^E.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

                    IV.  HYDROPS BURSiE.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
                              (   80   )

        V. CARTILAGINOUS  FORMATIONS IN THE BURS.E.

  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

                           VI.  GANGLION.

  Definition___Encysted tumor formed in the course of a tendon or its fibrous
sheath.
  Symptoms.
  Causes.
  Pathology.
  Joints most liable.
  Diagnosis.
  Prognosis.
  Treatment.
  1. Stimulating friction and blisters; 2.  Compression ;  3. Seton ; 4  Puncture
followed by compression; 5. Rupture of Cyst;  6. Acupuncture; 7. Extirpation.

                            VII.  BUNYON.

  Definition—An inflammation with thickening of the  bursa mucosa on the
inside of the great toe.
  Causes.
  Symptoms.
  Prognosis.
  Diagnosis___Dislocation from gout and Rheumatism.
   Treatment.—When acutely inflamed, leech, and apply cold or warm poul-
tices, and elevate the foot;  when chronic  inflammation takes place, blister and
use iodine locally, and avoid  pressure on  the foot; when suppuration takes
place, let out the pus, and apply a poultice.
  When the bursa becomes very  troublesome  it may be dissected  out.   (See
Brodie.)

                     VIII. HOUSEMAID'S KNEE.
  Definition.
  Causes.
  Symptoms.
  Diag?iosis.
  Prognosis.
   Treatment. 
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(  81  )
             V.  DISEASES  OF THE TENDONS.

                  I. WOUNDS  OF THE TENDONS.
   Varieties,
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Mode of reparation.—Depends  upon the nature of the wound.  In wounds
exposing the tendon to the air, the process differs essentially from that which
takes place when the tendon is not exposed.  The degree of separation of the
divided extremities also modifies  the process.—(See Velpeau, Ammon,  and
Bouvier.)
   Treatment.—1. Simple position and apparatus.  2. The  Suture, aided by
bandages and position.  3.  Antiphlogistic  system.   The apparatus or dressing
must be modified to suit each particular case.

                II.  INFLAMMATION OF TENDONS.

   Varieties.—Simple, rheumatic, or gouty; acute, or chronic.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                 III. OSSIFICATION  OF  TENDONS.

   Causes.
   Persons most liable.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                   IV.  TUMOURS  OF TENDONS.

   See chapter on " Tumours."
6 
(  82   )
 VI.  INJURIES AND DISEASES  OF  THE VOLUNTARY

             MUSCLES AND THEIR  TENDONS.

             I. WOUNDS AND RUPTURE OF MUSCLES.
   Varieties.
   Causes.
   Symptoms.
   Diagnosis.
   Prog?iosis.
   Mode of reparation.—This process is modified by the exposure or non-expo-
sure of the injured muscle to the action of the air.
   Treatment.—1. Rest, proper position, and apparatus.  2. Suture, or straps,
and bandages.  3. Antiphlogistics.

                II.  MYOSITIS OR  INFLAMMATION.
   Vatieties.—Simple, rheumatic, or gouty ; acute or chronic.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Terminations.—Palsy ,  irregular spasm ; suppuration, (Myositis purulenta ;)
softening, (Myesitis emolliens ;)  hypertrophy ; atrophy ; hardening ; and ossifi-
cation.
   Treatment.

                  III.  SUPPURATION IN MUSCLE.

   The symptoms indicative of suppuration in this tissue resemble those already
described under the general head " Suppuration," and the treatment is precisely
the same as that proper in cases of suppuration elsewhere.   The most striking
peculiarity of this  action here, is the circumstance of the entire muscle often
disappearing, aB in psoas abscess.

                         IV. SOFTENING.
   This condition of the muscle  may result from defective  nutrition, as  stated
by Laennec ; and also from inflammation, as Bouillaud has clearly shown.  The
muscle becomes pale, flabby, friable, and easily torn.  There is no remedy for
the difficulty.

           V. STEATOSIS, OR FATTY DEGENERATION.
   This degeneration is exceedingly uncommon, but cases are reported by Vicq.
d'Azyr and  others, in which the  muscles were reduced to all the physical pro-
perties of fat.

                        VI. OSSIFICATION.
   This is seen in old persons, and also in certain forms of exostosis.  It may
exist as the  result of inflammation. 
 
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(  83   )
                         VII.  HYPERTROPHY,

   This condition of the voluntary muscles is rare, but it  occasionally occurs
from inflammation, or excessive nutrition.  It is also sometimes congenital,

                            VIII.  ATROPHY.

   This is a very important  lesion of the muscles, and gives rise to many dis-
eases.   It presents itself under several forms.  We have—
   1.  Simple atrophy—the result of long disuse, palsy, or defective nutrition.
   2.  Rigid atrophy.—The  muscle is  here  shortened, rigid, inextensible, and
lighter colored  than  natural.  The  diseases produced by this variety are club-
foot, some  forms of wry neck, contracted  limbs,  stiff jaw, &c.  It generally
results from spasmodic affections, or from the muscles being confined for some
time to one position.
   3.  Atrophy,  with absorption of  the muscular tissue.—This is usually the
result of exposure to cold for a length of time.
   The  affections resulting from simple atrophy may occasionally be relieved by
removing the cause  and resorting to measures  calculated to restore tone and
vigor to the muscles.   The most common deformities produced by it are

                  I. PARALYSIS OF ONE LEG OR BOTH.

   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment___1.  Constitutional remedies.
   a  Strychnia.
   b.  Cold bath.
   c.  General frictions.
   d. Nutritious  diet.
   e.  Exercise  in the fresh air.  To accomplish this indication we are generally
obliged to use a go-cart.
   2.  Local measures.
   a.  Frictions.
   b.  Galvanism.
   c.  Acupuncture.
   d.  Mechanical support.
   e.  Operation of Stromeyer.

                            II.  FASCIAL PALSY.

   Causes.
   Muscles involved.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.—\. Constitutional remedies—the  same as those recommended
in the other case. 
(   84   )
   2 Local treatment.
   a Acupuncture.
   b. Moxa over the mastoid process.
   c. Galvanism.
   d. Excision of a portion of the paralysed cheek.  Proposed by Dieffenbach.
   e. Section of the antagonizing muscles.   Also proposed by Dieffenbach

                 III.  ATROPHY OF THE GLUTEI  MUSCLES.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

   To comprehend and to  manage properly the deformities resulting from rigid
atrophy, it will be necessary to consider each one separately.  And first of

                               CLUB FOOT.
   Definition.
   Varieties..—1.  Talapes varus, or inversion.  2. Talapes valgus, or eversion.
3.  Talapes equinus.  4.  Talapes calcaneous.  5. Talapes dorsalis or phalangeal.
   Each of these general divisions may be sub-divided into three groups which
1 have termed degrees; for example, we have first,  second, and third degrees
of varus, &c.
   Causes---1. Congenital;  2. Acquired or accidental.
   1st. Or congenital. Various theories entertained.  The most rational is that
nowgenerally adopted,  that unequal or irregular contraction  of the muscles, by
which  their  tendons  and fascia  are shortened, atrophied, and  rendered  more
dense,  is the proximate  cause of the defect.   In  some  cases, the extensors, in
others  the flexors are  in fault, sometimes only one, sometimes  several  muscles
are involved.—(Refer to some of the most ingenious theories  on this subject.)
   2d.  Or acquired.   Sprains, luxations, fractures, preternatural  laxity of the
ligaments,  partial or complete paralysis of one set of muscles, their antagonists
retaining  their natural  power and vigor,  convulsions, habit of using certain
muscles more than others, &c.
   Foot most liable.—The right.
   Sex most liable.—The male.
   Variety most common.—1st, or varus.
   Characteristics of each variety, and those of its various degrees.
   Condition of legs and knees.
   Dissection.—The  appearances, of course, depend on the variety of the defect,
its degree, cause,  age, and the mode of life of the patient.   Call  attention to
the bursa?, exostosis,  anchylosis, and abrasions, often met with in cases of long
standing.
   Diagnosis.—Talapes equinus I have known mistaken for certain forms of
contracted hip and knee.
   Prognosis---Depends on the degree of contraction, the variety of the defect,
the condition of the bones, the age of the patient, the character of the cause, the
complication of the case, and  the disposition of the patient to submit to our
remedies. 
 
1 
(   85   )
  Treatment___1. Prophylactic. 2. Treatment after the defect is fully established.
It is rarely possible for us to employ the first, or remove causes operating even
after birth.  Under the second head  several indications  present themselves,
  These are,  i.  The  application of such mechanical measures as shall bring
the  shortened muscles, tendons and fascia, to their proper position.
  2. Where mechanical contrivances alone, and unassisted, fail to accomplish
the  first indication, we may next  resort to the knife, aided by mechanical
measures.
  3. The third indication refers to  the retention of the foot in its proper posi-
tion, after the tendons, &c, have been elongated.
  4. The fourth, to the application  of such measures as shall give tone to the
weakened muscles,  and prevent the recurrence  of spasms, or irregular contrac-
tions which would cause a relapse.
  5. The fifth, to the preparation of the  patient for treatment.   Keeping those
indications in view, which obtain in the treatment of all the deformities result-
ing  from this cause, we shall next speak of the plan of  treatment best suited to
each variety of the defect, as  it presents itself at different ages; but  before  so
doing it will be well to explain the  character of certain  operations, to which I
must refer in the management of the most of these cases.  These are

               MYOTOMY,  TENOTOMY. AND APONEUROTOMY.

   The history of these operations.
   Their importance.
   Their relative  merits contrasted with mechanical treatment alone.
   The manner in which muscles and tendons are united after these wounds.
   The dangers of these operations.
   The question of immediate  separation of the divided organs discussed.
  Manner in which the operation should be performed.


  We. are now prepared to take up the special treatment, and first, of

                           CONGENITAL VARUS.

   1. Congenital  varus, 1st, 2d, or 3d degree at birth.
           <<       k       <<      a        2d or 4th  year.
           [(       u       a      c<        6th, or any subsequent age.
  2. Congenital  valgus, 1st, 2d, or 3d degree at birth.
           ((       k       u       «        2d or 4th  year.
           ((       (l       c       k        6th, or any subsequent age.
  3. Talapes equinus, 1st, 2d, or 3d degree at birth.
           IC       <<        «<       "        2d or 4th  year.
           (i       i(       ii       <<        6th, or any subsequent age.
  4. Talapes calcaneous, 1st, 2d, or 3d degree  at birth.
           ,,       ic       ti       u        2d or 4th  year.
           ,,       (<       tc       <i        6th, or any subsequent age.
  5. Talapes dorsalis, 1st, 2d,  or 3d degree at birth.
           ,t       u       <i       u        2d or 4th year.
           ,,       <c       u       it        6th, or any subsequent age. 
(   86   )
                            CONTRACTED KNEE.
    Varieties.
    Muscles and tendons involved in each.
    Causes of contraction___1. Congenital.  2. Acquired.
   Diagnosis.—May be confounded with the different varieties of anchylosis,
 dependent on other causes.
    Prognosis.
    Effects on the joint if neglected.
    Treatment.—1. By mechanical  means alone.   2. By section of the tendons,
 followed by the use of mechanical  measures.
    Condition of the joints after  contraction is overcome, and the  treatment
 required in this stage.
    Dangers to be apprehended during the treatment of the case.

                           CONTRACTED THIGH.
    Varieties.
    Muscles and tendons involved.
    Causes of contraction.—1. Congenital.  2. Acquired.
    Diagnosis.—Often confounded with coxalgia when the flexors are  involved.
    Prognosis.
    Effects  on the joint if neglected.
    Treatment---1. By mechanical means alone.   2. By myotomy, followed by
 mechanical measures.
    Condition of the joint after  contraction is overcome, and the treatment  re-
 quired at this time.
    Dangers to be apprehended during the treatment of the case.

               CONTRACTION OF THE FINGERS AND TOES.
    Varieties.                .
    Muscles and tendons involved in each.
    Causes  of contraction.—1. Congenital.   2. Acquired.
   Diagnosis.—May be mistaken for  contraction of the fascia  palmaris  or
plantaris, when the flexors are in fault.
   Prognosis.—Depends on the cause and the degree of lesion sustained by the
tendons.
    Treatment___Depends very much on  the cause; and we may require mecha-
nical means as  well as the knife for the relief of the difficulty,

                      CONTRACTION OF THE WRIST.
   Varieties.
   Muscles and tendons in fault  in each.
   Causes of contraction___1. Congenital.  2. Acquired.
   Diagnosis.
   Prognosis___Unfavorable generally.
   Treatment.—The same general  treatment applicable to  the  other cases  of
contraction, will answer here. 
 
 
(  87   )
                 CONTRACTION  OF THE ELBOW JOINT.
   Varieties.
   Muscles and tendons in fault in each.
   Causes of contraction.—1. Congenital.   2. Acquired.
   Diagnosis.
   Prognosis.
   Treatment___The same  general treatment is to be observed here as in the
other forms of contraction.

                   CONTRACTION OF THE SHOULDER.
   Varieties.
   Muscles and tendons in fault in each.
   Causes of contraction___1. Congenital.   2.  Acquired.
   Diagnosis.
   Prognosis.
   Treatment___The same as above.

                   CONTRACTION OF THE LOWER JAW.
   Varieties.
   Muscles and tendons in fault.
   Causes of contraction...—1. Congenital.   2.  Acquired.
   Diagnosis___Not to be confounded with adhesions, contractions from burns,
or cicatrices.
   Prognosis.
   Treatment.__In almost every case of this defect it is necessary to divide the
muscles before the different means usually employed can be used with any effect.
(See the cases of Mott, Fergusson, Smythe and myself.)

                              TORTICOLLIS.
   Synonymes.—Caput opstipum; wry neck.
   Definition.—An involuntary and fixed inclination of the head towards one of
the shoulders.   It is sometimes  intermittent.
   Symptoms.
   Causes.—1. Congenital. 2. Acquired.
   First, or congenital.
   a. Muscle or muscles  on one side too short.
   b. Paralysis of one set of muscles.
   Second or acquired.
   a. Hemiplegia.
   b. Chronic rheumatism.
   c Fevers of long standing.
   d. Chronic myositis.
   e. Mechanical injuries.
   /. Habit.
   g. Palsy of extensors of the neck.
   Muscles in fault.—Generally  the sterno-cleido-mastoid, but the trapezius,
platysma myoid, and, in  short,  the whole  set of muscles on one side may be
involved.   It is supposed by some to be dependent occasionally on  shortening
of the integuments or fascia of the neck, but I have never met with an example. 
(   88   )
   Diagnosis___May be confounded  with recent palsy of the  muscles, from
blows upon the neck ;  with acute rheumatism ; abscess in the neck ;  caries of
the bones ;  tumors; old luxations ; hydrocele of the neck, and curved spine.
   Prognosis.—Depends on a variety of circumstances.  State them.
   Dissection.
   Treatment___Depends on the cause, parts involved, and the duration of the
disease.  Mechanical  measures of  various kinds, the  knife, and  constitutional
treatment may all be required.

                               STRABISMUS.

   Definition.
   Muscles, tendons, and fascia in fault.
   Varieties.—1. Convergent.  2. Divergent.  3. Upward squint.  4. Down-
ward squint.
   The first is most frequent, in consequence of the internal rectus being stronger
than the external, from its insertion being nearer the cornea, and  from the natu-
ral habit we have of looking inwards more than outwards.
   Symptoms.
   Degree.
   Duration.—Occasional  or permanent.  It is also,  in  some cases,  volun-
tary.
   Eye generally attacked___According to some, the right; according to others
the left.   Both are often involved.
   Mode of ascertaining which eye is diseased.
   Effect on vision.
   Causes.—1.  Congenital.  2. Acquired.   3. Direct.  4. Indirect.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.—Several indications.   1. Remove the cause.  2. Use mechanical
means to correct the deformity.  3. Where these fail, resort to an operation.
   History of this operation.
   Cases to which it is applicable.
   Mode of performing it.
   Treatment after the operation,
 x  Dangers of the operation.
   Change in the muscular attachmejits.
   Results of the operation.—1. Favorable.   2. Unfavorable.
   First, or favorable.
   a. Disappearance of deformity.
   b. Improvement in vision.
   Second, or unfavorable—
   a. Operation fails to correct the deformity.  Why ?
   b. The  eye is everted.
   c. The  eye projects.
   d. A relapse takes place.
   Methods proposed to overcome these difficulties.
   Appreciation of the operation. 
 
 
(   89   )
                                 LEUCITAS.
   Definition.
   Muscles in fault.
   Varieties.
   Symptoms.
   Causes.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.
   The third form of atrophy is exceedingly rare, but when it occurs, it will of
 course give rise to a loss of function in the part or organ to which the muscle is
 attached.   The deformities to which it gives rise do not differ essentially from
 those occasioned by simple atrophy.  (See Mayo.)

                    IX. SPASM OF THE MUSCLES.
   Spasmodic affections of the muscles are exceedingly common, and referable
 in most,  cases,  to primary irritation of the nerves of the part; but the disease
 may originate in the  muscle, and gradually extend to the nerves.  It is highly
 important, in forming our diagnosis, to distinguish the true cause, as the treat-
 ment chiefly turns upon this point.   The permanent defects, resulting from this
 condition of the muscles, most frequently met with, are certain kinds of stam-
 mer, twitching  of the muscles of the face, scrivener's spasm, rigid atrophy and
 paralysis.

                              I. STAMMERING.
   Definition.
   Varieties.—1. Functional.   2.  Organic.
   Causes of functional.—Sometimes  inappreciable;  spasm of muscles, bad
 habit from imitation.
   Causes of organic.—The tongue may be  too large,  too long, tied, or badly
 shaped.  The fauces and roof of the mouth may also, when deformed, occasion
 a stammer.
   Diagnosis.
   Prognosis.
   Treatment___Various methods have been introduced, but of course the cha-
racter of the cause will modify the treatment.  There are  four plans chiefly in
vogue :—1. Vocal gymnastics.  2. Speaking with some hard substance between   «j
the teeth.  3. Acupuncture.  4. An operation. n ^         '  y-x-x^-*
   History of these operations.
   Different modes of operating described,  x
   Appreciations of these operations.

            II. TWITCHING OF THE  MUSCLES  OF THE FACE.
   Varieties.                                    ,      ,                  .  .
   Causes. A'.  » > *■■<,-<3»AA ry^ c t x---tx.Cr-x v  t-i-fcf  A <A<*4..... t\xG*r-* «-«-< '""' A *Va***'.«
   X.  ■■  y » ■- £v~                                                        A
   Diagnosis.
   Prognosis^  ^y' g        &    ^  • ft ^^V^^^ZA  >A&  W   -
   Treatment,   «✓ ^ < ~** -"J  .   v     r                  ^           /
   yZc^p- 4~xy-<*A-*-ll   /^ tx>     j  <l  Zt^j _ 'A f^  ^  J3  „,./ t ,/. _

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(  90   )
                       III.  SCRIVENER'S SPASM.
   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                            X.  ENTOZOOA.

   The muscles  frequently become the habitations of parasitic animals, and
especially of the Cysticercus cellulosa, and the Trichina spiralis, first described,
I believe, by Mr. Owen, of London.

                    XI.  MALIGNANT  DISEASES.

   The muscles, like all the  other tissues, are liable  to be  attacked by the
various affections to which  the term maliguaiit has been assigned.
            VII.  DISEASES OF THE ARTERIES.

                             I.  WOUNDS.

   Varieties.—Penetrating, non-penetrating,  punctured, incised, contused, lace-
rated, &c.
   Symptoms.—Depend on the nature of the wound, and the size of the vessel.
   Prognosis.—Depends on character of the wound, size of the vessels, and the
diathesis of the patient.
   Diagnosis___May be confounded with wounds of veins.
   Results.—The hemorrhage may cause death, unless arrested by the surgeon,
or by an effort of nature; the wound  may close, and the  circulation  continue
in the limb, as before; or the circulation  may he so much impaired as to occa-
sion gangrene ; and finally, aneurisms of different kinds may be developed.
   Mode of healing___Varies with the kind of wound.
   Treatment___See incised wounds.

                            II.  ARTERITIS.
   Definition.
   Comparatively rare.           «
   Varieties---1. Subacute.  2. Acute.   3. Chronic.
   Causes.
   Symptoms of each Variety.
   Diagnosis.
   Prognosis.
   Dissection,
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(  91   )
                  III.  DEGENERATION OF TISSUES.
   The arteries undergo a variety of pathological changes  termed » degenera-
 tions," the causes of which are often obscure, but usually may be referred to
 the pre-existence of  inflammation.   The most common of these degenerations
 are :  1.  Cartilaginous or  osseous deposites  between  the lining membrane and
 the proper tissue of  the vessel.   2.  Thickening of the lining  membrane.   3.
 Atheromatous deposites in different portions  of the vessel.   4. Steatomatous
 deposites.   5. Ulceration.  6. Softening.
   Diseases produced by these changes.—1. Dilatation; 2. Hypertrophy with
 dilatation; 3. Contractions;  4. Rupture; 5. Obliteration; 6. Aneurism.

                               DILATATION.
   Parts of the vessel usually involved.
   Vessels most liable to be affected.
   Effect on the shape and size of the vessel.
   Symptoms by which it may be recognized.
   Diagnosis.
   Prognosis.
   Treatment.
                    HYPERTROPHY WITH  DILATATION.
   This condition  is seen in the uterine arteries during utero-gestation, in aneu-
 rismal varix, and in  aneurism by anastomosis or vascular naevi.

                              CONTRACTION.
   A diminution in the capacity of an artery has been observed by Morgagni,
 Desault,  Laennec, Mayo, Elliottson, Baillie, and others.  The defect is usually
 met with in the larger vessels.

                                RUPTURE.
   This is the result of some mechanical  cause operating upon  a vessel weak-
 ened by some of the different forms of degeneration.  Its occurrence may result
 in the death of the individual, or the establishment of an aneurism.

