13 Surgery 1 2 3 4 5 Lecture 2nd Inflammation Characterized by heat pain redness, swelling, soreness upon pressure & if considerable a symptomatic fever. If considerable & extensive, constitutional irritation, or irritative fever may be produced. The pain is caused by some affection of the nerves, the swelling by effusion or by distention of the vessels The symptoms above described may occur successively and not all be present at the same time 6. Inflammation has been divided into two kinds Phlegmonous & Erysepelatous 1st Phlegmonous & 1st of that which arises from external injury. The injured part is the centre of the inflammation. The manner in which injury produces inflammation is not well understood. Hunter speaks of both increased and diminished action of the vessels & uses the term healthy inflammation in which there is increased action. Cullen thinks the action increased Wilson Philip thinks there is diminished action. At the present day surgeons consider that there is increased action at first in all cases Hunter thought the vessels were always diluted at first An injury is first followed by pain, caused by laceration & pressure of nerves perhaps. For an example an incised wound is followed by retraction of the lips, by pain swelling redness, heat, 7 and the inflammation spreads over adjacent parts The sense of fullness and the redness is probably caused by increased quantity of blood red blood is carried where it did not exist before as in ophthalmia The venous blood becomes red like arterial The cold stage is extensive inflammation should not be omitted. It is a part of the symptomatic fever & this fever sometimes also has a sweating stage Prof. H. thinks there is always in creased action in the commencement of infl. He thinks also that fever differs from inflammation The heat extends widely perhaps over the whole body It is principally a sensation however, and not much indicated by the [therm.] Inflammation of some parts as stomach & bowels the pulse will not be full & strong. This will also be the case in some constitutions, in which 8 there will be feeble pulse nausea vomiting etc. Prof. H. objects however to the term atonic inflammation Causes of infl. are mechanical & chemical heat, cold etc. Syphilis & some others are attributed to a specific cause & called specific inflammation Cold may cause inflam. by rendering the system or part more susceptible to heat afterwards. A frozen part will irritate as dead matter. The frozen fluids will irritate Prognosis will be dangerous 1st from violence or extent of infl. 2nd from nature of the part affected as the viscera the functions of these parts being suspended or destroyed. joints are dangerous parts 3d const. & habits of the patient Terminations are 1st resolution 2nd adhesion 3d suppura. 4 gangrene. Schirrhus was added by the older writers 9 1st Resolution is where the part is left healthy 2nd Adhesion takes place generally in serious membranes & in the cellular membrane especially in the linings where it is called hepatication Treatment. The cause as [illegible] should be immediately if possible removed Remedies These should be local as much as possible. Much may be done by prophylactic treatment especially in the case of wounds The first indication is to preserve the proper temperature of the part we may apply cold or tepid applications according to the sensations of the patient. If chilliness is produced by cold applications, apply warm ones though in infl. of the brain the production of chilliness is beneficial in many cases IN abdominal infl. fomentations & warm bath will be very useful and the French use poultices extensively in infl. of the lungs substituting them for blisters 10. We may apply cold applications too long. There is sometimes a choice in liquid appl. spts & water ac. pl. 1z to 1 pt. mur. amm. zii to pg. cold water alone ice especially for the brain vinegar & water though this irritates the skin & produces an eruption in some persons mur. amm. in very popular & seems to answer better than ac. pl. for deep-seated infl. Cold water is probably good enough in most cases, if there is no prejudice in the patient. Some surgeons use sulph zinc. Others depend much upon narcotic applications as of stramonium Prof. H. does not use them Blisters are especially useful in chronic & deep seated infl. Prof. H. prefers a repetition of the blisters for keeping up a perpetual discharge The first general treatment is bleeding which is recommended by W. Philip for two reasons to dimin. the vis a tergo & to dim. the quantity of fluid in the part. Those of opposite theories use it 11 There seems to be no doubt about bleeding in phlegmonous infl. and Prof. H. has often found benefit from it in erysipelatous Venesection is the most common the most convenient for several reasons. Prof. H. has thought that drawing blood from a vein near the inflamed part relieves the pain sooner though it may have no effect afterwards. Continue the flow till pain is relieved or faintness is produced patient not being in a horizontal posture. If the pain etc. return repeat the bleeding Blood letting has been objected to in old persons and in the feeble. Brit Prof H. has frequently bled both with advantage Arteriotomy has no advantages Leeches are not fashionable but Prof. H. thinks they have no advantage over venesection. He thinks experiments on their relative advantage have not been sufficiently tried They may be better in some cases of chronic infl. but Prof. H. has used repeated bleedings in such cases with advantage Cupping combines bloodletting & and counterirritation Lecture 3d The next remedy in importance for inflammation is cathartics The saline are recomm. but the merc. are better. As W. Philip says they undoubtedly have a specific effect Antimonials have a powerful effect In Italy many have used them exclusively Beginning with small doses & increasing gradually, they gave a large quantity and depend upon this alone I have known a patient bear 4 gr of tart. em. once in 4 hour Narcotics have been much used It is safe to give opium, contrary to Brown. Dovers powder may be given But perhaps the best article for inflammation which we have, perhaps is calomel and opium. This practice is now much used in G. Br. A little opium is combined in order to quiet irritation. Hyoscyamus has been used. 13 where opium would not agree It has been my practice to give opium enough to quiet the irritation from excessive pain & continue my other treatment at the same time Rest & quiet must be used to relieve pain An elevated position well often relieve pain in paronychia for instance & in pneumonia, & in infl. of kidnies Diet should be light & vegetably an. food to be avoided, including broth also which many consume, in injurious quantities Attention must be paid to the constitution. We must be cautious about bleeding drunkards Often a state of debility succeeds such as to require tonics Opium has sometimes to be continued after recovery Adhesions in the cell. mem. are apt to take place after inflam. of joints These are to be relieved by fiction and motion 14 Chronic infl. will be treated hereafter Often the most Erysipelas is principally confined to the skin though the cell. mem. is generally more or less affected There is a redness in erys. which disappears after pressure. The redness also is exactly defined at the edge. There is a remarkable propensity to spread The redness is of a darker colour then in phlegmon & in the progress of the disease inclines to yell. The skin is shining. The pain is not throbbing as in phlegmon, but burning. Sometimes there is a deep seated part at the same time The infl. frequently leaves one part and spreads over another The eruption disappears in [brawny] scales. There is a slighter swelling of the skin perceptible to the finger, a hard leathery feel of the skin 15 The fever is considerable. Vomiting bitter taste in the mouth bile is thrown up heat very great Old persons frequently have coma When as is sometimes the case erysipelas comes on at intervals or is periodical Its occurrence may be preceded in old persons by come Delirium may be caused by it 1st erys. eff. skin only 2nd erys. aff. cell. mem. which may or may not be accompanied with aff of the [skin] 1st This does not suppurate & terminate in branny scales. Found in all ages 2nd Skin and cell. mem. affected there is swelling suppuration etc. sometimes the fasciae & tendons are involved. It affects principally the old and the intemperate especially the legs Erys. is dist. from phlegmon by col. by circumscription by fixedness Erys. when suppurate does not have a regularly defined abscess like phlegmon 16. Erys. aff 1st nerv. syst. by coma for instance delirium when the head is affected, by burning heat 2nd heart & arteries by a pulse smaller weaker and quicker than in phleg. 3d al. can. by bitter taste dryness of mouth diarrhoea vomiting From the bilious vomiting yellowness of skin & of the affected part Some have supposed the liver to be aff. but this takes place from sounds merely & from the bit of the rattlesnake Caused by wounds ulcers etc. and in erys. the infl. is not necessarily near the part injured The causes operating upon the constitution are malaria and the crowded air of hospitals, feebleness and intemperance etc. In Pomfret after draining the [meadow] one summer there was more erysipelas (St. Antonys fire) than in 10 years In the Mass. hospital Heated air produced this effect. The violence of erys. is generally proportioned to that of the local aff. 17 Sometimes however it affects internal parts Sometimes erys. alternate with other diseases Prognosis depends upon the violence of the infl. upon the cell. membranes being affected upon the head & face being aff. upon the constitution age and habits of the patient The indication is to promote a resolution and prevent suppuration if possible Though some suppose that suppuration never occurs Resolution is to be accomplished 1st topical 2nd by general app 1st Many object to topical applications Though S. Cooper and Lawrence do not object to them Ac. pl zi to pt. is the best Milk & water or cold water is good Use the cold or warm acc to choice of pat. mur. amm. zii to pt. corr. sub. 10 to 20 gr. to pit. will often be good Narcot as 6 p. zi to pt water or op. zi ac. pl. zi mercurial ointment has been 18 celebrated as a catholicon Another however though lard a catholicon Prof. H. has derived much benefit from lard or tallow alone In violent or extensive infl. I have found ointments inferior to liquid applications Though ointments are very agreeable when the cuticle is peeling off A new remedy is not silv. moisten a stick and sub it over the part (Mr Higginbottom) There is considerable testimony in favour of this mode of treatment. It is said to prevent the spreading. Mr. H. trusted to this alone without internal remedies. Prof. H. has used it but has not trusted to it alone he recommends however Blisters have been proposed by Dr Rush & used by Dr Physick Dr Rush recommended them for gangrene Prof H. has used them with the greatest benefit Case of a man’s face so swelled as to blind him. Prof. H. blistered the whole face & cured the patient Blisters are not t be applied to every extensive erysipelas 19 When the cell. mem. is affected blisters undoubtedly ought to be used Undoubtedly erysipelatous inflammation may affect the cell. mem. without the skin It has been called erys. phlegmonode Dissection [illegible] are in Prof. H.’s opinion are of this nature. The propriety of treating erysipelatous infl. like phlegmonic has been very much questioned but Prof H. has often bled and reduced with great success. It is often very difficult to cure returning after an apparent cessation Purgatives have probably been more used on account of the notion that there was bile in the skin and on account of the humoral pathology Bark opium etc. will be proper when the pulse is very feeble etc. but not when the tongue is dry, skin hot etc. etc. (Thomp) Infants have erysipelas sometimes caused apparently by irritation from improper tying of the navel string. I have 20 also seen if affect the pudenda and sometimes be very dangerous The cause of the latter I do not know. I have treated erysipelas in children with cal. ipecac & rhubarb etc. and the same ext. appl. as in adults Erysipelas of cell. memb. the skin not being affected. It usually attacks old, intemperate broken down persons commences with chills skin feels doughy pits on pressure Generally there is much derangement of stomach, vomiting etc. Sometimes delirium & even del. tremens Lotions are not of so much use Prof. H resorts immediately to blisters Narcotics are generally strongly indicated. Suppuration is to be expected and promoted. In this kind incisions are proper. Pus will collect in a day or two and should be let out. The pus will collect in parts & the skin have a boggy feel. 21 Treatment of erys by incisions. Considerable blood may flow & in one case Mr Hutchinson the inventor lost a patient from haem. owing to the negligence of the dresser Tinct. myrrh is an old article, formerly much used for injection into erysipelatous absceses (Dr Ives) Chronic inflammation. This is generally a sequel of acute inflammation Some constitutions are predisposed to it For instance an injury of a joint will being it on in some persons Scrofulous persons are more subject The gland and joints are the most common parts affected Treatment Bleeding should be local rather than general. Blisters cupping etc. Mercury in small doses narcotics as opium & conium. Deobstruents are very important. Vide Mat. Med. 22 Suppuration Infl terminates in suppuration when it resists the usual means used for discussion & increases & swells more Phlegmonic infl. has a soft part in the middle more or less pointing & in a round or oval form Erysipelas does not suppurate in a circular pointing abscess and the us collects more suddenly. Nothing perhaps distinguishes an experienced surgeon more than tact in discovering matter An abscess always tends to [illegible] the skin Pus is not now thought not to be formed from coagulated blood neither from the solids but to be a secretion Properties globules in a fluid cream coloured sweetish coagulated by mur. amm. Putrifies upon exposure to the air, & may rust a silver probe Delpect maintains that it is secreted from a membrane Pus is detected by placing the two thumbs at some distance from 23 each other & pressing alternately. In the thigh do not place the thumbs transversely upon the limb. lest you be deceived by the slipping of the muscles on the contrary place the thumbs up and down the limb S. Cooper thinks it is often better to suffer many abscesses to burst themselves thinking that the cavity will gradually contract & the healing will be more favorable. Prof. H. dissects entirely from this and always lets pus out by an incision It abscesses open themselves, the pain is often excessive at the close, just before opening feeling like the cutting of a knife There are no advantages to be derived Erysipelatous pus should always be evacuated immediately. If not, it may become acid and fetid Sometimes fetid gas will issue & fill the room Abscesses are opened with the abscess lancet, or with a bistoury. Large ones with a double edged knife Prof. H. knows of no medicines which promote suppuration unless it be warm applications fomentations etc. which 24 soften the skin and allow it to distend They are very comfortable and may be allowed An abscess after opening should not be violently squeezed, but pressed a little and afterwards, pressed again, or subsequent days. When there is difficulty in getting out all the matter bandage so as to make constant pressure leaving a hole for the pus to issue Do not attempt to discuss deep seated abscesses & those about the joints. The pus is often contained in a bursa mucosa & will not evacuate itself and patients often are suddenly in such cases Abscesses continued. It may be advisable to keep a small slip of linen in the opening at first to prevent [closure] of the cavity If the healing is slow, touch with nitrate silver. Sometimes inject corrosive sublimate 25 If these things with bandaging fail to cure, look out for the constitution be careful to keep up a strick rest of the part. The fore arm may often be healed in this way, when other means failed before applying a splint As illustrations of abscesses take these of the female mammae. 1st We have simple phlegmonic infl. & abscess. Treat just like any other inflammation pro re nata Robust women may be bled. Sling the breast. The skin always adheres over an inflamed gland 2nd erysipelatous infl. of the breast pus in the cell. memb. sometimes the ducts are laid open by # suppuration Inf. of the bursa mucosa under the gland commencing like rheumatism constit. disturbance considerable The breast is not hardened but the whole of it is pushed out. Suppuration takes place within, and points below. Open the abscess and keep it open by a bougie keeping on a bougie as long as you can & then introduce a probe. If these means all fail Introduce a seton and take out a thread a day until the abscess heals. Dr Physick invented this practice Hey advises to lay open the whole breast & calls them chronic abscesses Finally bandage the breast The seton may be introduced by Acute inflam. of hip joint [illegible] supervenes upon an injury violent pain inability to use the limb const. irrit. violent fever convulsions death in a few days if not opened. Prof. H. has not with several cases. We must not hesitate about opening the joint, to evacuate pus in these cases Case of erysipelatous abscess Hard drinking patient infl. of leg below the knee del. tremens came on opium 175 drops & more a day Abscesses repeatedly opened until the whole leg was open under the skin pus collecting very quickly recovered Cases in which pus collects in the cell. memb. in various parts & finally 27 death or loss of a limb. The treatment must be very much varied Opium bark etc. Bark is of little use when the tongue is brown, dry etc. In the early part of his practice Prof. H. gave much more bark than at present Chronic abscesses Limits not very well defined. They are merely those which are long in collecting. Bryer divides into acute chronic & congestive or those where the pus is found in a different place You will be called & sometimes [& be] told of a fever, sometimes previously at other times there is no apparent cause Often the pain is in a different part. Case of a child treated for aff. of the knee is hip had an abscess It was opened & cured Much is said about absorption of pus. But Prof. H. has never known cases completely cured without opening Prognosis is very difficult in chronic abscess Sometimes death ensues in a few days after opening sometimes only 28 after months Prof. H has never opened with caustic Lumbar abscess caused sometimes by strains & bruises sometimes no apparent cause Scrofula is given as a cause but it is necessarily Most common in the young though it is found at middle age Commences like rheumatism without much severity of symptoms A peculiar bending forwards & to one side characterises the walking pain on pressure Prof. H. thinks it is seated in the bursa of the psoas muscle The pus points below [illegible] ligament or lower down on the thigh even on the outside of the thigh It is sometimes mistaken for aneurism & for inguinal hernia It is easily distinguished The pus is described in the books as pointing always in the groin Prof. H. has seen it point in the loins If pointing in the groin let this patient stand up when you 29 open the abscess It may be necessary to introduce a probe to bring out the coagula which are numerous & sometimes large but be cautious in using a probe, lest you excite internal hemorrhage Make the opening keeping the surface tense about the width of the lancet (into the cyst) for the size of the opening Evacuate all the pus & heal by the first intention. When pus collects again make a second opening in another place because it would not heal so soon in the first place and evacuate & heal up as before. After a few such openings the pus will ulcerate out & then a modification of treatment is required “The patients may recover in the country but in cities & hospitals” Old surgeons introduced tents with great mischief Prof H has read of no lumbar abscesses cured by absorption where the patient ultimately recovered an abscess of the lungs is apt to occur as a sequel & take off the patient 30 Hectic fever may be acute and violent, soon 2 or 3 days or even 24 hours after opening lumbar abscess or hip joint heat fever nausea vomiting great local pain inability of motion of the part from pain These symptoms appear so like an attack of common fever that they are sometimes falsely accounted for in this way. This hectic may occur after the bursting of an absc. It is different from confirmed chronic hectic though called by the same name vide “acute hectic” A lumbar abscess opened by a large incision gives rise to more violent symptoms. Though they may occur often a spontaneous opening or a small incision Case of a young woman who feel from a horse was somewhat lame finally there was a pointing in the groin patient was about the abscess burst violent symptoms took to her bed lay a year & died The doctrine of absorption of pus was first denied by J. Hunter. 31 Some have attributed the bad effects upon a free opening are owing to admission of air others to cold air But Baron Larrey dressed wounds below zero When a lumbar abscess becomes permanently open. Prof H. injects corrosive sub. 10 gr. to a pint. 2 or 3 times a week taking pains to have the solution touch the whole internal surface of the abscess, by turning the patient stroking up the part etc. If after continuing the injection about a fortnight discontinue it if no benefit is derived we should increase the strength until some sensation is produced. Sometimes the injection will produce a slight ptyalism but this is of no consequence Prof. Smit injected the cavity immediately upon first opening Prof H. has tried this, but prefers Abernethy’s mode. The injection generally somewhat increase the discharge The constitutional treatment shd be with opium especially conjoining calomel. Tonics also as bark. prof. H. cannot think that lumbar abscess proceed from an affection of 32 the vertebrae because the disease often arises from injury to the muscles merely & is cured more readily than we could expect if the vertebrae were affected he has examined the vertebrae also, when about to make the opening & could not find them affected. Languid scrofulous abscesses take on an oral form & are to be treated like others. Do not wait until the skin becomes very thin and of a purple colour If we wait too long the skin will form loose flabby granulations so that the skin will perhaps have to be cut away Quality of the discharge from abscesses Sometimes is is pure pus, sometimes thick or curdy But before the abscess closes the discharge becomes whey like, thin, watery. This is not noticed by writers. It must not be mistaken for a bad action of the abscess 33 Furunculus or boil Called an instance of phlegmonous infl. Still it differs much. For in common phlegmonous inflammation there is a cavity for the pus or no cure Furunculus commences with a pimple and a small vesicle which when pricked yield a serum. Hardness purple colour pointing is not always in the centre. One or more small holes out of which the pus issues The pus is apparently contained in the cells of the cell. memb. The boils do not heal until the core [illegible] which is rotten cell. mem. Treat sometimes by bleeding if const. infl. is great at other times give calomel. Poultice or plaisters They may be cured more speedily by opening than by suffering then to burst So says Prof. H. Sometimes they contain clots of blood (called blood boil) Where there have been very many on a limb Prof. H. has enveloped the whole limb in ac. plumbi 34 Anthrax (burning) or carbuncle most commonly found on the face neck or back found also on the hands and feet and in other parts Often preceded by violent pains and heat in the part. A malignant fever may be the cause. Sometimes it is preceded by a sort of anomalous [illegible] [illegible] [illegible] [illegible] of health. It may commence with a broad inflamed spot on the skin Begins differently in different localities. Generally with several points Begins with a fiery pimple which gives a burning pain & often Begins on the hand with one pimple cause considerable const. irrit. Colour of the skin around not bright like furunculus but dark like erysipelas a hard cake in the cell. mem. equally around the centre. lymphatics affected becoming hard & red cords much const. irrit. chills, flashes of heat, nausea, restlessness etc. Small holes appear & keep occurring in a fresh part of the swelling A piece of skin mortifies & comes off often The pimples emit a yellowish fluid More dangerous about the head generally but not always fatal there Sometimes 35 very rapid gangrene ensues Case of a man who observed a small pimple while shaving a few days after Prof. H. was called, he died of gangrene Occurs oftenest on the old & in the intemperate Coma & delirium often ensue in the old where the gangrene is near the head Authors differ as to treatment The French use the actual cautery at a white heat The pains [illegible] is said not to be great Prof H. blisters at first It relieves the burning pain & heat. Then he applies an emollient poultice If the burning heat returns apply another blister. Apply ac. pl. [illegible] & cerate Sometimes where the fever is high bleeding has been beneficial in Prof. H’s practice. Always give calomel Dr Physick recommends caustic kali he says it relieves the pain Prof. H. has not tried it. He has always found blisters promote suppuration When pus collects squeese it out, and pull out the slough of dead cell. mem. which gives great relief If necessary in order to extract the pus & 36 sloughs in incision if sufficient size may be made Incis. at first though highly recommended are not approved of by Prof. H. Various affections of the hand called felons, whitlows etc. & paronychia Paronychia The term is applied to a variety of sores upon the fingers & hands sometimes upon the toes. Four kinds 1st a superficial suppuration around the root of the nail cured by nit. sil. 2nd suppuration in the cell. memb. of the fingers or hands a real anthrax 3d Inflamm. in bursae mucosae 4 deep suppuration between periosteum and bone & leading to necrosis 1st Commences with heat, [burning] pain, redness finally yellowness The nail is best unless properly treated These are commonly located with poultices They are comfortable. Mr. Higginbottom recommends nit. sil. If suppuration takes place open through the cuticle & clip off as much as possible of the skin The suppuration extends around and you 37 must continue to clip off skin. To stop this continually spreading ulceration, inject corr. sub. or sprinkle on cal. Finally dress with cerates or with saturnine cerate Sat. cer. Rx ac. pl. zii sulph. sod zfs sim. cerate ziifs. 2nd Is an anthrax & to be treated as such by blistering at first etc. Generally the tendons when laid bare continue white and glistening & do not turn yellow and die. If they are laid bare in this state by sloughing of cell. mem. they will generally become covered afterwards. 