                             OBLITERATION.
   A variety of causes may produce  obliteration, but inflammation maybe con-
 sidered the most common.  The results of this condition of a large artery, are
gangrene, paralysis, and sometimes  death.

                             IV. ANEURISM.
   Definition.
   Varieties.— I.  Spontaneous.  2. Traumatic.  3.  Internal.  4. External.   5.
True.  6. False.   7. Mixed.   8. Circumscribed.  9. Diffused.  10. Dissecting.
 11. Varicose.   12. Aneurismal varix.  13.  Aneurism  by Anastomosis.
  Breschet's classification___1. Sacciform.  2. Fusiform.  3. Cylindroid.   4.
 Varix like.
  Number.—Varies  in different  individuals.    Usually but one.   May have
several, as in the cases of Pelletan and Cloquet.
   Causes.—1. Predisposing.   2.  Accidental, or proximate.
\ 
(   92   )
  First, or predisposing:
  a. Disease of the coats of the vessel.   (See degenerations.)
  b. Sex.  Male most liable.
  c. Age.   Old persons most liable.
  d. Location of vessel.   Vessels of the lower limb most liable.
  e. Vocation.    Laboring classes most liable.
  f. Size of the artery.  Large more frequently affected than the small.
  Second or accidental.
  a. Some violent exertion.
  b. Wounds.
  c. Ulceration of the coats of vessel.
  Symptoms.— 1. Constitutional.   2. Local.  Both  classes  modified  by the
location, variety, size, and duration of the tumour.
  Diagnosis.—The diagnosis is not difficult in the early stages of the complaint.
As  the tumour becomes solid it is more uncertain.  An aneurism has been con-
founded with an abscess, tumours of different kinds situated  near large arteries,
dilatation of Arteries, and diseases of different organs.
  Prognosis.—Influenced by  circumstances.  It is,  under  all  circumstances,
however,  to be  considered a most formidable  disease—usually requiring an
operation for its relief, although nature is occasionally competent to the task of
" spontaneous cure."
  Progress of the disease___Great diversity in this respect.   Sometimes it runs
its course rapidly; and again, years may elapse before a fatal result takes place.
  Effects of an aneurism on surrounding structures.
  State of the blood in the aneurismal sac.
  Changes which take place in the  sac as the disease advances.
  Terminations of the disease.
  a. Spontaneous cure.
  b. Death from hemorrhage.
  c Death from  exhaustion.
  d. Death from direct influence of the tumour upon some vital organ, as  the
brain, &c.
  Processes by which a spontaneous cure is accomplished.
  a. Obliteration of the sac by concrete fibrine.
  b. Obliteration of both sac and artery by fibrine.
  c. Pressure on the trunk of the vessel by the  tumour itself.
  d. Inflammation, suppuration, and  sloughing of the sac, and a portion of  the
artery.
  e. Bursting of  the sac, the effusion  of blood  under the adjacent tissues, and
the subsequent  coagulation of this blood, which, pressing  upon  the  artery,
causes its obliteration.
  Treatment---The indication in the treatment of every case of aneurism of
the usual kind, is to cause an obliteration of the artery involved.   To carry this
indication into effect, two general modes of management have been introduced : —
1. The first has for its object the diminution  of the force of circulation, so that
the blood may coagulate in the tumour, and the artery contract.   2. In  the
second we attempt a complete  arrestation of  the  circulation through the  part,
by  the  obliteration of the vessel by some mechanical measure  or surgical
operation. 
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(  93   )
  First, or, as it is called, the method of Valsalva.—Agents employed under
this head—
  General remedies.—1. Barely sufficient nourishment to support life.   2. Rest
in the horizontal position.   3. Small quantity of fluid in the diet.   4. Digitalis
and the antimonials.  5. Venesection.
  Local remedies.—1. Leeches.  2. Astringents and refrigerants.   3. Ice.
  Second method.—Agents employed under this head.— 1. Compression. 2. Liga-
ture of the vessel or vessels.    3. Application of the actual cautery—(employed
by Severinus, Monteggia, Sir E. Home, and others.)  4.  Injecting the sac with
some fluid which produces  coagulation of  the blood—(proposed by Wardrop.)
5. The introduction of needles, or a seton, into the sac—(Pravaz,  Philips, &c.
6. The use of needles and galvanism at the same time—(Keate and Faraday.)
                              COMPRESSION.
   Mode of applying compression.—Two or three methods—1. That  of Vernet, on
the capillary side of the tumour.   2.  That of Guatanni along the artery, above
the tumour, and on the tumour itself.   3. General pressure over the whole limb.
   Agents employed___Tourniquet, bandage  and compress, starch bandages ;
plaster of Paris mould, compressor of Dupuytren, compressor of Sunfio, &c.
   Modus operandi of compression.
   Objections to its employment.
   Appreciation of the -method.
                               LIGATURE.
   Not  properly employed until  the time of Hunter.   Before this period the
operations for the cure of aneurism were rude and dangerous.   By some, the sac
was opened, the contents  turned  out, and compresses or the actual  cautery
applied to arrest the hemorrhage.  By others, the sac was emptied, and then an
attempt made to tie the bleeding vessels.  By others, Aetius, Philogius, Guille-
meau, &c, the artery was tied  above and behind  the  tumour, the latter  then
opened, and the  vessels tied.   The dangers of these measures have  induced sur-
geons to abandon them, and we now choose, when an operation is decided upon,
between three different methods of applying a ligature.   These are—
   1.  The operation of Hunter.  The ligature is here placed on the cardiac side
of the tumour, or above the sac.
   2.  The operation of Brasdor.   The ligature is here applied on the distal side
of the tumour, or between it  and the capillaries.
   3.  The operation of  Wardrop.   The  ligature is here applied to a branch of
the diseased artery on the capillary side of the tumour.
                          HUNTER'S OPERATION.
   Mode of performing it.
   Instruments required.
   Cautions to be observed  in the application of the ligature.
   Immediate effect upon the tumor when the ligature is properly placed.
   Subsequent effect on the tumour.
   Immediate effect on the limb.
   Subsequent effect on the limb.
   Time required for the establishment of anastomosing circulation.
   Effect on the general System, and especially the brain.
   Dressing the wound.
   After treatment of the case. 
(   94   )
                          brasdorA operation.
   Mode of performing it.
   Instruments required.
   Cuii.i-ons to be observed in the application of the ligature.
   l.iini'-iliatc effect upon the tumour.
   Subsequent effect.
   Immediate effect on the limb.
   Subsequent effect.
   Time required for the establishment of the anastomosing circulation.
   Effect on the general system.
   Dressing the wound.
   After treatment.
                        WARDROP'S OPERATION.
   Mode of performing it.
   In struments required.
   C-iiiiiini-. to be observed in the application of the ligature.
   Immediate effect on the tumour.
   Subsequent effect.
   Immediate effect on the limb.
   Time required for the establishment of the anastomosing circulation Aire.
   Effects on the general system.
   Dressing the wound.
   After treatment.
   Accidents which may follow the performance of either of these operations :
   a. Convulsions.
   b. Fever.
   c. Secondary hemorrhage.
   d. Increase in the size of the tumor.
   e. Rupture  of the  sac.
   /. Gangrene of the tumor.
   g. Gangrene of the limb.
   h. Chronic inflammation and subsequent ulceration of the artery or sac.
   i. Plethora.
   Peculiar advantages of the different operations discussed.

   CAUTERY---INJECTION---NEEDLES---GALVANISM  AND ACUPUNCTURE.
   These different modes of treatment have recently been introduced into general
practice, and, although one  or all may prove more or less  useful as adjuvants to
other remedies of more importance, it is hardly probable  that  anything more
than this will ever be claimed for them.
   Appreciation of all the various methods of treatment for aneurism.

                   TRAUMATIC, OR FALSE ANEURISM.
   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment. 
 
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(   95   )
VARICOSE ANEURISM.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
                                 ANEURISMAL  VARIX.
          Definition.
          Causes.
          Symptoms.
          Diagnosis.
          Prognosis.
          Dissection.
          Treatment.

                              ANEURISM  BY ANASTOMOSIS.
          Synonymes.
          Definition.
          Causes.
          Symptoms.
          Diagnosis.
          Prognosis.
          Progress.
          Dissection.
          Treatment___1. Compression.  2. Ligature of main arterial trunks.  3. En-
j'Cl'l<ft,iif|'Atlgi.tllpitf 1B9W'^V JC&ilVii\  4. Seton.  5. Breaking up cells.  6. Puncture,
       followed by caustic probe.  7.  Puncture, and injec^igr^fth.»^a>a.^timti]fe*inlg
       liquid.  8. Vaccination.  9. Caustic potash.  10. Nitric acid.  11.  Tart, antim.
       12. Actual cautery.  13. Incisions under the skin.  14. Acupuncture. 15. Darn-
       ing.   16.  Ligature of the whole mass.   17.  Excision.  18. Tattooing.

                                  OSSEOUS ANEURISM.
          Definition,
          Ca_uses.
          Symptoms.
          Diagnosis.
          Prognosis.
          Dissection.
          Treatment.
                           V.  PARTICULAR  ANEURISxMS.  %

          The symptoms and treatment of  each one described. 
(  96   )
              VIII.  DISEASES OF THE VEINS.

                             I. WOUNDS.
  Varieties.
  Symptoms.
  Diagnosis.
  Prognosis.
  Results.
  Mode of healing.
  Treatment.
                            II. RUPTURE.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.
               III.  INFLAMMATION,  OR  PHLEBITIS.
  Varieties___1. Acute.   2. Chronic.
  Causes.—1.  Constitutional.  2. Local.
  Symptoms.—Vary with the  intensity of the attack.  They may be divided
into the constitutional and local.
  Diagnosis.
  Prognosis.
  Dissection.
  Effects resulting from phlebitis___Obliteration of the vein, visceral abscess,
t.-deaia, ulceration of the vessel, calcareous deposites, &c.               »  ' tt-f*
   Treut„y,t.—\.  Constitutional.   2. Local. J$<*—*y + **+ **A&>--*»***• C«

        '                 IV. AIR IN VEINS.
  Effect produced by the introduction of air into the veins.
   The manner in which it gains admission.
   The causes of convulsion and death in these  cases.
   Means of preventing its introduction while an operation is going on.
   Treatment in the event of its introduction.
                         V.  VARICOSE VEIN.
   Nature.
   Location.
   Extent___The dilation may be uniform or unequal, and  involve a portion of,
or the entire vein.
   Causes___Anything that will prevent a free  circulation of the blood through
the vein,
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Results.
   Treatment.—1. Palliative.   2. Radical. 
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(  97   )
   Agents employed as Palliatives___1. Compression with rollers or straps, or
both, or laced stockings.  2. Frictions with iodine ointment, or Davis's solution
of iodine; repeated blisters.   3.  Galvanism.   4.  Puncture of the vein.
   Agents employed  with a view to a radical cure.—1. The ligature.   2. The
needle and ligature, as used by Davat, Velpeau, and others.   3.  Caustic paste
which occasions a slough—(recommended by Cartwright, Mayo, &c. 4. Trans-
verse subcutaneous incisions, followed by compression—(Brodie.)  5. Excision,
followed by compression.  6. Acupuncture.  7. Seton.   8. Subcutaneous liga-
ture__(Ricord.)  9.  Irregular compression with graduated  compresses  and a
bandage.  10. Position, rest for several months.
   Dangers of these  measures.
   Appreciation  of the different methods.
                         VI.  OSSIFICATION.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.
                         VII. PHLEBOLITES.
   Definition.
   Veins in which they are usually found.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Chemical composition.
   Treatment.
                    VIII. MALIGNANT DISEASES.
   The veins are frequently involved in the different malignant diseases which
attack all organized  tissues.
           IX.  DISEASES OF  THE  LYMPHATICS.

                             I.  WOUNDS.
   Varieties.
   Symptoms.
   Diagnosis.
   Prognosis.
   Restilts.
   Mode of healing.
   Treatment.
                            II.  RUPTURE.
   This lesion is stated to have occurred in a patient of Guiffort's, but the symp-
toms are too obscure to merit our attention.  It was supposed by Morton to be
one cause  of consumption ;  by Ackermann, to exist in scrofula ;  by Hendy to
exist in Barbadoes leg;  by White it  was considered  the cause of phlegmasia
dolens ; by Assalini and others it was reckoned the cause of dropsy ; and Brom-
billa thought it the cause of white swelling.
        7 
(  98   )
              III. VARICOSE  DILATATION, OR CIRSUS.

    A rare and obscure lesion, present usually in dropsy and some other com-
 plaints.  As it is an effect, it can only be relieved by removing  the cause on
 which it depends.

                          IV.  OSSIFICATION.

    Like the arteries and veins, these vessels are liable to calcareous deposites in
 their coats.

             V. ANGEIOLEUCITIS, OR INFLAMMATION.

    Varieties---1. Acute.  2.  Chronic.
    Causes.—1.  Direct.  2. Indirect.
    Age most liable___Puberty and old  age.
    Symptoms___1. Local.  2.  General.
    Diagnosis---May be confounded with phlebitis, neuritis, nexiralgia, erysipe-
 las, and phlegmon.
    Prognosis.—It is to be considered  generally a dangerous disease.
    Progress and duration___Variable.
    Terminations.—Resolution, suppuration, induration, ulceration, sloughing,
 death.
   Dissection.—Three classes of phenomena to study.
    1. Those which take place  in the vessels.
   2. Those which take place in the interposed tissues.
   3. Those  which take place in  the viscera,  remote regions,  and  blood—
 (Velpeau.)
   Treatment.—1. Constitutional.  2.  Local.

          VI. INFLAMMATION  OF  LYMPHATIC GLANDS,
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Te rminations.
   Treatment.

              VII. ENLARGEMENT AND INDURATION.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Terminations.
   Treatment.

                         VIII.  OSSIFICATION.

   Usually the result of inflammation,  and the glands most liable are those of
the lungs. 
 
 
(  99  )
                   IX. MALIGNANT DISEASES.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Terminations.
  Treatment.
X. CONSEQUENCES  RESULTING FROM THE EXTIRPATION OF A
                  LARGE NUMBER OF GLANDS.
             X. DISEASES  OF  THE NERVES.
                           I. WOUNDS.
  Varieties.
  Symptoms.
  Diagnosis.
  Prognosis.
  Mode of healing.
  Treatment.
                II. STRETCHING AND RUPTURE.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.
                          III. NEURITIS.
  Varieties.—1.  Acute.  2  Chronic.
  Causes.—1. Constitutional.   2. Local.
  Snmptoms.—Depend upon the nature of the attack.
  Diagnosis.
  Prognosis.
  Dissection.
  Terminations.—Resolution,  effusion  of  lymph,  ulceration, hypertrophy,
atrophy, hardening, softening.
  Treatment.
                         IV.  NEURALGIA.
  Definition.
  Varieties.
  Causes.__1. Those which act upon the nerve itself.  2. Those which ope-
rate through the system at large.
  Symptoms.
  Parts most liable to be attacked.
  Diagnosis.
  Prognosis.
  Pathology.
  Treatment___Indications—1.  Remove the cause, whether constitutional or
local.   2.   Palliate the pain.  3.  Divide the nerve.   4. Excise  a portion of the
nerve   5   Acupuncturation. 6. Electro-magnetism, &c.  7.  Moxa, &c.
             V. ANOMALOUS NERVOUS AFFECTIONS.
  These  vary in character ; and of course the treatment must be based upon the
peculiarity of each. 
(   100  )
                   VI.  HYSTERICAL NEURALGIA.
   Definition.
   Persons most liable.
   Parts most liable to be attacked.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Pathology.
   Treatment.
                            VII. TUMOURS.
   Varieties.—Solid, or encysted.
   Location.—In the neurilema;  between the superficial fibres of a nerve, or
they may implicate all the fasciculi at the part attacked ; and again, they may
be developed upon the extremity of a divided nerve in the shape of a little but-
ton.   Lastly, they may occupy the large and deeply seated nerves, or the super-
ficial and cutaneous; when developed in the latter situation, the tumour is called
"painful subcutaneous tubercle A
   Causes.—Blows upon the part, the application of a ligature, &c.
   Symptoms___Depend upon the location of the tumour.  They belong, how-
ever, to the class of << nervous symptoms," general as well as local.
   Diagnosis.                       >
   Prognosis.
   Pathology.
   Treatment.—1.  Palliative.  2. Radical.
   Palliative means—
   a. Leeches.
   b. Counter irritation.
   c Fomentations.
   d. Anodynes.
   Radical means—
   a. Division  of the nerve above the tumour.
   b. Extirpation of the tumour.
   c. When the tumour is a cyst, puncture followed by compression.
   Condition of the limb after the removal of a portion of the nerve.

                           VIIT.  TETANUS.
   Definition.
   Varieties as to muscles affected.—1. Opisthotonos.   2. Emprosthotones.   3.
Pleurosthotonos.  4. Trismus, or locked jaw.
   Varieties as to cause  and duration.—1.  Traumatic.  2.  Idiopathic.   3.
Acute.  4. Chronic.
   Causes.—1. Constitutional.   2. Local.
   Symptoms..—Vary with the location as well  as the intensity of the attack.
General symptoms stated.
   Diagnosis.
   Prognosis.
   Pathology.
   Treatment.—1. General.   2. Local. 
 
 
(  ioi   )
                         IX. PARALYSIS.
  Definition.
  Varieties.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Pathology.
  Treatment.
                  X. OTHER ORGANIC LESIONS.
  The nerves, like the other tissues, are liable to hypertrophy, atrophy, harden-
ing,  softening,  ulceration, and malignant diseases of various kinds.   But these
lesions are rarely recognized until after death,  or they give rise to the pheno-
mena already referred to as characteristic  of diseases to which specific names
have been assigned.
      XI.  DISEASES OF  THE CELLULAR TISSUE.

                   I. SIMPLE INFLAMMATION.
  See << Inflammation."
     II. PHLEGMON, OR CIRCUMSCRIBED INFLAMMATION.
  See " Phlegmon "

             III. ERYSIPELATOUS INFLAMMATION.
  See " Erysipelas."
                        IV. CARBUNCLE.
  See "Charbon or Carbuncle."
                           V. ABSCESS.
  See " Abscess."
                       VI. HEMORRHAGE.
  Causes.—Mechanical injuries,  and diseases of a peculiar character, as pur-
pura, scorbutus, typhus, &c.
  Character of the blood.
  Symptoms.
  Prognosis.
  Diagnosis.
  Treatment.
                     VII. SEROUS EFFUSION.
 ' Synonym.—(Edema, anasarca, aqua intercus, leucophlegmasia, &c.
  Causes.
  Symptoms.
  Prognosis.
  Diagnosis.
  Different kinds of serum effused.
  Treatment. 
(  102   )
                     VIII.  INDURATION.
Synonym.— Scleroma, skin-bind.
Persons most liable.—Children.
Causes.
Symptoms.
Duration.
Prognosis.
Diagnosis.
Character of the tissue
Treatment.
                      IX. EMPHYSEMA.
Synonym—Pneumatosis spontanea et traumatica.
Causes.—Mechanical injuries, and sometimes it occurs spontaneously.
Parts of the body most liable to this collection.
Symptoms.
Prognosis.
Diagnosis.
Treatment.
            X. TUMOURS OF DIFFERENT KINDS.
See " Tumours."
             XI.  CONDENSATION INTO CYSTS.
Causes.
Indications that they have formed.
Uses of these  cysts.
     XII.  DISEASES OF  THE ADIPOSE TISSUE.

                     I. INFLAMMATION.
See "Inflammation."

                        II. WOUNDS.
See << Wounds." •
                     III. HEMORRHAGE.
Causes,
Character of the blood.
Symptoms.
Prognosis,
Diagnosis.
Treatment.
            IV.  HYPERTROPHY, OR POLYSARCIA.
Varieties___1. Partial.  2. Complete.
Causes.
Symptoms.
Prognosis.
Diagnosis.
Dissection.
Treatment. 
 
 
                          (   103   )

                         V. ATROPHY.

Varieties.
Causes.
Symptoms.
Prognosis.
Diagnosis.
Treatment.

              VI.  TUMOURS OF VARIOUS  KINDS.

See " Tumours."
  Diseases of the Skin, Hair, Nails, and Teeth cannot be embraced in a course
so rigidly restricted to the most important points in Surgery; they will, how-
ever, be found in my work on Surgery. 
   THIRD  DIVISION,   OR  DISEASES  OF

             REGIONS AND  ORGANS.


              I. INJURIES OF  THE  HEAD.

                         I. WOUNDS.
  Importance of these injuries.
  Classification.
1' a. Wounds involving the scalp alone.
  b. Wounds involving the scalp and bones.
  c. Wounds involving the brain and its membranes, as well as the scalp and
bones.

                  a. SUPERFICIAL WOUNDS.

                      I. INCISED WOUNDS.
  Causes.
  Symptoms.
  Prognosis.
  Results.
  Treatment.

                    II.  LACERATED WOUNDS.
  Varieties.
  Causes.
  Symptoms.
  Prognosis.
  Results.
  Treatment.

                     III. CONTUSED WOUNDS.
  Causes.
  Symptoms.
  Prognosis.
  Results.
  Treatment.

              IV. PRODUCTS OF CONTUSED WOUNDS.

                      a.  BLOODY TUMOUR.

    b. SUPPURATION BETWEEN SCALP OR PERICRANIUM AND BONE.
C. SEPARATION OF DURA MATER. 
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(  105   )
V. PUNCTURED  WOUNDS.
VI.  WOUNDS OF  TEMPORAL ARTERY.
Causes.
Symptoms,
Prognosis.
Diagnosis.
Results.
Treatment.
 Causes.
 Symptoms.
 Prognosis.
 Diagnosis.
 Results.
 Treatment.

      b.  WOUNDS INVOLVING THE  SCALP AND BONES.

     I. INCISED, LACERATED,  CONTUSED, OR PUNCTURED WOUNDS.
 Causes.
 Symptoms.
 Prognosis.
 Diagnosis.
 Results.
 Treatment.

                    II. PENETRATING WOUNDS.
 Causes.
 Symptoms.
 Prognosis.
 Diagnosis.
 Results.
 Treatment.
                      III.  GUN-SHOT  WOUNDS.
 Causes.
 Symptoms.
 Prognosis.
 Diagnosis.
 Results.
 Treatment.
. WOUNDS  INVOLVING THE BRAIN AND ITS MEMBRANES, ETC.

 Varieties.
 Causes.
 Symptoms.
 Prognosis.
 Diagnosis.
 Results.
 Treatment. 
(   106   )
    ENCEPHALOCELE  AN OCCASIONAL PRODUCT  OF THESE WOUNDS.
   Definition.
   Symptoms.
   Prognosis.
   Diagnosis.
   Results.
   Treatment.

               II. DISEASES OF THE SCALP, kc. &c.

                            I.  ERYSIPELAS.
   See "Erysipelas."

                            II. ANTHRAX.
   See " Anthrax."

                     III. TRAUMATIC  NEURALGIA.
   See " Neuralgia."

                          IV. PERICRANITIS.

                     V.  THICKENING OF PERICRANIUM.

                      VI. TUMOURS OF THE SCALP.
   See " Tumours."

         III. FRACTURES OF THE BONES OF THE HEAD.
   Causes.
   Varieties.
   Parts of the cranium most liable to fracture.
   Age most liable.
   Symptoms___Depend on location  of fracture,  &c.
   Prognosis.
   Diagnosis.
   Mode of union.
   Treatment.

                         IV. CONCUSSION.
   Definition.
   Extent or degree.
   Causes.
   Symptoms.—Three  groups—1.  Stunning.  2  Loss of consciousness, &c.
3.  Convulsions, &c.
   Prognosis.
   Diagnosis.
   Anatomical examination.
   Results.
   Treatment. 
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(   107   )
                V. COMPRESSION  OF  THE BRAIN.

  Definition.
  Illustration of the influence of pressure upon the brain.
  Causes___Depressed bone, effused blood, collection of pus, &c.
  Symptoms.—Depend on the nature of the cause.
  Prognosis.— Depends on—1. Extent of surface involved.  2. Location of the
compressing body.  3. Location with reference to depth.   4.  Nature of com-
pressing body.  5. Suddenness with which compression is applied.
  Diagnosis.
  Manner of ascertaining the seat of the injury.
  Manner of ascertaining the nature of the compressing body.
  Dissection.
  Results.
   Treatment. —Varies with cause.—
  a. When the bone is depressed. -'■'"' "/
  b. When effused blood is the cause.
  c. When pus constitutes the compressing agent. ,


                              TREPHINING.

   History of the operation. <     * ~ '   -A- '■■>'■
   Diseases of the head for which it is employed.
   Dangers of the operation.
   Parts to be avoided in applying the instrument.
   The operation itself described.
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   Marnier in which the opening is closed.
                     PARACENTISIS.

INFLAMMATION OF BRAIN.—(See "Effusion.")
     II. INJURIES AND DISEASES  OF THE SPINE.


   Classification.
   a. Injuries and diseases of the spinal column.
   b  Injuries and diseases of the spinal marrow and its nerves.  1. Concentric
diseases of the true spinal marrow.  2.  Eccentric diseases or those attacking
the incident or excitor nerves.  3.  Diseases of the  reflex, or  motor nerves.
4.  Spinal irritation. 
(   108   )
  a.  INJURIES AND DISEASES OF THE  SPINAL COLUMN
                               ITSELF.

                           I.  FRACTURES.
   Liability.
   Causes.—External violence directly or indirectly applied.
   Usual seat of fracture.—Spines, bony bridges, and body.
   Division.—1. Those occurring above the fourth cervical.   2. Those occur-
ring  below  this point.
   Symptoms.—Depend upon the location of the fracture and its extent.
   Prognosis.—Depend on location and extent of fracture.
   Diagnosis.—May be confounded with luxation,  concussion of spine, com-
pression from effused blood, inflammation of marrow or its membranes.
   Dissection.
   Treatment.
                           II. LUXATION.
   Liability.
   Causes.—External violence.
   Vertebra most liable.— The cervical, especially the second.
   Division.—1. Partial.  2.  Complete.
   Symptoms.—Depend on seat of injury and its extent.
   Prognosis.—Depends on the seat and extent of injury.
   Diagnosis.                                  %
   Dissection.
   Treatment.

   III.  SPONTANEOUS  LUXATION OF THE  FIRST CERVICAL.
   Definition.
   Causes.
   Symptoms.—In 1st, 2d, and 3d stages.
   Progress.
   Prognosis.
   Diagnosis.
   Dissection.
   Treatment.
                          IV.  CURVATURE.
   Definition.
   Varieties.—1. Lateral, or scoliosis.   2. Posterior,  or gibbus  or cyphosis.  3.
Anterior, or lardosis.
   Causes.—Predisposing and immediate.
   Prophylaxis.
   Symptoms.—Depend on  the variety of the defect.
   Prognosis.—Depends on the age of the  individual, the duration, cause, de-
gree, and complication of the case.
   Diagjiosis.—May be confounded with caries, partial paralysis, natural ine-
quality in size of the two halves of the body, &c.
   Pathology.
   Effects on the spinal column, its contents, and the health of the individual.
   (Question of marriage.
   Treatment. 
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(  109   )
                     V. SHORTENED  SPINE.
  Definition.
  Causes.
  Symptoms.
  Prognosis.
  Diagnosis.
  Treatment.
                     VI. CARIES OF  SPINE.
  Liability.—Children most liable ; may occur in adults.
  Causes.—1. Constitutional.   2. Local.
  Symptoms.—Vary in the 1st, 2d, and 3d stages; and also depend on the age
of the individual.
  Prognosis.
  Diagnosis.
  Effects zipon the viscera of the thorax and abdomen, and general health of
the patient.
  Dissection.
  Treatment.
                          VII.  ABSCESS.
  Causes.
  Symptoms.
  Prognosis.
  Diagnosis.
  Dissection.
   Treatment.
                         VIII.  EXOSTOSIS.
   Effects of these tumours on the functions of the spine, and those of the adja-
 cent viscera.
                         IX. ANCHYLOSIS.
   Effects of this condition of the joints upon the functions of the column.
                         X.  SPINA BIFIDA.
   Definition.
   Causes.
   Symptoms.
   Prognosis.
   Diagnosis.
    Treatment.

 b.   INJURIES AND DISEASES OF  THE SPINAL  MARROW,
                ITS  MEMBRANES AND NERVES.

                     I. CONCENTRIC DISEASES.
                             I. WOUNDS.
    Varieties.
    Causes.
    Symptoms.
    Prognosis.
    Diagnosis.
    Treatment. 
(  no   )
II. CONCUSSION.
III. COMPRESSION.
Causes.
Symptoms.
Prognosis.
Diagnosis.
Treatment.
   C arises.
   Symptoms.
   Prognosis.
   Diagnosis.
   Treatment.

                           IV.  CONGESTION.
   Causes.
   Symptoms.
   Prognosis.
   Diagnosis.
   Treatment.

                   V. INFLAMMATION,  OR  MYELITIS.
   Causes.
   Symptoms.
   Prognosis.
   Diagnosis.
   Dissection.
   Results, or products.—Convulsions, epilepsy, paralysis agitans, either gene-
ral or partial,  tremor mercurialis.
   Treatment.

   VI.  INFLAMMATION OF  THE  MEMBRANES, OR SPINAL  MENINGITIS.

   Causes.
   Symptoms.
   Prognosis.
   Diagnosis.
   Dissection.
   Treatment.
II.  ECCENTRIC DISEASES, OR THOSE  OF THE EXCITOR NERVES.
  These are certain forms of epilepsy, puerperal convulsions, tetanus, hydro-
phobia,  hysteria, chorea, stammering, asthma, vomiting, tenesmus, strangury,
and abortion.   Most of these affections are treated of under other heads.

      III. DISEASES OF  THE  REFLEX OR MOTOR  NERVES.
  Spasmodic  strabismus,  spasmodic  tic,  spasmodic  torticollis, spasm of the
respiratory nerves—already referred to. 
 
 
Definition.
Causes.
Symptoms.
Prognosis.
Diagnosis.
Dissection.
Treatment.
        (   HI   )

IV. SPINAL  IRRITATION.
   III.  INJURIES  AND DISEASES OF  THE EYE.

             I. INJURIES, &c. OF THE  EYELIDS.

                          WOUNDS.
Varieties.
Symptoms.
Prognosis.
Results.
Treatment.

                 INFLAMMATION OF  THE LIDS.
Texture usually involved.
Causes.
Varieties.
Symptoms.
Prognosis.
Results.
Treatment.
                           CEDEMA
Causes.
Symptoms.
Prognosis.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

Definition
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
OPHTHALMIA TARSI.
PSOROPHTHALMIA. 
 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Treatment.


 Definition.
 Causes.
 Symptoms.
 Prognosis.
 Treatment.


 Definition.
 Causes.
 Symptoms.
 Prognosis.
 Treatment.


 Definition.
 Causes.
 Varieties.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.


 Definition.
 Causes.
Symptoms.
Prognosis.
 Treatment.
(   H2   )

HORDEOLUM.
TYLOSIS.
MADAROSIS.
TRICHIASIS.
DISTICHIASIS.
PTOSIS.
ECTROP1TJM. 
 
 
(   113   )
                               ENTROPIUM.
   Definition.
   Causes.
   Symptoms.
   Prognosis.
   Treatment.
                ANCYLOBLEPHARON AND  SYMBLEPHARON.
   Definition.
   Causes.
   Symptoms.
   Prognosis.
   Treatment.
                              EPICANTHUS.
   Definition.
   Causes.
   Symptoms.
   Prognosis.
   Treatment.
                                TUMOURS.
   Varieties---Noevi materni, encysted, half-encysted, tarsal tumours, chalazion,
or grando, milium, and veruca..
   Causes of each.
   Symptoms of each.
   Diagnosis.
   Prognosis.
   Treatment.
                         MALIGNANT DISEASES.
  The lids, like all other portions of the body, are sometimes involved in ma-
lignant diseases,  by which they are partially or entirely  destroyed.   These
cases are  generally troublesome, and often require  an extensive operation for
their relief.   (See Blepharoplastic operations.)

      II.  INJURIES AND DISEASES OF THE  CONJUNCTIVA

                 FOREIGN BODIES LODGED IN THE EYE.
   Various kinds.
  Symptoms.
  Mode of examining the lids.
  Diagnosis.
   Prognosis.
   Treatment.

                    WOUNDS OF THE  CONJUNCTIVA.
   Varieties.
  Symptoms.
  Diagnosis.
  Prognosis
  Treatment.
        3 
(   114   )
                SIMPLE INFLAMMATION  OF CONJUNCTIVA.
   Causes.—1. Constitutional.   2.  Local.
   Symptoms.
   Prognosis.
   Diagnosis.
   Effects of products.
   Treatment.—1. General.  2. Local.

                       CATARRHAL OPHTHALMIA.
   Definition.
   Synonymes___Conjunctivitis catarrhalis, conjunctivitis puromucosa catarrha-
lis, ophthalmia purulenta metior, cold blight, &c.
   Causes___Cold in some shape, often  accompanying influenza, and is occa-
sionally epidemic.
   Symptoms.
   Diagnosis.
   Prognosis.
   Seat of the affection.—Seldom involves any other tissue than the conjunctiva.
   Terminations,
   Treatment.
                        PURULENT OPHTHALMIA.
   Definition
   Varieties.—That of newly-born children, and that attacking adults.  Acute
and chronic.
   Symptoms.
   Diagnosis.
   Prognosis.
   Terminations or products.—1.  Sloughing of  cornea.   2.  Ulceration.  3.
Opacity of cornea.  4.  Bursting of  cornea.  5.  Adhesion of iris.  6. Detach-
ment of conjunctiva.  7. Staphyloma.  8. Ectropium, or Entropium.
   Treatment.

                       GONORRHCEAL OPHTHALMIA.
   Definition.
   Varieties—Acute, chronic,  and  that involving both the conjunctiva and
sclerotic coat.
   Causes.—Is it contagious ?
   Symptoms.—In each variety.
   Diagnosis.
   Prognosis.
   Effects.
   Treatment.
                     ERYSIPELATOUS OPHTHALMIA.
   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment. 
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(   115   )
PUSTULAR OPHTHALMIA.
Definition.
Causes.
Age most liable.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
SCROFULOUS  OR STRUMOUS  OPHTHALMIA.
Definition.
Causes___1. Predisposing.
Symptoms.
Diagnosis.
Prognosis.
Results.
Treatment.
2.  Exciting.
VARIOLOUS OPHTHALMIA.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
MORBILLIOUS AND SCARLATINOUS OPHTHALMIA.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
ULCERS OF THE CONJUNCTIVA.
GRANULATED  CONJUNCTIVA. 
(   116   )
                  HYPERTROPHY OF CONJUNCTIVA.
Causes.
Symjitoms.
Diagnosis.
Prognosis.
Effect on lids.
Treatment.
                            PTERYGIUM.
Definition.
Varieties.—1.  Tenue.  2. Crassum.  3. Malignant.  4. Single.  -3. Pannus.
Location---Usually the inner canthus.
Age most liable.—Adult.
Causes.—Often obscure.
Symptoms and growth.
Diagnosis.
Prognosis.
Pathology.
Treatment.
                  XEROMA, OR DRY CONJUNCTIVA.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatmoit.

POLYPI, WARTS, AND OTHER  EXCRESCENCES OF THE CONJUNCTIVA.
Characteristics of these tumours.
Causes.
Diagnosis.
Prognosis.
Treatment.

       III. INJURIES AND DISEASES OF THE CORNEA.

                             WOUNDS.
Varieties.
Symptoms.
Diagnosis.
Prognosis.
Effects.
Treatment.

Varieties.
Symptoms.
Diagnosis.
Prognosis.
Effects.
Treatment.
FOREIGN BODIES  IN THE CORNEA. 
 
 
(   117   )
                     INFLAMMATION  OF THE CORNEA.
    Varieties.—1. Acute.  2. Chronic.   3. Partial.   4.  Complete.  5.  Scro-
 fulous.
    Causes.—1. Constitutional.  2. Local.
    Symptoms,
    Diagnosis.
    Prognosis.
    Effects.
    Treatment.

                     SUPPURATION OF THE CORNEA.
    Causes.
    Symptoms.
    Diagnosis.
    Prognosis.
    Efleets.
    Treatment.

                        ULCERS  OF THE CORNEA.
    Causes.
    Symptoms.
    Diagnosis.
    Prognosis.
    Effects.
    Complications—Hernia corneas, fistula cornea;, &c,
    Treatment.

                       OPACITY  OF THE CORNEA.
   Varieties---1.  Arcus senilis.   2. Nebula.  3.  Albugo, or leucoma.   !
Macula.   5. Congenital.
   C arises.
   Symptoms---In each variety.
   Diagnosis.
   Prognosis.
   Effect on vision.
   Treatment___1. General remedies.  2.  Local remedies.  3.  Cunier's opera-
tion.  4. Bigger's operation.

                              STAPHYLOMA.
   Definil ion.
   Extent.—1.  Partial.  2.  Complete.
   Shape.—Varies.   Hence we have the  staphyloma hemisphericum, globosum,
conicum, racemosum, &c.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Structure.
   Treatment. 
(  118   )
                       CONICAL CORNEA.
Definition.
Causes.
Symptoms.
Diagnosis,
Prognosis.
Treatment.
    IV.  INJURIES  AND DISEASES OF THE SCLEROTICA.

                           WOUNDS.
Varieties.
Symptoms.
Diagnosis.
Prognosis.
Effects.
Treatment.

      SCLEROTITIS, OR  INFLAMMATION OF  THE SCLEROTICA.

Varieties.
Causes.
Diag7iosis.
Prognosis.
Results.
Treatment.

                    STAPHYLOMA SCLEROTICA.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

            CYSTS  AND TUMOURS OF  THE SCLEROTICA.
 Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

V. INJURIES AND DISEASES OF  THE AQUEOUS  MEMBRANE
                       AND  CHAMBERS.

      FOREIGN BODIES  LODGED IN  THE  ANTERIOR CHAMBER.
Nature of these bodies.
Manner of introduction.
Symptoms produced by their presence.
Prognosis.
 Treatment. 
I 
 
(   119   )
AQU0-CAPSULITI3.
HYPOPYON.
                        H.EMOPHTHALMUS.
Definition.
Causes.
Symptoms.
Diag7iosis.
Prognosis.
Effect.
Treatment.

Definition.
 Varieties.
 Causes.
Symptoms.
Diagnosis.
 Prognosis.
 Results.
 Treatment.

 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Results.
 Treatment.
               DROPSY OF  THE  ANTERIOR CHAMBER.
 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Results.
 Treatment.
          VI.  INJURIES AND DISEASES OF  THE  IRIS.
                            IRIDEREMIA.
 Definition.
 Causes.
 Appearance of the eye.
 Effect on vision.
 Prognosis.
  Treatment.
COLOBOMA  IRIDIS.
Definition.
Causes.
Appearance of the eye.
Effect on vision.
Prognosis.
Treatment. 
                             (   120   )

                  CHANGE OF COLOUR  IN  THE IRIS.

 Causes.
 Appearance of the eye.
 Effect on vision.
 Prognosis.
 Treatment.

                PROCIDENTIA, OR STAPHYLOMA IRIDIS.

 Definition.
 Causes.
 8 ymptoms.
 Effect on vision.
 Prognosis.
 Treatment.

                              SYNECHIA.

 Definition.
 Varieties___Anterior and posterior.
 Causes.
 Symptoms.
 Prognosis.
 Treatment.

       FUNGOUS EXCRESCENCES AND TUMOURS OF  THE  IR

 Varieties.
 Causes.
 Symptoms.
 Prognosis.
 Treatment.

                              MYOSIS.
 Definition.
 Causes.
 Symptoms.
 Effect on vision.
 Prognosis.
 Treatment.

                           MYDRIASIS.
Definition.
 Causes.
Symptoms.
Effect on vision.
Prognosis.
Treatment. 
 
 
(   121   )
                            TREMULOUS IRIS.

    Definition.
    Causes.
    Symptoms.
    Effect on vision.
    Prognosis.
    Treatment.


                                  IRITIS.

    Definition.
    Varieties. — I. Acute.   2. Chronic.   3. Idiopathic.  4. Sympathetic, which
 includes the syphilitic, arthritic, &c.
    Causes.—1st, or constitutional, as  yphilis, gout, rheumatism, scrofula, cold,
 wet, &c.
    2d, or local.—Direct injuries, over exertion of the eye, &c.
    Age most liable—Adult and old age.  Rarely occurs before puberty.
    Symptoms.—1  Constitutional.  2.  Local.  These are  of course modified
 by the extent,  duration, and intensity of the inflammation.
    Effects of this inflammation___1. Effusion of coagulable lymph.  2. Change
 in the color of the iris.  3. Displacement of the iris.   4. Hypopion.  5. Effusion
 of blood in the chambers.   6. Adhesions between the iris and cornea, or capsule
 of the lens.  7. Loss of motion in the iris.  8. Closure of the pupil.  9. Atrophy
 of  the globe.  10.  Opacity and thinning of the  cornea.  11. Partial or entire
 loss of vision.
    Diagnosis.
    Prognosis___Depends on circumstances ; for the most part it is unfavorable.
    Treatment___Three  indications—1.  Arrest the inflammation.   2. Prevent
 the  further  effusion  of lymph, and  promote  the  absorption  of that  already
 secreted.   3. Prevent the  contraction and obliteration of the pupil.   Remedies
 to be employed for the  accomplishment of these indications.


                 OPERATIONS FOR  ARTIFICIAL PUPIL.

   Object of these operations.
   States of the eye requiring the operation.
   Proper condition of the eye for an operation.
   Prognosis.
   Position of the artificial pupil.
   Should we operate when one eye is sound !
   Should we operate on both when both eyes are  diseased.
   Preparation of the patient for an operation.
   Various operations described.—Three principal methods at present in vogue,
1  Incision.   2. Excision   3. Separation.
  Relative merits of each.
  Formation of an artificial pupil in the sclerotica. 
(   122  )
              VII.  DISEASES  OF THE CHOROID COAT.

                              CHOROIDITIS.
   Definition.
   Varieties___Acute and chronic.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                       DEFICIENCY OF PIGMENT.
   Causes.
   Symptoms.
   Diagnosis.
   Prog?iosis.
   Treatment.

                 VIII. DISEASES OF THE RETINA.

                               RETINITIS.
   Definition.
   Varieties.—Acute and chronic.
   Causes.
   Symptoms.
   Diag)iosis.
   Prognosis.
   Treatment.

                               AMAUROSIS.
   Definition.
   Synonymes.—Gutta serena, suffusion.
   Varieties___1.  Idiopathic.  2. Sympathetic.  3.  Symptomatic.  4. Incipient,
or recent.  5. Inveterate, or confirmed.   6. Partial.  7. Complete.  8. Organic.
9.  Functional.  10. Continued.   11. Intermittent.   12. Periodical.  13. Local,
or nervous.  14.  Complicated.
   Cause.—Several classes—
   1. Those operating immediately on the nervous apparatus of the eye.
   2 Those operating indirectly  through the  medium of  some other organ, or
by sympathy.
   3. Those operating through the medium of the sensorium.
   4. Congenital causes.
   Symptoms---Depend on the stage at which we examine the case.
   Diagnosis.—May be confounded with cataract, glaucoma,  muscae,t &c.
Refer to the catoptric examination.                                       -
   Prognosis.—Depends on  the  cause,  duration, and  degree of the attack.
Influence on sound eye when but  one is affected.
   Pathology.
   Treatment.—Modified to  suit the peculiarities of the case. 
 
 
(   123   )
WEAKNESS OF SIGHT.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Pathology.
Treatment.

Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Pathology.
Treatment.

Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Pathology.
 Treatment.