3 Of bursae mucosae They are excessively painful Generally common at a point & feel for some days as of a splinter was sticking there We can do little better than to continue to poultice until suppuration comes on. Then open thoroughly & keep the abscess if necessary open by a piece of linen. Pencil with caustic. It will not readily burst [illegible] through the bursa 38 4th The periosteum covers the pus. Treat by an incision in the first place without [reacting] for the formation of pus keep the part [illegible] This is a necrosis and is to be treated as such. There is much pain long before the swelling & much const. disturbance It may be necessary to extract a dead phalanx. The finger will heal up well afterwards This kind affects perhaps the canellae of the bone in some cases, producing complete necrosis Mortification. Conversion into a dark ash coloured mass, which is cold & if kept dry becomes black & finally fetid. It is said that mortif. for gangrene may commence without previous inflammation. This doubtful Two kinds acute & chronic 1st acute, takes place, by becoming orange coloured forms livid or purple vesications, containing bloody serum Bloody serum is a diagnostic, unless proceeding from ecchymosis Pulse becomes weak sometimes intermitting A mortified part is always insensible to a prick or cut, by a pin or knife 39 Chronic mortification takes place without any apparent inflammation though often preceded by severe burning j& pain A good example is that of old mens toes which commences with small vesicles & extends over the whole foot & the leg There generally precedes a severe pain in the part Two circumstances will always distinguish a mortified part, 1st an insensibility 2 fullness of blood vessels in the parts adjacent? Mortific. may be caused by injury, especially if violent enough to destroy the vitality of the [part] in the skin for instance by obstruction of the bloodvessels leading to the part by malignant diseases suddenly destroying a whole limb without any previous inflammation occasionally also from palsy in this way Cases 1813 pneu. typh. Infl. especially, erysipela & anthrax & in the old & intemperate is the most common cause fire frost bite The pathology of mortification 49 is very obscure. Sometimes excessive action There is sometimes a predisposition to mortif. & in such cases it will follow trifling injuries e.g. in broken down const. Prognosis is often difficult. All causes are dangerous. Prognosis depends upon constitution, part affected, & rapidity of progress It is very dangerous to have mortification succeed a trifling injury Chronic mortific. is always dangerous and especially if the tendons & fasciae are affected, when there is [little] probability of a cure for tendons are very slow in healing If possible dissect out dead portions of tendon etc. Sometimes the patient is suddenly carried off by a new attack of erysipelatous infl. or an infl. of one of the viscera especially the lungs Indications are 1st to moderate the violence of infl. 2nd remove sources of irritation 3d to prevent spreading 4th support sonstit 41 According to the opinion that the line of demarcation instituted by nature should be [initiated] and promoted by art it was formerly proposed to apply stimulating articles as hot oil of turpentine, etc. but these do injury. Cutting down for the purpose of separating the sphacelus does not stop the spread The const. sympt attend are sudden sinking of pulse, great anxiety of mortal restlessness cold sweat etc. If the mortif. comes on gradually these symptoms may be gradual in their occurrence. Sometimes however their attack is sudden The indications of treatment were 1st To moderate violence of reaction If the pulse is strong & the pain very great so that there is danger of mort. we may bleed. But the period for it is short. Where bleeding cannot be admitted leeches are recommended by some. There will be a dry tongue & the secretions are to be improved, by full doses of cal. when there is constip. but 42 small alterative doses when there is diarrhoea. Prof. H was in the habit of using it before he saw Sir A. Cooper’s remarks Bark is not how much relied on and is ever objected to b y many when there is fever. Mr. Pott found it useless for toes of old men & relied on opium instead For local application, use mur. amm. & ac. pl. either cold or warm according to the sensations of the patient Some object to cold applications Poultices are useful [Yest] poultices are merely useful. Prof H thinks by correcting fetor Bark poultices he thinks useless and if they are used are better made by a decoction than by powder 2nd In old men; to remove cause of irritation. be careful about splinters etc. Be careful to open abscesses to prevent irritation Remove sloughs if it can be done readily Continue opium all along beginning with cal. if bow. are costive but continue opium long after ceasing with cal. To prevent the spread 3dly It is very difficult to stop the spread 43 of gangr. Sometimes it will extend in the cell sub. under the skin, producing a crackling feel. Bark was formerly relied on’ but it is not now valued Blisters must be our great reliance. (Dr Phys. introduced them) but be cautious not to blister too near the gangrenous part. In case of chronic mort. as of old toes this is [illegible] Dr Phys & Dors. disputed Nitrous acid is now much applied 1, 2, or 3 or drops to a pint of water As for the const. treatment 4th This ind. is answered partly by the 2nd Besides this where the bowels are good etc. & it will do well give bark. Give wine, porter, etc. and indulge, but do not force the patient to generous diet In the suppurative stage give poultices & sat. cerate. Sometimes relief will be great from removing sloughs. Case in which the whole [gastrocnemius] muscle [illegible] removed, with relief & a cure Death from mort. even if external is sometimes very sudden. In 44 some such cases I have suspected phlebitis might have been the cause Hiccup has been called a fatal symptom, but I have seen it occur in the suppurative stage & yet the patient recover When the patient sinks, vomiting diarrhoea hiccup etc. comes on sinking of the pulse, cold sweat mortal restlessness etc. As to amputation in these cases, it must not be done if the whole limb is affected, but must be in cases of dead toes not spontaneous and other such for we must not expect a good separation, spontaneously to occur. As to time it was long considered as a certain axiom to wait until a complete line of demarcation is formed Baron Larrey was the first to change the practice Others here imitated him Prof. H. was at first driven to the practice by a hemorrhage of the post tibial art. He has never known a case where the limb has separated of itself. Though it has occurred undoubtedly 45 When mort. takes place spontaneously & from const. causes it will be of no use to amputate, but it should be done when preceding from fire, frost or erys. infl. Prof H. has always found the arteries of the toes, in such cases, ossified Sometimes in such cases it will be proper to amputate high up upon the thigh. Chronic mortification requires amputation occasionally especially of the limb is amputated high enough. In general however we cannot expect much success from amp. in chron. mort. Prof H. has known many deaths are often very sudden in such cases, and unaccountable. The line of demarcation is at first red, and afterwards whitish 46 Hectic fever. This was formerly thought to arise from suppuration but it occurs from irritation in chronic infl. of joints etc. when there is no suppuration. Prof. H. thinks it has always a local cause & is never idiopathic Unless it attacks suddenly and violently as after opening a lumber abscess it generally comes on insensibly It may be divided into acute & chronic acute when sudden and violent chronic when coming on gradually and continuing a long time, as in phthisis tubercularis Commences with a chill, and a hot fit In the midst of a hot fit a chill may occur. This was considered pathognomonic by Heberden. Considerable cough & expectoration of purulent matter may occur when the disease is produced entirely from a local cause & one not seated in the lungs & may be removed by amputation as of white swelling. Parox 2 in 24 h. pulse sharp Sweating generally occurs 47 only after an abscess is open as in disease of the hip joint, lumbar abscess etc. A good constitution is no safeguard neither is youth, where a cause, as an abscess exist. The chance of restoration of the local part is greater in the young, but the rapidity of the hectic is much greater in the young It is in them that we have galloping consumption” Indications are 1st to remove the cause 2nd allay & abate symptoms irritation 3d support strength 1st Open abscesses etc. We may warm the [illegible] when about to open an absc. that we esp. the sym. will be [illegible] for a time. 2nd to abate the symptoms restore the secretions by calomel relieve irrit. by opium not. but op. will stop the diarrh. whch often occurs Relieve thirst by acid cool drinks Keep the bowels soluble by cal. at first, afterwards by rhubarb etc. or if cath. exhaust too much use injection 3d To restore strength use opium also This procures sleep etc. Give bark also. Sulphuric acid has been much used but Prof. H does not think it anything more than a pleasant article Give nutritious 48 food. if the patient will take no stronger food, he may sometimes be kept along for sometime or milk porridge & similar articles Be very particular in searching out the cause. Case of young married woman with hectic. The unsuspected cause was the breasts cured by opening Wounds. Solutions of continuity in a soft part. There is a great variety in their nature & the part affected Symptomatic, or inflammatory fever usually follow considerable wounds This in good constitutions & when the wound is not too severe is generally short & easily subdued Six kinds 1st incised 2. punct. 3 lacer. 4 contusa 5 poisoned 6 gun shot 1st Incised wounds. The edges immediately retract but the first thing is to stop the haemorrh. by pouring or cold water by a short compression with the finger or lint. sometimes 49 by elevating the limb, as in wounds of the foot by the dressing merely if the wound is slight by exposure to the air. If a large artery is divided, it must be tied, but in small arteries completely dividing the art. will often answer as a substitute for tying. Tying should be by pulling out with forceps if possible, if not with tenaculum. Use a surgeon’s knot for large arteries. It is convenient else in the 1st knot from not slipping Leather ligatures shd be made of French kid (with the epidermis peeled off) & rolled round. Buckskin will answer. Leather tanned with bark will not be absorbed. Small ligatures are now used, in order to cut the int. & middle coats. Lec. haem. is now less common Mr. Lawrence recommends silk ligatures, cut close off. The knots however sometimes suppurate out. Prof. H. has no experience of this method The old method of tying with a needle is not now used if it can be avoided Other mode of stopping haemorrage 50 are by styptics, by compression. The best mode of applying pressure is by placing a [illegible] of lint on the artery & holding it there with the thumb Fungus as lycoperdon, agaric astringents as alum act. cautery The latter is especially convenient in the mouth. It is used in other cases also by the French. Re Remove foreign bodies Bring the edges together After cleaning the wound of blood & coagula. bring the edge carefully together, & apply adhesive plaster. Mode of applying them Begin at one angle etc. Leave about a quarter or an eighth of an inch between the strips. In the large town they use plaster spread by machinery & plaster cloths but they do not hold so well as if recently spread Mr Liston recommends glazed [ribands] smeared with a solution of isinglass & brandy 51 The main indication for a strong plaister, and made of material which will not irritate the skin Do not dress a second time at all unless there is some indication for it not under 3 or 4 days Where artery has been tied, do not dress under a week or 10 days Dress as seldom as possible unless called upon to do so by accumulation of pus, or offensiveness of discharge etc. When you dress, do it after carefully washing and softening the old dressings and if the wound is large and open apply a new strip of plaister after removing one so as to have but one strip off at a time Inflammation should be guarded against thought it is the fashion with many to make no applications but the dry dressings. Prof. H. has been led by experience of both methods to prefer wetting the dressing with cold lotions in the robust, & [illegible] tepid nor the feeble & 52 delicate, if they prefer it Where it is of consequence adhesive straps be sure to hold wait a few hours before you wet the dressings In longitudinal wounds of the limbs the rolling bandage, with one end drawn through a slit in the other will be a very useful adjuvant Splints also may be necessary. A proper posture is of great consequence Haemorrhage continued. Jones found that small ligatures cut the inner coats and thus promote the closures. Vide his work on haemorrhage. Torsion of arteries another mode & may be useful in the [orbit] of change for instance When called to a wound, if the hemorrh. has been already stopped by dressing, the cautious about removing them for fear of reproducing the haemorrh. Generally let the first dressings remain about a week Secondary haem. may occur Prof H. has been obliged to tie arteries 6 weeks after the wound An artery should not be tied in an old wound. The wound shd be 53 dilated It will not always answer to be the artery at a distance on account of the anastomoses In the first place where a limb is bleeding freely, apply a tourniquet Much has been said about the reunion of parts totally separated. Prof H. has never succeeded, where the separation has been total Yet othes have succeeded The diet shd be attended to We expect more or less fever, and of course a moderate and generally vegetable diet shd be prescribed. Sometimes also bleeding & cath. may be needed Generally [illegible] the fever subsides readily Sometimes pus forms underneath and must be let out Punctured wounds Shd be dressed & the attempt made to heal them in the same was as incised wounds They are more difficult to heal however much const. irr. may ensue 54 Suppuration is apt to come on It is necessary to dilate if the symptoms are very severe and the local pain and inflammation are very severe. Case of a lady in convulsion from a prick on the toes relieved by dilating the wounds to the bottom (Dr Phys.) Where other means fail of relieving the symptoms, then dilate freely. Tetanus is oftenest a consequence of punctured wounds The cases of idiopathic tetanus which Prof. H. has seen differed much in the symptoms from traumatic tetanus & he thinks the dis. is different Pathology of tet. is very obscure. Some have thought the spinal marrow the [illegible] other can find no disorganizat. there Tet. takes place about 10 days after the injury Wounds producing it are less liable to inflam. and may have healed up & from their insignificance have been forgotten entirely by the patient Commences with stiffness of the jaws, as if patient had taken cold 55 The stiffness increases. Spasms in the jaws & neck come on which increase and affect the dorsal pectoral and abdominal muscles The pat. is drowsy after a spasm and requests to be allowed to sleep The bending generally is backwards. Prof. H. has never seen a case of [empusthotonos] The spasms grow more violent & the patient generally expires in one. An effort to swallow may bring on one. A good constitution is no security. If the pat. is to recover the species grow less violent. After recovery a stiffness remains of the jaw for some time I have known a stiffness of the muscles of the back remain for a year. Treatment 1st local open and dilute the wound endeavour to excite inf. (according to Dr Rush’s plan) by corr. sub. in the wound Baron Larrey recommends act. cautery 2nd const. treat. Sometimes Prof. H. bleeds always gives cal. Some bleed enormously and have cured 56 Dr Phys. applies mercurial ointment until salvation is produced. All give opium largely some by injection Chapman gives injections of antimony & succeeds Arsenic has been strongly recommended, in large doses All remedies must be in large doses, for small ones do not affect the system. The bowels are costive & not however in consequence of opium Cath. must be given. Croton oil promises well Hamilton’s cases tetanus cured by cath. were merely idiopathic cases arising from irritation of al. can. Amputation has succeeded where there were spiculae of bone have irritated (with thumb) Prof. H. tried it in the case Bark & wine have cured (Hosack) Alcohol (Rush) Case of a young man who had cut his foot with glass. When he first began to have tetanus he would fall on the blood & his mother thought him rheumatic. Cured 1st large bleeding [illegible] cal. spasm continued laudanum beginning 57 with 25 or 30 drops (any strong SS) increasing to 40 & eventually a teaspoonful frequently reputed. After recovery his neck was bent back for a long time. Case in London Cal. grs 6 once in 6 hours Ol. turp zii – zj ol. oliv. by injection gave the most relief & first checked the disease They were given 3 times a day. Opium seems to do no good & was relinquished. The woman was long in recovering So that his case was not the most violent Lacerated wound have been supposed to require a peculiar treatment not to attempt the union by first intention There is little or no hemorrh. Prof. H. however brings the edges together & keeps them in contact by adhesive plaster keeping the dressing wet He has had much better success Often they heal principally by the first intention. The injection of the cell. memb. with lymph, and swelling etc. is prevented The only systematic writer who has as yet recommended this practice is Mr. Mann. 58 Poisoned wounds The bite of the rattlesnake is an instance Some persons seem to suffer very much from the stings of bees & wasps It is a question whether the bite of a rattlesnake is injurious by absorption or by an affect upon the nervous system merely Some late exper. seem to prove the former opinion Symptoms of phlebitis have appeared to show themselves in some of these cases The tendency to gangrene is very strong Remedies At first excision caustic ligature. The French use muriate of ammonia as a strong caustic (old butter of ant.) After the first stage apply blisters and treat as for erysipelatous inflammation. For the const. shock & exhaustion ammonia seems to be best article opium also Cordials and stimulant are strongly indicated Case of a man in St Lucie [colub???] [illegible] stupid in ten min. amput. of finger which was not felt 8 grs arsenic in 4 hours cordials mint water laudanum spts terp. amm. & ol. oliv. in a liniment for 59 the hand Cured in 10 hours Several persons had previously died of the bite of this serpent Case of a woman stung near the eye Cured by bleeding & calomel A young woman died in 20 m. after being strong with leg [illegible] Hydrophobia. Prof. H. has always cut out the part. It seems to answer Prof. H. has performed excision 6 days after the accident no hydroph. followed Dissection wounds A wound seems to be necessary. Various circumstances are supposed to predispose, but Prof. H. thinks they are not necessary & that the most we can say is that the inoculation does not always take Symptoms infl. of the wound redness of lymphatics all along the arm Const. sump. very severe from the first, great prostration, restlessness etc. Suppuration forms along the arm in the axilla or under the pectoral muscle or within the pleura Or the patient may recover with a suppuration of the finger, & perhaps 60 a loss of the finger Prof. H has seen the same symptoms take place to the greatest extent from wounds of simple puncture e.g. from [illegible] of fist in N. Haven from a fish spear the latter case related wounded the tendon of the gastroc. while wading suppurat. all along the leg in the axilla finally in the pleura Prof. H. has had his own fingers very sore & for a long time after dressing gangrenous ulcers & has known women effected in this way from washing bandages losing the nail etc. Caustic should be applied to the very bottom of the puncture & not merely on the top. Contusions. Injuries of the vessels & a rupture of their contents without breaking the skin. Ecchymosis or “black & blue” In favourable cases the extravasated fluids will be absorbed In others the colour changes becomes mottled and yellow etc. The effused fluids often descend in the direction of gravity & produce discoloration in another part 61 In dicutions 1st to prevent further effusion by keeping cloths constantly moistened with ac. pl. or cold water. 2nd prevent inflammation, by const. rem. if necessary 2d to promote absorption, by fomentations & [sometimes] application camphor and soap etc. It may be necessary to let out the effused fluid Sometimes these “bloody abscesses” as they are called by the French shd be opened at first. Case of a man whose foot had been crushed in a saw mill pain absolutely intolerable relief was given by letting out about ½ just of effused blood Prof. H. can derive no rule from the coagulation of the blood The blood is generally dark fluid tar like If means for absorption fail we must make an incision. This will oftenest be the case in the old and especially when the effusion is in a bursa as that of the patella. Prof. H. has often been obliged to open the bursa of the patella open on the outside of the tendon of the rectus 62 On the olecranon also the same state of things occurs absorption here is uncommon. Serous effusion is apt here and elsewhere to follow the letting out the blood If the abscess does not heal, inject corr. sub. & probe the abscess every day Often a part of the skin is killed if this is the case, puncture through the dead part. Contusions of abdomen kick of a horse The peristaltic motion is suspended the abd. immediately swells constant vomiting great anxiety of continuance etc. mortal restlessness no sleep etc. Blood may or may not be united Vomiting may be of blood and immediately. Bleed at first the pulse will rise after it repeat it bleeding gives great relief the patient will call for it [illegible] Apply cold lotions bandages to the abdomen. Purge with large doses of calomel & injection until relief is obtained. Blister early if there is great pain 63 In the progress of the treatment a blister may be applied to the abdomen The thirst will be very great and is to be relieved with cold water These cases are very severe The abdomen will infl. up suddenly after the blow, before there is any time for inflammation & immediately vomiting of blood may supervene Case A young man in Prof. Brown barn yard. Vomited blood all day warbled 2 or 3 times Large quantities of calomel In two or three days was able to be removed A phys. who had received such an injury called for repetitions of the bleedings saying that they afforded his great relief After the first stage cordials etc. may be necessary on account of the shock of the system. Or at the first where there is no vomiting etc. Blows on the pit of the stomach may extinguish life 64 Strains Hardly known to writers except Boyer Extension of ligaments with rupture. Joints subjet are those with but little motion and strong ligament viz knee ankle, wrist, fingers & toes. Shoulder & hip very rarely At first the joint can be moved freely in all directions enquire after this to distinguish from fract. & disb. Very soon affus. takes place perhaps a sac of burs-mucosa Dieting from cont. by nature of accident by being treated Sometimes however it may be doubtful or both may be combined The treat however is the same for both Dieting from disloc. (this is of great consequence) Prognosis doubtful Bayer remarks that the ligam. become lengthened Constit. makes great difference rending some more liable (delicate persons) ternia rate in white well. perhaps is scrof . persons Treat like contusion Boyer 65 advises cold water at first. Use tepid water for a very delicate fem. perhaps) For consid. infl. use ac. pl. Some are afraid o fit Prof. H. has seen no injury A bandage moistened will give actual relief instead of pain & will promote absorption Opodeldoc also For great pain apply fomentation or a steam bath. After infl. is subd. apply frict. Give the attendants some camphor perhaps to encourage them in using friction When the proper time arrives use motion & exercise passive at first afterwards by the action of the [muscles] There is a golden time for exercise. A plaister bandage around the joint applied so as to keep the whole joint at rest & firm when pat. first begins to walk let him have a shoe or boot with a stiff sole # Burns Infl. or destruct. of parts by heat No part of surg. more empirical No advantage in dividing into species. It must be remembered that a burn or scald when slight is merely a blister just as from canth. or hot water and shd be treated as a blister, by excluding # not bundled up in blankets more motion 66 the air. Case of a child blistered over the whole body by cantharides & vinegar died If the cuticle peels off immediately after the barn, we may be sure that the injury is very extensive The highest danger is from the shock Often perhaps the [glaze] is inhaled, when the clothes are on fire. Prof. H. has not however with nothing more than a hoarseness from this cause & dissections have not shown much of this kind Sometimes the viscera immediately under the skin are inflamed vide Journals It has been remarked also that child. often die some weeks after the burn unaccountably 3 weeks is the critical period when the suppuration Convulsions often occur in children when after the first shock reaction begins to come on When any application apparently comfortable has been made do not disturb it. Sir James Earle contended for 67 cold water, ice, bleeding & cathartics [illegible] [illegible] on the other hand contended for spts turp. & intern. stim. Prof. H. thinks truth lies in the mean Where the shock is very severe the const. must be supported The best application for the vesicles a simple cerate prick but do not clip off the vesicles. Always have your dressings ready when you take off the old one when the cuticle merely is separated the granulations will be very small and no scar will be left But when the true skin is separated the ulcer will be long in healing & leave a scar The best dressing in the latter case is a mixture of spts turp. & cerate. Rx common basilicon of the shops & basilicon or cerate equal parts Prof. H has seen all sorts of applications. He at first tried Ben. Bell’s plan of ac. pl but it does not promote healthy suppuration. Poultices are very inconvenient requiring frequent exposure 68 to air and being [heavy] Besides they do not promote suppuration When supp. is established the spts turp. cerate will cause smarting and should not be continued then dress with simple cer. Keep on the first dressing as long as you can dress as seldom as possible. Keep the air of the room equably warm [illegible] keep in cold weather a warming pan near the body In the latter stages especially if the sores heal over & break out again use sat. cer. Before this Prof. H uses Turner’s cerate & cer. ox. zinc If granulations do not proceed well use nitrate of silver to touch the ulcers. This is a most valuable surgical remedy. Mr. Higginbottoms plan of applying it to infl. though it produces smarting at first, alleviates irritability & promotes resolution Case which Prof H treated with nit. sil. & simple [cerate] did well Sometimes for the fungus sulph. 69 cupri is better than nit sil. The shock is very severe coma excessive coldness of extremities etc. Ben. Bell advises opium. Be careful how you give opium in coma. Prof. H. gives one dose of SS & follows up with alcohol ext. heat etc. When infl. comes on depend especially upon cal. cath. keeping the bowels loose vide [Motherby] Considerable fever may ensue which is to be treated with cal. cath. Generally the pain is so great as to require op. When supp. is extens. & strength fails give bark Cotton will do well enough for superficial burns excluding the air Prof. H has seen much inconvenience from it in deep burns Case A man fell into a [kettle] of boiling potatoes about half of the cuticle from the head to the feet came off He drank a large quantity of spts. Prof. H. applied spts turp. & basilicon, as above. Next morning fever high bled him cal 70 Afterwards treated with cal. & according to symptoms Supp. came on Barks Finally bark injured & was [emitted] & cal. given ulcers touched with nit. sil. Recovered well & has the use of his limbs Distortions from burns The growing together of the fingers may be prevented by separate dressing. The tendons also may be burnt and contract Then keep the fingers straight by splints The object is to keep them straight they can be bent well enough after healing. So also of the feet and toes Case of a man with a ridge of scar extending along the back of the leg up the thigh like a [illegible] finally a growth of [horn] began finally had his thigh amputated. Cicatrices shd be cured by cutting out the whole scar not by dividing it & suffering it to heal up. This las way fails Case 1 ft long 1 inch wide 71. Frost bites Long continued cold produces a degree of torpor in the system tendency to sleep. Case of Prof. H’s instructor warned his companion not to stop; was the first to stop & endeavoured to conceal himself & rest was very torpid when brought to the fire. So Dr Solander The treatment of a limb partially frozen shd be by rubbing with snow or better by putting into cold water afterwards gradually warming the water A limb thoroughly frozen cannot be successfully managed in this way so as to prevent inflammation The infl. resembles that of burns It may be moderated at first by ac. pl. or spt. & wat. When suppuration comes on treat with cerate etc. When the whole limb is thoroughly frozen, gangrene will come in, beginning as usual with dark & ash coloured spots vesicles etc. line of demarcation etc. Prevent this by amputation The const. not being effected the operation will succeed. Do not delay the operation too long 72 Case Gent. in Brooklyn thrown from a wagon lay the whole of a very cold night when found in the morning was able to tell his name When carried into the house blood could not be obtained When Prof. H. found excitement coming on & bled him “with relief” Soon coma came on Thought the man must die But eventually amputated the fingers very bad leg etc. Recovered The amputation was delayed much too long Prof H. has had many cases of frozen toes He always amputates as soon as possible Case at our Almshouse 73 Tumours Varieties are very numerous 1st encysted 2nd sarcomatous 3 medullary Also malignant & non malignant The former may change into the latter We know little of their origin Abernethy thinks they arise from an extravasated clot of blood Sir E. Home has lately advanced a similar opinion It is undoubtedly true that the nature of the part alters the nature of the tumour as Abernethy thinks (The growth of tumours is somewhat similar to chronic infl.) Near the scalp we often find hairs in tumours. In glands the tumours will have a glandular appearance. In the adipose membrane, adipose tumours Yes there are many exceptions Some suppose tumours arise from hydatids (which are decided to be living beings). But this explains nothing The growth may be rapid or very slow or slow & then suddenly very rapid In general their increase seems to be in geometrical ratio 74 As a general rule when it can be done they shd be extirpated before arriving at large size 1st Encys. tum. are 1st atheromat (curdy) 2 vellic (honey) 3 steaton. (fatty) The cyst is generally firm & opaque Tumours that have no cyst or a very [thin one] are generally sarcom. or medull. There is a kind of tumour of a bluish colour [illegible] within cyst, which appears upon the lips and is considered cancerous Cyst very thin filled with matter like the white of an egg extirpated immediately is the remedy (by dissecting around) Often upon the head encysted tumours are very numerous and keep reappearing Discutient applications have been much tried. They do no good, and often change the tumour into a cancer Caustics may be a successful substitute for the knife in small tumours Such small encysted tumours are [illegible] away by the cancer doctors and add much to their reputation These tumours sometimes inflam. of themselves and this in a few rare instances 75 cure themselves. Generally however the part eaten by the caustic heals up and the tumours continue The only remedy is extirpation. This was formerly directed to be done without wounding the cyst this is difficult without cutting away much flesh Sir A. Coop. mode of [illegible] open the cyst and then everting it with heat The cyst is easily distinguished by its appearance Sometimes from an injury the tumour [inflam.] and suppurates of itself. Then Prof. H. introduces a little caustic kali upon lint Lately however he has often succeeded in such cases in pulling out the cyst Sometimes membranous bands have to be cut Sarcamatous tumours are of very various consistence fatty with fat in large cells fleshy & others Extirpate, by removing [illegible] skin as may be advisable remove as much as possible by the fingers cutting membraneous bands if any removing very carefully from their adhesions to muscles & tendons Sometimes an infl. comes on accidentally and very bad ulcers are 76 formed, and the tumours must be removed even from very old persons to whom they have previously given no trouble Arteries do not generally require to be tied. Then after appear about the perineum and the art. may require tying 2 cases in females of Prof. H. Sometimes these tumours are very vascular case in which from are about the size of a goose egg after the first incision a gush of blood by which the tumour was much reduced in size and was extirpated The largest tumours are adipose even 40 50 & 70 pds Tumours of the scrotum seem to be an enlargement of the nat. parts in whole or in part. Adipose tumours feel like a bag of cotton are very irregular in shape and when the skin is pushed along it rises in ridges, from its adhering in some parts and not in others This last is pathognomic Prof. H. believes the shole parotid gland has been extirpated McClellan Glandular enlargement are apt to be called tumours Enlargement of the mammae will often subside after child bearing 77 malignant tumours are these liable to return Medullary Tumours substance resembles that of the brain Called fungus haematodes may spring from any texture even as Prof. H. believes from the bones They have an elastic feel when under a fascia they may be mistaken for [aneurism] or abscesses They were formerly called cancers Their growth is very rapid Prof H has known one is large as a milk pail upon the thigh. They are most common in the young, but are found even in the very aged. They may spring up in the testicle, in the eye & in every part of the body. They have often been mistaken for abscesses and opened. The only marks of distinction are 1st they are at first deeply seated and do not arise from the cell’ memb. under the skin, but from deep seated part apparently, in many cases from the muscles. 