Definition.
 Causes.
Symptoms.
Diagnosis.
Prognosis.
Pathology.
 Treatment.

Definition.
 Causes.
Symptoms.
Diagnosis.
 Prognosis.
 Pathology.
 Treatment.

 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Pathology.
 Treatment.
MUSCiE VOLITANTES.
HEMERALOPIA.
NYCTALOPIA.
HEMIOPIA.
NEAR-SIGHT. 
(   124  )
                               FAR-SIGHT.
  Definition.
  Causes.
  Symptoms.
  Diagyiosis.
  Prognosis.
  Pathology.
  Treatment.
                               PHOTOPSIA.                         ■*
  Definition.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Pathology.
  Treatment.
                     CHRUPSIA. OR COLORED VISION
  Definition.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Pathology.
  Treatment.
           IX.  DISEASES OF THE LENS AND CAPSULE.
                               CATARACT.
  Definition.—Partial or complete opacity of the crystaline lens, of its cap-
sule, of both conjointly,  or of the liquor Morgagni.
  Varieties.—Lenticular, capsular, capsulo-lenticular, and  Morgagnian;  true
and false;  radiated and  arborescent; hard, soft, and  fluid, and cataracts of
various colours ; congenital and acquired.
  Age most liable.
  Causes'.
  Symptoms___Impaired vision, opacity in or behind the pupil, &c. &c.
  Diagnosis —May be confounded with amaurosis, glaucoma, weakened sight,
deposites of lymph, &c.   Use the catoptric test to ascertain the true character
of the case.
  Prognosis.—Depends on the complication of the case, its duration,  &c.
  Progress of the defect.
   Question of operating when but one eye is affected.
   Treatment___Nothing short of an operation will cure the complaint.   Several
operations have been devised, viz :  1. Extraction.  2. Depression, or couching.
3. Reclination.  4.  Solution or absorption.  (Anterior and posterior operation.)
  Appreciation of these  different operations.
  Description of each, and the instruments required for its performance.
  Preparation of the patient.
   Season most favorable for operating.
  After treatment.
   Condition of the eye when the operation succeeds.
   Cataract glasses. 
 
 
(   125   )
                              GLAUCOMA.
  Although  this affection, strictly speaking, cannot be considered an affection
of the lens in every case, yet as glaucoma is often confounded with cataract, and
the lens is often involved, it may be as well to speak of it under this head.
  Definition.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
   Pathology.
   Treatment.

            X.  DISEASES OF THE GLOBE OF THE EYE.

                             INFLAMMATION.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.
                            HYDROPHTHALMIA.
   Definition.
   Varieties.,__1.  Dropsy of the anterior and posterior chambers.  2. Dropsy of
 the  vitreous humour.  3.  General dropsy of the eye-ball.
    Causes.
   Symptoms in each form.
    Diagnosis.
    Prognosis.
    Treatment.
                         ATEOPHY  OF THE BALL.

    Causes.
    Symptoms.
    Diagnosis.
    Prognosis.
     Treatment.
                       COLLAPSE FROM  SUPPURATION.

     Character of the defect.
     Mode of relieving the deformity.
                               EXOPHTHALMIA.
     Definition.
     Causes.
     Symptoms.
     Diagnosis.
     Prognosis.
     Treatment. 
(  126   )
      XL  AFFECTIONS OF  THE LACHYRYMAL ORGANS

           INFLAMMATION  OF THE LACHRYMAL GLANDS.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.
   ENLARGEMENT AND INDURATION OF  THE LACHRYMAL GLAND.
 Causes.
 Symptoms.
 Prognosis.
 Diagnosis.
 Treatment.

      EPIPHORA, OR  EXCESSIVE SECRETION OF THE TEARS.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.
                  STILLICID1UM LACHRYMARUM.
 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

    XII.  DISEASES OF  THE CARUNCULA  LACHRYMALIS.

                          ENCANTHIS.
 Definition.
 Varieties.—Innocent and malignant.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.
                  TUMOURS OF  VARIOUS KINDS.
  XIII.  DISEASES OF THE  LACHRYMAL SAC  AND DUCT

                        INFLAMMATION.
 Causes.
 Varieties.—Acute and chronic.
 Symptoms.
Diagnosis.
Prognosis.
 Treatment. 
 
 
(  127   )
                            ABSCESS.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
                     FISTULA LACHRYMALIS.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
         PERMANENT OBSTRUCTION OF  THE NASAL DUCT.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

          CONGENITAL  DEFICIENCY OF THE NASAL DUCT.
Operation for its relief—(see Berard.)
         XIV. MALIGNANT  DISEASES  OF THE EYE.
                     FUNGOUS  EXCRESCENCES.
 Causes.
Symptoms.
Diagnosis,
Prognosis.
 Treatment.
                     CARCINOMA OF  THE  EYE.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.
               XV. EXTIRPATION  OF  THE EYE.
 Mode of performing the operation.
FUNGOUS HEMATODES OF THE EYE.
MELANOSIS OF THE EYE. 
                           (   128   )

       XVI. INTRODUCTION OF AN  ARTIFICIAL EYE.
Preparation of the eye.
Mode of placing it.

     XVII. ANALOGOUS DEGENERATIONS  OF THE EYE.

           OSSIFICATIONS AND  CALCULOUS CONCRETIONS.
               XVIII. ENTOZOOA IN THE EYES.
Kinds usually met with.
Symptoms produced by their presence.
Effect upon the eyes.
Treatment.

               XIX.  DISEASES OF  THE ORBIT.

                            WOUNDS.
Varieties.
Symptoms.
Diagnosis.
Prognosis.
Treatmeiit.
                   FRACTURES OF THE  BONES.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
             FOREIGN BODIES  LODGED IN THE  ORBIT.
Symptoms.
Prognosis.
Treatment.
    INFLAMMATION OF THE  CELLULAR TEXTURE OF  THE ORBIT.
Causes.
Varieties.
Symptoms.
Diagnosis.
Prognosis.
Results.
Treatment.
                    TUMOURS  IN  THE ORBIT.
Various kinds.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
 
 
(   129   )
                 IV. DISEASES OF THE EAR.

   Anatomy of the Ear.—Divided into external, middle, and internal ear.  The
external  ear  consists  of the auricle, and the meatus  auditorius externus.
The middle ear consists of the tympanum and its appendages, namely, the mem-
brana tympani; the four ossicula auditus with their ligaments and muscles; the
eustachian tube;  and the mastoid cells.
   The internal ear, or labyrinth, as it is  termed, from its complexity of orga-
nization,  is divided  into  bony and membranous labyrinth—the  bony is subdi-
vided into vestibule, three semicircular canals, and the cochlea—the membranous
labyrinth is found within the semicircular canals and the vestibule and contains
the thin serous fluid called liquor cotunnii.

                 MALFORMATIONS  OF  THE  EAR.

                    MALFORMATIONS OF THE AURICLE.
   Cases most frequently met with.—1.  Deficiency of helix, and sometimes its
division from the lobus.  2. An entire absence of the lobus—its division by a
slit into an anterior and posterior portion—or its attachment wholly or partially
to the integuments of the side of the head.   3. The tragus and  anti-tragus are
sometimes united, or inverted so as to partially close the opening of the meatus.
4. The total  absence  of the auricle.  5.  An enormous enlargement  of the
auricle.
   Causes.—1.  Congenital.   2. Acquired, from  wounds,  bites,   ulceration,
sloughing___an increase in size  is often the result of manipulation, or  of the
dress stretching the part.
   Effect upon sense of hearing.
   Treatment___By artificial ear, by  removal of overlapping portion, by dila-
tation.

        MALFORMATIONS OF MEATUS  AUDITORIUS  EXTERNUS.

   Most  frequent varieties.—1.  A very narrow canal.   2.  An unusual short-
ness of canal.   3. A total absence  of  canal.  4. A closure of  the  canal at
birth by  a slimy caseous  matter.  5. A closure of the orifice by the integument
stretching across it and being attached to its margin; or by a membrane in any
part of the canal;  by a contraction  in the cartilage, or by undue ossification of
the bony part of the lube.
   Causes.—Mostly congenital—sometimes acquired.
   Effect upon hearing
   Examination of meatus exter?ius.
   Prognosis.—Modified by cause.
   Treatment.—Varies with the case.
        9 
(   130  )
                MALFORMATIONS  OF  THR MIDDLE  EAR.

   Importance.—Most of them are attended with deafness, and the cause is
 generally not to be removed.
   Most frequent  variations.— 1.  The cavity has been  found much smaller
 than usual.   2.  The  cavity  has been inordinately large.  3. The  outer wall
 has been ossified—in fact a bony plate has occupied the place of the membrana
 tympani.   4. The ossicula auditus are often varied in their conformation, thus
 one or more  of them may be too small or  too large or deficient in ossification,
 or ossified together, or altogether wanting.  Supernumerary bones have also
 been found.  5. The tympanum has been found filled with a soft white matter
 resembling inspissated  albumen ;  also with a  scrofulous deposite.    6. The
 eustachian tube  may be wholly or  partially obliterated.
   Causes.—1.  Constitutional.  2. Acquired.
   Diagnosis.—An examination will  teach the condition  of the membrara
 tympani.   Catheterizing and  injection of air will  teach  the  condition of the
 eustachian tube.
   Prognosis.— Only favorable in partial obliteration of the eustachian tube.
   Treatment___Varies with the kind and cause.

              MALFORMATIONS  OF THE  INTERNAL  EAR.

   Various malformations  of the  labyrinth  have been noticed—it has been
 entirely wanting—it has been deficient in ossification—change in quantity and
 consistence of the  liquor cotunnii has also been observed.
   Such deficiencies are of course beyond the  reach of art.

                         WOUNDS  OF  AURICLE.

   Usual varieties.—Incised, lacerated, contused.
   Treatment.— Differs in no  respect  from that  for similar injuries in othej
 parts ; bearing in  mind the deformity resulting from the  loss of even a small
 portion, union is always to be attempted.


                       PARTICULAR  DISEASES.

                                 OTITIS.

   Definition.—Generic term, implying general disease of the whole organ.
   Division of.—Acute, chronic, external, internal.
   External includes inflammation of the auricle, and of  the meatus auditorius
 externus.
   Internal includes inflammation of the tympanum and labyrinth.
   Causes.—1. Exciting.    2. Predisposing.
   Symptoms  and  consequences.— As  acute inflammation seldom attacks the
entire organ at the  same time, or from the same cause, these vary according to
the structure  of the part inflamed,'and will be described under the heads  of dis-
 uses of particular  parts. 
 
 
(   131   )
                       ACUTE  EXTERNAL OTITIS.

   Seat.—Sometimes commences  simultaneously in the auricle and meatus—
more frequently it extends from  the  auricle to the canal—it however is some-
times limited to the meatus.
   Most frequent forms---Erysipelas, erythema, in short, all the inflammatory
actions, either common or peculiar, which affect the cutaneous system.
   Causes.
   Symptoms.—Vary with the form.
   Consequences.
   Diagnosis.
   Prognosis.—Favorable.
   Treatment.—1. Local.  2.  General.


                     ACUTE  INTERNAL  OTITIS.

         INFLAMMATION  OF  TYMPANUM  AND  LABYRINTH.

   Forms___Primary.    Consecutive.
   Seat.—Mucous lining membrane at first,  then extending- to cellular tissue, to
 eriosteum and to the bone itself.
   Causes.—Exciting.   Predisposing.
   Symptoms.—Agree with  those of external otitis, differing only in conse-
quence of their much greater severity, and of the circumstances of the matter
formed not  finding a ready outlet.
   Consequences.
   Diagnosis.—May be confounded with external otitis, with meningitis or
phrenitis.
   Prognosis.—Grave—as troublesome otorrhcea may  result—the ossicula may
be lost__the membrana  tympani or the mastoid  cells  may be perforated—per-
manent closure of the eustachian tube may result—or phrenitis, meningitis,
and death may follow.
   Treatment.

                           CHRONIC OTITIS.

             DIVISION--INTO EXTERNAL AND INTERNAL.

   External is divided into that of the auricle and that of the auditory meatus.
   Chronic  Inflammation of the auditory meatus  includes—
   1st. Erythema of meatus  with diminished secretion.
   2d.  Inflammation of dermal membrane with inordinate secretion.
   3d.  Polypus, fungus,  and  vegetations of auditory canal.
  4th. Sinus of meatus.
  Oth.  Inordinate ceruminous secretion.
  6th.  Aphtha: or herpetic ulcerations of lining membrane of meatus. 
(   132   )
               CHRONIC INFLAMMATION OF THE AURICLE.

   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.—Local and  constitutional, as the local  affection  is often  main-
tained by general derangement of the health.

     CHRONIC  INFLAMMATION  OF  MEATUS  AUDITORIUS
                              EXTERNUS.

           ERYTHEMATIC  CHRONIC DISEASES OF THE MEATUS.

   Synonyme.—l'Otite chronique seche.  (Roche.)
   Causes___General derangements of health.
   Symptoms.—Uneasiness, slight  pain,  itching,  dry sensation,  difficulty of
hearing, tinnitus aurium.
   Diagnosis—Tube unusually dry—wax in  small quantity—most frequently
a vitiated section of a white or yellowish scaly matter.
   Prognosis.—Favorable.
   Treatment---Attention  to  general  health—tonics—counter   irritants—
astringents.

II.  CHRONIC  INFLAMMATION  OF  DERMAL  MEMBRANE  WITH INORDINATE
                               SECRETION.

   Synonymes---Humid  chronic external  otitis, (Roche,) mucous or catarrhal
otorrhcea.   (Itard and Andial.)
   Frequency of occurrence.—Very  frequent.
   Age most liable.—Childhood—sometimes occurs in old age.
   Causes.—Acute inflammation—irritation of dentition___metastasis of gout,
gonorrhoea, and mucous ophthalmia—presence of a  foreign body.
   Symptoms.—Usually mild—uneasiness—audition slightly diminished—pro-
fuse discharge  either serous, mucous, or puriform, or mixed.
   Diagnosis.
   Prognosis.
   Treatment.—Removal of the cause—improvement  of ffeneral health___cau-
tious use of astringents.

    III. POLYPUS, FUNGUS,  AND VEGETATIONS OF  AUDITORY  CANAL.
   Difference between them---Polypus is oval or  round, attached  by a single
root, usually regular in its shape and firm  in consistence.   Fundus  is a mass of
exuberant granulations, soft and vascular, irregular in its shape  and attach-
ments, and always attended with free discharge.  Vegetations consist of nume-
rous small diseased growths,  sometimes soft  and fungoid, at  others,  firm and
conical, and attended with slight discharge. 
 
 
(   133   )
   Causes---Chronic  inflammation—local irritation  from foreign bodies—
injury to lining membrane by the ear-picker.
   Symptoms.
   Diagnosis.
   Prognosis.—Favorable in polypus—not so favorable in fungus and  vegeta-
tions.
   Treatment.—By excision  and  caustics—by ligature.—by  extraction with
forceps—by caustics alone.

                        IV.  SINUS  OF  MEATUS.
   Definition.
   Causes.—An abscess external to the meatus—a diseased  mastoid bone.
   Symptoms.
   Diagnosis.
   Prognosis.—Unfavorable.
   Treatment.—Modified by cause—palliative chiefly.

               V.  INORDINATE  CERUMINOUS  SECRETION.
   Causes.—Acute or chronic inflammation of the meatus.
   Symptoms.
   Diagnosis.__May  be  confounded with almost any of the other diseases  of
the ear ;  a careful examination must decide.
   Prognosis.—Favorable.
   Treatment.__Allay any  existing  inflammation;  remove  any  inspissated
cerumen; apply  some  gentle  stimulant.  Dangers arising  from incautious
syringing.

 VI. APHTHiE OR HERPETIC  ULCERATIONS OF  LINING  MEMBRANE
                              OF MEATUS.
   Causes.—Chiefly constitutional.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.__Tonics, and alteratives for the general health; local alterative
astringent injections.

     FOREIGN BODIES  IN  THE MEATUS  AUDITORIUS EXTERNUS.

   Nature of  these.—Round and smooth substances,  as  beans,  peas, glass
beads ;  sometimes insects of various kinds.
   Origin of insects.
   Symptoms___Those of  chronic inflammation, occasioning  an  otorrhcea,
where the cause continues to operate for any length of time.
   Treatment.__Removal of the cause will sometimes alone be sufficient; solid
substances may be removed by the forceps ;  insects may be removed by a few
drops of oil, or of infusion of tobacco, &c. &c.
   Danger! arising from force applied for the extraction of foreign bodies. 
(   134  )
                    INTERNAL  CHRONIC OTITIS.

         CHRONIC  INFLAMMATION OF MEMBRANA TYMPANI.

   Causes.
   Effects.—Ulceration ;  perforation ; complete destruction.
   Mode  of inspection and examination.—By speculum;  by forcible expira-
tion ;  by sounding and by the otoscope.
   Symptoms.
   Diagnosis.—May be  confounded  with disease of meatus, or of tympanic
cavity.
   Prognosis___Unfavorable to audition.
   Treatment.

              CHRONIC  INFLAMMATION  OF  TYMPANUM.

   Forms___Primary.  Consecutive.
   Seat of disease___Mucous membrane ;  frequently extending to the cellular
tissue, and onwards to periosteum and bone.
   Causes.
   Effects. — Perforation of membrana tympani; loss  of ossicula;  abscess of
mastoid cells ;  caries of  petrous bone ;  effusion of  pus  under dura mater or
between the cerebral membranes.
   Symptoms.
   Diagnosis.—May be confounded with other inflammatory diseases of internal
ear, with meningitis or phrenitis.
   Prognosis.—Unfavorable.
   Treatment.—Modified antiphlogistic ; injections of  mild  fluids through the
eustachian tube.

               RELAXATION  OF  MEMBRANA TYMPANI.
   Definition.
   Varieties___1. From want of tone in the membrane.  2.  Paralysis of the
internal muscle of the malleus.  3.  Rupture of the same muscle.
   Causes of each.
   Symptoms.
   Diagnosis.
   Prognosis___Of first two, favorable ; of the last, unfavorable.
   Treatment.—Dry  warm tonic applications; tonic and astringent injections.

CARTILAGINOUS AND  OSSEOUS  CONDITION OF  MEMBRANA TYMPANI.

   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.—By perforation.
   History of operation.—First proposed by Cheselden;  proposed and per-
formed by Sir  Astley Cooper in cases of obliteration of eustachian tube. 
 
 
(   135    )
   Dangers of  operation.—Wound of vascular lining  of membrane giving
rise to effusion of blood ;  injury to the chorda tympani, and to the malleus.
   Mode of operation---A simple puncture by trocar, Astley Cooper's opera-
tion ;  by caustic, Richerand's; by drilling with a quadrangular  perforator,
Buchanan's, Himle's, &c.

                   OBSTRUCTION  OF  EUSTACHIAN  TUBE.
   Forms---1. Partial.   2.  Complete.
   Causes.—Inflammation,  acute and  chronic ;  extension  from the throat of
such diseases, as scarlatina, variola, syphilis, cynanche  tousillaris, enlarged
tonsils, descent of nasal polypi.
   Symptoms.
   Diagnosis---May be confounded with deafness from other causes.
   Prognosis___Favorable.
   Treatment---By reducing existing  inflammation—by  constitutional treat-
ment, if the cause  requires it—by dilatation, if stricture  exists in the course
of the tube.

              MODE OF CATHETERIZING  EUSTACHIAN TUBE.
   Instruments used.
   History  of operation___First  performed on himself  by  Guyot,  a  Post
Master at  Versailles, in the year 1700, revived  by Itard, and materially im-
proved.
   Indications for its use___1.  An important means of diagnosis.  2. To re-
move  mucous or  blood from tympanic  cavity or  from eustachian tube.  3.  To
dilate a stricture.  4. To stimulate  the nervous system of the ear.
   Dangers of the  operation.—1. Inflammation  of  throat, and catarrh of the
tympanum.  2. Emphysema  3. Rupture of membrana tympani.  4.  Strangu-
lation.
   Mode of passing instrument.
   Air press.
                    NERVOUS DISEASES  OF  THE  EAR.
   Arranged under  two heads.   1.  Disordered function of the acoustic nerve.
2.  Disordered functions of  the  nerves of common  sensibility and  motion, or
the tympanic nerves,
   1.  Disordered  function  of the acoustic nerve.
   Division.—\.  The excited or acute state.  2. The torpid or chronic state.

                              ACUTE STATE.
   Causes.—From local affection—sometimes sympathetic with general health,
or  some disorder of brain,  stomach,  bowels,  or uterus—from overuse of organ.
   Symptoms.—Tinnitus aurium, deafness, an  annoying  pulsation synchronous
with the heart.
   Diagnosis.
   Prognosis.
   Treatment.—The removal of the cause, administration of tonics, alteratives,
counter irritants. 
(   136   )
                 I.  TORPID FUNCTIONAL DERANGEMENT.
   Age most liable.—Old age.
   Causes.—Over excitement of organ ;  severe constitutional disorder, &c.
   Symptoms.
   Diagnosis.—May be assisted by the  absence of disease in the external and
middle ear, by a want of perception of  sounds  when  the cranial bones are
thrown into vibration by a watch.
   Prognosis.—Unfavorable.
   Treatment.—xYttention must first be paid to general health ;  various nervous
excitants, as electricity and galvanism, may be tried.  Application of aetherous
vapour is recommended by Itard and Krahmer.
   Mode of introducing vapour.

         II. FUNCTIONAL DERANGEMENT OF  TYMPANIC NERVES.

   Synonym.—Otalgia or ear ache.
   Causes. — The common causes  of neuralgia;  enlarged  tonsils; any  local
disease in the  vicinity ;  direct injury in sounding tfte membrana  tympani, or
eustachian tube.
   Symptoms.
   D ingnosis.
   Prognosis.—Favorable.
   Treatment.

                        FORMS  OF DEAFNESS.

                               DEAFNESS.
   Synonymes.—Surditas, cophosis.
   Degrees.— 1.  That  marked by impossibility of hearing at all, usually con-
genital and a cause of dumbness. 2. By power of distinguishing certain sounds,
as the pronunciation of the vowels, whistling, &c.
   Causes.—Mostly congenital, sometimes acquired.   The  congenital  cases
most frequently depend on morbid  changes in the  soft parts, in a small propor-
tion of cases upon an anomaly in the structure of the solid parts.
   Diagnosis.
   Prognosis.—Unfavorable in congenital cases;  more favorable in  acquired
cases.
   Treatment.

                         HARDNESS OF  HEARING.
   Syuouyme.—Dyscecia.
   Definition.—Where the faculty of hearing is so diminished  that articulate
sounds cannot  be heard without the assistance of some particular apparatus.
   Degrees.—1.  Where  the individual  cannot  hear a distant  noise, and espe-
cially high tones, but can perceive articulated sounds when the voice is a good
deal raised  2.  He hears and distinguishes  both  high and  low tones, and also
words, but only when  the voice is  somewhat  raised.
   Causes.—Either some alteration in  that part of  the organ which  serves 
 
*' 
(   137  )
as a conductor for the vibration of sound;  or also an increased sensibility of
the acoustic nerve.
   Alterations of the conductive parts are of two kinds ;  1. A total obliteration
of the meatus auditorius  externus; its imperforation, or complete absence.
2. A diseased condition of the tympanum, as inflammation of its lining mem-
brane ; caries of its parieties ; and collections of blood, pus, or other fluid in its
cavity.
   Diagnosis.—Of  some alteration  of conducting parts, may be  assisted by
the patient  only  hearing when  solid bodies are placed between his  teeth.
while his dull perception of sound  does not appear to be less when the ear is
covered.   Of some disease of tympanum, by the history, or by marks of pre-
vious inflammation.
  Prognosis.—Unfavourable.
   Treatment.

             ALTERATION  OR  DIMINUTION OF  HEARING.

   Synonym.—Paracusis.
   Definition---Where the faculty of hearing articulated sounds in the natural
way is imperfect for want of precision.
   Causes---1.  Alterations of the membrana tympani from congenital malfor-
mation, or from  thickening, ossification, perforation, or laceration.   2. The
lodgment of fluid  in the tympanic cavity, as in some cases of obstruction of the
eustachian tube, as in some new bom infants.  3. Alterations in the membrane
of the fenestra rotunda, such as its  imperfect form, its erroneous situation, its
thickened  state, &c.  4.  Depression, or excitement of nervous influence, the
natural consequence of the patient's sensibility.
  Diagnosis.
  Prognosis.
   Treatment.
    V.  INJURIES  AND  DISEASES OF THE NOSE.

                             WOUNDS.

Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

               FRACTURES OF  THE OSSA NASI.

                         See << Fractures." 
(   138   )
                              EPISTAXIS.
  J)efiuition
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

    ACUTE  INFLAMMATION OF THE  SCHNEIDERIAN  MEMBRANE.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

CHRONIC  INFLAMMATION WITH THICKENING  OF THE  SCHNEIDERIAN
                             MEMBRANE.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
   Treatment.

                               ABSCESS.

   Causes.
   Symptoms.
  Diagnosis.
  Prognosis.
   Treatment.
CEDEMA  OF  THE SCHNEIDERIAN MKMBRANE
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis
Prognosis.
Treatment.
OZCENA. 

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(   139   )
             ULCERATION OF THE NASAL CARjTILAGES.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
           CARIES  AND  NECROSIS  OF THE NASAL BONKS.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

       ENLARGEMENT OF THE INFERIOR  TURBINATED BONE.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
               DEVIATION OF  THE SEPTUM NAR1UM.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
        LODGEMENT OF FOREIGN  BODIES IN THE  NOSTRILS.
Nature of these bodies.
Mode of introduction.
Symptoms produced by their presence.
Diagnosis.
Prognosis.
Treatment.
         FIBROUS  TUMORS  AND CYSTS OF THE NOSTRILS.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
                      POLYPUS OF THE NOSE.
Definition.
Locatioyi.
Form.
Number.
Size.
Consistence. 
(   140
   Color.
   Termination.
   Division.—1.  Nonmalignant.  2. Malignant.
   1.  Or nonmalignant.
   a.  The vesicular.
   b   The gelatinous.
   c  The fleshy.
   A.  The fibrous.
   e.  The hard.
   2.  Or malignant.
   '/-.  The cancerous.
   b.  The medullary or hcematoid.
   c  The schirrous.
   Causes.—Of simple polypus.
   General Symptoms.
   Sjiecial Symptoms.—Each  form is characterised by  peculiar  symptoms.
State  what these are.
   Causes of malignant polypus.
   Special symptoms in each variety.
   Diagnosis  of polypus tumour.—Has been confounded with a great  variety
of diseases, viz. enlarged  turbinated bone ;  inclination of the septum;  disease
of the nasal bones ;  cedema of the  mucous  membrane ; chronic inflammation ;
abscesses : ozcena; fibrous tumours of the nostrils; polypus of the antrum;
hernia cerebri;  foreign bodies in the nostril.
   Prognosis.—Depends on the form of polypus.
   Treatment.—Varies in the different species of polypus.

                           EXTERNAL  POLYPUS.
   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                               LIPOMA.
   Definition.
   Causes.
   Diagnosis.
   Prognosis.
   Treatmetit.

               LOSS OF  NOSTRIL OR  THE  ENTIRE NOSE.
See " Rhinoplastic operations.'' 
 
 
(  141   )
   VI.  INJURIES AND DISEASES OF THE  CHEEKS.

                              WOUNDS.
  Varieties.
  Parts liable to be involved.
  Symptoms.
  Prognosis.
  Treatment.

                           TIC DOLEREUX.
  Definition.
  Causes,
  Symptoms.
  Prognosis.
  Treatment.

                 SPASMODIC ACTION OF  THE  MUSCLES.
  Causes.
  Symptoms.
  Prognosis.
  Treatment.

                     PARALYSIS  OF THE CHEEK.
  Varieties.
  Causes.
  Symptoms.
  Prognosis.
  Treatment.—1. Constitutional.  2. Local.
  1. Only required when the  defect depends on a constitutional cause, and
must be  modified by the nature of this cause.
  2  Or local.
  a. Blisters.
  h  Application of strychnia or  veratria.
  c. Electricity.
  d. Acupuncture.
  e. Excision of a portion of the cheek.
  /. Section of the antagonising  muscles.  (Dieffenbach.)

                       TUMOURS  OF THE  CHEEK.
  Varieties.
  Mode of operating in each.

                       ULCERS  OF THE CHEEK.
  Division.—External and internal.
  Varieties.
  Causes.
  Symptoms.
  Prognosis.
  Treatment. 
(  U2  )
                           MACULzE.

I 'a! icties.
Causes.
Symptoms.
Prognosis.
Treatment.
                        LOSS  OF CHEEK.
                  See " Chieloplastic operations/'
  VII.  INJURIES  AND DISEASES  OF THE JAWS.

                          FRACTURES.
                        See "Fractures."

                          LUXATIONS.
                        See ('Luxations."

                           WOUNDS.

Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
   INFLAMMATION OF  THE LINING MEMBRANE OF THE ANTRUM.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
                   ABsCESS OF THE ANTRUM.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
               ULCERATION OF  LINING MEMBRANE.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
 
 
(   143   )
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
SERO-CYSTIC TUMOUR  OF ANTRUM.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
FIBROUS TUMOUR  OF ANTRUM.
FUNGUS TUMOUR OF  ANTRUM.
POLYPUS OF  ANTRUM.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
                    BONY  TUMOUR  OF ANTRUM.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
    FOREIGN BODIES  LODGED IN THE CAVITY OF  THE  ANTRUM.

Varieties.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
OSTEO-SARCOMA OF  UPPER JAW.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
(   144   )
OSTEO-SARCOMA OF  LOWER JAW.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
SPINA-VENTOSA  OF LOWER JAW.
EXOSTOSIS  OF LOWER JAW.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
                  ANCHYLOSIS  OF LOWER JAW.
Varieties.—True and false.
Causes of each.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
REMOVAL OF UPPER  JAW.
Mode of operatin.i
                   REMOVAL OF LOWER JAW.

Mode of operating.

            REMOVAL OF  SYMPHISIS OF LOWER JAW.

Mode of operating.

      RESECTION OF  DIFFERENT PORTIONS  OF THESE BONES.

Mode of operating.
EPULIS.
Definition.
Varieties.
Causes.
Symptoms in each variety.
Diagnosis.
Prognosis.
Treatment. 
 
 
                         (   145   )

                           PARULIS.
Definition.
Causes.
Symptoms.
Prognosis.
Treatment.
 VIII. DISEASES OF THE SALIVARY APPARATUS.

    I. DISEASES OF THE PAROTID GLAND AND ITS DUCT.

                            WOUNDS.
 Varieties.
 Causes.
 Symptoms.
 Prognosis.
 Treatment.

                 INFLAMMATION  OF THE GLAND.
 Varieties.x—kcxiXe and chronic.
 Causes.
 Symptoms.
 Prognosis.
 Treatment.

                    ABSCESS  OF  THE GLAND.
 Causes.
 Symptoms.
 Prognosis.
 Treatment.
                   TUMOUR  OF  THE GLAND.
 Varieties.
 a. Fatty.
 b. Melanotic.
 c Encysted.
 d. Fibrous.
 e. Simple hypertrophy.
/. Erectile.
g. Aneurismal.
h. Swelling from salivary concretion.
i.  Schirrous.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.—In each variety.
     10 
                              (   146   )

              TUMOURS  OCCUPYING THE PAROTID SPACE.

  Varieties.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

                      WOUNDS  OF PAROTID  DUCT.

  Varieties.
  Symptoms.
  Prognosis.
  Treatment.

                      FISTULA  OF PAROTID DUCT.

  Varieties.
  Causes.
  Symptoms.
  Prognosis.
  Treatment.—Four  methods.   1.  Cicatrization of the Fistulous orifice.   2.
Dilatation of the inner portion  of the duct.  3. The establishment of a new
opening in the mouth,  or forming a new portion of the canal, where the original
has  been destroyed. 4. Destruction of parotid gland.

  Agents employed under the 1st head—
  a. Suture.
  b. Cauterization.
  c. Compression.
  d. Plastic operation.
  Agents employed under the 2d head—
  a. Seton.
  b. Probing.
  Agents employed under the 3d head—
  a. Operation of Deroy.
  b.      »    "  Duphenix.
   e.      i'    "  Monro.
  d.      <<    "  Tessard and Flajani.
   e.      «    «  Atti.
  /.      «    <<  Deguise.
  g.      <<    '<  Bannafons.
  h.      "    "J. Rhea Barton.
   i.      "    "  Horner.
   Agents employed under the 4th head—
   a. Pressure on the  duct.
   b. Ligature of duct.
   c. Pressure on the  gland itself. 
 
 
                            (  147   )

                   FISTULjE of parotid gland.
  Varieties.—Two.
  Causes.
  Symptoms.
  Prognosis.
  Treatment.—a. Cauterization.
              b. Suture.
              c Excision.
              d. Blisters.
              e. Gold leaf plaster of Malgaigne.

        II. DISEASES OF THE SUB-MAXILLARY GLAND.

                             WOUNDS.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

                             FISTULA.
  Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

                  ENLARGEMENT  OF THE GLAND.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

        III. DISEASES  OF  THE SUBLINGUAL GLAND.

                            WOUNDS.
 Causes.
 Symptoms.
Diagnosis.
Prognosis.
 Treatment.
                            FISTULA.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
(  148   )
RANULA.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatme?it.
Location.
Varieties.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
ENLARGEMENTS OF THE GLAND.
SALIVARY  CALCULI.
IX.  DISEASES AND  INJURIES  OF THE  MOUTH.
I.  AFFECTIONS OF THE LIPS.
WOUNDS OF  THE LIPS.
Varieties.
Causes.
Symptoms.
Treatment.
                   SIMPLE TUMOURS OF THE LIPS-

   Varieties—Encysted, fatty, transparent cyst, enlarged follicles, verruca,
moles, &c. &c.
   Causes.—Vary in each form.
   Symptoms.—Depend on the variety.
   Prognosis.—Depends on the kind of tumour.
   Treatment.—Varies with the form of tumour. 
 
 
(   149   )
                         CANCER OF  THE  LIP.
  Point a- usually attacked___Margin, and especially that of the lower lip.
   Varieties.—Superficial and deep seated.
   Causes.
  Symptoms---Vary with the stage and form of cancer.
   Diagnosis.
  Prognosis.—More favorable than in any other form of cancer.
   Treatment.

                             CANCRUM ORIS.
   Definition.
   Persons  most liable to be attacked.
   Causes.—Constitutional and local.
  Symptoms___Vary with stage.
  Prognosis___Unfavorable.
   Treatment.—Depends on the stage of the disease, the part attacked, and the
situation of the patient.

                       EVERSION OR DOUBLE  LIP.
   Definition.
   Causes.
   Symptoms.
   Prognosis.
   Treatment.
                      HYPERTROPHY OF  THE  LIPS.
   Definition.
   Causes.
   Symptoms.
   Prognosis.
   Treatment.
                       ADHESIONS OF THE LIPS.
   Causes.
   Symptoms.
   Prognosis.
   Treatment.
                               HARE-LIP.
  Definition.
   Varieties.
   Lip most frequently affected.
   Complications.
   Causes.
   Symptoms.
   Prognosis.
   Treatment.—Depends on the age of the patient and the nature of the defect
  a. The usual operation.
  b. Barton's curvilinear operation.
  c. Malgaigne's operation.
  d Operation without needles. 
(   150   )
                             ATRESIA ORIS.

   Definition.
   Causes.
   Symptoms ■
   Prognosis.
   Treatment.

                          MOUTH TOO LARGE.

   See Report by Velpeau  of a case where the mouth was open nearly to
each ear.

                             LOSS OF LIP.
                     See " Chieloplastic operations."


                II.  AFFECTIONS OF  THE  TONGUE.

                      WOUNDS  OF  THE TONGUE.
   Varieties.
   Causes.
   Symptoms.
   Prognosis.
   Results.
   Treatment.

                              GLOSSITIS.
   Definition-
   Varieties.—Acute and chronic.
   Causes.
   Symptoms.
   Prognosis.
   Result.
   Treatment.

                      HYPERTROPHY  OF TONGUE.

   Varieties.—Congenital or acquired.
   Causes.
   Symptoms.
   Prognosis.
   Effects on the bones of the mouth.
   Treatment.
   a. Remedies calculated to promote absorption.
   b. Pressure.
   c. Ligature.
   d. Scarifications.
   t. Excision. 
 
 
(   151   j
TUMOURS  OF THE TONGUE.
Varieties---Simple and malignant.
Causes.
Symptoms.
Prognosis,
Diagnosis.
Treatment.
FISSURE  OF THE TONGUE.
Definition.
Causes.
Symptoms.
Prognosis.
Treatment.
Definition.
Causes.
Symptoms.
Prognosis.
Treatment.
GLAZED  TONGUE.
ULCERS OF  THE  TONGUE.
Varieties.—Simple and malignant.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
CANCER OF THE TONGUE.
Parts most frequently attacked.
Various forms presented in its origin.
Causes.
Symptoms.
Prognosis.
Treatment.
Causes.
Symptoms.
Prognosis.
Treatment.
ADHESION OF  THE  TONGUE. 
(  152   )
                             TONGUE TYE.

  Defi?iitro7i.
  Causes.
  Symptoms.
  Prognosis.
  Treatment,


                            STAMMERING.

  Definition.
  Causes.— 1. Congenital.  2. Acquired.   3. Functional.  4. Organic.
  Symptoms.—Vary in different cases.
  Prognosis.—As regards relief.
  Treatment.
    o. Vocal gymnastics; (so called.)
    h. Different surgical operations.
    c Acupuncture as proposed by Detmold;
  Examination of the results of these measures.


                        DEFORMED TONGUE.
  Varieties.
  Causes.
  Symptoms.
  Prognosis.
  Treatment.


                      PARALYSIS OF TONGUE.
  Causes.
 Symptoms.
 Prognosis.
 Treatment.


  HI.   DISEASES   OF  THE  TONSILS  AND  ROOF  OF  THE
                             MOUTH.

                     WOUNDS OF THE  VELUM.

 Varieties.
Causes.
Symptoms.
Prognosis.
Treatment. 
 
 
(   153   )
                   TUMOURS  OF  THE VELUM.

                     See <' Warren and others."

Varieties.
Causes.
Symptoms.
Prognosis.
Treatment.

                         INFLAMMATION.

Varieties.—Acute and chronic.
Causes.   -
Symptoms.
Prognosis.
Treatment.

                            ABSCESS.

Causes.
Symptoms.
Prognosis.
Treatment.

                             ULCERS.

Varieties.
Causes.
Symptoms.
Prognosis.
Treatment.

                          CLEFT VELUM.

Varieties.—Vary in extent.
Causes.—Congenital.
Symptoms.
Effect on the voice.
Prognosis.—As regards a cure by operation.
Treatment.—Operation of staphyloraphia.

       FISSURE AND  OPENINGS  OF  THE HARD PALATE.

Varieties.
Causes.
Symptoms.
Effect on the voice.
Prognosis.
Treatment.__Operations of staphyloraphia and staphyloplasty. 
(   154   )
                   AFFECTIONS OF THE UVULA.

    a. Cleft uvula.
    b. Hypertrophy of uvula.
    c Enlarged uvula.
    d. (Edema of the uvula.
    e. Relaxation of the mucous membrane of the uvula.
  Causes in each of these defects.
  Symptoms in each.
  Prognosis in each.
  Treatment in each.

        LODGEMENT OF  FOREIGN  BODIES  IN THE  FAUCES.

  Different kinds.—Fish bones, bits of bread, pins and needles, a thimble,
(see Parish,) &c.
  Symptoms developed by the lodgement of such matters.
  Treatment.

                 ENLARGEMENT OF  THE TONSILS.

  Location of the gland.
  Structure of the gland.
  Different kinds of enlargement.
     a. From acute inflammation.
     b. From chronic inflammation.
     c. From contagious inflammation, as is seen in anginosa putrida.
     d. From closure of the orifices of the follicles.
     e. From inspissation of its secretion.
     /. From calcareous deposites.
   Persons most liable___Children of a scrofulous diathesis.
   Causes.—Vary with the kind of enlargement.
   Symptoms.
   Effects on the thorax—(see Warren.)
   Prognosis.
   Treatment.—Depends on the kind of enlargement.
   X.  INJURIES AND  DISEASES  OF  THE NECK.

                I. SUPERFICIAL AFFECTIONS.

                            WOUNDS.
Varieties,
Causes.
Symptoms.
Prognosis.
Treatment. 
 
 
(   155   )
                                 ABSCESS.
    Varieties.
    Causes.
    Symptoms.
    Prognosis.
    Treatment.

                                 ULCERS.
    Varieties.
    Causes.
    Symptoms.
    Prognosis.
    Treatment.

                        TUMOURS  OF  THE NECK.
    Varieties.—Simple and malignant.
    Causes.                                                   <
    Symptoms.
    Prognosis.
    Treatment.

                      HYDROCELE OF THE  NECK.
                              See "Maunoir."
    Definition.
    Causes.
    Symptoms.
    Prognosis.
    Treatment.

                             BRONCHOCELE.
    Definition.—Tumour of thyroid gland ;  from Bpoi/xo? the windpipe.
    Synonymes___Gotre or goitre, tracheocele, Derbyshire neck, thyrophrasia,
 &c.
    Varieties.—Simple, complicated, and malignant—(see N. R. Smith.)
    Age most liable.
    Countries in which it is usually found.
    Causes.
   Symptoms.
   Diagnosis.__May be confounded  with other tumours.
   Prognosis.
    Complications___Often with disease of the heart.
   Treatment.
     a. Iodine.
     b. Mercury.
     c. Frictions with various liniments.
     d. Operations of various kinds.
   1. Electricity.  2. Caustics.   3. Seton.  4.  Tapping when it  contains a
cyst.   5.  Ligation of the thyroid arteries.  6.  Extirpation.
   Examination of these different operations. 
                            (   156   )

                       HERNIA  BRONCHALIS.
  Definition.
  Causes.
  Symptoms.
  Prognosis.
  Treatment,

                     DEFORMITY FROM BURNS.
                     See "Chapter on cicatrices."

                   TORTICOLLIS OR  WRY NECK.

 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

      II. AFFECTIONS OF THE LARYNX AND  TRACHEA.

                            WOUNDS.
 Varieties.
 Causes.
 Symptoms.
 Prognosis.
 Treatment.

                         INFLAMMATION.
 Varieties---Acute and  chronic.
 Causes.
 Symptoms.
 Prognosis.
 Treatment.

                            ABSCESS.
 Causes.
 Symptoms.
 Prognosis.
 Treatment.

                           ULCERS.
 Causes.
Symptoms.
 Diagnosis.
Prognosis.
 Treatment. 
 
 
(    157   )
                            CEDEMA.
Causes.
Symptoms.
Prognosis.
Treatment.

                            SCALD?.
Causes.
Symptoms.
Prognosis.
Treatment.

                  CARIES OF THE CARTILAGES.
Causes.
Symptoms.                                                 0
Prognosis.
Treatment.

         FOREIGN BODIES IN THE LARYNX OR TRACHEA-
Nature of these bodies.
How introduced.
Symptoms developed by their presence.
Prognosis.
Effects when the case is not promptly relieved.
Treatment,—Various operations.
   a. Tracheotomy.
   b. Laryngotomy.
   c. Laryngo Tracheotomy.
   d. Operation of Malgaigne.

                    ARTIFICIAL RESPIRATION.
Manner of employing this measure.

   III. AFFECTIONS  OF THE PHARYNX AND GESOPHAGUS.

                            WOUNDS.
Varieties.
Causes.
Symptoms.
Prognosis.
Treatment.