2nd not powerful in themselves only so by pressure & distention of surrounding parts and the pain is generally in a distant part, and will often be 78 attributed to hreumatism 3d Great const. disturbance & hectic The only remedy is extirpation but the tumour generally returns, and others often spring out in other parts of the body. So that the prognosis must be very doubtful. In the progress of the tumours the patient will suffer nausea vomiting & will grow sallow. The patients generally recover rapidly after an extirpation and are much pleased with the success of an operation. Yet the tumour soon returns. From some late accounts Prof. H. is inclined in future to persevere in extirpating. They may be distinguished from chronic abscesses by an elastic [illegible] instead of the fluctuation of pus The skin over them is not tender and sore, as when an abscess [illegible]. Distinguished from scrof. etc. by not beginning in the lymphatic glands If we are in much doubt we may make a very small incision without danger closing up immediately 79 When they reappear you will see at first a small gelatinous vesicle which swells and grows very rapidly Many cases related in which they returned in the same [illegible] other parts Schurrhus or Cancer They are different states of the same affection Schirrhus is a hard cartilaginous malignant tumor. Cancer is the same tumour in a state of open suppuration It has been said that infl. may terminate in schirrhus not so. It seems to result from peculiar action we see that tumour improperly tampered with may terminate in cancer. Most commonly found in the female mammae. Found also on the mucous membranes Cancer of the skin will be treated of under the head of cancerous tubercle of the skin Cancer of the breast for an example Begin with an uneasiness soon a small hard tumour finally 80 inflammation of the skin and the skin adheres the nipple retracts afterwards perhaps an ichorous fluid issues next small knobby tumours next a vesicle which bursts and we have suppuration and an open cancer The suppuration does not always begin on the outside but frequently within the substance of the schirrhus. All this while the pain keeps increasing About this time or sometimes before ulceration, the lymphatic glands begin to be [illegible] appearing like inflamed cords giving the skin a hard puckered appearance. Then inflamed and enlarged glands appear not only in the axilla but in all directions The mamma and the pectoral muscle adhere to the ribs and sternum. The affection may extend to the other breast. The swelling of the glands in the axilla may cause so great an edema of the arm that the skin must be punctured. Effusions take place in the pleura or tubercular 81 consumption comes on. It is not true that the cancer “eats through” as they ] say. Hydrothorax is the most common termination. Prof. H. has thought from the supervention of pains in the back etc. that the disease becomes transferred to the uterus Various other symptoms may occur sometimes a paralysis of a part or all of the limbs sometimes the bones break easily Distinguished from fungus hematodes by being an affection of advanced life by ulcerating and destroying the skin by not beginning in the muscle or bones by being not smooth but knobby by lancinating pains Cancer destroys adjacent parts fung. haem. grows through them Above all cancer is always hard to the feel. As to the great question whether cancer is a constitutional or local affection Other tumours and even simple ulceration of the lip may terminate in cancer. Cancers are very liable to return and most so of their previous progress has been very rapid Schirrhus tumours in old persons give 82 perhaps little pain project little, are very insensible, and the old patients converse to their removal As to curing the Prof. H. does not believe in its practicability Mercury seems to be injurious. Storck introduced conium. Carmichael Smith made iron especially the phosphate, fashionable The London Cancer institution has been abandoned from want of success No remedy seems to promise anything but extirpation by the knife Small ones may be eaten away by caustic but the process is very slow and painful Caustics applied to a large cancer produce great and highly injurious irritation Prof Smith never knew a female with cancerous breasts survive caustic for a year It is impossible to say how long it may be before the return in one case 7 years intervened Much is said about the incurability of them after they have become open ulcers. This distinction is not a good one. When you extirpate be sure 83 to cut out all the diseased parts including the infected glands Persevere in extirpating as long as they return, if complete extirpation is practicable in each case. Never amuse the patient with the prospect of a cure by any mode of treatment Prof. H. has extirpated one hard cartilaginous schirrhus of 4 pounds weight Patient recovered for the time Superficial cancer Occurs oftenest in the lip Generally commences with a small crack in the lip which is neglected A scab forms, and upon examination at this time we shall find a hardness beneath The glands under the chin or under the side of the jaw, swell & harden Ultimately the lip becomes excavated, with an ulcer which has cartilaginous edges Finally the whole lip, jaw etc. are eaten away & the patient dies miserably Caustics are generally very injurious. Excision is made by taking out a v0shaped piece Richerand advises to take 84 off the whole lip the lip afterwards elongating This mode not so good As to cancer in other parts Prof. H. has known ulcerated leg terminate in this way and once case of necrosis With respect to the cancerous diathesis or a disposition in the constitution there may exist something of the kind but the practice of telling patients that they have a cancerous humour in the blood is very reprehensible making them very unhappy Extirpation is not necessarily followed by reappearance Cutaneous cancerous tubercle of MR. Lawrence. Commence with a small insignificant tubercle, hard, resemble seeds of mallows called warts often by the patient but they are vascular they finally ulcerate they may become extensive cancers Old men are subject to them about the face. Women have them in the pudenda Men have them upon the glands penis Prof. H. has seen them about the pudenda 85 in cases of amenorrhoea emit blood periodically at the menstrual periods. These cancerous tubercle may occur about the eye and the nose. The success of extirpation is far greater in these cases than in common cancer. Be careful to cut far enough with two semilunar incisions They leave no scar. These cases are different from noli metangere. Noli metangere Intermediate as it were between cancer and common ulcers. Appear about the face and nose An ulcer forms 7 becomes covered with a scab. The ulcer is often irregular & oblong. They are often converted into cancers by caustic In the course of time the scab comes off permanently and an open ulcer continues The ulceration of noli metangere may affect the cell. memb. or the cartilage of the nose or they may not even penetrate the true skin. The best remedy is arsenic The most common form is an oint. of which arsenic zi to zi cerate. Apply a plaister 86 of this one day and then a plaister of common cerate or satur. cer. for a few days. Inflammation S. Cooper uses 4 gr. to 4 oz mint water & 1 oz spirit applied in lint. Sir E. Home applies a solution made by boiling A powder also of arsenic & tapis caliminaris Others apply sulphur & arsenic Fowlers solution also. It seems that any form of arsenic will answer. Prof. H. has cured also by nit. sil. also by red precipitate ointment Occasionally touch with nit. sil. to promote the healing in the latter stages There seems to be little need of the old plan of giving constitutional remedies A disease similar to this if not [proceeded] to far If the cartilage has become affected cut out a piece. If the eye has become affected extirpate the eye. There seems to be nothing specific in the cure of noli metangere other ulcers also are to be treated by exciting an action in this way. 87 Prof H has known the experiment of low diet also of a diet of [illegible] thoroughly in use of cancer but without benefit Subcutaneous tumour in the cellular membrane It may occur in any part covered by acutis vera not on lips They are about the size of a walnut excessively hard First mentioned in Cheselden’s anatomy (calling them a tumour of the nerves) Described by Mr. Wood in the Ed. Journ. also & by Mr. Lawrence in his lectures Very painful skin is emaciated and adheres looking like a cicatrix painful when the cloths rub over them, or when they are struck or examined. Not dangerous but troublesome May continue many years (20 Mr Wood) without charge. Extirpate them 88 Ulcers A solution of continuity which gives out pus. Absorption goes in faster than deposition opposite to the process of healing a wound by granulation Caused by wounds opened abscesses, injures caustics, acids irritation of foreign bodies Constitutional causes are syphilis scurvy scrofula and a predisposition in some families to sore legs Varicose veins, oedema, dropsy, phlegmasia dolens are causes 1st simple 2 irritable 3 indolent 4 varicose 5 specific 1st simple an open sore after a time a bluish skin covers the sore & becomes a cicatrix This is cuticle not true skin. The part underneath is hard cartilaginous In simple ulcers as much benefit may be derived from adhesive straps to approximate the edges as in [wounds] 89 Place over them a compress & bandage If the granulations rise too high (proud flesh) touch with nit. sil. or sulph. cupri. Another advantage of bandaging is to prevent the swelling. Bandage a whole limb. Irritable ulcers painful the adjoining parts sore granulations absorbed bitter smooth Often irregular in shape sometimes however round and cup shaped. On the shins small sized These ulcers do not bear bandaging Frequently touch them with nit. sil. Sometimes however they will not bear this. in this case then apply a solution of nit. sil. 3 or 4 grs. to 1 oz. or corr. sub. 10 gr. to 1 pt or the yellow wash lime water 1 pot corr. sub [illegible] ? or sprinkle on calomel or black wash which is milder than cal. z2 cal. to 1 pt lime water or apply the blacker oxide this generated Also zjfs op. to 1 pt water. Also saturine 90 cer. Also ac. pl. zj to 1 pt of mucilage of slippery elm, when parts are excoriated Warm fomentations and poultices shd not be continued long they are too relaxing We are obliged often to try a variety of applications Indolent ulcers Usually large granulations lax and flabby discharge serous a substance like curd white or yellowish or brown lies upon the surface. Ulcer excavated as if cut out with a knife surface smooth no granulations edges swollen making the ulcer appear deeper surrounding cell. memb. hard Very insensible Patients will continue to labour as usual they apply spirits salt and vinegar urine etc. with no effect In the species also apply nit. sil. 2 or 3 times a week corr. sub. dilute nit. ac. 100 drops to 1 pt. is a good application red precip zi 91 to zi of cerate is an old application Above all other modes is to be recommended the plaister bandage Take common adhesive plaister or dyachylon having a plaister soft enough to spread & yet adhesive soften with tallow or lard if necessary Apply the strips of plaister so as to approximate the edges Then apply a compress & bandage the whole limb. Leave a little interval for pus to escape, or cut a little hole for the escape of the pus Leave the dressings on as long as possible say 3 or 4 days in hot weather it may be necessary to dress every day the sore becoming offensive You may let the patient walk about during the cure, if in this mode Sometimes an erysipelas commences in the neighboring parts And sometimes the ulcerations suddenly spreads with rapidity Surgeons speak of a sloughing 92 ulcer But all ulcers may exhibit this appearance After the erysipelatous infl. suppuration sometimes takes place in the cell. memb. Varicose ulcers Varicose veins accompany them either in neighborhood or over the whole limb May be cured by proper bandages They are ulcers from injury of varicose veins Bandage the whole limbs In the hospitals the patients can be cured of ulcers more speedily than in private practice but they are very liable to a relapse When pat. apply to Prof. H. with a high state of infl. & irritation in consequence of an ulcer, he bleeds But if pat. is cold in extremities feeble etc. he gives cal. & op. as recommended by A. Cooper Prof. H. had however given them long before seeing his work 93 For varicose ulcers cutting the vena saphena is practiced in the Mass. Hospit. (cut inside the skin) In the Penns. Hosp. they cut out a piece after emptying the vein by means of a bandage Mr [illegible] destroys the vein by caustic kali Tying the vein is not to be recommended Cases in which sore legs have become cancerous from tampering with them Propriety of drying up old ulcers The prejudice probably has arisen partly from the drying up of old ulcers after and attack of fever Prof. H. has been in the habit of healing or attempting to heal every old ulcer. He has never either known or heard of a well authenticated case of injury resulting They frequently however break out again If plethora arises it would be much better to bleed etc. as directed by A. Coop. 94 Specific ulcers are syphilitic noli metangere scrofula etc. etc. Some ulcers cannot be classed Sir E. Home speaks of a peculiar sore upon the ankle which yield a serous discharge and covered with scabs Apply after softening the scabs with a poultice and washing them off, cal. or nit. sil. or corr. sub. or ac. pl. with slippery elm or poultices with narcotics cerate sat. or dyach. S. Cooper mentions fungated ulcers upon the calf of the leg nit. sil. or sul. cup. And to prevent apply ac. pl. Occur in corpulent young women especially ‘ those who work in factories and stand much on their feet & live pretty well. Prof. H. has known several females affected with varicose veins & ulcers after phlegm. dolens. Scrofulous ulcers are long in bursting flabby fungous granulating overhung by the think skin upon the edges of the 95. ulcer skin sometimes purple. Apply nit. sil. under the skin and if necessary clip off this skin at the edges. Sometimes there is only a very small orifice in the skin. In this case if they do not heal lay open the ulcer & touch with nit. sil. They will then soon heal. Introduce a stick of nit. sil. upon a quill through the opening and touch all around Diseases of Mammae Vide A. Coop. Lect. by Tyrrel Hydatid or encysted tumour not the hardness of schirrus, skin not discoloured after a while a fluid is felt when upon puncturing serum issues but soon collects again. The tumour may be even 13 lbs in weight not painful Generally a dis. of advanced age sometimes attacks at 20 yrs Upon dissection, one or more cysts are formed the body of the breast not being much affected Sometimes the cyst inflames & 96 suppuration may come on and destroy the patient. Tents and stimulating injections shd not be used they may prove fatal. Diagnosis absence of pain const. not affected swelling smooth firm & hard fluid clear. Cure by extirpating It will not return Simple chronic tumour of the breast. Not hard like schirrhus appears superficial (schirrhus feels deep seated) grows slowly not very painful. Extirpate. Does not return. The tumour seems composed of lobes like the sweet bread (pancreas) Cause unknown though by some to arise from pressure of cloth Adipose tumour of breast Seated sometimes under the gland occasionally of enormous size 14 or 15 pds. The large tumours called cancers which are extirpated are Irritable breast Lobe of the breast slightly swollen and 97. tender pains in the shoulder amenorrhoea irritability of nervous system Do not think of extirpation Bleed the plethoric give sub. & opium etc. Apply spt. & wat. or lard & laudanum or sometimes litharge plaister. Often what is better than all is a piece of soft fur or cotton wool The main thing is to quiet the alarm about cancer. These cases occur in a neighborhood where an operation has been performed Ossific tumour Extirpat Lacteal tumour Soon after parturition Caused by an obstruction of a lacteal tube Introduce a lancet and let out the milk & then pencil with lunar caust. to stop the flow of milk Abscesses of breast that let out milk, by sloughing off a part of a lacteal tube. Touch with nit. sil. Some women are subject to abscesses when the child is 6 mo. old Wean Enlarged breast Generally diminishing upon child bearing. Suspend 98 the breast The breast sometimes enlarges and is painful during pregnancy Bleed. Calomel etc. Operation for taking off the breast. Always remove the whole glandular tumour of the breast except in the case of the simple [uremic] tumour. Instruments 2 or 3 scalpels 1 tenaculum needle ligatures, sponge a broad bandage to pass around the body straps to go over the shoulder [illegible] compresses cordials a pitcher of cold water Place the patient on a table with the feet in a chair An assistant holds the arm at right angles to the body Make the first incision in the longest direction or otherwise in an oblique direction Make two incisions to include diseased skin if necessary and always include the nipple which shd never be left Be careful to make the incisions long enough If two incisions are to be made make the 99 lower one first Then dissect down first on the lower side then on the upper & finally at the bottom The most painful part of the operation is the cutting through the skin The glands in the axilla can frequently be borne out and always when you have fairly cut down to them pull them partly out and then divide the membranous bands this is much safer than to cut around them in the dark Prof H. removes the lymphatic glands first and makes a handle of them instead of making a handle of the breast as recommended by Gibson Wait awhile before you dress the French surgeons say ¾ hour. It is very unfortunate to be obliged to [illegible] the wound. Give but little medicine, as a general rule after the operation Usually in about 4 days the wound must be dressed with dressings become offensive. Dress as at first The nervous irritation and the shock 100 to the system is great in proportion to the length of time taken up in the operation Be careful not to move the arm before the healing of the wound After the healing of the wound remedy the stiffness of the arm by motion Other tumours are extirpated in a similar way. It is too much the fashion to tie the large arteries (as to carotids) at the present day and the plan of tying an artery for the sake of stopping the growth of a tumour fails Fistula Lacyrymalis This name has been given to nervous affections which obstruct the nasal duct. 1st Enlargement of lac. sac is most common 2nd Suppuration of lac. sac. 3d an open ulcer of the lac. sac 4th ulcer with aff. of [illegible] or with nasal polypii Prof. H. has never seen a case of obstruction of the canals leading to the sac which is a 5th kind. 1st Obstruction of nasal duct by enlargement of the sac. May be of 15 yrs standing without going further Most common in females who work over the fire & live in smoke Generally the duct is only partially obstructed Tears flow over the cheek sometimes a gelatinous fluid issues & glues the eyelashes together. There will be a sense of fullness and the patient will press the corner of the eye & a fluid will issue into the eye & down the nasal duct. Tears flow more freely with smoke & in cold air (Sometimes the distention of the sac is large as large as a hickory nut and is mistaken for a tumour (encysted) Some patients in this stage are unwilling to have any thing done Prof. H. has often succeeded in curing the disease in this stage by remedies for infl. sol. nit. sil. dropped into the eye anoint the edges of the lids with red precipitate sat. cer. or citrine ointment ac. pl. Give calomel Prof H. has never used either the probe or the injecting syringe He has seen no account of cure, performed in this way. Mr. Liston disapproves of them. Prof. H. has not used them because the diseases cured by the above means or passes into the second kind 2nd Suppuration Open the abscess and introduce a stilette 3d An open ulcer with complete obstruction. Introduce the stilette. And generally make a new orifice with a small round edged scalpel just below the tendon of the orbicularis. Sometimes Prof. H. has not been able to introduce the stilette at first and has first used a sharp steel knitting needle. Some introduce in gold silver or lead canula Mr. Liston condemns it The stilette will not completely obstruct the passage the tears will pass down Prof. H. has never found it necessary to pierce the os unguis a practice which Mr Liston condemns the hole closes again Let the stilette be worn about 6 mo. occasionally cleansed little syringing is necessary Sometimes a fracture of the nasal bones is the cause. Treat as others 4th Prof. H. has seen no cases of affection of the bones (e.g. venereal) If polypus is the cause cure it The treatment of fistula lach must be varied according to the degree of the aff. its cause & the constitutional health Sometimes, says Mr Liston, the gland and sac & duct are wholly obliterated without inconvenience to the eye Aneurisms 1st true 2 false 3 varicose 4th an. from anastomosis In the true all the coats are not ruptured but all of them are distended equally forming a tumour with an orifice communicating with the artery which is smaller. It is maintained however that the arterial and middle coats are ruptured Begins with a small tumour pulsating externally & when small all the contents may be pressed back into the [illegible] artery. When lager the disposition of lymph prevents this As the tumour increase the pulsation is disagreeable more or less pain numbness from pressure on the nerves obstruction of the progress of the blood which [last] often causes hemorrhages in distant parts as, abdomen [heart] etc. Absorption of soft parts or of bones may be caused Cartilage however being the most indestructible parts of the body resist the absorption In aneurisms near the surface the pointing is towards the skin & ultimately a slough is formed [illegible] the patient dies of haemorrhage. Internal aneurisms besides pointing to the skin point towards a mucous or serous membrane in the latter they make a rent. Causes; wounds, injuries, mistakes in bleeding. From the latter cause The 2nd species or false aneurism arises from a wound of an artery by mistake for a vein the blood is contained in the cell. memb. 3d Varicose aneurisms happen from mistakes in bleeding, the lancet being carried through the vein into the artery The blood at every stroke of the heart issues into the vein (which has adhered to the art.) with a whirring noise & feel. By pressing upon the artery above, or on the cicatrix this whizzing may be stopped Causes of aneurism are very obscure There seems to be a disposition in the circulating systems of many persons. It has been found in many instances that the coats of the arteries in the neighborhood are diseased being brittle etc. [Postillions] & cavalry soldiers are thought to be more liable to aneurisms in the lower extremities Porters who lift heavy burdens are thought to be more liable. Old persons also Occasionally they have spontaneously cured themselves probably by the filling up of the cavity, and the subsequent absorption Treatment. Valsalva’s plan was by bleeding the lowest diet External application of ice has been proposed Ligature of the arteries has superseded every other plan History of the various modes things necessary 1st a small round cord 2n tied very tight 3d the vessel shd be detected as little as possible 4th the aneurismal tumour shd be touched # as little as possible Vide Coop. Surgs Dict One ligature only is now used The first cause of danger is from interruption of the circulation producing perhaps gangrene The second is from const. disturbance both from the operation & probably also in some cases from the interruption of the circulation. Thirdly from secondary haemorrhage Cut one end of the ligature short. Mr. Lawrence cuts both short and lets the wound heal over the ligatures afterwards finding their way out Warm the limb by hot flannels Take care however not to burn the patient who will be very insensible # Vide Prof. Knight’s lectures Mr Wardrop proposed to tie the artery beyond the aneurism as in the arteria innominated in order to check the circulation The operation seems not to have succeeded Varicose aneurisms are more or less inconvenient but not dangerous and are all pretty much alike After the wound of an artery we often meet subsequently with a small pulsating tumour which occasionally bursts & bleeds and are obliged to cut down above and tie Waevae Maternae In small tumours of a reddish or purple colour & at consist of a congeries of vessels They are called marks and denominated cherries, strawberries, figs etc. according to their colour and the recollected longing Sometimes these enlarge and have a doughy feel or are pulsating and enlarged when the child cries When the skin in the neighborhood is purplish the tumour is called aneurism from anastomosis Sometimes these marks ulcerate and perhaps extensively Sometimes aneurism from anastomosis occurs in adults without any previous congenital affection the vessels enlarge and are tortuous, and the tumour may be even pulsating from a considerable distance distinguished from [fung.] haem. by pulsation from the first by its originating near the skin by freedom from pain unless after ulceration etc. etc. They sometimes grow to a great size and came to a very troublesome ulceration Congenital [illegible] are sometimes fatal from their great size etc. The congenital [naevi] are to be cut off if practicable where they disfigure Aneurisms from anastomosis have been cured by caustic & by spontaneous ulceration We may as Abernethy recommends apply cold lotion constantly, as ac. pl. The most effectual mode of cure is by extirpation. Cut out for the haemorrhages though considerable is for less than if they are cut into. Cut quickly & let the assistants check bleeding with their fingers Another mode which is calculated to avoid haemorrhage, is that of ligatures passed through & around. Marshall Hall has introduced the plan of piercing through with a white hot needle the tumour then gradually sloughs away In cases of ulceration of the tumour Prof. H. has succeeded by the constant application of nit. sil. caustic. Another mode of [illegible] them has been proposed & practiced by inoculating them with vaccine matter Tying the principal artery leading to the tumour has succeeded, but the plan is now going into disease e.g. carotid, art. when the tumours are upon the head Collections in the Bursae mucosae Not abscesses, which have already been treated of These collections may be fluid curdy or (by absorption of the liquid part) solid. “I have seen more than a gill of something like boiled rice” (Prof. H.) in the wrist. On the patella they resemble a half of an orange # The joints of the toes also get sore Old persons have corns Prof. H has also known in chronic cases the serous part be absorbed and several hard bodies are left he has extracted them without injury. He has known a creaking noise from the cause in the wrists of reapers Treat by ac. pl. finally by a succession of blisters. Bandage tightly to promote absorption If they have suppurated in toes of old persons do not amputate but heal with nit. sil. Ganglions which resist these processes shd be opened & squeezed # N.B. There is a bursa between the skin & the patella Classification of Poisons Prof. T’s attention has been turned to the deleterious effects of medicines from the commencement of his practice 1st Exhausting poisons which extinguish vitality almost as soon as lightning in excessive doses e.g. prussic acid. The measles do not contract & the blood does not coagulate (the last efforts of its vitality) Found in the animal kingdom e.g. fish bites & stings They produce no lesion but destroy vitality 2nd Narcotics (simple & pure) 3d Acrid narcotic (not acrid & narcotic but a peculiar sort of narcotic power which produces no coma e.g. veratrum) Those acrid narcotics are evacuants or non-evacuants. The former kill more speedily 4th Irritant poisons which produce irritation & inflamm. e.g. the salts, the acids & the caustic alkalies 5th Composite poisons which possess several or all of the above kinds of power 1st Exhausting poisons are fish, bites, stings There is considerable mystery upon the subject of poisonous fish The same poisons well sometimes be preserved and sometimes escape. Some will be effected & others escape We have abundant evidence of this but cannot explain it. There is equal mistery about poisonous mushrooms probably some can eat every sort. In the north of Europe every kind is eaten Poisonous fish are more common in tropical climates Even the same fish appear not to be poisonous in cold climates Several species of crab & lobster cancer (sea lobster) cancer miricula (land crab) our common lobster is poisonous to some Clopea murina a species of shad mitylis edulis ([illegible]) is apt to be poisonous in tropical climates Vipera verus (European viper) [illegible] several species (the black snake genus) Cobra di capello [illegible] [illegible] which last is however probably not worse than the candisona horridus (rattlesnake) & the candisona durissi [illegible] in the southern states the commencement of the symptoms Commence with languor, headache, [nausea] oppression, pricking in the skin, hands & feet articaria etc. etc. Spams of abdominal muscles, [illegible] etc. convulsions, coma etc. death When recovery takes place the cuticle comes off, the hair comes off. The strength is long in returning etc. Good calls these symptoms colica cibaria They constitute cholera or diarrhoea as much as they do colics. There is no cessation of peristaltic action as in colic The tormina is not caused by it The tropical writers say that it is of very little consequence whether you evacuate the food or not that vomiting at first will rouse the patient but in the latter stages the patient will often die in the act. They recommend stimulants & nervines above all alcohol also