                         INFLAMMATION.
Varieties.
Causes.
Location.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
(   158   )
ABSCESS.
EXOSTOSIS OF CERVICAL VERTEBRZE.
TUMOURS.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
   Varieties.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                   LODGEMENT OF FOREIGN BODIES.

   Nature of these bodies.
   How introduced.
   Symptoms developed by their presence.
   Prognosis.
   Treatment.—Various  means, and as a last resort pharyngotomy or ceso-
phayotomy.
DILATATION OR POUCH OF  THE  (ESOPHAGUS.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
 
 
(  159   )
                   STRICTURES  OF THE (ESOPHAGUS.
    Varieties---1. Spasmodic.  2. Permanent.   3. Simple.   4. Malignant or
» cancerous.
    Causes.
    Symptoms.
    Diagnosis
    Prognosis.
    Treatment.

                 SPASM OR NEURALGIA OF OESOPHAGUS.
    Causes.
    Symptoms.
    Diagnosis.
    Prognosis.
    Treatment.

                      PARALYSIS  OF OESOPHAGUS.
    Causes.
    Symptoms.
    Diagnosis.
    Prognosis.
    Treatment.
 XI.  INJURIES  AND DISEASES  OF THE  THORAX.

                           WOUNDS.
 Varieties..—Superficial and penetrating.
 Causes.
Symptoms.—In each form.
Prognosis.__Depends on nature of the wound, &c.
Effects produced by a simple wound of the chest.
 Treatment.—In each variety.
                    WOUNDS OF  THE LUNGS.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
                     HERNIA PULMONALIS.

Definition.
Causes.
Symptoms.
Prognosis'.
Treatment. 
(   160   )
                     WOUNDS OF THE HEART.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

             WOUNDS OF  THE  INTERCOSTAL ARTERY.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
                           EMPHYSEMA.

Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

        EMPHYSEMA--HYDROTHORAX--HYDROPS PERICARDII.
                    See << Chapter on effusions."

                      CARIES OF THE RIBS.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

                     TUMOURS OF  THE RIBS.
Varieties.
Causes.
Symptoms.
Prognosis.
Treatment.

                    FRACTURES OF THE  RIBS.
                        See  " Fractures."

                    PARACENTESIS  THORACIS.
                         See "Effusions."

               DISEASES OF THE  MAMMARY GLAND.
             See " Amputation and diseases of females." 
 
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(   161   )
XII.  INJURIES  AND  DISEASES OF THE ABDOMEN.

                               WOUNDS.
   Varieties.—Superficial and Penetrating.
   Causes.
   Symptoms in the first or superficial-
   Prognosis in superficial wounds.—Generally favorable, but may give rise to
peritoneal inflammation,  abscess, which  may dissect up the integuments to  a
considerable extent in consequence of the resistance of the fascia, and finally to
hernia from the weakness of the cicatrix.
   Symptoms in penetrating wounds when no important viscera are injured.
   Prognosis in such cases.
   Mode of examining such wounds.
   Treatment hi each form of wounds.
   Treatment  of penetrating wounds complicated  with protrusions  of the
riscera.
WOUNDS OF THE STOMACH.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
                   WOUNDS OF  THE INTESTINES.

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          h ,        BLOWS ON THE ABDOMEN.   /, . A  V
  Symptoms to which they give rise.
  Prognosis.
  Manner in which death is produced.             ,
  Treatment.A^A^ \A~iAA <  <fl--*v  Ov^—"*A

              ABSCESS IN THE WALLS OF  THE ABDOMEN.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

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                   POISONS IN THE STOMACH.
 Introduction of the stomach pump.

                   PARACENTIS1S  ABDOMENIS.
                        See " Effusions."

       EXTRAVASATIONS IN  THE CAVITY OF THE  ABDOMEN.
 Fluids extravasaled.
  a. Blood.
  b. Chyle and lymph.
  p. Bile.
  d. Urine.
  e. Fceces.
Symptoms produced by these extravasations.
Prognosis.
 Treatment.
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(   163   )
                                 HERNIA.

   Definition---Derived from the Greek f poos a protrusion.
   Location---Groin, Umbilicus, Labia, Foramen ovale, Vagina,  Perineum,
Ischiatic notch and Diaphragm.   Through the broad ligament, (Casteron  and
Saussier) Pilcher reports a case where the protrusion rested in a hollow of the
bone of the pelvis.  Mesenteric and Mesocolic hernia, and through the abdomi-
nal parietes.
   Contents---Vary in different cases.
   Size.—Depends on the size  of the viscus involved.
   Sac---Definition, mode of formation, and division.   Cases in which the sac
is  wanting.
   Division---a. With reference to the contents of the  hernia___Enterocele,
Epiplocele, entero-epiplocele, Gastrocele, Hepatocele, Cystocele, &c. &c.
   b. With reference to the  situation it occupies___Inguinal or Bubonocele—
Oscheocele or Scrotal—Merocele or Femoral—Exomphalos or Umbilical—
Ventral—Ventro-inguinal—Phrenic, &c. &c.
   c. With reference to the period of  its  appearance.   Congenital and  Ac-
quired.
   d.  With reference to the condition of the contents.   Reducible—Irreducible
without  Strangulation—Strangulated  without  adhesion—Strangulated  with
Adhesion.
   Causes.—1. Predisposing.  2.  Exciting.
   Symptoms.—Depend on the variety  and location of the  hernia;  there are
certain  general  symptoms  characteristic of  the Reducible, Irreducible,  and
Strangulated.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.—Depends on the variety

   ].  For reducible hernia.
     a. The truss.
     b. Injection of the sac.
     c.. Caustics.
     d. Acupuncture.
     e. Scarification.
     /. Introduction of gelatine strips.
     g. Ligature of Schmucher.
     /*. Ligature of sac.
     i. Seton or royal stitch.
     i. Plastic operation.
     /-. Pins.
     t.  Invagination of integument.
     m.     Do.          do.
     ii. Rest in the horizontal  position
     o. Hernotomy.
(Velpeau.)
{Belmas.)
(Jamieson.)
(Bonnet.)
(Gerdy.)
(Velpeau.)
(Ravin.)
(DetmokU 
(   164  )
 2. For irreducible hernia.
    a.  Suspensary truss.
    b.  Rest.
    c.  Low diet for a length of time.
 3. For strangulated hernia.
    a.  The taxis.
    b.  Blood letting.                            (Pott.)
    c  Warm bath
    d.  Tobacco injection.                       (Heister.)
    e.  Purgatives.                              (Monro and Shaipe.)
    /.  Purgative injections.
    g.  Opium.
    h.  Introduction of a stomach tube into the rectum.   (O'Beirne.)
    /.  Distensionof lowerportion of the intestine. (Arnott.)
    j.  Pressure and cold to the tumour.          (Arnott.)
    k.  Ice to the tumour.
    /  Application of ether to the tumour.       (Vela.)
    m. Application of Belladona to  tumour and urethra by means of a bougie.
    n. Application of a large cupping glass over the tumour.
    o.  Reduction en masse.                     (Luke.)
    ;;.  Operations.
       1. The  usual operation.
       2. Subcutaneous operation.               (Guerin.)
       3. Division of stricture without opening the sac.
       4. Dilatation without cu'ting the stricture. (Arnott and Le Blanc.)
  Question as to how long the operation may be deferred.
  Treatment of the case  after the stricture is divided.


                   PARTICULAR.  FORMS OF HERNIA.

                   I.   INGUINAL AND  SCROTAL.

  Definition.
  Varieties —1. Oblique.  2.  Direct.  3. Concealed.   4. Congenital.
  Most common variety.—The oblique.
  Sex most liable.
  Anatomy of the parts  concerned in inguinal hernia.
  Mode of formation.
  Seat of Stricture.
  Symptoms.
  Diagnosis.—May be confounded with—1.  Hydrocele of  both  the tunica
vaginalis and cord.   2.  Circocele.   3. Retained testis.  4.  Diseased testis.
5.  Hematocele.  6. Crural hernia.   7. Tumours of the scrotum.
  Diag?iosis between oblique and direct hernia.
  Prognosis.
   Dissection of the tumour.
   Treatment.—Depends on the form. 
 
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   y,'1       cJ,  /    <?  j/  "i                     ■_. Cx -Ave* a- A.
 *7^...   f*-/-     -  (   165  )

                II. FEMORAL OR CRURAL  HERNIA.
   „  „  . .               •              '  -t-,           -t-<?-■■-'*  •-.  O-"v ■  -c.
   Definition.        ,      „_.    .»_*■     c~  ' *"                  ,              u
   Sex most liable. u-xCA^t^A^ -A-Z^'^yC  ^  PUT^-^^ «~^«. -

   Anatomy of the parts concerned in femoral  hernia.
   Mode of formation.
   Seat of stricture.
   Symptoms.
   Diagnosis.—May be confounded with—1.  Inguinal hernia.   2.  Bubo.  3.
Varicose femoral vein.  4. Psoas Abscess. 5. Fatty tumour.   6.  Aneurism.
   Prognosis.
   Dissection of the tumour.                                        i    J, L    tA"
   Treatment. ~Fh,-xo■-> "A-  Ct-i^xy-  CZt^-tijc^ |^_  j.*. » *^ttt  .'-/K.  /y-   ^
 c,.a.^ - "Ap  /i^-,X ,v *i*r£a, >&,    Ax  cy  <A>w*  ^ r<J-'tri y ~
                     CONCEALED  FEMORAL  HERNIA.
   Definition.
   Mode of formation.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.
                                                    Cy_ crxyyyx-Jt A a  CO-*
                      III. UMBILICAL HERNIA.

  Definition.
  Synonymes.
  Varieties__1. Congenital.  2.  That of young persons.   3. That of adults.
  Exact point  of protrusion.—Depends  somewhat on the age of the in-
dividual.
  Contents of the hernia.
  Form. ^y^y^--^--i~A,   C-v-w* <r*£_o
  Size.
  Symptoms.
  Diagnosis.
  Prognosis.
  Dissection of the tumour.
  Treatment—Modified to suit the age of the individual.
IV. VENTRAL HERNIA.
Definition.
Varieties,
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment. 
       (   166   )
V. PUDENDAL HERNIA.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Definition
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
VI. VAGINAL HERNIA.
VII.  PERINEAL HERNIA.
VIII.  THYROIDEAL HERNIA.
IX. VESICAL  HERNIA. 
 
 
(  167  )
X. ISCHIATIC HERNIA.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
XI. PHRENIC HERNIA.
        XII. MESENTERIC AND MESOCOLIC HERNIA.

Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.

 XIII.  STRANGULATION  OF  INTESTINES  WITHIN  THE
                         ABDOMEN.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment. 
(  168   )
XIII.  INJURIES AND  DISEASES  OF THE ANUS AND
                            RECTUM.
                         IMPERFORATE ANUS.
  Definition___Congenital occlusion of the natural orifice of the rectum.
  Varieties.—a. Simple contraction.
            b. Closure by a thin membrane.
            c. Termination of the rectum in a cul-de-sac, no vestige of the
                 anus being present.
            d. Termination of the rectum in other organs.
            e. Formation of a septum above, while the anus itself is open.
  Causes.
  Symptoms—Depend on the nature of the defect.
  Diagnosis.—Has been confounded with colic,  &c.
  Prognosis.—Depends on the form.
  Treatment.
  Treatment when the usual operations cannot be performed.—Various  opera-
tions for artificial anus.

              WOUNDS AND LACERATIONS OF THE  ANUS.
  Varieties.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.
                    INFLAMMATION OF THE ANUS.
  Varieties.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.
                       ABSCESS OF  THE ANUS.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.
                             PRURITUS.
  Definition.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment. 
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toA3i«Ac  Iyaxx-i^U-x.   ^v-. ■ '--TAA  A   A ... u U —- 
 
                             (   169   )

                     NEURALGIA OF  THE ANUS.
 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment,

                        SPASM  OF THE ANUS.
 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

                       ATONY OF  THE  ANUS.
 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

                   BLENORRHAGIA OF THE  ANUS.
 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

                  HEMORRHAGE FROM  THE ANUS.

 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

                ORGANIC STRICTURE  OF THE  ANUS.

 Definition.
 Causes.
Symptoms.
Diagnosis.
Prognosis.
 Treatment. 
(   170   )
                         TUMOURS  OF THE ANUS.
   Varieties.—Verruca5, condylomata, &c.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                        SCHIRROl'S OF THE ANUS.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                         ULCERS OF THE ANUS.

   Varieties.—a.  Common ulcer,  b.  Aphthous ulcer,  c. Venereal ulcer.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                         FISSURE  OF  THE  ANUS.
   Definition.
   Causes.—Constipation, piles, hard fceces, mechanical injuries, spasm of the
sphincter, &c. &c.
   Symptoms.
   Diagnosis.—Often confounded with neuralgia, sacs, &c.
   Prognosis.
   Persons most liable___Women from their sedentary habits.
   Progress.—Generally slow ;  may be rapid.
   Extent.
   Treatment.—Various methods employed :
        a. Washes and ointments of various kinds.
        b. Dilatation.
        c. Incision of sphincter.
        d. Excision of fissure.  (Mothe, Guerin, Velpeau, &c.)

                          POUCH OF  THE  ANUS.
   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment. 
 
 
(   171   )
                             PROLAPSUS  ANI.
   Definition.
   Varieties'.—1. External.  2. Internal.   3.  Prolapsus of the mucous mem-
brane alone.   4.  Prolapsus of all the coats of the intestine, (doubted by some.)
0.  Reducible.   6.  Irreducible.
   Causes.—1. Predisposing.   2. Exciting.
   1.—a.  Childhood and old age.   b. Constitutional relaxation,  c. Want  of
tone in the muscular apparatus of the anus.  d. Debility of the whole intestine.
e.  Peculiar arrangement of longitudinal fibres of the rectum.
   2.___a.  Constipation,  b. Lodgment of foreign bodies in the rectum,   c. Piles.
d. Ascarides.   e.  Drastic  purgatives.  /. Prolapsus uteri,   g. Stricture.  /*.
Stone in the bladder,   i. Violent coughs, &c.
   Extent.—Varies in different cases.
   Symptoms.—Depend on the form of displacement.
   Diagnosis.—Piles, &c.
   Prognosis.
   Treatment.___Indications.   1. Return  the  protruded  part.  2. Maintain it
reduced.   3. Remove the cause of prolapsus.
   Mode of returning the prolapsus.
   Measures enjoyed under the second indication.—a.  Laxative diet.  b.
Voiding  fceces in  the erect  posture,  c.  Astringent washes  and ointments.
,/. Pressure,   e.  Pessaries.  /.  Cold  douche,  g. Ligature of  small  folds of
the mucous membrane,  (Heavyside and  Howship.)   h. Excision  of  radiated
folds,  (Hey and  Dupuytren.)  i. Excision of a circular  portion of mucous
membrane, (Sabatier and Ricord.)  j. Excision  of a portion  of the  external
sphincter, (Robert.)  k.  Radiated incisions  and the nitrate  of silver, (Coates.)
/. Cautery, (Chesselden.)
   Measures employed under the third indication.
   Treatment of irreducible prolapsus.
PROLAPSUS OF  THE  RECTUM.
Definition.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
FISTULA IN ANO.
   Definition.—k. suppurating cavity of greater or less extent,  situated in the
neighbourhood  of the  anus and  rectum, discharging by one or more  orifices,
either externally or into the gut, the walls of which it is very difficult to cause

t0 Clauses —Any cause, constitutional or local, calculated to produce inflam-
mation in the cellular  tissue surrounding  the anus or rectum, may give rise to
Fistula. 
(   172   )
   Varieties---1. Incomplete or  external  blind  Fistula.  2.  Incomplete  or
internal blind, or occult Fistula.  3. Complete Fistula.
   Course or direction.—Varies.
   Number.—Varies.
   Depth or extent.—Varies.
   Seat of the internal orifice in Fistula.
   Symptoms.—Vary with the  variety.
   Mode of examining the anus, for the detection of internal Fistula.
   Diagnosis.—May  be confounded  with urinary  fistula,   when  external.
Occult fistula may be confounded with sacs of the rectum, internal piles, ulcers,
blenorrhagia, &c.
   Prognosis.—Varies in different cases.
   Causes which prevent closure of the Sinus, and which must be overcome.—
1. The action of the sphincter and levator ani muscles.  2.  The surfaces be-
coming callous.   3.  Lodgment  of pus.   4.  The passage of fcecal matter through
the fistula.
   Treatment---Various plans of treatment have been employed, and frequently
constitutional  as well as local remedies are required.
   1st. or  Constitutional---Modified to suit the case.
   2d. or Local—
     a. Baths, mineral waters, &c.
     b. Caustics and cautery.
     c Compression—excentric and external.
     d. Ligature.
     e. Incision.
     f. Excision.
   After treatment when operations  are performed.
   Method to be preferred.—Depends on circumstances.

                                  PILES.
   Definition.
   Varieties---1. Blind.  2.  Open.  3. External   4. Internal.
   Causes.
   Sex most liable.
   Class of Society  most liable.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.-^-!. Palliative.  2. Radical.

                        WOUNDS OF  THE RECTUM.
   Varieties.
   Causes.                                                 •
   Symptoms.
   Din gnosis.
   Prognosis.
   Treatment. 
 
 
(   173   )
RECTIT1S.
Definition.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.


Causes.
Symptoms.
Diagnosis.
Prog?iosis.
 'Treatment.

 Varieties.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.
ABSCESS OF THE RECTUM.
ULCERS OF  THE RECTUM.
FOREIGN BODIES  LODGED IN THE RECTUM.
        STRICTURE  OF THE RECTUM.

.1. Spasmodic.   2. Permanent.
Nature of these bodies.
Mode of introduction.
Symptoms developed by their presence.
Diagnosis.
Prognosis.
Treatment.


Definition-
 Varieties—
Causes
Symptoms
Diagnosis.
Prognosis.
 Treatment.


 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

   ESTABLISHMENT  OF AN ARTIFICIAL  ANUS  IN  CERTAIN  CASES OF
             COMPLETE  OBSTRUCTION  OF THE  RECTUM.
SCIRROUS OF THE RECTUM. 
(  174  )
  XIV. INJURIES  AND DISEASES OF THE URINARY
                         APPARATUS.

  Under this head is included all the affections of the Kidney, Ureter, Bladder,
Perineum, Prostrate, and Urethra.

                I. AFFECTIONS OF THE KIDNEY.

                            WOUNDS.
  Varieties.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.
Varieties.
Causes.
Symptoms.
Diagnosis
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
NEPHRITIS.
ABSCESS IN KIDNEY.
H.EMATUUIA.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
 
 
(   175   )
ALBUMINURIA.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Definition.
Cans es.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
DIURESIS  SIMPLEX.
DIURESIS  UREOSA,
DIURESIS  SACCHARINA.
DIURESIS  CHYLOSA.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection-
Treatment. 
(   176    )
                             DIURESIS SEROSA.

   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.

                         SUPPRESSION OF URINE.

   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Dissection.
   Treatment.

                            URINARY CALCULI.

   Definition.
   Forms assumed by Calculus Matter.—a. Amorphous sediments,   b. Crys-
 tallized sediments or gravel,   c. Solid concretions or Stones.

                   1.  Amorphous Sediments and Gravel.

   Lithic Sediments—
      a. Yellowish sediment.
      b. Red or lateritious sediment.
      c. Pink sediment.
   Crystallized Lithic Deposites.
      a. Red gravel.
   Oxalic Acid Deposites,
   Phosphatic Deposites—-
      a. Triple Phosphate, or  Phosphate of Ammonia and Magnesia.
      b. Phosphate of Lime.
      c. Mixed or fusible Phosphates.

                          2. Stone or Calculus.

   Varieties.
      a. Lithic acid.
      b. Lithate of ammonia.
      c Phosphate of Lime or bone-earth.
     d. Phosphate of Ammonia and Magnesia, or Triple.
     e. Phosphate of  Lime  and Ammonia,  and Phosphate of Magnesia,  or
mixed Phosphate, or Fusible. 
 
 
(   177   )
  /. Oxalate of lime or mulberry.
  g. Carbonate of lime.
  /'.. Alternating.
  i. Mixed.
  j. Cystic oxide.
  Ac. Xanthic oxide.
  I. Fibrinous.
  tn. Silicious.
  n. Prostratic.
Origin and ingrement of calculi.
Forms of calculi.
Size.
Specific gravity.
Surface.
Colour.
Odour.
Nucleus.
Consistence.
Chemical composition of the individual calculi.

                    CALCULUS  IN THE  KIDNEY.

Symptoms.
Diagnosis.
Prognosis.
Treatment.

              II. AFFECTIONS OF  THE URETER.

                             WOUNDS.

Varieties.
Sympioms.
Diagnosis.
Prognosis.
Treatment.

                           INFLAMMATION.

 Causes.
Sympioms.
Diagnosis.
Prognosis.
 Treatment.

        PASSAGE OF CALCULUS MATTER ALONG THE UR1

 Si/mptoms.
 Diagnosis.
 Prog* os is.
 Treatment.
       12 
(   178   )
STONE IN THE URETER.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
DILATATION.
III. AFFECTIONS OF THE BLADDER,
WOUNDS.
RUPTURE.
ACUTE INFLAMMATION OF THE MUCOUS COAT.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment,
         CHRONIC INFLAMMATION OF THE MUCOUS COAT.
Synonyme.—Catarrhus vesicae.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment. 
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(   179   )
INFLAMMATION OF  THE MUSCULAR  COAT.
Causes.
Symptoms.
Diag?iosis.
Prognosis.
Dissection.
Treatment.
INFLAMMATION OF  THE  PERITONEAL COAT.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.