capsicum, [ether] [amomum] granum paradisis etc. etc. opium Those are said almost infallibly to cure even if the disease is far advanced The best emetics are mustard distilled water of ranunculus flammula, which vomits speedily & with no nausea the next best is the bi per sulph. copper then sulph zinc then turpeth mineral The common account of the effects of the bites of snakes is also meagre They are said to be in India pain in the wounded part violent acute burning pain with part. tumefac. in the adj. parts in slight cases the effects stop here otherwise the whole limb & perhaps the whole body swells Colour of the bitten part is first crimson then greenish livid etc. Sir E. Home found that these local effects proceed from emission of serum. He found also that the patient might die from the abscess subsequently formed in the part Sometimes the death is too speedy for the administration of any remedy. Sometimes the vomiting is such as to prevent the retention of any medicine The topical affection unites the characters of erythema edematosum & anatomicum & the const. syrup those of a cold malignant typhus Post mortem examinations show no lesion except some infl. near the part bitten. Patients generally recover completely, but they often suffer long after One has been rendered hemiplegic Various circumstances, as the size of the snake, the degree of his irritation, the part of the body bitten, the climate the season of the year, the delicacy & the apprehensiveness of the patient etc. etc. vary the severity and the danger of the symptoms The surgical writers make much of surgical treatment But all the surgical treatment, as excision etc. seems to be useless There is abundance of testimony in the periodicals & even in the newspapers that efficient quantities of alcohol are infallible. Prof. T. has also conversed with Dr McBride & the late Dr Osborn of N.Y. who had practiced at the south. Accounts are to be found in our periodicals of giving a gallon of spirit in 12 hours with success. The alc. however is much more efficacious, when combined with acrids Simple narcotic poisons. Gelsenum nitidum. Helonias erythrosp. Datura stram. hyoscyamus hydrocyanic ac. Cicuta maculata which destroys some every year the most active of our poisonous plants though deobstruents destroys life as a narcotic So also conium digitalis etc. & probably also alcohol Good calls the disease producing by such articles colica cibaria comatosa with no propriety. Another set produce common or epileptic convulsions e.g. oil of tansy [illegible], cinnamon nutmeg etc. these destroy life as narcotics however Another set, as strychnos, actaea etc. etc. produce tetanic convulsions Another set are evacuants, as aconitum delphinium helleborus veratrum sanguinaria etc. Simple irritant poisons as rhus venenata, [pumila], toxicodendron & radicens [Hippona??] manchinella The aroideae, especillia leontia clematides dephne mezereon euphorbia lithysis sedum acre Ranunculus anemone pulsatilla capisicum if it can destroy life Those of animal origin are phosphorus, the acids, cantharis the larvae of phalaena menstora The caustic salts as nit. sil. the antimonials, blue vitriol etc. Red precipitate & corr. sub. Carbonate of barytes & the caustic alkalies etc. Glass Collection in the wrist Prof. H. has succeeded in curing after trying discutients by opening them amply and keeping in a slip of linen & keeping up inflammation Ganglion, if they do not heal after being punctured may be opened & treated with nit., sil. to create infl. These collections are apt to be confounded with encysted tumours but the latter grow gradually from a small beginning and are round the former spread quickly and are flattened. It would only be the mellicerous tumours that could be mistaken for these Wearing plates of metal & various mercurial & other plaisters are sometimes used for their cure Prof. H. has succeeded upon the olecranon & patella, after they had been opened & yet filled again by [illegible] & injecting nit. sil. & creating infl. After puncture the part shd be kept perfectly at rest Sometimes it is necessary to inject a second time Hard & cartilaginous bodies in the joints as in the bursae muc. also The two situations seem to have been confounded together. Prof. H. has seen some of them and thinks they are rather hardened lymph, and that they are not cartilaginous Mr. Hey recommends a laced knee cap. Prof. H. has endeavoured to affect the same purpose by plaister bandages They cease after a while to give trouble. Case related in which very dangerous consequences resulted from removing them If you desire to remove them place the knee horizontally confine the substance & make a free incision directly over it. Vide C. Bell. Mr. Travers relates a case in which Mr. Young Fractures They are solutions of contin. in bones 1st of the differences which are in the part of the bone the mode of breaking etc. Compound fractures are those in which the skin is likewise broken They differ also in the causes of breaking the direction, nature, & [illegible] of the blood Some fractures are complicated with other circumstances Prognosis varies according to the injury the constitution, the treatment, 6thly The formation of calles varies with the treatment. It will be small & quickly formed when the ends of the bones are kept closely in contact. Much is said by natural bone setters about the split bones but according to Prof. [illegible] experience this is a rare occurrence except in case of gum shot wounds Bones are seldom fractured in two places except when a heavy body has passed over the limb and comminuted the bone. Bones are often supposed to be broken in two places in consequence of the overlapping of the ends. Often we are unable to determine for some time the exact nature of the fracture Fractures are distinguished by the distortion, inability to use the limb, & especially by the crepitus. We think we hear but we in fact feel the crepitus The piercing of the skin is in consequence of an exertion subsequent to the fracture It is common when a limb has been shortened for the surgeon to say that the fracture was oblique but in many such cases you can feel the transverse surface of the end Children are subject to partial fractures or bending of the bones. Prof. H. has generally succeeded in straightening them sometimes however you may break them completely while straightening them probably one side of the bone is always broken in such accidents It is only in the thigh and leg that we meet with spasms. Hard labouring men and irritable females are most liable to spasm. Of course compound fractures are mor liable to cause spasm. Old age is a less obstacle to recovery than we might suppose. Delirium trem. is apt to be produced by fractures in the intemperate Callus Dupuytren made many observations 21st a deposition upon the periosteum [illegible] the bones by what he called temporary callus 2nd callus between the bones. S. Hunter thought there were granulations of the ends of the bones The union of the bones is not [illegible] for several months as the patient is [illegible] or unwilling to rest his weight upon the limb goes on crutches and if he falls it is broken again B. Bell says an arm unites in a month a leg in 6 weeks & a thigh in 3 mo. The union however is by no means firm at this time many cases of refractures occur for slight causes after this time The setting of fractured bones is generally a simple business. It is done by extension counterextension and [coaptation] Extensive may be made at the nearest joint or farther off. Coaptation is of far less efficacy and requires far less skill & [illegible] than used to be supposed It is of little use when the muscles are covered by thick flesh as in the thigh By means of his fingers the surgeon can ascertain when the ends are in place Splints are applied by some only after inflammation has gone down. Apply splints as early as you can Do not bandage too tight and wet the bandages with ac. pl. etc. In some cases a partial application of splints and bandages may be made If the limb is excessively swollen you must wait until you have subdued the violence of the infl. Generally however if you are called soon you can dress immediately The symptoms to be attended to are pain spasms inflammation, & constit. irrit. Relieve these by the usual means For const. irrit. give cal. & op. spasms may take the limb and displace the bones give opium for them and in robust men, bleed sometimes Fractures of ossa nasi These are only dangerous as the [ethmoides] may be driven into the brain. Boyer thinks the brain cannot be injured in this way but Prof. H. has known two cases of death from infl. of brain in consequence of a kick of a horse upon the [nose] Treat by introducing something as a direction under the bones and squeesing up with your fingers. If they do not retain’ their place, keep them there by catheters & lint within & compresses on the outside Wet the bandages Fract. of cartilage of the nose nose twisted Keep in place by straps of plaister Fracture of Lower Jaw Onn one or both sides often on both never exactly at the symphisis Use a compress a four headed bandage tied behind & above and then apply a thick bandage over all Fracture of upper jaw [Arise] from blow bones driven into the antrum etc. Fract. of Vertebrae Prof. H. has had perhaps 30 cases only 2 recoveries Paralysis of the lower limbs immediately takes place retention of urine etc. Infl. comes on. They die in a few days or live for several days Fract. of the dentata occasion sudden death It is perfectly absurd to attempt to restore the function of the limb by blisters etc. The infl. of the spinal marrow occasion, enormous irritation restlessness & fever. Although the legs are insensible & perfectly paralytic yet they will sometimes require their legs to be constantly moved by the assistants owing to some irritation at the origin of the crural nerves The urine is always to be drawn off by a catheter which a surgeon shd always carry with him in such cases If the injury abo e the origin of the phrenic nerves the patient cannot expectorate & dies of suffocation The bowels generally puff up and are constipated In robust men you may bleed and you may always give cathartics The urine finally becomes turbid & eventually purulent When the patient survives 10 days or a fortnight he generally dies from infl. If he lives several months he seems to die of fever of irritation. Opium is the principal remedy Extensive sores from in the muscles of the back. The urine has to be drawn off continually Fractures of the Sternum May generally be distinguished by inequality of the surface. You can often feel a crepitus when the pat. breathes. Treat by preventing motion of the part in respiration by a broad bandage around the breast with a compress under it It gives great relief When the fragments are forced in and the circulation & respiration are impeded do not wait for infl. but bleed immediately the pulse will rise after it. Afterwards apply a blister Treat with opium and cal. Trepanning has been recommended It can hardly be necessary. Pus will not be apt to form if the infl. has been properly checked if necessary however we should trepan In many cases the infl. of the thoracic viscera, cough etc. will [combine] often [The] healing of the wound. The case however will not be so dangerous as one of the phthisis pul. Fracture of the Clavicle May result from direct violence or from a fall on the shoulder elbow and hand, and in the former case there will generally be considerable contusion and the fracture will be between the coracoid process & sternum in the latter often between the corac. proc & the acrom. The shoulder falls the patient carries his head on that ride & supports that arm with the other hand his whole appearance is peculiar or he walks very carefully, to avoid motion of the parts In some cases the subclavian artery and in some cases the lungs have been wounded. Fractures of the clavicle are very often mistaken for a dislocation of the shoulder Reduce the fracture by placing one hand in the axilla & the other under the elbow Place a compress under the axilla & confine it there by a strap passing from it The arms are not very perfect in cases of fract. clav. Fractures of the Scapula When the acromion process is broken the arm falls down and the parts may be brought easily into contact by pressing up the elbow and you can feel the motion of the broken parts Treat pretty much as for fract. clavicle. It is said that the union is ligamentous When the body is fractured pass a bandage around the body and support it with shoulder straps Boyer speaks of fract. of coracoid process. Prof. H. has never met with a case It might be necessary to cut down The ligament of the Fract. of the neck of the os humeri So called when within an inch of the head Caused by falls upon the shoulder Distinguished by the mode of receiving the injury. Examine whether the fall was upon the hand. The ecchymosis is upon the top of the shoulder where the injury was received & not in the fore part near the axilla is in dislocation. The deltoid muscle will be shortened instead of lengthened The bony tumour will be of a different shape in the axilla. The upper fragment is drawn outwards by the [teresm] & subsception? The lower fragment is drawn downwards by the pectoralis Distinguished from fract. of acromion by The whole limb generally swells therefore begin to bandage at the hand & bandage up to the shoulder. Apply on the outside of the arm Smith’s splint & bandage over the splint. Keep a compress in the axilla and bandage [aroun] the body and arm Support the forearm, not the elbow with a sling. Let the elbow hang down Fract. rib Sometime the rib is fractured at a place different from that where the injury was received e.g. the neck. Examine by feeling along the rib when you come to the fracture, pain will be produced You may scarify for the emphysema. When the broken point of the rib is caught, & respiration and all motion of the body is prevented Prof. H. has succeeded in affording relief and disengaging the end of the rib by standing behind the pat. placing the knee against the back and embracing the [illegible] with the hands and at the time of a full inspiration jerking in the abdomen Treat the fract. by a broad bandage around the thorax supported by shoulder straps. The most important part of the treatment is that for the infl. of the thoracic viscera by bleeding cal. & opium & in extreme cases by taking off the bandage and applying blisters. Use demulcents for the cough If the blood does not flow put the hand in warm water Fract. of the body of the condyles of the os humeri Generally distinguished [illegible] by the deformity, loss of motion & crepitus. Fract. near or at the condyles of the bone are to be distinguished from dislocation. The arm will be slightly but the fragments will be drawn up there it will be a depression above them Generally by rolling the fore arm you can feel a crepitus. Sometimes the int. cond. is broken off and drawn up, without aff. of the joint. If the init. cond. is broken the arm will be bent inwards if the ext. cond. the arm will be bent outwards make extension with the elbow bent coaptation will not be needed. Bandage the whole arm. Support the fore arm and let the weight of the elbow hang down For fractured condyles we shd use a bent splint and occasionally after a while bend and extend the limb every day in order to secure perfect motion of the joint Prof. H lets the splint stay on but about a fortnight, for the reason. There is great tendency to a permanent pronation of the fore arm especially when the int. cond. is fract. This accident is very common in young children and sometimes arises from a blow [on] the lower part of the humerus Fract. of both bones of the fore arm. Arise from violence Sometime one bone is broken in a place not opposite to the fract. of the other. Easily distinguished by deformity Reduce by taking hold of the hand & pulling counterextension at the elbow To prevent the union of the ulna to the radius dress with two compresses rolled so as to be thicker in the middle & then over then two splints which by pressure upon the compresses keep the bones apart Fract. of the body of the ulna is easily distinguished coaptate if necessary dress with Smith’s splints & sometimes apply another splint on the other side Fract. of the lower end Radius Looks much like a dislocation of the wrist and is often mistaken for it the styloid process looks towards the palm of the hand The upper end of the lower portion of the radius project backward & the lower end of the upper forwards Put a compress on the inside to keep down the lower end of the upper part Bandage apply a splint on the inside & bandage so as to bring the hand back Sling so as the hand fall down towards the ulna. Leave the fingers out Fract. of the olecranon Put a cloth at the back of the olecranon longitudinally Bandage it down letting the ends come out. The assistants in the meanwhile pushing down the muscles pull up and down the ends & pin them. Use a crooked splint or else fill up the cavity of the elbow the arm being a little bent The danger is not of a stiff but of a weak joint. The union is ligamentous Keep the dressings on about 3 or 4 weeks Begin to move the arm however before this period. Exercise the muscles at first passively, in order to restore the use of the arm Compound fract. of the olec. are very serious accidents When the elbow is going to be stiff place the arm at a little more than right angle Fract. of bones of the carpus From blows etc. effusion very grat yet you can generally feel a crepitus The principal indication is to treat the great infl. Bleed cal. op. etc. warm or cold appl. etc. Keep a splint on to prevent distortion Fract. of metac. bones Ascertain by prying & feeling with the thumb. Apply a splint to the hand. If the pat. insists upon using the hand, apply plaister bandage Compound fract. of the metac. bones are sometimes followed by mortif. of the fingers. Take them off if so Fract. finger Apply a little roller & a splint of basket stuff a roller over it Bend it to the next finger. Sometimes they are so washed that they must be amputated Still however they often recover when exceedingly crushed Fract. of os. innom. In consequence of passage of loads etc. Sir A. C. observes that in fract. of the acetab. the limb will be drawn upwards like disloc into the ischist. notch The most we can do is to apply a strap around the pelvis Purgatives & injections will be needed & a catheter Fract. of the lower extremities We always have much constit disturbance Fract. of body of os femoris Limb is distorted crepitus can be felt unless the ends are too far by each other or too far apart. When broken high up the upper fragment is drawn forwards and upwards Children have the bones oftener broken transversely. To reduce the fracture make extension. Let the assistant take hold under the arms. Great diversity in the mode of treatment exists. Mr. Pott & others advocated the bent position. Mr. S. Cooper changed his opinion & gave up the bent position Prof H has succeeded very well with 3 splints one on each side and one in front especially with children putting a pillow under the knee [Amesby’s] splint exhibited. The limb will shorten under almost any treatment in oblique fractures of adults The fractures commonly unite by bony union In children the cure is perfect Fract. of neck of os femoris An obscure subject. illustrated best by Sir A. C. who 1st wholly within the caps. lig. 2nd through the neck at the root of the great trochanter 3d through the body of the bone & the great trochar 1st This sort occurs oftenest in the aged & in aged females often from very little force the foot perhaps catching & causing a fall. (The neck of the os fem. undergoes a considerable change in advanced life Sometimes not shortened until often the lapse of several hours. The foot is turned outwards the heel resting in the hollow beside the tendon achillis Desault gives a good diagnostic mark of all the 3 kinds viz. the trochanter in rotation does not describe an arc upon a circle You can generally feel some crepitus Most apt to be confounded with dislocation upon the os ilium but in the latter the head of the bone can generally be felt & the toes turn inwards In pract. there is little pain except on motion & the pat. is liable to sudden starts in sleep. Splints and bandages are of no use Pass however a broad band around the pelvis to bring in the trochanter Place a pillow under the [illegible] sometimes a bolster under the whole limb confine the foot with rolls of cloth or billets of wood so as to prevent the turning out of the toes 2nd Fract. without the caps. lig. Occurs at all ages. Toes turned out limb shortened about an inch. Occurs from falls etc. Trochanter appears to be somewhat sunken in a swelling about it. Appears less like a dislocation Pain is often entirely in the knee hence the accident is sometimes mistaken Dr Physick advises treatment for a fracture whenever there is a suspicion of a fracture This fract. is treated by A., Coop. with a long splint extending from the knee up above the hip etc. etc. Prof. H. has treated them very successfully with Desault’s long splint He pulls the foot down & keeps it down the cross piece by means of a wooden gaiter 3d Fract. through the trochanter Not so much shortening The lower part of the trochanter seems to project too much outwards the broken end may frequently be felt Caused by falls on the trochanter Fract. below the trochanter are treated with a double inclined plane Separation of the epiphysis of the head of the bone sometimes occurs We cannot distinguish it before death. Indeed in all these cases we must be cautious in our prognostication. Sometimes excessive pain and long confinement occur without any apparent fract. and the pat. recovers completely without distortion 4 rules given 1st a roller & 3 splints are enough for children 2nd in fract. within it caps. lig. in very old persons depend principally on position. 3d in fract without the caps. lig. depend on Smith’s splint or Desault’s long splint 4th in fract. of the body use Smith’s splints or Amesby’s or Desault’s long splint & Prof. H. generally applies another splint on the inside Fract. of condyles of os [com.] Caused by falls Distinguished by distortion the lower end is drawn backwards and the patella seems below the joint Generally there is much tumefaction & injury Often the fract. is oblique & the upper end pierces the rectus muscle & perhaps the skin. Distinguished from disloc. by greater mobility, greater tumefaction etc. Treat for the infl. etc. in the first place Treatment by Smith’s splint or two lateral pasteboard splints applied wet 1st a roller then the pasteboard & splints then a roller over them. Compound fractures here are very serious accident we must consider about amputation Fract. of patella Caused by direct violence or by muscular exertion, when the foot slips The fragments separate They unite by ligamentous union A.C. directs to apply two straps & draw them together etc. Prof. H. applies a thick narrow compress fig. 8 bandages also above and below keeping them wet with a lotion to reduce the infl. Swollen along the thigh will in all cases be proper to keep the muscles from acting Keep the foot higher than the hip. If there is no tumefaction Prof. H. applies straps of sticking plaister. In all cases apply a splint we may use a bit of board with notches to keep it from slipping up and down. Give no violent motion even after the joint begins to have strength We may commence exercising the limb by motion made by another person, or by setting on a table and swinging the legs. Secondary fractures are apt to occur they are troublesome but not dangerous they may make the ligamentous union longer let the pat. walk with a splint Fract. of tibia & fibula Broken by blows or by falls on the feet or by slips of the foot. The two bones may be broken at different places, when the accident results from falls etc. The notion of a fracture in two places is generally a mistake caused by the overlapping of the bones In compound fractures it may be necessary to to cut off a projecting point of bone Compd fract. near the ankle joint are dangerous, especially when as is often the case compounded with a compound dislocation. Amputation will generally be needed Fract. of the lower end of the fibula with compound disloc. internally are not so dangerous. In fract. of the upper portion of the tibia the upper fragment sticks directly upwards there is a difficulty in keeping the fragments in contact Smith splints are best put a pillow under the [illegible] In every other fract. of the leg the best position is decidedly preferable by a double inclined plane or what is often better by placing the limb on the outside In fract of the tibia the upper fragment is generally forced inwards Apply a compress over the projecting end of bone bandage the whole limb. Apply a splint in the inside with a hole for the malleolus bandage over the whole Counterextension Prof. H. thinks of little use in fract. of the leg Smith’s splint is advantageous for preserving the foot in a proper position The time of keeping in the splints in simple fractures is 6 or 8 weeks the surgeon must examine & there is a certain consciousness of strength in the limb. If upon attempting to walk the pat. feels a pain in the part & a sense of giving way, he must lie by longer & perhaps have the dressings reapplied Sometimes the tibia alone is fractured distinguished by rotating the limb by passing the fingers along etc. Some think confinement is all that is needed but Prof. H finds it advantageous to treat as for fracture of both bones Fract. of Fibula Pat. will continue perhaps a long time lame and wonder what is the matter Examine with the fingers for a tenderness by moving the foot, etc. Prof. H. has had great satisfaction expresses with his treatment Apply a roller bandage and then a slender splint and another roller Compound fract. of leg more frequent than those of other parts First cut off the boot, stocking etc. Replace the bones if possible. Let one assistant grasp the thigh above the knee and make counterextension extension to be made by another at the heel the surgeon attempts to force the fragment into their place. Perhaps you can introduce your finger into the wound and lift up the skin Saw off a long sharp & projecting point an inch or two a spatula, or piece of sheet lead or tin being placed under the bone. It may be necessary to dilate aa little with a probe pointed bistoury. Do not use much force in removing fragments Dress carefully. Place a series of [slips] one over another each [indricated] lapping about half Extend the limb in both directions & thus left up the limb and place it upon the slips. Cross one set of the slips. Then equalize pressure by compresses, place a splint over then cross over the splint and limb both with the other set of slips Put a bridle around the foot & pin it up towards the knee to keep the foot from being permanently extended It will often be advisable to have another splint on the outside. Wetting the bandages will be advisable to prevent infl. It is well to stay by a patient a little while to see whether the bandages are too light or give uneasiness from other causes Great const irr generally follows it will be necessary to bleed a strong robust man op. cal etc. Spasm often occur the greatest relief for the time will be afforded by compressing the muscles with the hands Infl. of cell. memb. may come on Collections of pus may occur requiring [illegible] opening If every thing goes on well do not remove the dressing for some days It will be well however to call the next day Sometimes there is a deep seated collection of matter, which will require to be opened by a deep incision If the abscesses continue to form with great suppuration sloughing of periosteum looseness of the bones etc. the patient’s strength failing we must amputate. In the worst cases of shattered limbs they have been treated simply by placing them in a trough and covering them with bran crowding it down around them probably limbs may be saved by this mode If the great blood vessels are too much injured immediate amputation will be necessary Fract. of tarsal bones Generally they are compound but sometimes simple. 1st of the os calcis Dress by a roller & compresses then a broad splint along the bottom of the foot & bandage If the upper end is broken off and drawn up by the tendo achillis keep the foot permanently extended by bandages and a splint & endeavour to keep down the fragment. Apply warmer cold applications, or poultices for the infl. Splints give great relief in fract. about the joints by preventing the motion If the bones are too much broken in the tarsus, amput. must be performed but better in the leg than at the ankle It has been proposed to amputate in some cases at the astrag. & os. calcis Fract. metacarp. bones Press by pasteboard or other splints or in slight cases by plaister bandages Fract. of toes The best splint generally is the other behind the two together A plaister bandage will often be serviceable Fract. which do not unite by bone Imputed to motion [illegible] to want of nutrition 2d to effusion of serum. But there are cases where none of these causes operate & yet the union is ligamentous Gunshot wounds sometimes terminate thus but do not always. The frequent motion of the limb has been considered as a cause of these accidental cases but animals go with their broken limbs dangling about and yet the union become [illegible] An epileptic man broke both femurs the fits continued nothing could be done for the limbs yet they united firmly Also it is best in first dressings of fracture to make extension it gives relief Interposition of muscles has been assigned also old age & pregnancy yet none of these reasons are satisfactory The causes may be conjectured to be accidental in the particular limb not constitutional & perhaps another bone in the same person might unite Mr. Amesby cured a great many a great many cases he found also that many of the incurable cases exhibited an artificial joint & a pseudo-serous membrane The best plan of cure seems to be to keep the bones as firmly pressed together as possible binding the limb as firmly as can be endured Dr Physick has effected a cure by keeping a seton through the limb which produced either inflammation or granulation. This method has been extensively tried since that time both in Europe and in this country it sometimes fails A Mr. Burke of St. Thomas cured by electricity but then he used also an apparatus Dr White Sen. of Cherry Valley cut down & bored repeatedly into the bones with an awl he cured but then he used an apparatus Counterirritation has been extensively used As a last resort an incision has been made down to the bones & the ends of the bones. [Let] the operation has been fatal & has often failed Prof. Smith tried it once he had to saw off again on account of overlapping the bones about 10 days after The case was successful. But he declared that he never would again perform the op. Prof. H gives the preference to the plan by setons. Keep them in a long time Dr Physick kept his in at first 6 or 8 weeks. Probably some cases have failed from the short time during which the seton is kept in Dislocations It is of the highest consequence to be thoroughly acquainted with dislocations so as to be able to set a bone at once Failures are peculiarly unfortunate Dislocations may be caused by direct violence, by disease of the joint, by muscular action as in epilepsy. The swelling at first and the infl. afterwards may render the diagnosis obscure. The immediate swelling must be from effused blood. Van Swieten thought dislocation of the hip could not occur Many have believed this. Indications are 1st restoration 2nd retention in place 3d obviating of the effects of the accident The principal obstacle to restoration is muscular action which is overcome by for e applied with sufficient strength at first or by gradual force The British surgeons apply the extending force to the bone itself. The French apply it at the end of the member Splints etc. are often necessary to keep the bone in place Prof. H. has never seen simple dislocation compounded with simple fracture. But such cases may perhaps occur. Compd disl. & fract. may occur e.g. at the ankle But a short time only shd be allotted to the previous reduction of inflammation We may bleed largely etc. [Ganglinoid] joints can seldom be reduced [illegible] a month Orbicular joints have been reduced after 5 or 6 mo even. But the axillary artery has been ruptured in these attempts upon the shoulder Constit. means to facilitate are 1st bled ad deliq. 2d tart. ant. 3d warm bath continued as long as the patient can bear it. Begin with tart. ant. (say) then warm bath then bleeding. Tobacco has been proposed but it is too dangerous. Opium cannot be depended [illegible] Intoxication is a favorable state but it cannot be managed at pleasure. If you find a man drunk take immediate advantage of the oportunity Partial dislocations can only occur in ginglynoid joints Desaults notion about rupturing adherent (or new) ligaments in old luxations by moving the limb in every direction is perhaps a good one, but is not much attended to. He supposed that the bone was often girt about by the ligaments Luxation of lower jaw Occurs in one or both sides the condyle is thrown forwards & the chin is oblique except when both are dislocated Does not occur in children Prof H’s first case was that of a young man courting! about midnight In one case epileptic fits caused a continual recurrence of luxations The teeth will be 1 or 1 ½ in. apart. It is a mistake to suppose that the mouth must be wide open. Some cases have been mistaken for spasm & treated accordingly Place the pat. in a low chair Put the thumbs as far back on the jaw as possible bear down with the thumbs & upwards with the fingers, upon the chin If this fails place a lever of wood bark & then press down with one hand upon that & up with the other at the chin and reduce one side at a time Place the pat. on his back in bad cases. Bandage for awhile Luxation from epilepsy are apt to recur Sir A.C. mentions a sub luxation caused by relaxation producing a snapping while eating Push the jaw upwards N.B. when you use a lever of wood make the upper jaw the fulcrum At the same time pullup the chin with your fingers Luxation of the Clavicle When at the sternal end, it is caused by a blow on the shoulder & the end of the bones project outwards. Reduce by putting the shoulder backwards (by an assistant) & pushing in the end of the bone Dress as for fract. clav. Great difficulty is found in keeping the part in place A tumour forms Sir A.C. mentions one case of an internal dislocation of the sternal end of the clavicle About an inch of the bone was sawed out The fracture of the scapular end may be treated by raising the shoulder bandaging as for fract. clav. putting a compress on the part etc. They are not readily restored to perfect soundness Luxations of Vertebrae Prof H. has known persons fall (as from a load of hay) upon their heads & their heads be permanently bent forwards & depressed. He has not ventured to interfere, but if he should have another case he would endeavour to brace the head back Luxation of shoulder Said to be equal in frequency to all other dislocations hardly so When unreduced the arm remains permanently extended from the side & is almost useless sometimes a semiparalysis of the arm occurs This luxation can only occur when the arm is removed from the side Boyer thinks the luxation forward is always consecutive this is denied by others The general signs are depression above, the head of the bone percesptible etc. the arm is directed obliquely Sir A. C. speaks of subluxations but Prof. H. coincides with Abernethy in thinking this impossible Two classes of modes of reduction 1st manual 2 by machinery Prof. H. has never used the latter. No account of fatal accidents has been given from manual reductions In recent cases Sir A.C. reduces by the heel in the axilla. Dr Wells, formerly of N. [Stonington] succeeded in one case by placing the other foot in the acremium & thus making additional counterextensions Prof. Smith’s mode Prof. H.’s mode Generally press the scapula down After sufficient extensions, lower the arm & the bone will go into its place If possible divert the attention of the patient so as to relax the muscles Sometimes constitutional means are necessary vide supra Sometimes a reduction is effected by first fatiguing the muscles, by long continued extension Compound dislocation of the shoulder occasionally occur case of Sir A.C.’s in which the bone projected through the pect. muscle The suppuration caused anchylosis ultimately Compd disl. occur by the arm’s being caught in machinery Displacement of the long head of the biceps. This is probably what Sir A. C. called partial dislocation After reduction of the shoulder, in these cases there will be [lameness], pain etc. which is removed by raising the [illegible] & rotating it outward Prof. H. has frequently seen this affection when there had been no dislocation The [elevation] of the arm about 45 [degrees] gives great pain after however a higher elevation gives no pain. Rotations of the arm gives no pain. Often great pain is felt during sleep say Prof. H thinks that the displacement is backwards generally Prof. H. diverts the attention & then suddenly rotates the arm. If necessary repeat the process frequently & make the pat. do so likewise Luxation of elbow 1st both bones backward. The arm is shortened the bones project backward & a depression is felt on each side of their ends Frequently caused by a fall on the hand Most apt to be confounded with a fract. of os. hum. just above the condyles But in fracture all the marks of displacement are immediately he removed by extending the limb We can also move the joint more & can feel the crepitus. In children luxation does not occur so often as the fracture of the os hum. Prof. H has an assistant grasp the arm firmly above the elbow for the counterextension & then he grips with his fingers the ends of the bones, pulls down & forwards & then suddenly bends the arm. Dress with the arm bent in a sling. The inflammation will be considerable Sir A.C. applies his knee, or puts the elbow across the back of a chair 2nd Radius and ulna laterally If internally the head of the rad. is in the posterior fossa of the humerus 3d dislocation of the ulna alone backwards distinguished by the projection of the ulna & the turning of the hand inwards Caused & cured in a similar way 4th Radius forwards its head upon the coromoid process. The arm is partly prone the elbow cannot be completely bent. There will be no contusion & now swelling & a mistake is apt to be made in the nature of the accident the shoulder being considered in fault Clap your right thumb on the head of the radius press with it make extension with the left hand then turn the arm supine & immediately flex the elbow For adults an assistant or two may be needed in order to exert greater force Prof. H. has seen many cases & has known many cases of mistake Bandage & sling 5 Radius backwards Sir A. C. met with a case in a subject brought into the dissecting room Smith’s splints Fract. of corp. proc. of ulna Caused by falls Keep the arm in a sling Sir A. C. Union by ligament Fract of neck and rad. Sir A.C. has never met with a case Luxations of wrist 1st both bones either forwards (palmar) or backwards (dorsal) Generally discovered easily may be confounded perhaps with effusions of the bursae mucosa but in this case the projection will be only on one side May be confounded with fracture of lower ends but we can generally discover the lower end of the radius the arm is more bent in fract also the lower projecting end is lower down in dislocation Let an assistant hold the arm place your thumbs in the back against the projecting ends of the forearm your fingers in the palm extend press & bend the wrist up so as to make the hand straight Smith’s splints 2nd Radius forwards easily reduced 3d Rad. backwards set in the same way Always apply splints 4th ulna alone Prof. H. has seen it the end projects forwards reduce in the same way let the hand hang down in the sling to keep the ulna up next to the radius Luxations of the Carpal bones Rare accidents reduce them as the above cases Great infl. generally attends Apply Smith’s splints If the tumour is only from effusion, it will feel soft. Luxation of metacarpal bones caused only by passage of heavy bodies by # bursting of [illegible] etc. Generally compound We may if necessary remove any one or a majority of the metacarpal bones Sometimes a luxation of digital extremity of a metacarpal bone occurs. It feels like a dislocation, but gives a crepitus Generally in most such cases put a round body in the hand, to dress upon Luxation of metacarpal bone of the thumb forwards & backwards Make extension & carry the bone into its places. Pat. are generally impatient of dressings & will come to you with a sort of sub luxation. Then apply a plaister bandage Luxat. of first phal. of thumb backwards easily recognised difficult to reduce difficult to et the bone over the projection of the met. bone The thumb has been torn off in attempts to reduce Sir A. C. directs to soak the parts then apply a piece of soft leather then a piece of tape with a clove hitch Let the assist. pull on this while the surgeon pulls inwards. If this fails he recommends a [illegible] the elbow being around a bed post Mr. Hey recommended divis. of lig Boyer failed in one 10 days old The disl the other way is easily [illegible] The second phal. is easily reduced After all dist. of fingers & thumbs splints give great relief they will relieve pain Luxations of hip joints 4 directions 1st upwards upon the dorsum of il. knee & toes turned inwards [illegible] 2 in. short. head of the bone can be felt Buttocks flattened Trochanter higher up & pointing inwards forwards Dist. from fract. of [illegible] of fem. by the bone being fixed not easily moved no crepitus by the toes not turned inwards This is the most common kind Prof. H. has succeeded by Dorseys mode Pass a sheet around the perinaeum make [illegible] by a handkerchief around the limb just below the bent knee one assistant pull the thigh outwards by a napkin the surgeon rotates the limb outwards & the bone comes into its place. Two assistants will be needed for adults Sir A. C. advises in the first place const. means by v.s. 10, 20 or more oz. warm bath & tart. emet. Place the pat. between the two strong parts with staples. Pass a strap around the perinaeum & fasten to the first staple another (by a wet roller) above the knee 7 fastened to a pulley make exten. gradually finally when the muscles are fatigued & the head is drawn down, then rotate outwards as above. It may be necessary to lift the bone outwards to get it over the edge of the ilium 2nd Dist. into foram. ovale Limb length 2 in. stands out from the other body bent forwards toes turned outwards Caused by force applied to the upper part of the thigh Sir A. C. Fastens the body firmly to a table & by a pulley pulls outwards the surgeon with his hand on the ankle suddenly crosses the limb over the opposite one 3d backwards into ischemic notch limb ½ to in. shorter troch. mag. projects less & is turned forwards knee & foot turned inwards great toe in the hollow of the other foot toes touch the ground head of the bone can often be felt Reduce (Sir A.C.) about as the first except that the assistant lifts the bone upwards by a towel around his neck 4th on os pubis head of the bone can be felt & rolls foot turned outwards limb shortened caused by falling backwards to a hole Place pat. on the table make ext. backwards & downwards left the head of the bone over by a towel around the neck of an assistant Fract. of ossa immon. have been mistaken In 20 cases [illegible] 5 [in] isch. notch 2 in for. ov. 1 in os pubis Sir A.C. Boyer does not direct pulleys Abernethy [illegible] After reduct. apply a 8 bandage Treat for const. infl. & irrit. Bleed & cath. [illegible] Benedict [Def??st] [not] Shelton Totten Next to Totten The [tabula] vitrea or internal plate may be fractured while the external [illegible] [illegible] These are irregular depressions of [the] internal plate, which the surgeon [illegible] calculate on a generally [illegible] near the longitudinal sinus They are not often found in the young In the youngest [illegible] [there] [are] not [illegible] tables In the very old [bone] the [illegible] is nearly [???ting] In [illegible] [to] [know] in [illegible] [illegible] [for] [this] [illegible] [illegible] 13 Surgery 1 2 3 4 5 Lecture 2nd Inflammation Characterized by heat pain redness, swelling, soreness upon pressure & if considerable a symptomatic fever. If considerable & extensive, constitutional irritation, or irritative fever may be produced. The pain is caused by some affection of the nerves, the swelling by effusion or by distention of the vessels The symptoms above described may occur successively and not all be present at the same time 6. Inflammation has been divided into two kinds Phlegmonous & Erysepelatous 1st Phlegmonous & 1st of that which arises from external injury. The injured part is the centre of the inflammation. The manner in which injury produces inflammation is not well understood. Hunter speaks of both increased and diminished action of the vessels & uses the term healthy inflammation in which there is increased action. Cullen thinks the action increased Wilson Philip thinks there is diminished action. At the present day surgeons consider that there is increased action at first in all cases Hunter thought the vessels were always diluted at first An injury is first followed by pain, caused by laceration & pressure of nerves perhaps. For an example an incised wound is followed by retraction of the lips, by pain swelling redness, heat, 7 and the inflammation spreads over adjacent parts The sense of fullness and the redness is probably caused by increased quantity of blood red blood is carried where it did not exist before as in ophthalmia The venous blood becomes red like arterial The cold stage is extensive inflammation should not be omitted. It is a part of the symptomatic fever & this fever sometimes also has a sweating stage Prof. H. thinks there is always in creased action in the commencement of infl. He thinks also that fever differs from inflammation The heat extends widely perhaps over the whole body It is principally a sensation however, and not much indicated by the [therm.] Inflammation of some parts as stomach & bowels the pulse will not be full & strong. This will also be the case in some constitutions, in which 8 there will be feeble pulse nausea vomiting etc. Prof. H. objects however to the term atonic inflammation Causes of infl. are mechanical & chemical heat, cold etc. Syphilis & some others are attributed to a specific cause & called specific inflammation Cold may cause inflam. by rendering the system or part more susceptible to heat afterwards. A frozen part will irritate as dead matter. The frozen fluids will irritate Prognosis will be dangerous 1st from violence or extent of infl. 2nd from nature of the part affected as the viscera the functions of these parts being suspended or destroyed. joints are dangerous parts 3d const. & habits of the patient Terminations are 1st resolution 2nd adhesion 3d suppura. 4 gangrene. Schirrhus was added by the older writers 9 1st Resolution is where the part is left healthy 2nd Adhesion takes place generally in serious membranes & in the cellular membrane especially in the linings where it is called hepatication Treatment. The cause as [illegible] should be immediately if possible removed Remedies These should be local as much as possible. Much may be done by prophylactic treatment especially in the case of wounds The first indication is to preserve the proper temperature of the part we may apply cold or tepid applications according to the sensations of the patient. If chilliness is produced by cold applications, apply warm ones though in infl. of the brain the production of chilliness is beneficial in many cases IN abdominal infl. fomentations & warm bath will be very useful and the French use poultices extensively in infl. of the lungs substituting them for blisters 10. We may apply cold applications too long. There is sometimes a choice in liquid appl. spts & water ac. pl. 1z to 1 pt. mur. amm. zii to pg. cold water alone ice especially for the brain vinegar & water though this irritates the skin & produces an eruption in some persons mur. amm. in very popular & seems to answer better than ac. pl. for deep-seated infl. Cold water is probably good enough in most cases, if there is no prejudice in the patient. Some surgeons use sulph zinc. Others depend much upon narcotic applications as of stramonium Prof. H. does not use them Blisters are especially useful in chronic & deep seated infl. Prof. H. prefers a repetition of the blisters for keeping up a perpetual discharge The first general treatment is bleeding which is recommended by W. Philip for two reasons to dimin. the vis a tergo & to dim. the quantity of fluid in the part. Those of opposite theories use it 11 There seems to be no doubt about bleeding in phlegmonous infl. and Prof. H. has often found benefit from it in erysipelatous Venesection is the most common the most convenient for several reasons. Prof. H. has thought that drawing blood from a vein near the inflamed part relieves the pain sooner though it may have no effect afterwards. Continue the flow till pain is relieved or faintness is produced patient not being in a horizontal posture. If the pain etc. return repeat the bleeding Blood letting has been objected to in old persons and in the feeble. Brit Prof H. has frequently bled both with advantage Arteriotomy has no advantages Leeches are not fashionable but Prof. H. thinks they have no advantage over venesection. He thinks experiments on their relative advantage have not been sufficiently tried They may be better in some cases of chronic infl. but Prof. H. has used repeated bleedings in such cases with advantage Cupping combines bloodletting & and counterirritation Lecture 3d The next remedy in importance for inflammation is cathartics The saline are recomm. but the merc. are better. As W. Philip says they undoubtedly have a specific effect Antimonials have a powerful effect In Italy many have used them exclusively Beginning with small doses & increasing gradually, they gave a large quantity and depend upon this alone I have known a patient bear 4 gr of tart. em. once in 4 hour Narcotics have been much used It is safe to give opium, contrary to Brown. Dovers powder may be given But perhaps the best article for inflammation which we have, perhaps is calomel and opium. This practice is now much used in G. Br. A little opium is combined in order to quiet irritation. Hyoscyamus has been used. 13 where opium would not agree It has been my practice to give opium enough to quiet the irritation from excessive pain & continue my other treatment at the same time Rest & quiet must be used to relieve pain An elevated position well often relieve pain in paronychia for instance & in pneumonia, & in infl. of kidnies Diet should be light & vegetably an. food to be avoided, including broth also which many consume, in injurious quantities Attention must be paid to the constitution. We must be cautious about bleeding drunkards Often a state of debility succeeds such as to require tonics Opium has sometimes to be continued after recovery Adhesions in the cell. mem. are apt to take place after inflam. of joints These are to be relieved by fiction and motion 14 Chronic infl. will be treated hereafter Often the most Erysipelas is principally confined to the skin though the cell. mem. is generally more or less affected There is a redness in erys. which disappears after pressure. The redness also is exactly defined at the edge. There is a remarkable propensity to spread The redness is of a darker colour then in phlegmon & in the progress of the disease inclines to yell. The skin is shining. The pain is not throbbing as in phlegmon, but burning. Sometimes there is a deep seated part at the same time The infl. frequently leaves one part and spreads over another The eruption disappears in [brawny] scales. There is a slighter swelling of the skin perceptible to the finger, a hard leathery feel of the skin 15 The fever is considerable. Vomiting bitter taste in the mouth bile is thrown up heat very great Old persons frequently have coma When as is sometimes the case erysipelas comes on at intervals or is periodical Its occurrence may be preceded in old persons by come Delirium may be caused by it 1st erys. eff. skin only 2nd erys. aff. cell. mem. which may or may not be accompanied with aff of the [skin] 1st This does not suppurate & terminate in branny scales. Found in all ages 2nd Skin and cell. mem. affected there is swelling suppuration etc. sometimes the fasciae & tendons are involved. It affects principally the old and the intemperate especially the legs Erys. is dist. from phlegmon by col. by circumscription by fixedness Erys. when suppurate does not have a regularly defined abscess like phlegmon 16. Erys. aff 1st nerv. syst. by coma for instance delirium when the head is affected, by burning heat 2nd heart & arteries by a pulse smaller weaker and quicker than in phleg. 3d al. can. by bitter taste dryness of mouth diarrhoea vomiting From the bilious vomiting yellowness of skin & of the affected part Some have supposed the liver to be aff. but this takes place from sounds merely & from the bit of the rattlesnake Caused by wounds ulcers etc. and in erys. the infl. is not necessarily near the part injured The causes operating upon the constitution are malaria and the crowded air of hospitals, feebleness and intemperance etc. In Pomfret after draining the [meadow] one summer there was more erysipelas (St. Antonys fire) than in 10 years In the Mass. hospital Heated air produced this effect. The violence of erys. is generally proportioned to that of the local aff. 17 Sometimes however it affects internal parts Sometimes erys. alternate with other diseases Prognosis depends upon the violence of the infl. upon the cell. membranes being affected upon the head & face being aff. upon the constitution age and habits of the patient The indication is to promote a resolution and prevent suppuration if possible Though some suppose that suppuration never occurs Resolution is to be accomplished 1st topical 2nd by general app 1st Many object to topical applications Though S. Cooper and Lawrence do not object to them Ac. pl zi to pt. is the best Milk & water or cold water is good Use the cold or warm acc to choice of pat. mur. amm. zii to pt. corr. sub. 10 to 20 gr. to pit. will often be good Narcot as 6 p. zi to pt water or op. zi ac. pl. zi mercurial ointment has been 18 celebrated as a catholicon Another however though lard a catholicon Prof. H. has derived much benefit from lard or tallow alone In violent or extensive infl. I have found ointments inferior to liquid applications Though ointments are very agreeable when the cuticle is peeling off A new remedy is not silv. moisten a stick and sub it over the part (Mr Higginbottom) There is considerable testimony in favour of this mode of treatment. It is said to prevent the spreading. Mr. H. trusted to this alone without internal remedies. Prof. H. has used it but has not trusted to it alone he recommends however Blisters have been proposed by Dr Rush & used by Dr Physick Dr Rush recommended them for gangrene Prof H. has used them with the greatest benefit Case of a man’s face so swelled as to blind him. Prof. H. blistered the whole face & cured the patient Blisters are not t be applied to every extensive erysipelas 19 When the cell. mem. is affected blisters undoubtedly ought to be used Undoubtedly erysipelatous inflammation may affect the cell. mem. without the skin It has been called erys. phlegmonode Dissection [illegible] are in Prof. H.’s opinion are of this nature. The propriety of treating erysipelatous infl. like phlegmonic has been very much questioned but Prof H. has often bled and reduced with great success. It is often very difficult to cure returning after an apparent cessation Purgatives have probably been more used on account of the notion that there was bile in the skin and on account of the humoral pathology Bark opium etc. will be proper when the pulse is very feeble etc. but not when the tongue is dry, skin hot etc. etc. (Thomp) Infants have erysipelas sometimes caused apparently by irritation from improper tying of the navel string. I have 20 also seen if affect the pudenda and sometimes be very dangerous The cause of the latter I do not know. I have treated erysipelas in children with cal. ipecac & rhubarb etc. and the same ext. appl. as in adults Erysipelas of cell. memb. the skin not being affected. It usually attacks old, intemperate broken down persons commences with chills skin feels doughy pits on pressure Generally there is much derangement of stomach, vomiting etc. Sometimes delirium & even del. tremens Lotions are not of so much use Prof. H resorts immediately to blisters Narcotics are generally strongly indicated. Suppuration is to be expected and promoted. In this kind incisions are proper. Pus will collect in a day or two and should be let out. The pus will collect in parts & the skin have a boggy feel. 21 Treatment of erys by incisions. Considerable blood may flow & in one case Mr Hutchinson the inventor lost a patient from haem. owing to the negligence of the dresser Tinct. myrrh is an old article, formerly much used for injection into erysipelatous absceses (Dr Ives) Chronic inflammation. This is generally a sequel of acute inflammation Some constitutions are predisposed to it For instance an injury of a joint will being it on in some persons Scrofulous persons are more subject The gland and joints are the most common parts affected Treatment Bleeding should be local rather than general. Blisters cupping etc. Mercury in small doses narcotics as opium & conium. Deobstruents are very important. Vide Mat. Med. 22 Suppuration Infl terminates in suppuration when it resists the usual means used for discussion & increases & swells more Phlegmonic infl. has a soft part in the middle more or less pointing & in a round or oval form Erysipelas does not suppurate in a circular pointing abscess and the us collects more suddenly. Nothing perhaps distinguishes an experienced surgeon more than tact in discovering matter An abscess always tends to [illegible] the skin Pus is not now thought not to be formed from coagulated blood neither from the solids but to be a secretion Properties globules in a fluid cream coloured sweetish coagulated by mur. amm. Putrifies upon exposure to the air, & may rust a silver probe Delpect maintains that it is secreted from a membrane Pus is detected by placing the two thumbs at some distance from 23 each other & pressing alternately. In the thigh do not place the thumbs transversely upon the limb. lest you be deceived by the slipping of the muscles on the contrary place the thumbs up and down the limb S. Cooper thinks it is often better to suffer many abscesses to burst themselves thinking that the cavity will gradually contract & the healing will be more favorable. Prof. H. dissects entirely from this and always lets pus out by an incision It abscesses open themselves, the pain is often excessive at the close, just before opening feeling like the cutting of a knife There are no advantages to be derived Erysipelatous pus should always be evacuated immediately. If not, it may become acid and fetid Sometimes fetid gas will issue & fill the room Abscesses are opened with the abscess lancet, or with a bistoury. Large ones with a double edged knife Prof. H. knows of no medicines which promote suppuration unless it be warm applications fomentations etc. which 24 soften the skin and allow it to distend They are very comfortable and may be allowed An abscess after opening should not be violently squeezed, but pressed a little and afterwards, pressed again, or subsequent days. When there is difficulty in getting out all the matter bandage so as to make constant pressure leaving a hole for the pus to issue Do not attempt to discuss deep seated abscesses & those about the joints. The pus is often contained in a bursa mucosa & will not evacuate itself and patients often are suddenly in such cases Abscesses continued. It may be advisable to keep a small slip of linen in the opening at first to prevent [closure] of the cavity If the healing is slow, touch with nitrate silver. Sometimes inject corrosive sublimate 25 If these things with bandaging fail to cure, look out for the constitution be careful to keep up a strick rest of the part. The fore arm may often be healed in this way, when other means failed before applying a splint As illustrations of abscesses take these of the female mammae. 