Definition.
Causes---Teething, &c.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
                     ly
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IRRITABLE BLADDER.
SPASM OF THE BLADDER.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Dissection.
Treatment.
PARALYSIS  OF  THE  BLADDER.
  Causes.
  Sijmptoms.
  Diagnosis.
  Prognosis.
  Dissection.
  Treatment.
                          RETENTION OF URINE.
   Definition. Ai-x         w-A  ' Zv -e >.    -x-x--A^./^  £-*-'   yT-  "7*"    " ZZl^AtV.//c
   Causes.__Paralysis of bladder.   Inflammation  of bladder.   Spasm  of  the
neck of the bladder, from  cold, excess in wine, cantharides, &c.   Irritation
produced by dentition, hysteria, &c.    Enlarged prostrate, displacements of the)
womb,  pregnancy, stricture of  the  urethra, calculus, laceration of urethra, i'Vvw <"'•**•'
abscess and tumours of the bladder.  '■^"                       ,
   Age most liable.  *-  •■ ^/^ x..->..■*          A-           -  *x.-A<-^   y -
   Sex mostfiaile.   j  .»  - xi-.^^,  'Ac y
rxO 
(   180   )
   Symptoms.—Depend very much on the cause.
   Diagnosis___Incontinence, tumour of the bladder, &c.
   Prognosis—Depends on the cause.
   Treatment.—a. Warm bath.   b. Opiate injection,  c. Evacuant injection.
d. Loss of blood, general and topical,  e.  The catheter,  f. Forcing the stric-
ture or dividing it, where it exists as the cause of reteniion.  g.  Puncturing
the bladder, which may be done in three places by the rectum above X\\e pube.s,
or by the perineum,  h.  The inhalation of ether.  '■'-  !Ar   .'.
   Remedies useful in certain rare cases.
   a. Quinine in intermittent or peAodic attacks.
   b. Caust:c bougie  in irritable neck of bladder or spasmodic stricture.
   c  Affusion of cold water in relaxed paiients.
   d. Strychnia in paralysis of bladder.
   e. Alkalies, when the urine is too acid.
   /. Large doses of opium, and  perfect quiet when  the usual modes of relief
fail.

                        INCONTINENCE  OF URINE.
   Definition.
   Age most liable___Early life and advanced age.
   Causes___Diseased  urine : habit ; irritable bladder, hereditary predisposi-
tion, paralysis of the sphincter vesicae, from any cause, &c.
   S i/mp/oins.
   Diagnosis___Retent'on of urine, contracted  bladder, &c.
   Prognosis.
   Treatment.—Depends on the cause.

                    HYPERTROPHY  OF THE ELADDER.
   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                     CONTRACTION  OF THE BLADDER.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                          SACCULATED BLADDER.
   Definition.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment. 
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(   181   )
ULCERS OF  THE BLADDER.
Causes.
Sympioms.
Diagnosis.
Prognosis.
Treatment.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
TUMOURS  OF THE BLADDER.
SCHIRROUS AND FUNGUS  OF THE BLADDER.
HERNIA VESICAE AND PROTRUSION OF  THE  BLADDER.

                   (See " Hernia.")
RECTO-VESICAL  FISTULA.
Definition.
Varieties.
Causes.
Symptoms:
Diagnosis.
Prognosis.
Treatment.
Definition.
Varieiies.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
VESICO-VAGINAL FISTULA. 
<L(c£i,<^    aAAA^'   1?  ^  ''fc   ''^i*.
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(   182   )
                        STONE IN THE BLADDER.

   Mode of formation in the bladder.
   Causes—1. Predisposing. y2. Local. r„   _^_  ^v^r , <*T^-
   1.  Or predisposing—a. Sex.  b. Race.'*' A. Age.   /Constitution,  e. Cli-
mate.  /.  Mode of life.  g. Water.   A. Dyspepsia.'*'"***'       -**+■'■+
   2.  Or local.—a. Stricture of the urethra,  b.  Enlarged prostate,  c.  Sacs
of the bladder,  d. Paralysis of the bladder,  e.  Chronic inflammation of the
bladder.  /.  Lodgement of foreign  bodies  of different kinds  in the bladder,
which serve as nuclei.
   Varieties;.
   Size.     jA*-'4~ AAcixx.  A/jyW-

   ?, umber,  ^y .   ^£     £•      f
   Mode of growth.            C^ Zu  ■ *->..>-                   > / . x-j.
   Condition in the bladder.— Encysted; or loose, or encrusted. £xy-- .w.*■-»-'>>  *-*-«-
   Symptoms___Depend on a variety of circumstances.
   Diagnosis___Manner of sounding and use of the stethoscope, &c.
   Prognosis.—Depends on the age and sex of the person, the condition of the
organs concerned, and the size, composition, and condition of  the stone  in  the
bladder.
   Dissection of the bladder when the stone has existed for some time.
   Effects  upon the ureter and kidneys.
   Treatment.—Several indications.
   a.  Remove  the diseased state of the  urine upon which the secretion of the
stone depends.
   b.  Palliate the sufferings of the patient.
   c.  Remove the stone.
   1.  This indication  may be fulfilled by a number of agents, most of  which
have already been alluded to under the head of « Calculus."
   2.  The second  may be accomplished by demulcent drinks, acid or alkaline
medicine,  according to the composition of the stone, warm baths,  leeches,
anodyne injections and perfect rest.
   ].  The third is answered by  a variety of methods.
   a.  Extraction of the urethra.
   b.  Solution by injections.
   c.  Lithotomy,  which  includes—1.  Cutting  upon the gripe.  2. The high
operation.   3. The single lateral.  4. The bilateral.   5.  The recto-vesical.
   d. Lithotrity and Lithontripsy.
   Preparation of the patient for either  of these operations.

                     EXTRACTION  BY  THE URETHRA.    '
       ..   .\l»y  it     t£*yf xA^  4,           .IJ^AYCtJ
   Cases to which it is applicable.
   Cjndition of the bladder before the instrument is introduced.
   Instruments employed.
   Position of the patient during the operation and mode of performing it. 
 
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                                 (   183   )

                          SOLUTION  BY INJECTIONS.^              V   w ,  /A' A'Ayx.
    Cases to which it is applicable.    A^2" "A__     •  .-   ■   .;   1  '    -     —Y  Z
    Agents  employed as solvents.    lA^xtZA-t- ■•-■  ' SU.  < j   *  ' ««' .*',.  (A .-■-'
    Manner of using them.           7 fZiA   A A A ).-• ,.<_,> ™~-
    Dangers.
    Utility  of the measure discussed.

                                 LITHOTOMY.

                  1.  Cutting on the Gripe or Celsian operation.
                                     i                          /      /   /*    Z TlAx-^y
    Cases to which it is applicable. 1 -H.-*- (■ <5u--a—*~^  ,. . ^ s  /,.«/ <•-      «.  .'   w
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     Utility of the operatioA discussed.  <*-*"   ^ V* -~ -' l *^  ^^f ™l ( **~? *•""*

                     2. The High or Hypogastric operation.

     History of tlie operation.  } t{yf$Z.       ^A   '  ^AA C/>-~t, A  :  '-'
     Anatomy of the parts concerned in the operation.
     Cases to which it is deemed applicable.
     Supposed advantages of the operation.
     Dangers of  the operation.—I.   Peritonitis.   2. Extravasation of  Urine.
   ■,i. Wounds of  the peritoneum.   4.  Lodgements of  fragments  of the  stone.
   5. Hemorrhage. 6.  Urinary fistula.
     Instruments  employed.
     Manner of performing the operation.
     After treatment.

                             3. The simple Lateral.

     History ofthe operation. , •.            A'S.-^-^-^   <S'
     Anatomy of the  parts concerned in the operation.
     Cases  to which it  is deemed applicable.
     Supposed advantages of the operation. r   04/^t., Ate ,  tLa>x ■■ ■ ■            .  A^-*/<*■£**
     Dangers.—\. Peritonitis.   2.  Extravasation of Urine.    3.  Cystitis.   4.^,^*.,
   Hemorrhage.   5.  Inflammation with sloughing.   6. Incontinence of urine.   '
   7. Fistula.  8. Wounds of the rectum.
     Instruments employed.               A A. Z, , -~
     Manner of performing the operation, -^f^*
     After treatment.
                                4. The Bilateral.

     History of the operation.
     Anatomy of the parts concerned in the operation.
     Cases  to which it is deemed applicable.
     Supposed advantages of the operation.
     Dangers.
     Instruments employed.
     Manner of performing the operation.
      After  treatment. 
{   184  )
                        5. The Recto-vesical.

History of the operation.
Anatomy of Ate parts concerned in the operation.
Cases to which it is deemed applicable.
Supposed advantages of the operation.  .
Dangers.   ' '
Instruments employed.              -  _
Manner of performing the operation. £
After treatment.

                           LITHOTRITY.
                   /  '  "
History of the operation.
Cases to which it is deemed applicable.
Supposed advantages of the operation.
Dangers.
Instruments employed.
Manner of performing ihe operation.
Treatment during the  course of operations.

                          LITHONTRIPSY.
History of the operation.
Cases to which it is deemed applicable.
Advantages of the operation.
Dangers,
Instruments employed.
Manner of performing the operation.
Treatment during ihe  course of operations.

                      STONE  IN THE FEMALE.
Symptoms.
Operation to be preferred  when an operation becomes necessary.
Manner of performing the different operations.

HYDATIDS  AND ENTOZOOA OF  DIFFERENT KINDS IN  THE  BLADDER.
Varieties.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

        IV.  AFFECTIONS OF THE PROSTATE  GLAND.

                   WOUNDS  OF THE PROSTATE.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
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(   185   )
ACUTE INFLAMMATION OF THE  PROSTATE.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Sympioms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
ABSCESS OF  THE PROSTATE.
ULCER OF  THE PROSTATE.
CHRONIC INFLAMMATION, WITH  ENLARGEMENT OF  THE PROSTATE.
Causes.
Persons most liable.
Progress.
Sympioms.
Diagnosis.
Prognosis.
Treatment.
CHRONIC INFLAMMATION WITH ATROPHY'OF THE  PROSTATE.
Causes.
Symptoms.
Diagnosis.
Prognosis
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
POUCH OF  THE PROSTATE. 
(  186   )
HEMORRHAGE FROM THE PROSTATE.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prog?wsis.
Treatment.
Nature.
Causes.
Number.
Size.
Composition.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
EXCESSIVE SECRETION OF THE PROSTATE.
PROSTATIC CALCULI.
MALIGNANT  DISEASE OF THE PROSTATE.
V. AFFECTIONS OF  THE PERINEUM.
WOUNDS.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
ACUTE  INFLAMMATION. 
 
 
(  187  )
ABSCESS IN THE  PERINEUM.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
URINARY  INFILTRATION.
DEPOSITES OF LYMPH.
FISTULA.
NEURALGIA.
VI. AFFECTIONS OF THE URETHRA.

               WOUNDS. 
(   188  )
                HEMORRHAGE FROM THE  URETHRA.

  Causes.
  Sympioms.
  Diagnosis.
  Prognosis.
  Treatment.

                     RUPTURE OR LACERATION.
  Causes.
  .Symptoms.
  Diagnosis.
  Prog7iosis.
  Treatment.

                           FALSE  PASSAGE.
  Definition.
  Causer.
  Sympioms.
  Diagnosis.
  Prognosis.
  Treatment.

                        ACUTE INFLAMMATION.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

                      CHRONIC  INFLAMMATION.
  Causes,
  Sympioms.
  Diagnosis.
  Prognosis.
  Treatment.

                                 GLEET.
  Definition.
  Causes.—An  improperly treated gonorrhoea—disease of Cowper's gland, or
the  mucous  lacunnae of the urethra, disease of the prostate ;  strictures ; some-
times constitutional causes, as scrofula, gout, rheumatism, &c.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.—Astringent and alterative  injections ; the argent nit; in sub-
stance ;  bougies, medicated or simple; constitutional remedies, &c. 
 
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(   189   )
                              GONORRHOEA.
   Definition.
   Causes.
   Symptoms.—1. Those affecting :he part itself.   2.  Those attacking other
parts from sympathy.
   Period of incubation.
   Diagnosis.
   Prognosis.
   Extent of ..ie inflammation.
   Products of xite disease.
   Connection between gonorrhoea and syphilis.
   Treatment.
                               STRICTURE.
   Definition.
   Varieties.—1.  Permanent.   2.  Spasmodic.   3. Mixed.
   Most common  Variety.—The permanent.
   Seat of spaxmodlc sirictuye.
   Causes.—Va.y wita the form of stricture.
   Progress.—Usually incteases very slowly.
   Number.—Varies.
   Extent.—Vaues.
   Location.—1.  At the  orifice.   2.  Nea;  the middle.    3. Near the  bulb.
 Surgeons do not ag.ee, however, on  this point.
   Symptoms___]. Local.  2. Const'tutional.
   Diagnosis.—May be con (bunded with gleet; diseased prostate; stone in the blad-
 der; hernia humourhalis; neu, u'gia ofthe testis; neuralgia of the perineum; ague,&c.
   Prognosis___Depeads oa the varieiy of stricture, the age and health of the
 patient, &c.
    Termination___Mu 7 occasionally terminal in ulceration and thus a cure be
 accomplished,
   Effects on adjacent organs.
    Treatment.—Mode of examining ibe ureth:a.
   Different meihod-s of i, raiment.
                     a. Dilatation.  By bougies, Arnott's dilators,  &c.
                     b. Ceusu'.c.
   Local remedies.—c. Incision fiom  wiih;n.
                     d. Incision from  without.
                     e. Forcing the stricture.
                    /. E.:cision.
                     g.  Catheterism.
                     h.  Cauterizing with argent nit; to alley irritability.
                     i.  Absorbent operation.
    Constitutional.—a. E(ood-Ie1 iing.
 Remedies.—        b.  Hot bath.
                     c.  0,i;am.
                     d.  Inhalations of ether.
    When the  stricture  is impervious  and the  patient cannot pass  urine, the
 bladder must  be tapped,  but this  should never  be done  until all our other
 remedies have been employed. 
(   190  )
                                FISTULA.
   Definition.
   Varieties___1. In urethra anterior to  perineum.   2.  In urethra, and  dis-
charging through the perineum.
   Causes.—Inflammation and abscess, wounds, &c.
   Symptoms.
   Diag?iosis.
   Prognosis.
   Treatment—.Remove the cause, if possible, then use according to circum-
stances the  catneter, caustics, suture, incision, blisters, plastic operation.

         CONTRACTION OF  THE  ORIFICE OF  THE URETHRA.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.
ORIFICE TERMINATING  TOO FAR  BACK.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
TUMORS OF THE  URETHRA.
 Varieties.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

         PAINFUL  TUMOR  OF  THE FEMALE URETHRA.
 Varieties.
 Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
HARDENING OF THE  FEMALE URETHRA.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
 
 
(  191   )
              FOREIGN BODIES IN  THE  URETHRA.
Varieties.
Mode of introduction.
Symptoms to which they give rise.
Diagnosis.
Prognosis.
Treatment.

                  CALCULI IN  THE URETHRA.
Mode of introduction.
Symptoms to which they give rise.
Manner of removing them.
            XV.  DISEASES OF THE  PENIS.

                          EPISPADIAS.

Definition.
Varieties.
Causes___Mostly congenital—sometimes accidental.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
HYPOSPADIAS.
Definition.
Varieties.
Causes.—Mostly congenital.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
PECULIAR  MALFORMATION OF METTEAUR.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
(   192  )
BENT  OR  DISTORTED PENIS.
PRIAPISM.
INFLAMMATION OF THE  PENIS.
Varieties.
Causes.
Sympioms.
Diagnosis.
Progno-is.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
  Causes.
  Sympioms.
  Diagnosis.
  Prognosis.
  Treatment.

                               ABSCESS.

  Causes.
  Symptoms.
  Diaguois.
  Prognosis.
  Treatment.
                          URINARY ABSCESS.
  Definition.
  Causes.
  Varieties.__The urine may be collected in a single pouch or caviiy, bounded
by adhesive'inflamination; it may be widely d'ffused in the cellular tissue; or
it may be mixed with pus, forming a urinary abscess proper.
  Cause--.__Peroration of the urethra from wounds, ulceration, &c.
  S ij mptoms.
  Diagnosis.
  Prognosis.
   Treatment.
WOUNDS  OF THE PENIS.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment. 
 
 
(    193   )
                                (EDEMA.
  Definition.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

                                TUMORS.
  Varieties.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.
                                 WARTS.
  Definition.
  Causes.
  Symptoms.
  Diagnosis
  Prognosis.
  Treatment.
                             SHORT  FRENUM.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

                      CONTRACTION OF PREPUCE.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.
                                PHYMOSIS.
  Definition.
  Causes—l.  Congenital.   2. Acquired.
  Degrees.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.__Varies with  the cause.   In  congenital cases an operation is
usually required, when produced by accidental causes,  we should never operate
without a due  regaid to the condition ofthe parts.
  Operations.—1. Slitting up the prepuce.  2.  Circumcision.   3. Division of
external portion, the mucous  lining being left entire.  4. Lisfranc's operation.
Removing a semicircular slice.  5. Velpeau's operation. Removing a triangular
piece.
   Operation to  be preferred.
         13 
(   194   )
                          PARAPHYMOSIS.
Definition.
Causes.
Degrees.
Symptoms.
Diagnosis.
Prognosis.
Treatment.—1. Compression.  2. Cold.   3. Operation.
Definition.
Causes.
Symptoms.
Diagnosis.
Prog7iosis.
Treatment.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Varieties.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
BALANITIS.
POSTHITIS.
SIMPLE  ULCER.
ABRASIONS.
Definition.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
Definition.
Causes.
Age most liable.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
HERPES PREPUTIALIS. 
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(   195,  )
                         (EDEMA  OF  PREPUCE.

   Causes.                                                    m
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.


       "'-  "         " ADHESION OF PREPUCE.

   Causes,  '"*•—«*
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.


                           LOSS  OF  PREPUCE.

   Causes.
   Effects to which it gives rise.
   Treatment.

                                SYPHILIS.

   Definition.—5r cjuAsw (mutual love.)
   Synonymes__Lues veneria, venereal disease, morbus gallicus, pox, &c.
   History.•__1.  Was syphilis known  to the ancients ?   2.  Was  it  imported
from America into Europe ?  3. If not imported thus, when  and  where did it
originate ?
   Causes.___Supposed by some  to occur often spontaneously.   Impure sexual
intercourse.   (See Skey.)
   Period of incubation.
   Question of  a  special virus.— Broussais and his schools,  and  others  also,
denied the existence of a specific virus.  The experiments of Ricord, Parker,
Carmichael, Mayo, Wallace, &c. prove  the contrary.
   Does gonorrheal matter ever produce the -primary symptoms, of syphilis ?
   Classification  of Sympioms.---
                                  1. Primitive or  direct.
                                 2. Successive.
                                 3. Secondary.
                                 4. Tertiaiy.
                                 5. Diseases unconnected  with syphilis —
                                         (Ricord.) or
                                  1. Primal v or local.
                                 2. Consecutive, general,  or constitutional,
                                         (Hunter.) 
(    196   )
                         PRIMARY SYPHILIS.

                               CHANCRE.
  Definition.
  Mode of development.—1. Pustule.  2. Ulceration or abrasion.  3. Abscess.
  Physical character.—Varies with the location, number, degree of inflamma-
tion, duration, &c.
  Character ofthe pus.—Varies, and is modified by the stage ofthe chancre.
  Stages of  chancre.___1.  Ulceration, during which the matter secreted will
pi oduce  the  disease if we  inoculate with it;  it may last several years, but
usually only one or two months.  (Ricord.;
  2.  Granulation and Cicatrization.   The matter secreted now ceases to pos-
sess inoculable properties.
   Division.—1. External.
              2. Internal, larvated or concealed.
              ■1. Follicular.
              2. Indurated.
              3. Phagedenic.
              4. Furunculus.
   Seat of chancre in the different sexes.
   Causes.—Sexual intercourse, touching a chancre; during labor the child
 may be inoculated.
   Diagnosis.—Often difficult.
   Proguo.?*.*.—Varies with the form of chancre.   Chancre produced by artifi-
 cial inoculation  ; characteristics of—(Ricord.)
    Prophylaxis.
    Treatment of chancre.—1. Local.  2. Constitutional.
    Cases in which mercury should be employed.
    Cases in -which it  should not be, administered.
    Extent to which it  should be carried.

                       CONSECUTIVE SYPHILIS.

                                 I.  BUBO.
    Definition.
    Causes.
    Symptoms.
    Diagnosis. .
    Prognosis.
    Treatment.

                II.  SYPHILITIC  CUTANEOUS AFFECTIONS.

    Varieties.
    Period at which they appear.—Sometimes along with the primary symptoms,
  but generally after these are cured.
    Parts of the body most liable to be attacked.
    Symptoms.—1.  Local.   2.  Constitutional.
    Diagnosis.
    Prognosis.
    Treatment.

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{   197    )
                  III. SYPHILITIC SORE  THROAT.
Period at which it appears.
Symptoms.
Diagnosis.
Prognosis.                    ,
Treatment.

           IV.  GLANDULAR  DISEASE  FROM  SYPHILIS.
Glands most  liable.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
                    V.  IRITIS FROM SYPHILIS.
Period at which it makes its appearance.
Symptoms.
Diagnosis.
Prognosis.
Treatment.

                  VI. SYPHILITIC RHEUMATISM.
Period at which it maices its appearance.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
                            VII.  NODES.
Definition.
Period at which they appear.
Sympioms.
Diagnosis.
Prognosis.
Treatment.

         VIII.  DISEASE OF  THE  BONES-FROM  SYPHILIS

Varieties.
Symptoms.
Diagnosis
Prognosis.
Treat7neiit.

Definitio?/.
Treatment.
IX.  ALOPCECIA.
AMPUTATION  OF  PENIS.
Cases requiring the  operation.
Mode of performing the operation. 
(   198  )
                          CANCER  OF PENIS.
   Symptoms.—Commencing with a wart, or a tubercle on  the  prepuce, Ire-
num, or glans penis, and often remaining quiet for years.   Being irritated, it
becomes painful and enlarges, often rapidly and to a very great extent;  ulcera-
tion then takes place, accompanied by  a discharge of sanious fetid matter ; pain.
sometimes excessive ;  constitutional symptoms and inflammation of glands  of
groin.
   Diagnosis.—May be confounded with venereal warts or simple tumors ;  in
its ulcerated stage, with sloughing ulcers.
   Tissue affected.
   Prognosis.
   Treatment.
              XVI. DISEASES  OF  THE TESTIS.