1st We have simple phlegmonic infl. & abscess. Treat just like any other inflammation pro re nata Robust women may be bled. Sling the breast. The skin always adheres over an inflamed gland 2nd erysipelatous infl. of the breast pus in the cell. memb. sometimes the ducts are laid open by # suppuration Inf. of the bursa mucosa under the gland commencing like rheumatism constit. disturbance considerable The breast is not hardened but the whole of it is pushed out. Suppuration takes place within, and points below. Open the abscess and keep it open by a bougie keeping on a bougie as long as you can & then introduce a probe. If these means all fail Introduce a seton and take out a thread a day until the abscess heals. Dr Physick invented this practice Hey advises to lay open the whole breast & calls them chronic abscesses Finally bandage the breast The seton may be introduced by Acute inflam. of hip joint [illegible] supervenes upon an injury violent pain inability to use the limb const. irrit. violent fever convulsions death in a few days if not opened. Prof. H. has not with several cases. We must not hesitate about opening the joint, to evacuate pus in these cases Case of erysipelatous abscess Hard drinking patient infl. of leg below the knee del. tremens came on opium 175 drops & more a day Abscesses repeatedly opened until the whole leg was open under the skin pus collecting very quickly recovered Cases in which pus collects in the cell. memb. in various parts & finally 27 death or loss of a limb. The treatment must be very much varied Opium bark etc. Bark is of little use when the tongue is brown, dry etc. In the early part of his practice Prof. H. gave much more bark than at present Chronic abscesses Limits not very well defined. They are merely those which are long in collecting. Bryer divides into acute chronic & congestive or those where the pus is found in a different place You will be called & sometimes [& be] told of a fever, sometimes previously at other times there is no apparent cause Often the pain is in a different part. Case of a child treated for aff. of the knee is hip had an abscess It was opened & cured Much is said about absorption of pus. But Prof. H. has never known cases completely cured without opening Prognosis is very difficult in chronic abscess Sometimes death ensues in a few days after opening sometimes only 28 after months Prof. H has never opened with caustic Lumbar abscess caused sometimes by strains & bruises sometimes no apparent cause Scrofula is given as a cause but it is necessarily Most common in the young though it is found at middle age Commences like rheumatism without much severity of symptoms A peculiar bending forwards & to one side characterises the walking pain on pressure Prof. H. thinks it is seated in the bursa of the psoas muscle The pus points below [illegible] ligament or lower down on the thigh even on the outside of the thigh It is sometimes mistaken for aneurism & for inguinal hernia It is easily distinguished The pus is described in the books as pointing always in the groin Prof. H. has seen it point in the loins If pointing in the groin let this patient stand up when you 29 open the abscess It may be necessary to introduce a probe to bring out the coagula which are numerous & sometimes large but be cautious in using a probe, lest you excite internal hemorrhage Make the opening keeping the surface tense about the width of the lancet (into the cyst) for the size of the opening Evacuate all the pus & heal by the first intention. When pus collects again make a second opening in another place because it would not heal so soon in the first place and evacuate & heal up as before. After a few such openings the pus will ulcerate out & then a modification of treatment is required “The patients may recover in the country but in cities & hospitals” Old surgeons introduced tents with great mischief Prof H has read of no lumbar abscesses cured by absorption where the patient ultimately recovered an abscess of the lungs is apt to occur as a sequel & take off the patient 30 Hectic fever may be acute and violent, soon 2 or 3 days or even 24 hours after opening lumbar abscess or hip joint heat fever nausea vomiting great local pain inability of motion of the part from pain These symptoms appear so like an attack of common fever that they are sometimes falsely accounted for in this way. This hectic may occur after the bursting of an absc. It is different from confirmed chronic hectic though called by the same name vide “acute hectic” A lumbar abscess opened by a large incision gives rise to more violent symptoms. Though they may occur often a spontaneous opening or a small incision Case of a young woman who feel from a horse was somewhat lame finally there was a pointing in the groin patient was about the abscess burst violent symptoms took to her bed lay a year & died The doctrine of absorption of pus was first denied by J. Hunter. 31 Some have attributed the bad effects upon a free opening are owing to admission of air others to cold air But Baron Larrey dressed wounds below zero When a lumbar abscess becomes permanently open. Prof H. injects corrosive sub. 10 gr. to a pint. 2 or 3 times a week taking pains to have the solution touch the whole internal surface of the abscess, by turning the patient stroking up the part etc. If after continuing the injection about a fortnight discontinue it if no benefit is derived we should increase the strength until some sensation is produced. Sometimes the injection will produce a slight ptyalism but this is of no consequence Prof. Smit injected the cavity immediately upon first opening Prof H. has tried this, but prefers Abernethy’s mode. The injection generally somewhat increase the discharge The constitutional treatment shd be with opium especially conjoining calomel. Tonics also as bark. prof. H. cannot think that lumbar abscess proceed from an affection of 32 the vertebrae because the disease often arises from injury to the muscles merely & is cured more readily than we could expect if the vertebrae were affected he has examined the vertebrae also, when about to make the opening & could not find them affected. Languid scrofulous abscesses take on an oral form & are to be treated like others. Do not wait until the skin becomes very thin and of a purple colour If we wait too long the skin will form loose flabby granulations so that the skin will perhaps have to be cut away Quality of the discharge from abscesses Sometimes is is pure pus, sometimes thick or curdy But before the abscess closes the discharge becomes whey like, thin, watery. This is not noticed by writers. It must not be mistaken for a bad action of the abscess 33 Furunculus or boil Called an instance of phlegmonous infl. Still it differs much. For in common phlegmonous inflammation there is a cavity for the pus or no cure Furunculus commences with a pimple and a small vesicle which when pricked yield a serum. Hardness purple colour pointing is not always in the centre. One or more small holes out of which the pus issues The pus is apparently contained in the cells of the cell. memb. The boils do not heal until the core [illegible] which is rotten cell. mem. Treat sometimes by bleeding if const. infl. is great at other times give calomel. Poultice or plaisters They may be cured more speedily by opening than by suffering then to burst So says Prof. H. Sometimes they contain clots of blood (called blood boil) Where there have been very many on a limb Prof. H. has enveloped the whole limb in ac. plumbi 34 Anthrax (burning) or carbuncle most commonly found on the face neck or back found also on the hands and feet and in other parts Often preceded by violent pains and heat in the part. A malignant fever may be the cause. Sometimes it is preceded by a sort of anomalous [illegible] [illegible] [illegible] [illegible] of health. It may commence with a broad inflamed spot on the skin Begins differently in different localities. Generally with several points Begins with a fiery pimple which gives a burning pain & often Begins on the hand with one pimple cause considerable const. irrit. Colour of the skin around not bright like furunculus but dark like erysipelas a hard cake in the cell. mem. equally around the centre. lymphatics affected becoming hard & red cords much const. irrit. chills, flashes of heat, nausea, restlessness etc. Small holes appear & keep occurring in a fresh part of the swelling A piece of skin mortifies & comes off often The pimples emit a yellowish fluid More dangerous about the head generally but not always fatal there Sometimes 35 very rapid gangrene ensues Case of a man who observed a small pimple while shaving a few days after Prof. H. was called, he died of gangrene Occurs oftenest on the old & in the intemperate Coma & delirium often ensue in the old where the gangrene is near the head Authors differ as to treatment The French use the actual cautery at a white heat The pains [illegible] is said not to be great Prof H. blisters at first It relieves the burning pain & heat. Then he applies an emollient poultice If the burning heat returns apply another blister. Apply ac. pl. [illegible] & cerate Sometimes where the fever is high bleeding has been beneficial in Prof. H’s practice. Always give calomel Dr Physick recommends caustic kali he says it relieves the pain Prof. H. has not tried it. He has always found blisters promote suppuration When pus collects squeese it out, and pull out the slough of dead cell. mem. which gives great relief If necessary in order to extract the pus & 36 sloughs in incision if sufficient size may be made Incis. at first though highly recommended are not approved of by Prof. H. Various affections of the hand called felons, whitlows etc. & paronychia Paronychia The term is applied to a variety of sores upon the fingers & hands sometimes upon the toes. Four kinds 1st a superficial suppuration around the root of the nail cured by nit. sil. 2nd suppuration in the cell. memb. of the fingers or hands a real anthrax 3d Inflamm. in bursae mucosae 4 deep suppuration between periosteum and bone & leading to necrosis 1st Commences with heat, [burning] pain, redness finally yellowness The nail is best unless properly treated These are commonly located with poultices They are comfortable. Mr. Higginbottom recommends nit. sil. If suppuration takes place open through the cuticle & clip off as much as possible of the skin The suppuration extends around and you 37 must continue to clip off skin. To stop this continually spreading ulceration, inject corr. sub. or sprinkle on cal. Finally dress with cerates or with saturnine cerate Sat. cer. Rx ac. pl. zii sulph. sod zfs sim. cerate ziifs. 2nd Is an anthrax & to be treated as such by blistering at first etc. Generally the tendons when laid bare continue white and glistening & do not turn yellow and die. If they are laid bare in this state by sloughing of cell. mem. they will generally become covered afterwards. 3 Of bursae mucosae They are excessively painful Generally common at a point & feel for some days as of a splinter was sticking there We can do little better than to continue to poultice until suppuration comes on. Then open thoroughly & keep the abscess if necessary open by a piece of linen. Pencil with caustic. It will not readily burst [illegible] through the bursa 38 4th The periosteum covers the pus. Treat by an incision in the first place without [reacting] for the formation of pus keep the part [illegible] This is a necrosis and is to be treated as such. There is much pain long before the swelling & much const. disturbance It may be necessary to extract a dead phalanx. The finger will heal up well afterwards This kind affects perhaps the canellae of the bone in some cases, producing complete necrosis Mortification. Conversion into a dark ash coloured mass, which is cold & if kept dry becomes black & finally fetid. It is said that mortif. for gangrene may commence without previous inflammation. This doubtful Two kinds acute & chronic 1st acute, takes place, by becoming orange coloured forms livid or purple vesications, containing bloody serum Bloody serum is a diagnostic, unless proceeding from ecchymosis Pulse becomes weak sometimes intermitting A mortified part is always insensible to a prick or cut, by a pin or knife 39 Chronic mortification takes place without any apparent inflammation though often preceded by severe burning j& pain A good example is that of old mens toes which commences with small vesicles & extends over the whole foot & the leg There generally precedes a severe pain in the part Two circumstances will always distinguish a mortified part, 1st an insensibility 2 fullness of blood vessels in the parts adjacent? Mortific. may be caused by injury, especially if violent enough to destroy the vitality of the [part] in the skin for instance by obstruction of the bloodvessels leading to the part by malignant diseases suddenly destroying a whole limb without any previous inflammation occasionally also from palsy in this way Cases 1813 pneu. typh. Infl. especially, erysipela & anthrax & in the old & intemperate is the most common cause fire frost bite The pathology of mortification 49 is very obscure. Sometimes excessive action There is sometimes a predisposition to mortif. & in such cases it will follow trifling injuries e.g. in broken down const. Prognosis is often difficult. All causes are dangerous. Prognosis depends upon constitution, part affected, & rapidity of progress It is very dangerous to have mortification succeed a trifling injury Chronic mortific. is always dangerous and especially if the tendons & fasciae are affected, when there is [little] probability of a cure for tendons are very slow in healing If possible dissect out dead portions of tendon etc. Sometimes the patient is suddenly carried off by a new attack of erysipelatous infl. or an infl. of one of the viscera especially the lungs Indications are 1st to moderate the violence of infl. 2nd remove sources of irritation 3d to prevent spreading 4th support sonstit 41 According to the opinion that the line of demarcation instituted by nature should be [initiated] and promoted by art it was formerly proposed to apply stimulating articles as hot oil of turpentine, etc. but these do injury. Cutting down for the purpose of separating the sphacelus does not stop the spread The const. sympt attend are sudden sinking of pulse, great anxiety of mortal restlessness cold sweat etc. If the mortif. comes on gradually these symptoms may be gradual in their occurrence. Sometimes however their attack is sudden The indications of treatment were 1st To moderate violence of reaction If the pulse is strong & the pain very great so that there is danger of mort. we may bleed. But the period for it is short. Where bleeding cannot be admitted leeches are recommended by some. There will be a dry tongue & the secretions are to be improved, by full doses of cal. when there is constip. but 42 small alterative doses when there is diarrhoea. Prof. H was in the habit of using it before he saw Sir A. Cooper’s remarks Bark is not how much relied on and is ever objected to b y many when there is fever. Mr. Pott found it useless for toes of old men & relied on opium instead For local application, use mur. amm. & ac. pl. either cold or warm according to the sensations of the patient Some object to cold applications Poultices are useful [Yest] poultices are merely useful. Prof H thinks by correcting fetor Bark poultices he thinks useless and if they are used are better made by a decoction than by powder 2nd In old men; to remove cause of irritation. be careful about splinters etc. Be careful to open abscesses to prevent irritation Remove sloughs if it can be done readily Continue opium all along beginning with cal. if bow. are costive but continue opium long after ceasing with cal. To prevent the spread 3dly It is very difficult to stop the spread 43 of gangr. Sometimes it will extend in the cell sub. under the skin, producing a crackling feel. Bark was formerly relied on’ but it is not now valued Blisters must be our great reliance. (Dr Phys. introduced them) but be cautious not to blister too near the gangrenous part. In case of chronic mort. as of old toes this is [illegible] Dr Phys & Dors. disputed Nitrous acid is now much applied 1, 2, or 3 or drops to a pint of water As for the const. treatment 4th This ind. is answered partly by the 2nd Besides this where the bowels are good etc. & it will do well give bark. Give wine, porter, etc. and indulge, but do not force the patient to generous diet In the suppurative stage give poultices & sat. cerate. Sometimes relief will be great from removing sloughs. Case in which the whole [gastrocnemius] muscle [illegible] removed, with relief & a cure Death from mort. even if external is sometimes very sudden. In 44 some such cases I have suspected phlebitis might have been the cause Hiccup has been called a fatal symptom, but I have seen it occur in the suppurative stage & yet the patient recover When the patient sinks, vomiting diarrhoea hiccup etc. comes on sinking of the pulse, cold sweat mortal restlessness etc. As to amputation in these cases, it must not be done if the whole limb is affected, but must be in cases of dead toes not spontaneous and other such for we must not expect a good separation, spontaneously to occur. As to time it was long considered as a certain axiom to wait until a complete line of demarcation is formed Baron Larrey was the first to change the practice Others here imitated him Prof. H. was at first driven to the practice by a hemorrhage of the post tibial art. He has never known a case where the limb has separated of itself. Though it has occurred undoubtedly 45 When mort. takes place spontaneously & from const. causes it will be of no use to amputate, but it should be done when preceding from fire, frost or erys. infl. Prof H. has always found the arteries of the toes, in such cases, ossified Sometimes in such cases it will be proper to amputate high up upon the thigh. Chronic mortification requires amputation occasionally especially of the limb is amputated high enough. In general however we cannot expect much success from amp. in chron. mort. Prof H. has known many deaths are often very sudden in such cases, and unaccountable. The line of demarcation is at first red, and afterwards whitish 46 Hectic fever. This was formerly thought to arise from suppuration but it occurs from irritation in chronic infl. of joints etc. when there is no suppuration. Prof. H. thinks it has always a local cause & is never idiopathic Unless it attacks suddenly and violently as after opening a lumber abscess it generally comes on insensibly It may be divided into acute & chronic acute when sudden and violent chronic when coming on gradually and continuing a long time, as in phthisis tubercularis Commences with a chill, and a hot fit In the midst of a hot fit a chill may occur. This was considered pathognomonic by Heberden. Considerable cough & expectoration of purulent matter may occur when the disease is produced entirely from a local cause & one not seated in the lungs & may be removed by amputation as of white swelling. Parox 2 in 24 h. pulse sharp Sweating generally occurs 47 only after an abscess is open as in disease of the hip joint, lumbar abscess etc. A good constitution is no safeguard neither is youth, where a cause, as an abscess exist. The chance of restoration of the local part is greater in the young, but the rapidity of the hectic is much greater in the young It is in them that we have galloping consumption” Indications are 1st to remove the cause 2nd allay & abate symptoms irritation 3d support strength 1st Open abscesses etc. We may warm the [illegible] when about to open an absc. that we esp. the sym. will be [illegible] for a time. 2nd to abate the symptoms restore the secretions by calomel relieve irrit. by opium not. but op. will stop the diarrh. whch often occurs Relieve thirst by acid cool drinks Keep the bowels soluble by cal. at first, afterwards by rhubarb etc. or if cath. exhaust too much use injection 3d To restore strength use opium also This procures sleep etc. Give bark also. Sulphuric acid has been much used but Prof. H does not think it anything more than a pleasant article Give nutritious 48 food. if the patient will take no stronger food, he may sometimes be kept along for sometime or milk porridge & similar articles Be very particular in searching out the cause. Case of young married woman with hectic. The unsuspected cause was the breasts cured by opening Wounds. Solutions of continuity in a soft part. There is a great variety in their nature & the part affected Symptomatic, or inflammatory fever usually follow considerable wounds This in good constitutions & when the wound is not too severe is generally short & easily subdued Six kinds 1st incised 2. punct. 3 lacer. 4 contusa 5 poisoned 6 gun shot 1st Incised wounds. The edges immediately retract but the first thing is to stop the haemorrh. by pouring or cold water by a short compression with the finger or lint. sometimes 49 by elevating the limb, as in wounds of the foot by the dressing merely if the wound is slight by exposure to the air. If a large artery is divided, it must be tied, but in small arteries completely dividing the art. will often answer as a substitute for tying. Tying should be by pulling out with forceps if possible, if not with tenaculum. Use a surgeon’s knot for large arteries. It is convenient else in the 1st knot from not slipping Leather ligatures shd be made of French kid (with the epidermis peeled off) & rolled round. Buckskin will answer. Leather tanned with bark will not be absorbed. Small ligatures are now used, in order to cut the int. & middle coats. Lec. haem. is now less common Mr. Lawrence recommends silk ligatures, cut close off. The knots however sometimes suppurate out. Prof. H. has no experience of this method The old method of tying with a needle is not now used if it can be avoided Other mode of stopping haemorrage 50 are by styptics, by compression. The best mode of applying pressure is by placing a [illegible] of lint on the artery & holding it there with the thumb Fungus as lycoperdon, agaric astringents as alum act. cautery The latter is especially convenient in the mouth. It is used in other cases also by the French. Re Remove foreign bodies Bring the edges together After cleaning the wound of blood & coagula. bring the edge carefully together, & apply adhesive plaster. Mode of applying them Begin at one angle etc. Leave about a quarter or an eighth of an inch between the strips. In the large town they use plaster spread by machinery & plaster cloths but they do not hold so well as if recently spread Mr Liston recommends glazed [ribands] smeared with a solution of isinglass & brandy 51 The main indication for a strong plaister, and made of material which will not irritate the skin Do not dress a second time at all unless there is some indication for it not under 3 or 4 days Where artery has been tied, do not dress under a week or 10 days Dress as seldom as possible unless called upon to do so by accumulation of pus, or offensiveness of discharge etc. When you dress, do it after carefully washing and softening the old dressings and if the wound is large and open apply a new strip of plaister after removing one so as to have but one strip off at a time Inflammation should be guarded against thought it is the fashion with many to make no applications but the dry dressings. Prof. H. has been led by experience of both methods to prefer wetting the dressing with cold lotions in the robust, & [illegible] tepid nor the feeble & 52 delicate, if they prefer it Where it is of consequence adhesive straps be sure to hold wait a few hours before you wet the dressings In longitudinal wounds of the limbs the rolling bandage, with one end drawn through a slit in the other will be a very useful adjuvant Splints also may be necessary. A proper posture is of great consequence Haemorrhage continued. Jones found that small ligatures cut the inner coats and thus promote the closures. Vide his work on haemorrhage. Torsion of arteries another mode & may be useful in the [orbit] of change for instance When called to a wound, if the hemorrh. has been already stopped by dressing, the cautious about removing them for fear of reproducing the haemorrh. Generally let the first dressings remain about a week Secondary haem. may occur Prof H. has been obliged to tie arteries 6 weeks after the wound An artery should not be tied in an old wound. The wound shd be 53 dilated It will not always answer to be the artery at a distance on account of the anastomoses In the first place where a limb is bleeding freely, apply a tourniquet Much has been said about the reunion of parts totally separated. Prof H. has never succeeded, where the separation has been total Yet othes have succeeded The diet shd be attended to We expect more or less fever, and of course a moderate and generally vegetable diet shd be prescribed. Sometimes also bleeding & cath. may be needed Generally [illegible] the fever subsides readily Sometimes pus forms underneath and must be let out Punctured wounds Shd be dressed & the attempt made to heal them in the same was as incised wounds They are more difficult to heal however much const. irr. may ensue 54 Suppuration is apt to come on It is necessary to dilate if the symptoms are very severe and the local pain and inflammation are very severe. Case of a lady in convulsion from a prick on the toes relieved by dilating the wounds to the bottom (Dr Phys.) Where other means fail of relieving the symptoms, then dilate freely. Tetanus is oftenest a consequence of punctured wounds The cases of idiopathic tetanus which Prof. H. has seen differed much in the symptoms from traumatic tetanus & he thinks the dis. is different Pathology of tet. is very obscure. Some have thought the spinal marrow the [illegible] other can find no disorganizat. there Tet. takes place about 10 days after the injury Wounds producing it are less liable to inflam. and may have healed up & from their insignificance have been forgotten entirely by the patient Commences with stiffness of the jaws, as if patient had taken cold 55 The stiffness increases. Spasms in the jaws & neck come on which increase and affect the dorsal pectoral and abdominal muscles The pat. is drowsy after a spasm and requests to be allowed to sleep The bending generally is backwards. Prof. H. has never seen a case of [empusthotonos] The spasms grow more violent & the patient generally expires in one. An effort to swallow may bring on one. A good constitution is no security. If the pat. is to recover the species grow less violent. After recovery a stiffness remains of the jaw for some time I have known a stiffness of the muscles of the back remain for a year. Treatment 1st local open and dilute the wound endeavour to excite inf. (according to Dr Rush’s plan) by corr. sub. in the wound Baron Larrey recommends act. cautery 2nd const. treat. Sometimes Prof. H. bleeds always gives cal. Some bleed enormously and have cured 56 Dr Phys. applies mercurial ointment until salvation is produced. All give opium largely some by injection Chapman gives injections of antimony & succeeds Arsenic has been strongly recommended, in large doses All remedies must be in large doses, for small ones do not affect the system. The bowels are costive & not however in consequence of opium Cath. must be given. Croton oil promises well Hamilton’s cases tetanus cured by cath. were merely idiopathic cases arising from irritation of al. can. Amputation has succeeded where there were spiculae of bone have irritated (with thumb) Prof. H. tried it in the case Bark & wine have cured (Hosack) Alcohol (Rush) Case of a young man who had cut his foot with glass. When he first began to have tetanus he would fall on the blood & his mother thought him rheumatic. Cured 1st large bleeding [illegible] cal. spasm continued laudanum beginning 57 with 25 or 30 drops (any strong SS) increasing to 40 & eventually a teaspoonful frequently reputed. After recovery his neck was bent back for a long time. Case in London Cal. grs 6 once in 6 hours Ol. turp zii – zj ol. oliv. by injection gave the most relief & first checked the disease They were given 3 times a day. Opium seems to do no good & was relinquished. The woman was long in recovering So that his case was not the most violent Lacerated wound have been supposed to require a peculiar treatment not to attempt the union by first intention There is little or no hemorrh. Prof. H. however brings the edges together & keeps them in contact by adhesive plaster keeping the dressing wet He has had much better success Often they heal principally by the first intention. The injection of the cell. memb. with lymph, and swelling etc. is prevented The only systematic writer who has as yet recommended this practice is Mr. Mann. 58 Poisoned wounds The bite of the rattlesnake is an instance Some persons seem to suffer very much from the stings of bees & wasps It is a question whether the bite of a rattlesnake is injurious by absorption or by an affect upon the nervous system merely Some late exper. seem to prove the former opinion Symptoms of phlebitis have appeared to show themselves in some of these cases The tendency to gangrene is very strong Remedies At first excision caustic ligature. The French use muriate of ammonia as a strong caustic (old butter of ant.) After the first stage apply blisters and treat as for erysipelatous inflammation. For the const. shock & exhaustion ammonia seems to be best article opium also Cordials and stimulant are strongly indicated Case of a man in St Lucie [colub???] [illegible] stupid in ten min. amput. of finger which was not felt 8 grs arsenic in 4 hours cordials mint water laudanum spts terp. amm. & ol. oliv. in a liniment for 59 the hand Cured in 10 hours Several persons had previously died of the bite of this serpent Case of a woman stung near the eye Cured by bleeding & calomel A young woman died in 20 m. after being strong with leg [illegible] Hydrophobia. Prof. H. has always cut out the part. It seems to answer Prof. H. has performed excision 6 days after the accident no hydroph. followed Dissection wounds A wound seems to be necessary. Various circumstances are supposed to predispose, but Prof. H. thinks they are not necessary & that the most we can say is that the inoculation does not always take Symptoms infl. of the wound redness of lymphatics all along the arm Const. sump. very severe from the first, great prostration, restlessness etc. Suppuration forms along the arm in the axilla or under the pectoral muscle or within the pleura Or the patient may recover with a suppuration of the finger, & perhaps 60 a loss of the finger Prof. H has seen the same symptoms take place to the greatest extent from wounds of simple puncture e.g. from [illegible] of fist in N. Haven from a fish spear the latter case related wounded the tendon of the gastroc. while wading suppurat. all along the leg in the axilla finally in the pleura Prof. H. has had his own fingers very sore & for a long time after dressing gangrenous ulcers & has known women effected in this way from washing bandages losing the nail etc. Caustic should be applied to the very bottom of the puncture & not merely on the top. Contusions. Injuries of the vessels & a rupture of their contents without breaking the skin. Ecchymosis or “black & blue” In favourable cases the extravasated fluids will be absorbed In others the colour changes becomes mottled and yellow etc. The effused fluids often descend in the direction of gravity & produce discoloration in another part 61 In dicutions 1st to prevent further effusion by keeping cloths constantly moistened with ac. pl. or cold water. 2nd prevent inflammation, by const. rem. if necessary 2d to promote absorption, by fomentations & [sometimes] application camphor and soap etc. It may be necessary to let out the effused fluid Sometimes these “bloody abscesses” as they are called by the French shd be opened at first. Case of a man whose foot had been crushed in a saw mill pain absolutely intolerable relief was given by letting out about ½ just of effused blood Prof. H. can derive no rule from the coagulation of the blood The blood is generally dark fluid tar like If means for absorption fail we must make an incision. This will oftenest be the case in the old and especially when the effusion is in a bursa as that of the patella. Prof. H. has often been obliged to open the bursa of the patella open on the outside of the tendon of the rectus 62 On the olecranon also the same state of things occurs absorption here is uncommon. Serous effusion is apt here and elsewhere to follow the letting out the blood If the abscess does not heal, inject corr. sub. & probe the abscess every day Often a part of the skin is killed if this is the case, puncture through the dead part. Contusions of abdomen kick of a horse The peristaltic motion is suspended the abd. immediately swells constant vomiting great anxiety of continuance etc. mortal restlessness no sleep etc. Blood may or may not be united Vomiting may be of blood and immediately. Bleed at first the pulse will rise after it repeat it bleeding gives great relief the patient will call for it [illegible] Apply cold lotions bandages to the abdomen. Purge with large doses of calomel & injection until relief is obtained. Blister early if there is great pain 63 In the progress of the treatment a blister may be applied to the abdomen The thirst will be very great and is to be relieved with cold water These cases are very severe The abdomen will infl. up suddenly after the blow, before there is any time for inflammation & immediately vomiting of blood may supervene Case A young man in Prof. Brown barn yard. Vomited blood all day warbled 2 or 3 times Large quantities of calomel In two or three days was able to be removed A phys. who had received such an injury called for repetitions of the bleedings saying that they afforded his great relief After the first stage cordials etc. may be necessary on account of the shock of the system. Or at the first where there is no vomiting etc. Blows on the pit of the stomach may extinguish life 64 Strains Hardly known to writers except Boyer Extension of ligaments with rupture. Joints subjet are those with but little motion and strong ligament viz knee ankle, wrist, fingers & toes. Shoulder & hip very rarely At first the joint can be moved freely in all directions enquire after this to distinguish from fract. & disb. Very soon affus. takes place perhaps a sac of burs-mucosa Dieting from cont. by nature of accident by being treated Sometimes however it may be doubtful or both may be combined The treat however is the same for both Dieting from disloc. (this is of great consequence) Prognosis doubtful Bayer remarks that the ligam. become lengthened Constit. makes great difference rending some more liable (delicate persons) ternia rate in white well. perhaps is scrof . persons Treat like contusion Boyer 65 advises cold water at first. Use tepid water for a very delicate fem. perhaps) For consid. infl. use ac. pl. Some are afraid o fit Prof. H. has seen no injury A bandage moistened will give actual relief instead of pain & will promote absorption Opodeldoc also For great pain apply fomentation or a steam bath. After infl. is subd. apply frict. Give the attendants some camphor perhaps to encourage them in using friction When the proper time arrives use motion & exercise passive at first afterwards by the action of the [muscles] There is a golden time for exercise. A plaister bandage around the joint applied so as to keep the whole joint at rest & firm when pat. first begins to walk let him have a shoe or boot with a stiff sole # Burns Infl. or destruct. of parts by heat No part of surg. more empirical No advantage in dividing into species. It must be remembered that a burn or scald when slight is merely a blister just as from canth. or hot water and shd be treated as a blister, by excluding # not bundled up in blankets more motion 66 the air. Case of a child blistered over the whole body by cantharides & vinegar died If the cuticle peels off immediately after the barn, we may be sure that the injury is very extensive The highest danger is from the shock Often perhaps the [glaze] is inhaled, when the clothes are on fire. Prof. H. has not however with nothing more than a hoarseness from this cause & dissections have not shown much of this kind Sometimes the viscera immediately under the skin are inflamed vide Journals It has been remarked also that child. often die some weeks after the burn unaccountably 3 weeks is the critical period when the suppuration Convulsions often occur in children when after the first shock reaction begins to come on When any application apparently comfortable has been made do not disturb it. Sir James Earle contended for 67 cold water, ice, bleeding & cathartics [illegible] [illegible] on the other hand contended for spts turp. & intern. stim. Prof. H. thinks truth lies in the mean Where the shock is very severe the const. must be supported The best application for the vesicles a simple cerate prick but do not clip off the vesicles. Always have your dressings ready when you take off the old one when the cuticle merely is separated the granulations will be very small and no scar will be left But when the true skin is separated the ulcer will be long in healing & leave a scar The best dressing in the latter case is a mixture of spts turp. & cerate. Rx common basilicon of the shops & basilicon or cerate equal parts Prof. H has seen all sorts of applications. He at first tried Ben. Bell’s plan of ac. pl but it does not promote healthy suppuration. Poultices are very inconvenient requiring frequent exposure 68 to air and being [heavy] Besides they do not promote suppuration When supp. is established the spts turp. cerate will cause smarting and should not be continued then dress with simple cer. Keep on the first dressing as long as you can dress as seldom as possible. Keep the air of the room equably warm [illegible] keep in cold weather a warming pan near the body In the latter stages especially if the sores heal over & break out again use sat. cer. Before this Prof. H uses Turner’s cerate & cer. ox. zinc If granulations do not proceed well use nitrate of silver to touch the ulcers. This is a most valuable surgical remedy. Mr. Higginbottoms plan of applying it to infl. though it produces smarting at first, alleviates irritability & promotes resolution Case which Prof H treated with nit. sil. & simple [cerate] did well Sometimes for the fungus sulph. 69 cupri is better than nit sil. The shock is very severe coma excessive coldness of extremities etc. Ben. Bell advises opium. Be careful how you give opium in coma. Prof. H. gives one dose of SS & follows up with alcohol ext. heat etc. When infl. comes on depend especially upon cal. cath. keeping the bowels loose vide [Motherby] Considerable fever may ensue which is to be treated with cal. cath. Generally the pain is so great as to require op. When supp. is extens. & strength fails give bark Cotton will do well enough for superficial burns excluding the air Prof. H has seen much inconvenience from it in deep burns Case A man fell into a [kettle] of boiling potatoes about half of the cuticle from the head to the feet came off He drank a large quantity of spts. Prof. H. applied spts turp. & basilicon, as above. Next morning fever high bled him cal 70 Afterwards treated with cal. & according to symptoms Supp. came on Barks Finally bark injured & was [emitted] & cal. given ulcers touched with nit. sil. Recovered well & has the use of his limbs Distortions from burns The growing together of the fingers may be prevented by separate dressing. The tendons also may be burnt and contract Then keep the fingers straight by splints The object is to keep them straight they can be bent well enough after healing. So also of the feet and toes Case of a man with a ridge of scar extending along the back of the leg up the thigh like a [illegible] finally a growth of [horn] began finally had his thigh amputated. Cicatrices shd be cured by cutting out the whole scar not by dividing it & suffering it to heal up. This las way fails Case 1 ft long 1 inch wide 71. Frost bites Long continued cold produces a degree of torpor in the system tendency to sleep. Case of Prof. H’s instructor warned his companion not to stop; was the first to stop & endeavoured to conceal himself & rest was very torpid when brought to the fire. So Dr Solander The treatment of a limb partially frozen shd be by rubbing with snow or better by putting into cold water afterwards gradually warming the water A limb thoroughly frozen cannot be successfully managed in this way so as to prevent inflammation The infl. resembles that of burns It may be moderated at first by ac. pl. or spt. & wat. When suppuration comes on treat with cerate etc. When the whole limb is thoroughly frozen, gangrene will come in, beginning as usual with dark & ash coloured spots vesicles etc. line of demarcation etc. Prevent this by amputation The const. not being effected the operation will succeed. Do not delay the operation too long 72 Case Gent. in Brooklyn thrown from a wagon lay the whole of a very cold night when found in the morning was able to tell his name When carried into the house blood could not be obtained When Prof. H. found excitement coming on & bled him “with relief” Soon coma came on Thought the man must die But eventually amputated the fingers very bad leg etc. Recovered The amputation was delayed much too long Prof H. has had many cases of frozen toes He always amputates as soon as possible Case at our Almshouse 73 Tumours Varieties are very numerous 1st encysted 2nd sarcomatous 3 medullary Also malignant & non malignant The former may change into the latter We know little of their origin Abernethy thinks they arise from an extravasated clot of blood Sir E. Home has lately advanced a similar opinion It is undoubtedly true that the nature of the part alters the nature of the tumour as Abernethy thinks (The growth of tumours is somewhat similar to chronic infl.) Near the scalp we often find hairs in tumours. In glands the tumours will have a glandular appearance. In the adipose membrane, adipose tumours Yes there are many exceptions Some suppose tumours arise from hydatids (which are decided to be living beings). But this explains nothing The growth may be rapid or very slow or slow & then suddenly very rapid In general their increase seems to be in geometrical ratio 74 As a general rule when it can be done they shd be extirpated before arriving at large size 1st Encys. tum. are 1st atheromat (curdy) 2 vellic (honey) 3 steaton. (fatty) The cyst is generally firm & opaque Tumours that have no cyst or a very [thin one] are generally sarcom. or medull. There is a kind of tumour of a bluish colour [illegible] within cyst, which appears upon the lips and is considered cancerous Cyst very thin filled with matter like the white of an egg extirpated immediately is the remedy (by dissecting around) Often upon the head encysted tumours are very numerous and keep reappearing Discutient applications have been much tried. They do no good, and often change the tumour into a cancer Caustics may be a successful substitute for the knife in small tumours Such small encysted tumours are [illegible] away by the cancer doctors and add much to their reputation These tumours sometimes inflam. of themselves and this in a few rare instances 75 cure themselves. Generally however the part eaten by the caustic heals up and the tumours continue The only remedy is extirpation. This was formerly directed to be done without wounding the cyst this is difficult without cutting away much flesh Sir A. Coop. mode of [illegible] open the cyst and then everting it with heat The cyst is easily distinguished by its appearance Sometimes from an injury the tumour [inflam.] and suppurates of itself. Then Prof. H. introduces a little caustic kali upon lint Lately however he has often succeeded in such cases in pulling out the cyst Sometimes membranous bands have to be cut Sarcamatous tumours are of very various consistence fatty with fat in large cells fleshy & others Extirpate, by removing [illegible] skin as may be advisable remove as much as possible by the fingers cutting membraneous bands if any removing very carefully from their adhesions to muscles & tendons Sometimes an infl. comes on accidentally and very bad ulcers are 76 formed, and the tumours must be removed even from very old persons to whom they have previously given no trouble Arteries do not generally require to be tied. Then after appear about the perineum and the art. may require tying 2 cases in females of Prof. H. Sometimes these tumours are very vascular case in which from are about the size of a goose egg after the first incision a gush of blood by which the tumour was much reduced in size and was extirpated The largest tumours are adipose even 40 50 & 70 pds Tumours of the scrotum seem to be an enlargement of the nat. parts in whole or in part. Adipose tumours feel like a bag of cotton are very irregular in shape and when the skin is pushed along it rises in ridges, from its adhering in some parts and not in others This last is pathognomic Prof. H. believes the shole parotid gland has been extirpated McClellan Glandular enlargement are apt to be called tumours Enlargement of the mammae will often subside after child bearing 77 malignant tumours are these liable to return Medullary Tumours substance resembles that of the brain Called fungus haematodes may spring from any texture even as Prof. H. believes from the bones They have an elastic feel when under a fascia they may be mistaken for [aneurism] or abscesses They were formerly called cancers Their growth is very rapid Prof H has known one is large as a milk pail upon the thigh. They are most common in the young, but are found even in the very aged. They may spring up in the testicle, in the eye & in every part of the body. They have often been mistaken for abscesses and opened. The only marks of distinction are 1st they are at first deeply seated and do not arise from the cell’ memb. under the skin, but from deep seated part apparently, in many cases from the muscles. 2nd not powerful in themselves only so by pressure & distention of surrounding parts and the pain is generally in a distant part, and will often be 78 attributed to hreumatism 3d Great const. disturbance & hectic The only remedy is extirpation but the tumour generally returns, and others often spring out in other parts of the body. So that the prognosis must be very doubtful. In the progress of the tumours the patient will suffer nausea vomiting & will grow sallow. The patients generally recover rapidly after an extirpation and are much pleased with the success of an operation. Yet the tumour soon returns. From some late accounts Prof. H. is inclined in future to persevere in extirpating. They may be distinguished from chronic abscesses by an elastic [illegible] instead of the fluctuation of pus The skin over them is not tender and sore, as when an abscess [illegible]. Distinguished from scrof. etc. by not beginning in the lymphatic glands If we are in much doubt we may make a very small incision without danger closing up immediately 79 When they reappear you will see at first a small gelatinous vesicle which swells and grows very rapidly Many cases related in which they returned in the same [illegible] other parts Schurrhus or Cancer They are different states of the same affection Schirrhus is a hard cartilaginous malignant tumor. Cancer is the same tumour in a state of open suppuration It has been said that infl. may terminate in schirrhus not so. It seems to result from peculiar action we see that tumour improperly tampered with may terminate in cancer. Most commonly found in the female mammae. Found also on the mucous membranes Cancer of the skin will be treated of under the head of cancerous tubercle of the skin Cancer of the breast for an example Begin with an uneasiness soon a small hard tumour finally 80 inflammation of the skin and the skin adheres the nipple retracts afterwards perhaps an ichorous fluid issues next small knobby tumours next a vesicle which bursts and we have suppuration and an open cancer The suppuration does not always begin on the outside but frequently within the substance of the schirrhus. All this while the pain keeps increasing About this time or sometimes before ulceration, the lymphatic glands begin to be [illegible] appearing like inflamed cords giving the skin a hard puckered appearance. Then inflamed and enlarged glands appear not only in the axilla but in all directions The mamma and the pectoral muscle adhere to the ribs and sternum. The affection may extend to the other breast. The swelling of the glands in the axilla may cause so great an edema of the arm that the skin must be punctured. Effusions take place in the pleura or tubercular 81 consumption comes on. It is not true that the cancer “eats through” as they ] say. Hydrothorax is the most common termination. Prof. H. has thought from the supervention of pains in the back etc. that the disease becomes transferred to the uterus Various other symptoms may occur sometimes a paralysis of a part or all of the limbs sometimes the bones break easily Distinguished from fungus hematodes by being an affection of advanced life by ulcerating and destroying the skin by not beginning in the muscle or bones by being not smooth but knobby by lancinating pains Cancer destroys adjacent parts fung. haem. grows through them Above all cancer is always hard to the feel. As to the great question whether cancer is a constitutional or local affection Other tumours and even simple ulceration of the lip may terminate in cancer. Cancers are very liable to return and most so of their previous progress has been very rapid Schirrhus tumours in old persons give 82 perhaps little pain project little, are very insensible, and the old patients converse to their removal As to curing the Prof. H. does not believe in its practicability Mercury seems to be injurious. Storck introduced conium. Carmichael Smith made iron especially the phosphate, fashionable The London Cancer institution has been abandoned from want of success No remedy seems to promise anything but extirpation by the knife Small ones may be eaten away by caustic but the process is very slow and painful Caustics applied to a large cancer produce great and highly injurious irritation Prof Smith never knew a female with cancerous breasts survive caustic for a year It is impossible to say how long it may be before the return in one case 7 years intervened Much is said about the incurability of them after they have become open ulcers. This distinction is not a good one. When you extirpate be sure 83 to cut out all the diseased parts including the infected glands Persevere in extirpating as long as they return, if complete extirpation is practicable in each case. Never amuse the patient with the prospect of a cure by any mode of treatment Prof. H. has extirpated one hard cartilaginous schirrhus of 4 pounds weight Patient recovered for the time Superficial cancer Occurs oftenest in the lip Generally commences with a small crack in the lip which is neglected A scab forms, and upon examination at this time we shall find a hardness beneath The glands under the chin or under the side of the jaw, swell & harden Ultimately the lip becomes excavated, with an ulcer which has cartilaginous edges Finally the whole lip, jaw etc. are eaten away & the patient dies miserably Caustics are generally very injurious. Excision is made by taking out a v0shaped piece Richerand advises to take 84 off the whole lip the lip afterwards elongating This mode not so good As to cancer in other parts Prof. H. has known ulcerated leg terminate in this way and once case of necrosis With respect to the cancerous diathesis or a disposition in the constitution there may exist something of the kind but the practice of telling patients that they have a cancerous humour in the blood is very reprehensible making them very unhappy Extirpation is not necessarily followed by reappearance Cutaneous cancerous tubercle of MR. Lawrence. Commence with a small insignificant tubercle, hard, resemble seeds of mallows called warts often by the patient but they are vascular they finally ulcerate they may become extensive cancers Old men are subject to them about the face. Women have them in the pudenda Men have them upon the glands penis Prof. H. has seen them about the pudenda 85 in cases of amenorrhoea emit blood periodically at the menstrual periods. These cancerous tubercle may occur about the eye and the nose. The success of extirpation is far greater in these cases than in common cancer. Be careful to cut far enough with two semilunar incisions They leave no scar. These cases are different from noli metangere. Noli metangere Intermediate as it were between cancer and common ulcers. Appear about the face and nose An ulcer forms 7 becomes covered with a scab. The ulcer is often irregular & oblong. They are often converted into cancers by caustic In the course of time the scab comes off permanently and an open ulcer continues The ulceration of noli metangere may affect the cell. memb. or the cartilage of the nose or they may not even penetrate the true skin. The best remedy is arsenic The most common form is an oint. of which arsenic zi to zi cerate. Apply a plaister 86 of this one day and then a plaister of common cerate or satur. cer. for a few days. Inflammation S. Cooper uses 4 gr. to 4 oz mint water & 1 oz spirit applied in lint. Sir E. Home applies a solution made by boiling A powder also of arsenic & tapis caliminaris Others apply sulphur & arsenic Fowlers solution also. It seems that any form of arsenic will answer. Prof. H. has cured also by nit. sil. also by red precipitate ointment Occasionally touch with nit. sil. to promote the healing in the latter stages There seems to be little need of the old plan of giving constitutional remedies A disease similar to this if not [proceeded] to far If the cartilage has become affected cut out a piece. If the eye has become affected extirpate the eye. There seems to be nothing specific in the cure of noli metangere other ulcers also are to be treated by exciting an action in this way. 87 Prof H has known the experiment of low diet also of a diet of [illegible] thoroughly in use of cancer but without benefit Subcutaneous tumour in the cellular membrane It may occur in any part covered by acutis vera not on lips They are about the size of a walnut excessively hard First mentioned in Cheselden’s anatomy (calling them a tumour of the nerves) Described by Mr. Wood in the Ed. Journ. also & by Mr. Lawrence in his lectures Very painful skin is emaciated and adheres looking like a cicatrix painful when the cloths rub over them, or when they are struck or examined. Not dangerous but troublesome May continue many years (20 Mr Wood) without charge. Extirpate them 88 Ulcers A solution of continuity which gives out pus. Absorption goes in faster than deposition opposite to the process of healing a wound by granulation Caused by wounds opened abscesses, injures caustics, acids irritation of foreign bodies Constitutional causes are syphilis scurvy scrofula and a predisposition in some families to sore legs Varicose veins, oedema, dropsy, phlegmasia dolens are causes 1st simple 2 irritable 3 indolent 4 varicose 5 specific 1st simple an open sore after a time a bluish skin covers the sore & becomes a cicatrix This is cuticle not true skin. The part underneath is hard cartilaginous In simple ulcers as much benefit may be derived from adhesive straps to approximate the edges as in [wounds] 89 Place over them a compress & bandage If the granulations rise too high (proud flesh) touch with nit. sil. or sulph. cupri. Another advantage of bandaging is to prevent the swelling. Bandage a whole limb. Irritable ulcers painful the adjoining parts sore granulations absorbed bitter smooth Often irregular in shape sometimes however round and cup shaped. On the shins small sized These ulcers do not bear bandaging Frequently touch them with nit. sil. Sometimes however they will not bear this. in this case then apply a solution of nit. sil. 3 or 4 grs. to 1 oz. or corr. sub. 10 gr. to 1 pt or the yellow wash lime water 1 pot corr. sub [illegible] ? or sprinkle on calomel or black wash which is milder than cal. z2 cal. to 1 pt lime water or apply the blacker oxide this generated Also zjfs op. to 1 pt water. Also saturine 90 cer. Also ac. pl. zj to 1 pt of mucilage of slippery elm, when parts are excoriated Warm fomentations and poultices shd not be continued long they are too relaxing We are obliged often to try a variety of applications Indolent ulcers Usually large granulations lax and flabby discharge serous a substance like curd white or yellowish or brown lies upon the surface. Ulcer excavated as if cut out with a knife surface smooth no granulations edges swollen making the ulcer appear deeper surrounding cell. memb. hard Very insensible Patients will continue to labour as usual they apply spirits salt and vinegar urine etc. with no effect In the species also apply nit. sil. 2 or 3 times a week corr. sub. dilute nit. ac. 100 drops to 1 pt. is a good application red precip zi 91 to zi of cerate is an old application Above all other modes is to be recommended the plaister bandage Take common adhesive plaister or dyachylon having a plaister soft enough to spread & yet adhesive soften with tallow or lard if necessary Apply the strips of plaister so as to approximate the edges Then apply a compress & bandage the whole limb. Leave a little interval for pus to escape, or cut a little hole for the escape of the pus Leave the dressings on as long as possible say 3 or 4 days in hot weather it may be necessary to dress every day the sore becoming offensive You may let the patient walk about during the cure, if in this mode Sometimes an erysipelas commences in the neighboring parts And sometimes the ulcerations suddenly spreads with rapidity Surgeons speak of a sloughing 92 ulcer But all ulcers may exhibit this appearance After the erysipelatous infl. suppuration sometimes takes place in the cell. memb. Varicose ulcers Varicose veins accompany them either in neighborhood or over the whole limb May be cured by proper bandages They are ulcers from injury of varicose veins Bandage the whole limbs In the hospitals the patients can be cured of ulcers more speedily than in private practice but they are very liable to a relapse When pat. apply to Prof. H. with a high state of infl. & irritation in consequence of an ulcer, he bleeds But if pat. is cold in extremities feeble etc. he gives cal. & op. as recommended by A. Cooper Prof. H. had however given them long before seeing his work 93 For varicose ulcers cutting the vena saphena is practiced in the Mass. Hospit. (cut inside the skin) In the Penns. Hosp. they cut out a piece after emptying the vein by means of a bandage Mr [illegible] destroys the vein by caustic kali Tying the vein is not to be recommended Cases in which sore legs have become cancerous from tampering with them Propriety of drying up old ulcers The prejudice probably has arisen partly from the drying up of old ulcers after and attack of fever Prof. H. has been in the habit of healing or attempting to heal every old ulcer. He has never either known or heard of a well authenticated case of injury resulting They frequently however break out again If plethora arises it would be much better to bleed etc. as directed by A. Coop. 94 Specific ulcers are syphilitic noli metangere scrofula etc. etc. Some ulcers cannot be classed Sir E. Home speaks of a peculiar sore upon the ankle which yield a serous discharge and covered with scabs Apply after softening the scabs with a poultice and washing them off, cal. or nit. sil. or corr. sub. or ac. pl. with slippery elm or poultices with narcotics cerate sat. or dyach. S. Cooper mentions fungated ulcers upon the calf of the leg nit. sil. or sul. cup. And to prevent apply ac. pl. Occur in corpulent young women especially ‘ those who work in factories and stand much on their feet & live pretty well. Prof. H. has known several females affected with varicose veins & ulcers after phlegm. dolens. Scrofulous ulcers are long in bursting flabby fungous granulating overhung by the think skin upon the edges of the 95. ulcer skin sometimes purple. Apply nit. sil. under the skin and if necessary clip off this skin at the edges. Sometimes there is only a very small orifice in the skin. In this case if they do not heal lay open the ulcer & touch with nit. sil. They will then soon heal. Introduce a stick of nit. sil. upon a quill through the opening and touch all around Diseases of Mammae Vide A. Coop. Lect. by Tyrrel Hydatid or encysted tumour not the hardness of schirrus, skin not discoloured after a while a fluid is felt when upon puncturing serum issues but soon collects again. The tumour may be even 13 lbs in weight not painful Generally a dis. of advanced age sometimes attacks at 20 yrs Upon dissection, one or more cysts are formed the body of the breast not being much affected Sometimes the cyst inflames & 96 suppuration may come on and destroy the patient. Tents and stimulating injections shd not be used they may prove fatal. Diagnosis absence of pain const. not affected swelling smooth firm & hard fluid clear. Cure by extirpating It will not return Simple chronic tumour of the breast. Not hard like schirrhus appears superficial (schirrhus feels deep seated) grows slowly not very painful. Extirpate. Does not return. The tumour seems composed of lobes like the sweet bread (pancreas) Cause unknown though by some to arise from pressure of cloth Adipose tumour of breast Seated sometimes under the gland occasionally of enormous size 14 or 15 pds. The large tumours called cancers which are extirpated are Irritable breast Lobe of the breast slightly swollen and 97. tender pains in the shoulder amenorrhoea irritability of nervous system Do not think of extirpation Bleed the plethoric give sub. & opium etc. Apply spt. & wat. or lard & laudanum or sometimes litharge plaister. Often what is better than all is a piece of soft fur or cotton wool The main thing is to quiet the alarm about cancer. These cases occur in a neighborhood where an operation has been performed Ossific tumour Extirpat Lacteal tumour Soon after parturition Caused by an obstruction of a lacteal tube Introduce a lancet and let out the milk & then pencil with lunar caust. to stop the flow of milk Abscesses of breast that let out milk, by sloughing off a part of a lacteal tube. Touch with nit. sil. Some women are subject to abscesses when the child is 6 mo. old Wean Enlarged breast Generally diminishing upon child bearing. Suspend 98 the breast The breast sometimes