   Under this head are included diseases of the testis it&elf; diseases  ofthe
spermatic cord ; and diseases of the scrotum.

                    I. DISEASES OF THE  TESTIS.

                      SUPERNUMERARY  TESTIS.

   Numerical increase.—Generally one ; three have been enumerated.
   Diagnosis.—May be confounded with epiplocele, fatty or fibrous tumours in
the scrotum, or an encysted hydrocele ofthe cord.

                 ABSENCE OF ONE  OR  BOTH  TESTES.
   Diagnosis.
   Consequences.

                IMPERFECT  DESCENT OF  THE TESTIS.
   Varieties___Where one or both  testes have  been detained in the abdomen
near the internal ring, in  the. inguinal canal, or in the groin, just  outside  the
external ring.
   Causes__Peritonitis  before birth causing adhesions ; congenital smallness
ofthe external ring ;  want of power in the cremaster.
   Consequences.—Depend on the situation ofthe testis ;  if it is retained within
the abdomen, no uneasiness or  inconvenience is experienced, nor are the gene-
rative functions likely to be interfered with ; if, however, it should be retained
within the canal, it is liable to  compression by muscular action, it is exposed to
injury from blows  and various  other causes,  all of which may interfere with its
development, may  impede its nutrition, or excite disease.
   Diagnosis___May be confounded with bubonocele, &c.
   Importance of correct diagnosis.
   Prog?iosis.
   Treatment. 
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(   199   )
              DESCENT OF TESTIS INTO  THE PERINEUM.
   Causes.
   Diagnosis.
   Treatment.

                       ATROPHY  OF  THE TESTIS.

   Division—Into that which arises from arrest of development, and that the
consequence of wasting.
   Causes.—Of first variety,  imperfect descent,  congenital inguinal  hernia,
congenital imperfection  of the brain ;  of the second variety,  inflammation,
injuries of the head, impeded  circulation, pressure, want of exercise, loss  of
nervous influence, excessive venery, and by some writers  the long continued
use of iodine.
   Diagnosis.
   Prognosis.
   Treatment.

                       INJURIES  OF  THE TESTIS.
   Nature of these___Contusions and wounds.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                              HYDROCELE.

   Division.—Into  Simple Hydrocele  of the  Testis; Congenital Hydrocele;
and  Encysted Hydrocele of the Testis; Diffused  Hydrocele of  the Spermatic
Cord ; Encysted Hydrocele of the Cord  ; Hydrocele ofthe Hernial Sac; Hydro-
cele of the Female.

                    I.  HYDROCELE  OF  THE.  TESTIS.

   Definition.
   Varieties.—Single and double.
   Characteristic of fluid.—Its nature ;  its quantity.
   Predisposing causes---Age  and  climate.
   Exciting causes.—Inflammation, obstruction of circulation, inguinal hernia',
strains, or great fatigue, blows, the presence of loose bodies in the tunica vagi-
nalis testis, and disease ofthe testis itself.
   Symptoms.__A  pyriform swelling, elastic, and fluctuating,  transparent,
movable but remains constant under pressure, little or no pain.
   Time required for its formation.
   Situation of testis.
   Diagnosis.__May be confounded with scrotal  hernia, or  malignant disease
ofthe testis, or varicocele, &c.
   Mode of examination.
   Prognosis. 
(   200   )
   Treatment.—By external remedies and  by operation;  treatment by opera-
tion  is either palliative or radical.
   Nature of external remedies---Cases to which they are suited.
   Palliative treatment by operation.—By tapping ; by acupuncture.
   Period required for its re-accumulation.
   Radical  treatment  by operation___By incision;  excision; caustic;  tent  ;
seton ;  electro-puncture ; and by injection.
   Operation to be preferred.
   Apparatus required.
   Kinds of injection.
   Dangers  of operation.
   Advantages  of.
   Complications.—Encysted  hydrocele of  the  testis;  encysted hydrocele of
the cord ;  diffused  hydrocele of the cord ;  oscheo-hydrocele.

            II.  CONGENITAL  HYDROCELE OF  THE  TESTIS.

   Definition.              V
   Symptoms.
   Diagnosis.—May be confounded with simple hydrocele, or reducible scrotal
hernia.
   Prognosis.
  'Treatment.—By truss and by injection.
   Dangers  of latter.


             III.  ENCYSTED  HYDROCELE  OF  THE  TESTIS.

   Definition.
   Structure of cyst.
   Situation of cyst___Either beneath that  part of tun vagin. testis  covering
the epidymis;  between the tun. vaginal, testis and the tun. albuginea; or be-
tween the layers ofthe outer portion ofthe tunica vaginalis.
   TJsual situation.
   Nature of fluid.
   Symptoms.
   Diagnosis---May  be confounded with simple hydrocele.
   Prognosis.
   Treatment.
   Operation to be preferred.


        IV.  DIFFUSED HYDROCELE OF  THE  SPERMATIC CORD.  •

   Nature and seat of disease.
   Symptoms.
   Diagnosis.—May be confounded with an  omental hernia, an encysted hydro-
cele, or varicocele, or retained testis.
   Prognosis.—Favorable.
   Treatment. 
 
 
(   201   )
       V.  ENCYSTED HYDROCELE OF  THE  SPERMATIC CORD.

   Definition.
   Age most liable.
   Nature and seat of cyst.
   C arises.
   Symptoms.
   Diagnosis.—May be confounded with simple hydrocele or with hernia.
   Prognosis.
   Treatment___Palliative  and radical  by operation;  operation of Mr.  Hey
and others.

               VI.  HYDROCELE  OF  THE HERNIAL  SAC.

   Definition.
   Causes.—Congenital and accidental.
   Diagnosis.—May be confounded with simple hydrocele, or encysted hydro-
cele of the cord, or with hernia.
   Treatment.

                  VII.  HYDROCELE  IN  THE  FEMALE.

   Varieties___Diffused and encysted hydrocele of the round ligament ; hydro-
cele ofthe canal ofNuck.
   Diagnosis.                                       x
   Prognosis.
   Treatment.

                             HEMATOCELE.

   Definition.
   Varieties.—That of tunica vagin. testis, and that of the cord.

                   I.  HEMATOCELE OF THE  TESTIS.

   Varieties.—Where the extravasation takes  place in the healthy state of the
parts , where it succeeds or is combined with a hydrocele.
   Causes.—A blow or strain, or a wound of some vessel of tun. vagin. testif,
testis itself, or of spermatic artery.
   Situation of testis.
   Consequences.
   Symptoms.
   Diagnosis.—May  be confounded with hydrocele, chronic  enlargement of
the testis, extravasation of blood in the cellular tissue  of scrotum.
   Proguoxsis.
   Treatment. 
(   202   )
                  II.  HEMATOCELE  OF  THE SPERMATIC CORD.

         Causes.
         Liability of occurrence.—Rare.
         Symptoms.
         Diagnosis.—May be confounded with diffused hydrocele of the cord.
         Prognosis.—Favorable.
         Treatment.

                                 ACUTE  ORCHITIS.

         Varieties.—Primary and consecutive.
         Exciting  causes.—Contusion, compression, great  excitement of the sexual
      organs, metastasis from salivary glands, an inflammatory action ofthe urethra.
         Predisposing causes.—Scrofula.
         Symptoms.—Local and Constitutional,  and  vary with the form.
         Diag?iosis.—May be confounded with strangulated inguinal hernia, imperfect
      descent of testis,  &c.
         Prognosis.—Generally favorable, varies, however, with the cause.
         Consequences.
         Terminations.—Resolution, hardening, suppuration.
         Treatment.—Leeching, venesa;ction, cold and warm  lotions, purging,  com-
      pression, &c.

                              II.  CHRONIC  ORCHITIS.

         Anatomical characters.
         Consequences.
         Causes.—Slight contusions, venereal excesses,  masturbation, urethral dis-
/     ease, syphilis.
         Symptoms.—Usually of an indolent character.
         Terminations.—Resolution, suppuration, ulceration, sinusses and formation
      of spermatic fistulas, hernia testis.
         Diagnosis.—May be confounded with carcinoma of testis,  hematocele.
         Prognosis.—Generally favorable.
         Treatment.—Chiefly constitutional, mercury.

                     TUBERCULAR DISEASE OF THE  TESTIS.
         Seat.
      A Causes.
      v-y Age liable.—Rarely until after puberty.
         Symptoms.— Insidious in their approach and indolent in their progress.
         Diagnosis.—May.be confounded with chronic orchitis,  and malignant dis-
      ease ofthe testis.
         Prognosis.
         Treatment.—Ton ic.

                          CARCINOMA OF  THE TESTIS.

         Varieties.—Scirrhus,  Encephaloid, Colloid and Melanosis. 
 
 
(  203  )
                      I.  SCIRRHUS OF THE  TESTIS.
    Frequency of disease___Very rare.
    Seat---The tubuli seminiferi, the epididymis and sometimes the spermatic
 cord.
    Symptoms---An enlargement of body of the testis with great weight, and
 severe occasional pain, feeling tuberculated, irregular and excessively hard.
    Diagnosis---May be confounded with chronic enlargement and with ence-
 pialoid disease.
   Prognosis---Unfavorable.
    Treatment.

              II.  ENCEPHALOID CANCER OF THE  TESTIS.
   Synonymes —Pulpy testis, medullary sarcoma, soft cancer, fungoid disease,
 fungus haematodes.
   Age most liable---No age  is  exempt, but it is more common at the middle
 period of life.
   Symptoms___An  enlargement,  with  induration  of the  body of the  testis,
 which preserves its oval form and even surface ; slight tenderness, dull  pain,
 and occasionally a little effusion into the tun. vaginalis ; as the gland enlarges
 it becomes  uneven,  irregular and tuberculated, also soft and elastic; pain
 increases ;  spermatic cord becomes thick and full, scrotum is swollen and vari-
 cose ;  glands of neighboring regions become enlarged  and  painful;  general
 health suffers ;  ulceration ensues, and a morbid mass protrudes in the form of a
bleeding  fungus, and the disease makes rapid progress.
   Diag?wsis.—May be confounded with hydrocele, haematocele, cystic disease,
and, in its early stage, with chronic orchitis.
   Prognosis.
   Treatment.

   Carcinoma ofthe Tunica Vaginalis Testis has been observed.
   Diagnosis.—May be confounded with hydrocele.
   Prognosis.
   Treatment.
   Colloid or Gelatiniform Cancer and Melanosis of the Testis are very rarely
met with.
                  CYSTIC  SARCOMA  OF  THE TESTIS.
   Synonymes —Cystic Disease, Hydatid Disease, (Sir A. Cooper )
   Anatomical seat.—In the substance of the testis.
   Number.—From two or three to a countless multitude.
   Size___Vary from a millet  seed to that of a pigeon's egg.
   Nature of the contents.
   Mode  of origin.—Difference of opinion.   Sir A. Cooper's opinion.
   Age most liable.—Middle age.
   Causes.
  Symptoms.
  Diagnosis.—May be confounded with hydrocele and encephaloid cancer.
  Prognosis___Favorable.
  Treatment. 
(   204   )
             FIBROUS TRANSFORMATION OF THE  TESTIS.

   Anatomical seat.
   Consequences.
   Diagnosis.—May be confounded with malignant  disease.
   Prognosis.
   Treatment.

                   OSSIFIC DEPOSITS  IN THE  TESTIS.

   Anatomical seat.—Between the tunicse, or in the epidymis.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.


           LOOSE  CARTILAGES  IN THE  TUNICA VAGINALIS.

   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                  NERVOUS  DISEASES  OF  THE  TESTIS.

   Varieties.—An exaltation of the natural sensibility of the part, or the irritable
testis of most writers,  and neuralgia of the spermatic nerves.

                           1. IRRITABLE TESTIS.

   Symptoms.—No perceptible alteration in the parts, but a  morbid sensibility
accompanied  by pain, and generally referred to one paiticular spot.
   Causes.—  Constitutional, chiefly.
   Diagnosis.
   Prognosis.
   Treatment.

                       2.  NEURALGIA OF THE  TESTIS.

   Causes.—Disease of the kidney, the passage of a calculus along the  ureter.
varicocele, orchitis, but often  the cause is hidden.
   Symptoms.—Sudden, severe, remitting pain, either of a  lancinating  or of a
dragging  or  pricking  character,  and is commonly attended with  spasmodic
action ofthe  cremaster, and sometimes with nausea and  vomiting.
   Diagnosis.
   Prognosis.
   Treatment. 
 
 
(   205  )
HARDENING  OF THE EPIDIDYMIS.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
ABSCESS  OF  THE TESTIS  AND EPIDIDYMIS.
Causes.
Symptoms.
Diag?iosis.
Prognosis.
Treatment.
Causes.
Symptoms.
Diagnosis.
Prognosis.
Treatment.
FISTULA.
                       FUNGUS OF THE  TESTIS.
   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                              CASTRATION.
   Definition.
   History of operation.
   Diseases  rendering it necessary—The different forms of carcinoma, tuber-
cular  disease,  cystic disease, some of the terminations of inflammation, seveic
neuralgia combined with varicocele.
   Steps ofthe operation.
   Dangers
   Operations  required in Imperfect Descent of Testis.

             II.  DISEASES OF THE SPERMATIC CORD.
                              VARICOCELE.
   Definition.__A morbid dilatation of the spermatic veins.
   Division into varicocele and circocele not employed.
   Appearances on dissection.
   Testis most liable.
   Causes.__Anatomical structure, and accidental  causes,
   Effects.
   Symptoms.
   Tune required in formation. 
(   206   )
   Diagnosis.—May be confounded with scrotal hernia, or a congenital hydro-
cele,  &c.
   Prognosis.
   Treatment___Palliative and  radical; Sir A.  Cooper's operation; Ricord's
operation; Sir B. Brodie's  by division of the  vessels; Celsus by ligature;
modifications of  operation by ligature;  Breschet's by compression or excision ;
Pancoast's operation.   The  truss.
   Relative value of each.

            ADIPOSE TUMOURS OF  THE SPERMATIC CORD.

   Age most liable.—Advanced age.
   Symptoms___Loose movable tumour, of a soft  doughy  feel and  lobular
character.
   Diagnosis.—May be  confounded with  omental  hernia, or  varicocele, or
hydrocele.
   Prognosis.
   Treatment.

                    SPASM OF THE CREMASTER.

   Causes.—Generally symptomatic.
   Symptoms.
   Diagnosis.
   Prognosis.
 ■  Treatment.

                 III.  DISEASES  OF  THE SCROTUM.

                    WOUNDS OF THE  SCROTUM.
   Nature.
   Causes.
  Characteristics of contusions.
  Diagnosis.
  Prognosis.
  Treatment.

                          PRURIGO   SCROTI.
  Definition.
  Synipfn rns.
 Age most liable.—Adult.
  Causes.
 Prognosis.
  Treatment.

                VARICOSE  VEINS OF THE  SCROTUM.

 Age most liable.—Old age.
 Treatment. 
 
 
(  207   )
                           PNEUMATOCELE.
  Definition.
  Causes.
  Symptoms.
  Diagnosis.
  Prognosis.
  Treatment.

                            (EDEMA  SCROTI.
  Synonyme.—Anasarcous hydrocele.
  Causes.—Mostly  symptomatic.
  Symptoms.
  Diagnosis.—May be confounded with  hydrocele, and elephantiasis of the
scrotum.
  Prognosis.—Depends on cause.
  Treatment.

                  INFLAMMATION OF  THE  SCROTUM.

  Forms.—Mild and severe.
  Symptoms of each.
  Terminations of each.—Of the mild, resolution.  Ofthe severe, mortification,
and rarely effusion of lymph  or pus.
  Diagnosis___May be confounded with cedema.
   Treatment.

                  MORTIFICATION  OF  THE  SCROTUM.

   Causes.__Severe inflammation, excessive cold, extravasation of urine.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.
                      ABSCESS  OF  THE SCROTUM.

   Causes.
   Symptoms.
   Diagnosis.
   Prognosis.
   Treatment.

                  ELEPHANTIASIS  OF  THE SCROTUM.

   Definition.
   Anatomical seat.
   Pathology.
   Causes.
   Symptoms.
   Size of tumour. 
(  208   )
 Complications---Scrotal hernia and hydrocele.
 Diagnosis.—May be confounded with cedema, &c.
 Prognosis.
 Treatment.
 Dangers of operation.

                 HYPERTROPHY  OF  THE SCROTUM.
 Definition.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

                   CANCER  OF THE SCROTUM.

 Synonyme.—Chimney-sweeper's cancer.
 Symptoms,
 Causes.
 Diagnosis.
 Prognosis.—Unfavorable.
 Treatment.

    MELANOSIS OF  THE SCROTUM—RARELY MET WITH.

                   TUMOURS OF  THE SCROTUM.

 Varieties met with.—Adipose, fibrous, &c. &c.
 Anatomical seat.
 Causes.
 Symptoms.
 Diagnosis.
 Prognosis.
 Treatment.

                RESTORATION OF THE  SCROTUM.

 Causes demanding the operation.
 Mode of performance.

                           IMPOTENCE.
 Definition.
 Difference between impotence and sterility.
 Sex most liable---The male to  impotency, the female to sterility.
 Causes of impotency—1. Organic.   2.  Functional.  3. Moral.
Symptoms.—Depend on the cause.
Diagnosis.
Prognosis.
 Treatment. 
 
 
                            (   209   )

                        SPERMATORRHCEA.
Definition..
Causes.
Symptoms---1st and 2d stage.
Diagnosis.
Prognosis.
Dissection.
Treatment. 
FOURTH   DIVISION.
                          AMPUTATION
Definition.  'A   A<?yA
Importance.
History.        ^ y   y
Classification.''* '-Ax-AyyC^-tY&-yu_t_
          \ 1. Circular.
Methods.  ( 2. Flap, single and double.
          \ 3. Oval or oblique.
         ") 1. Primary.
r*OTe*    J 2. Consecutive. .

Place.   f Q  In Contig„ity 0f iimb.
1.  In Continuity of limb
         tiguity of limb
         Operations of necessity
              } 1. Operations of necessity.
Circumstance. £ 2  Operations of choice or complaisance.
      ) 1.  Operation of necessity.
 pot' (2.  Operations of election.
Causes demanding the operation.
Prognosis.—Favorable circumstances.
             1.  Youth.
             2.  Habit somewhat reduced but not too weak.
             3.  Cheerful temperament.
             4.  Good general health.
             5.  Simple disease or accident.
             6.  Part at some distance from the trunk.
             7.  The upper extremity.
             8.  Circumstances of the patient.
Statistics of amputatio?i.
Preparation of patient.
Instruments required.
Dressings.
Accidents. 'Xj-\S -                                                    f/
                \  1. Hemorrhage.
Accompanying.  \  2. Excessive pain.
                )  3.  Fainting.
                   4.  Convulsion.
                ~i  1.  Hemorrhage.
Secondary.     ^  2   Inflammation of stump.
                   3.  Conical stump.
                   4.  Abscess and sinus of stump.
                   5.  Necrosis or caries of bone.
                   6.  Cystitis.
                   7.  Phlebitis.
                   8.  Metastatic abscess.
                   9.  Gangrene.
                   10.  Hectic fever.
Healing ofthe stump and changes which tale place i,i the different tissues.
Modification of the constitution. 
/Ax  y-.
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(   211    )
    CONSIDERATION OF THE  DIFFERENT  GENERAL  METHODS.

                        1. Circular Amputation.
 History.
 Object had in view.
 Manner of calculating the flap.
 Manner of dividing the  tissues.
 Reversion of the flap.
 Instruments employed.
 Advantages ofthe operation.
 Cases to which it is most applicable.

                          2. Flap Operation.
 History.
 Object had in view.
 Manner of calculating the flap.
 Manner of dividing the tissues.
 Instruments employed.
 Advantages of the  operation.
 Cases to which it is applicable.

                          3.  Oval Operation.
 History.
 Object had in view.
 Manner of calculating the flap.
 Manner of dividing the  tissues.
 Instruments employed.
 Advantages of the  operation.
 Cases to which it is considered applicable.

                 4. Operation in Continuity of Limb.

 History.
 Object had in view.
 Manner of dividing the tissues.
 Instruments required.
 Advantages of the operation.
 Disadvantages.
 Cases to which it is applicable.

                 5. Operation in Contiguity of Limb.
 History.
 Object had in view.
 Manner of dividing the tissues.
Instruments required.
Advantages of the operation.
Disadvantages.
Cases to which it is applicable. 
(   212   )
                         SPECIAL AMPUTATIONS.

                        1.  Of the Upper Extremity.

   These consist of amputations of the Phalanges, metacarpophalangeal articu-
 lations, metacarpal bones, separately or  collectively,  metacarpo-carpal joints,
 radio-carpal articulations, of the fore-arm, elbow-joint, arm, shoulder-joint and
 shoulder-blade with the arm.

                        2.  Of the Lower Extremity.

   These consist of amputations of the  Phalanges, metatarso-phalangeal arti-
culations, metatarso-tarsal, ankle joint, leg, at the  knee joint, thigh, and hip
joint.

                         RESECTION  OF  BONES.
   Definition.
   History.
   Classification.—
                   1.  Those practised in  the continuity of a bone.
                  2.  Those practiced in the contiguity.
                  3.  Those in which the bone is extracted entire.
   Cases calling for resection.—Caries, necrosis, osteo sarcoma, spina ventosa,
compound and comminuted fractures, gunshot injuries, and compound luxations.
   Counter indications.
   Prognosis.
   Time of performance.
   Instruments and apparatus.
   Special application. 
> 
 
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