enlarges and is painful during pregnancy Bleed. Calomel etc. Operation for taking off the breast. Always remove the whole glandular tumour of the breast except in the case of the simple [uremic] tumour. Instruments 2 or 3 scalpels 1 tenaculum needle ligatures, sponge a broad bandage to pass around the body straps to go over the shoulder [illegible] compresses cordials a pitcher of cold water Place the patient on a table with the feet in a chair An assistant holds the arm at right angles to the body Make the first incision in the longest direction or otherwise in an oblique direction Make two incisions to include diseased skin if necessary and always include the nipple which shd never be left Be careful to make the incisions long enough If two incisions are to be made make the 99 lower one first Then dissect down first on the lower side then on the upper & finally at the bottom The most painful part of the operation is the cutting through the skin The glands in the axilla can frequently be borne out and always when you have fairly cut down to them pull them partly out and then divide the membranous bands this is much safer than to cut around them in the dark Prof H. removes the lymphatic glands first and makes a handle of them instead of making a handle of the breast as recommended by Gibson Wait awhile before you dress the French surgeons say ¾ hour. It is very unfortunate to be obliged to [illegible] the wound. Give but little medicine, as a general rule after the operation Usually in about 4 days the wound must be dressed with dressings become offensive. Dress as at first The nervous irritation and the shock 100 to the system is great in proportion to the length of time taken up in the operation Be careful not to move the arm before the healing of the wound After the healing of the wound remedy the stiffness of the arm by motion Other tumours are extirpated in a similar way. It is too much the fashion to tie the large arteries (as to carotids) at the present day and the plan of tying an artery for the sake of stopping the growth of a tumour fails Fistula Lacyrymalis This name has been given to nervous affections which obstruct the nasal duct. 1st Enlargement of lac. sac is most common 2nd Suppuration of lac. sac. 3d an open ulcer of the lac. sac 4th ulcer with aff. of [illegible] or with nasal polypii Prof. H. has never seen a case of obstruction of the canals leading to the sac which is a 5th kind. 1st Obstruction of nasal duct by enlargement of the sac. May be of 15 yrs standing without going further Most common in females who work over the fire & live in smoke Generally the duct is only partially obstructed Tears flow over the cheek sometimes a gelatinous fluid issues & glues the eyelashes together. There will be a sense of fullness and the patient will press the corner of the eye & a fluid will issue into the eye & down the nasal duct. Tears flow more freely with smoke & in cold air (Sometimes the distention of the sac is large as large as a hickory nut and is mistaken for a tumour (encysted) Some patients in this stage are unwilling to have any thing done Prof. H. has often succeeded in curing the disease in this stage by remedies for infl. sol. nit. sil. dropped into the eye anoint the edges of the lids with red precipitate sat. cer. or citrine ointment ac. pl. Give calomel Prof H. has never used either the probe or the injecting syringe He has seen no account of cure, performed in this way. Mr. Liston disapproves of them. Prof. H. has not used them because the diseases cured by the above means or passes into the second kind 2nd Suppuration Open the abscess and introduce a stilette 3d An open ulcer with complete obstruction. Introduce the stilette. And generally make a new orifice with a small round edged scalpel just below the tendon of the orbicularis. Sometimes Prof. H. has not been able to introduce the stilette at first and has first used a sharp steel knitting needle. Some introduce in gold silver or lead canula Mr. Liston condemns it The stilette will not completely obstruct the passage the tears will pass down Prof. H. has never found it necessary to pierce the os unguis a practice which Mr Liston condemns the hole closes again Let the stilette be worn about 6 mo. occasionally cleansed little syringing is necessary Sometimes a fracture of the nasal bones is the cause. Treat as others 4th Prof. H. has seen no cases of affection of the bones (e.g. venereal) If polypus is the cause cure it The treatment of fistula lach must be varied according to the degree of the aff. its cause & the constitutional health Sometimes, says Mr Liston, the gland and sac & duct are wholly obliterated without inconvenience to the eye Aneurisms 1st true 2 false 3 varicose 4th an. from anastomosis In the true all the coats are not ruptured but all of them are distended equally forming a tumour with an orifice communicating with the artery which is smaller. It is maintained however that the arterial and middle coats are ruptured Begins with a small tumour pulsating externally & when small all the contents may be pressed back into the [illegible] artery. When lager the disposition of lymph prevents this As the tumour increase the pulsation is disagreeable more or less pain numbness from pressure on the nerves obstruction of the progress of the blood which [last] often causes hemorrhages in distant parts as, abdomen [heart] etc. Absorption of soft parts or of bones may be caused Cartilage however being the most indestructible parts of the body resist the absorption In aneurisms near the surface the pointing is towards the skin & ultimately a slough is formed [illegible] the patient dies of haemorrhage. Internal aneurisms besides pointing to the skin point towards a mucous or serous membrane in the latter they make a rent. Causes; wounds, injuries, mistakes in bleeding. From the latter cause The 2nd species or false aneurism arises from a wound of an artery by mistake for a vein the blood is contained in the cell. memb. 3d Varicose aneurisms happen from mistakes in bleeding, the lancet being carried through the vein into the artery The blood at every stroke of the heart issues into the vein (which has adhered to the art.) with a whirring noise & feel. By pressing upon the artery above, or on the cicatrix this whizzing may be stopped Causes of aneurism are very obscure There seems to be a disposition in the circulating systems of many persons. It has been found in many instances that the coats of the arteries in the neighborhood are diseased being brittle etc. [Postillions] & cavalry soldiers are thought to be more liable to aneurisms in the lower extremities Porters who lift heavy burdens are thought to be more liable. Old persons also Occasionally they have spontaneously cured themselves probably by the filling up of the cavity, and the subsequent absorption Treatment. Valsalva’s plan was by bleeding the lowest diet External application of ice has been proposed Ligature of the arteries has superseded every other plan History of the various modes things necessary 1st a small round cord 2n tied very tight 3d the vessel shd be detected as little as possible 4th the aneurismal tumour shd be touched # as little as possible Vide Coop. Surgs Dict One ligature only is now used The first cause of danger is from interruption of the circulation producing perhaps gangrene The second is from const. disturbance both from the operation & probably also in some cases from the interruption of the circulation. Thirdly from secondary haemorrhage Cut one end of the ligature short. Mr. Lawrence cuts both short and lets the wound heal over the ligatures afterwards finding their way out Warm the limb by hot flannels Take care however not to burn the patient who will be very insensible # Vide Prof. Knight’s lectures Mr Wardrop proposed to tie the artery beyond the aneurism as in the arteria innominated in order to check the circulation The operation seems not to have succeeded Varicose aneurisms are more or less inconvenient but not dangerous and are all pretty much alike After the wound of an artery we often meet subsequently with a small pulsating tumour which occasionally bursts & bleeds and are obliged to cut down above and tie Waevae Maternae In small tumours of a reddish or purple colour & at consist of a congeries of vessels They are called marks and denominated cherries, strawberries, figs etc. according to their colour and the recollected longing Sometimes these enlarge and have a doughy feel or are pulsating and enlarged when the child cries When the skin in the neighborhood is purplish the tumour is called aneurism from anastomosis Sometimes these marks ulcerate and perhaps extensively Sometimes aneurism from anastomosis occurs in adults without any previous congenital affection the vessels enlarge and are tortuous, and the tumour may be even pulsating from a considerable distance distinguished from [fung.] haem. by pulsation from the first by its originating near the skin by freedom from pain unless after ulceration etc. etc. They sometimes grow to a great size and came to a very troublesome ulceration Congenital [illegible] are sometimes fatal from their great size etc. The congenital [naevi] are to be cut off if practicable where they disfigure Aneurisms from anastomosis have been cured by caustic & by spontaneous ulceration We may as Abernethy recommends apply cold lotion constantly, as ac. pl. The most effectual mode of cure is by extirpation. Cut out for the haemorrhages though considerable is for less than if they are cut into. Cut quickly & let the assistants check bleeding with their fingers Another mode which is calculated to avoid haemorrhage, is that of ligatures passed through & around. Marshall Hall has introduced the plan of piercing through with a white hot needle the tumour then gradually sloughs away In cases of ulceration of the tumour Prof. H. has succeeded by the constant application of nit. sil. caustic. Another mode of [illegible] them has been proposed & practiced by inoculating them with vaccine matter Tying the principal artery leading to the tumour has succeeded, but the plan is now going into disease e.g. carotid, art. when the tumours are upon the head Collections in the Bursae mucosae Not abscesses, which have already been treated of These collections may be fluid curdy or (by absorption of the liquid part) solid. “I have seen more than a gill of something like boiled rice” (Prof. H.) in the wrist. On the patella they resemble a half of an orange # The joints of the toes also get sore Old persons have corns Prof. H has also known in chronic cases the serous part be absorbed and several hard bodies are left he has extracted them without injury. He has known a creaking noise from the cause in the wrists of reapers Treat by ac. pl. finally by a succession of blisters. Bandage tightly to promote absorption If they have suppurated in toes of old persons do not amputate but heal with nit. sil. Ganglions which resist these processes shd be opened & squeezed # N.B. There is a bursa between the skin & the patella Classification of Poisons Prof. T’s attention has been turned to the deleterious effects of medicines from the commencement of his practice 1st Exhausting poisons which extinguish vitality almost as soon as lightning in excessive doses e.g. prussic acid. The measles do not contract & the blood does not coagulate (the last efforts of its vitality) Found in the animal kingdom e.g. fish bites & stings They produce no lesion but destroy vitality 2nd Narcotics (simple & pure) 3d Acrid narcotic (not acrid & narcotic but a peculiar sort of narcotic power which produces no coma e.g. veratrum) Those acrid narcotics are evacuants or non-evacuants. The former kill more speedily 4th Irritant poisons which produce irritation & inflamm. e.g. the salts, the acids & the caustic alkalies 5th Composite poisons which possess several or all of the above kinds of power 1st Exhausting poisons are fish, bites, stings There is considerable mystery upon the subject of poisonous fish The same poisons well sometimes be preserved and sometimes escape. Some will be effected & others escape We have abundant evidence of this but cannot explain it. There is equal mistery about poisonous mushrooms probably some can eat every sort. In the north of Europe every kind is eaten Poisonous fish are more common in tropical climates Even the same fish appear not to be poisonous in cold climates Several species of crab & lobster cancer (sea lobster) cancer miricula (land crab) our common lobster is poisonous to some Clopea murina a species of shad mitylis edulis ([illegible]) is apt to be poisonous in tropical climates Vipera verus (European viper) [illegible] several species (the black snake genus) Cobra di capello [illegible] [illegible] which last is however probably not worse than the candisona horridus (rattlesnake) & the candisona durissi [illegible] in the southern states the commencement of the symptoms Commence with languor, headache, [nausea] oppression, pricking in the skin, hands & feet articaria etc. etc. Spams of abdominal muscles, [illegible] etc. convulsions, coma etc. death When recovery takes place the cuticle comes off, the hair comes off. The strength is long in returning etc. Good calls these symptoms colica cibaria They constitute cholera or diarrhoea as much as they do colics. There is no cessation of peristaltic action as in colic The tormina is not caused by it The tropical writers say that it is of very little consequence whether you evacuate the food or not that vomiting at first will rouse the patient but in the latter stages the patient will often die in the act. They recommend stimulants & nervines above all alcohol also capsicum, [ether] [amomum] granum paradisis etc. etc. opium Those are said almost infallibly to cure even if the disease is far advanced The best emetics are mustard distilled water of ranunculus flammula, which vomits speedily & with no nausea the next best is the bi per sulph. copper then sulph zinc then turpeth mineral The common account of the effects of the bites of snakes is also meagre They are said to be in India pain in the wounded part violent acute burning pain with part. tumefac. in the adj. parts in slight cases the effects stop here otherwise the whole limb & perhaps the whole body swells Colour of the bitten part is first crimson then greenish livid etc. Sir E. Home found that these local effects proceed from emission of serum. He found also that the patient might die from the abscess subsequently formed in the part Sometimes the death is too speedy for the administration of any remedy. Sometimes the vomiting is such as to prevent the retention of any medicine The topical affection unites the characters of erythema edematosum & anatomicum & the const. syrup those of a cold malignant typhus Post mortem examinations show no lesion except some infl. near the part bitten. Patients generally recover completely, but they often suffer long after One has been rendered hemiplegic Various circumstances, as the size of the snake, the degree of his irritation, the part of the body bitten, the climate the season of the year, the delicacy & the apprehensiveness of the patient etc. etc. vary the severity and the danger of the symptoms The surgical writers make much of surgical treatment But all the surgical treatment, as excision etc. seems to be useless There is abundance of testimony in the periodicals & even in the newspapers that efficient quantities of alcohol are infallible. Prof. T. has also conversed with Dr McBride & the late Dr Osborn of N.Y. who had practiced at the south. Accounts are to be found in our periodicals of giving a gallon of spirit in 12 hours with success. The alc. however is much more efficacious, when combined with acrids Simple narcotic poisons. Gelsenum nitidum. Helonias erythrosp. Datura stram. hyoscyamus hydrocyanic ac. Cicuta maculata which destroys some every year the most active of our poisonous plants though deobstruents destroys life as a narcotic So also conium digitalis etc. & probably also alcohol Good calls the disease producing by such articles colica cibaria comatosa with no propriety. Another set produce common or epileptic convulsions e.g. oil of tansy [illegible], cinnamon nutmeg etc. these destroy life as narcotics however Another set, as strychnos, actaea etc. etc. produce tetanic convulsions Another set are evacuants, as aconitum delphinium helleborus veratrum sanguinaria etc. Simple irritant poisons as rhus venenata, [pumila], toxicodendron & radicens [Hippona??] manchinella The aroideae, especillia leontia clematides dephne mezereon euphorbia lithysis sedum acre Ranunculus anemone pulsatilla capisicum if it can destroy life Those of animal origin are phosphorus, the acids, cantharis the larvae of phalaena menstora The caustic salts as nit. sil. the antimonials, blue vitriol etc. Red precipitate & corr. sub. Carbonate of barytes & the caustic alkalies etc. Glass Collection in the wrist Prof. H. has succeeded in curing after trying discutients by opening them amply and keeping in a slip of linen & keeping up inflammation Ganglion, if they do not heal after being punctured may be opened & treated with nit., sil. to create infl. These collections are apt to be confounded with encysted tumours but the latter grow gradually from a small beginning and are round the former spread quickly and are flattened. It would only be the mellicerous tumours that could be mistaken for these Wearing plates of metal & various mercurial & other plaisters are sometimes used for their cure Prof. H. has succeeded upon the olecranon & patella, after they had been opened & yet filled again by [illegible] & injecting nit. sil. & creating infl. After puncture the part shd be kept perfectly at rest Sometimes it is necessary to inject a second time Hard & cartilaginous bodies in the joints as in the bursae muc. also The two situations seem to have been confounded together. Prof. H. has seen some of them and thinks they are rather hardened lymph, and that they are not cartilaginous Mr. Hey recommends a laced knee cap. Prof. H. has endeavoured to affect the same purpose by plaister bandages They cease after a while to give trouble. Case related in which very dangerous consequences resulted from removing them If you desire to remove them place the knee horizontally confine the substance & make a free incision directly over it. Vide C. Bell. Mr. Travers relates a case in which Mr. Young Fractures They are solutions of contin. in bones 1st of the differences which are in the part of the bone the mode of breaking etc. Compound fractures are those in which the skin is likewise broken They differ also in the causes of breaking the direction, nature, & [illegible] of the blood Some fractures are complicated with other circumstances Prognosis varies according to the injury the constitution, the treatment, 6thly The formation of calles varies with the treatment. It will be small & quickly formed when the ends of the bones are kept closely in contact. Much is said by natural bone setters about the split bones but according to Prof. [illegible] experience this is a rare occurrence except in case of gum shot wounds Bones are seldom fractured in two places except when a heavy body has passed over the limb and comminuted the bone. Bones are often supposed to be broken in two places in consequence of the overlapping of the ends. Often we are unable to determine for some time the exact nature of the fracture Fractures are distinguished by the distortion, inability to use the limb, & especially by the crepitus. We think we hear but we in fact feel the crepitus The piercing of the skin is in consequence of an exertion subsequent to the fracture It is common when a limb has been shortened for the surgeon to say that the fracture was oblique but in many such cases you can feel the transverse surface of the end Children are subject to partial fractures or bending of the bones. Prof. H. has generally succeeded in straightening them sometimes however you may break them completely while straightening them probably one side of the bone is always broken in such accidents It is only in the thigh and leg that we meet with spasms. Hard labouring men and irritable females are most liable to spasm. Of course compound fractures are mor liable to cause spasm. Old age is a less obstacle to recovery than we might suppose. Delirium trem. is apt to be produced by fractures in the intemperate Callus Dupuytren made many observations 21st a deposition upon the periosteum [illegible] the bones by what he called temporary callus 2nd callus between the bones. S. Hunter thought there were granulations of the ends of the bones The union of the bones is not [illegible] for several months as the patient is [illegible] or unwilling to rest his weight upon the limb goes on crutches and if he falls it is broken again B. Bell says an arm unites in a month a leg in 6 weeks & a thigh in 3 mo. The union however is by no means firm at this time many cases of refractures occur for slight causes after this time The setting of fractured bones is generally a simple business. It is done by extension counterextension and [coaptation] Extensive may be made at the nearest joint or farther off. Coaptation is of far less efficacy and requires far less skill & [illegible] than used to be supposed It is of little use when the muscles are covered by thick flesh as in the thigh By means of his fingers the surgeon can ascertain when the ends are in place Splints are applied by some only after inflammation has gone down. Apply splints as early as you can Do not bandage too tight and wet the bandages with ac. pl. etc. In some cases a partial application of splints and bandages may be made If the limb is excessively swollen you must wait until you have subdued the violence of the infl. Generally however if you are called soon you can dress immediately The symptoms to be attended to are pain spasms inflammation, & constit. irrit. Relieve these by the usual means For const. irrit. give cal. & op. spasms may take the limb and displace the bones give opium for them and in robust men, bleed sometimes Fractures of ossa nasi These are only dangerous as the [ethmoides] may be driven into the brain. Boyer thinks the brain cannot be injured in this way but Prof. H. has known two cases of death from infl. of brain in consequence of a kick of a horse upon the [nose] Treat by introducing something as a direction under the bones and squeesing up with your fingers. If they do not retain’ their place, keep them there by catheters & lint within & compresses on the outside Wet the bandages Fract. of cartilage of the nose nose twisted Keep in place by straps of plaister Fracture of Lower Jaw Onn one or both sides often on both never exactly at the symphisis Use a compress a four headed bandage tied behind & above and then apply a thick bandage over all Fracture of upper jaw [Arise] from blow bones driven into the antrum etc. Fract. of Vertebrae Prof. H. has had perhaps 30 cases only 2 recoveries Paralysis of the lower limbs immediately takes place retention of urine etc. Infl. comes on. They die in a few days or live for several days Fract. of the dentata occasion sudden death It is perfectly absurd to attempt to restore the function of the limb by blisters etc. The infl. of the spinal marrow occasion, enormous irritation restlessness & fever. Although the legs are insensible & perfectly paralytic yet they will sometimes require their legs to be constantly moved by the assistants owing to some irritation at the origin of the crural nerves The urine is always to be drawn off by a catheter which a surgeon shd always carry with him in such cases If the injury abo e the origin of the phrenic nerves the patient cannot expectorate & dies of suffocation The bowels generally puff up and are constipated In robust men you may bleed and you may always give cathartics The urine finally becomes turbid & eventually purulent When the patient survives 10 days or a fortnight he generally dies from infl. If he lives several months he seems to die of fever of irritation. Opium is the principal remedy Extensive sores from in the muscles of the back. The urine has to be drawn off continually Fractures of the Sternum May generally be distinguished by inequality of the surface. You can often feel a crepitus when the pat. breathes. Treat by preventing motion of the part in respiration by a broad bandage around the breast with a compress under it It gives great relief When the fragments are forced in and the circulation & respiration are impeded do not wait for infl. but bleed immediately the pulse will rise after it. Afterwards apply a blister Treat with opium and cal. Trepanning has been recommended It can hardly be necessary. Pus will not be apt to form if the infl. has been properly checked if necessary however we should trepan In many cases the infl. of the thoracic viscera, cough etc. will [combine] often [The] healing of the wound. The case however will not be so dangerous as one of the phthisis pul. Fracture of the Clavicle May result from direct violence or from a fall on the shoulder elbow and hand, and in the former case there will generally be considerable contusion and the fracture will be between the coracoid process & sternum in the latter often between the corac. proc & the acrom. The shoulder falls the patient carries his head on that ride & supports that arm with the other hand his whole appearance is peculiar or he walks very carefully, to avoid motion of the parts In some cases the subclavian artery and in some cases the lungs have been wounded. Fractures of the clavicle are very often mistaken for a dislocation of the shoulder Reduce the fracture by placing one hand in the axilla & the other under the elbow Place a compress under the axilla & confine it there by a strap passing from it The arms are not very perfect in cases of fract. clav. Fractures of the Scapula When the acromion process is broken the arm falls down and the parts may be brought easily into contact by pressing up the elbow and you can feel the motion of the broken parts Treat pretty much as for fract. clavicle. It is said that the union is ligamentous When the body is fractured pass a bandage around the body and support it with shoulder straps Boyer speaks of fract. of coracoid process. Prof. H. has never met with a case It might be necessary to cut down The ligament of the Fract. of the neck of the os humeri So called when within an inch of the head Caused by falls upon the shoulder Distinguished by the mode of receiving the injury. Examine whether the fall was upon the hand. The ecchymosis is upon the top of the shoulder where the injury was received & not in the fore part near the axilla is in dislocation. The deltoid muscle will be shortened instead of lengthened The bony tumour will be of a different shape in the axilla. The upper fragment is drawn outwards by the [teresm] & subsception? The lower fragment is drawn downwards by the pectoralis Distinguished from fract. of acromion by The whole limb generally swells therefore begin to bandage at the hand & bandage up to the shoulder. Apply on the outside of the arm Smith’s splint & bandage over the splint. Keep a compress in the axilla and bandage [aroun] the body and arm Support the forearm, not the elbow with a sling. Let the elbow hang down Fract. rib Sometime the rib is fractured at a place different from that where the injury was received e.g. the neck. Examine by feeling along the rib when you come to the fracture, pain will be produced You may scarify for the emphysema. When the broken point of the rib is caught, & respiration and all motion of the body is prevented Prof. H. has succeeded in affording relief and disengaging the end of the rib by standing behind the pat. placing the knee against the back and embracing the [illegible] with the hands and at the time of a full inspiration jerking in the abdomen Treat the fract. by a broad bandage around the thorax supported by shoulder straps. The most important part of the treatment is that for the infl. of the thoracic viscera by bleeding cal. & opium & in extreme cases by taking off the bandage and applying blisters. Use demulcents for the cough If the blood does not flow put the hand in warm water Fract. of the body of the condyles of the os humeri Generally distinguished [illegible] by the deformity, loss of motion & crepitus. Fract. near or at the condyles of the bone are to be distinguished from dislocation. The arm will be slightly but the fragments will be drawn up there it will be a depression above them Generally by rolling the fore arm you can feel a crepitus. Sometimes the int. cond. is broken off and drawn up, without aff. of the joint. If the init. cond. is broken the arm will be bent inwards if the ext. cond. the arm will be bent outwards make extension with the elbow bent coaptation will not be needed. Bandage the whole arm. Support the fore arm and let the weight of the elbow hang down For fractured condyles we shd use a bent splint and occasionally after a while bend and extend the limb every day in order to secure perfect motion of the joint Prof. H lets the splint stay on but about a fortnight, for the reason. There is great tendency to a permanent pronation of the fore arm especially when the int. cond. is fract. This accident is very common in young children and sometimes arises from a blow [on] the lower part of the humerus Fract. of both bones of the fore arm. Arise from violence Sometime one bone is broken in a place not opposite to the fract. of the other. Easily distinguished by deformity Reduce by taking hold of the hand & pulling counterextension at the elbow To prevent the union of the ulna to the radius dress with two compresses rolled so as to be thicker in the middle & then over then two splints which by pressure upon the compresses keep the bones apart Fract. of the body of the ulna is easily distinguished coaptate if necessary dress with Smith’s splints & sometimes apply another splint on the other side Fract. of the lower end Radius Looks much like a dislocation of the wrist and is often mistaken for it the styloid process looks towards the palm of the hand The upper end of the lower portion of the radius project backward & the lower end of the upper forwards Put a compress on the inside to keep down the lower end of the upper part Bandage apply a splint on the inside & bandage so as to bring the hand back Sling so as the hand fall down towards the ulna. Leave the fingers out Fract. of the olecranon Put a cloth at the back of the olecranon longitudinally Bandage it down letting the ends come out. The assistants in the meanwhile pushing down the muscles pull up and down the ends & pin them. Use a crooked splint or else fill up the cavity of the elbow the arm being a little bent The danger is not of a stiff but of a weak joint. The union is ligamentous Keep the dressings on about 3 or 4 weeks Begin to move the arm however before this period. Exercise the muscles at first passively, in order to restore the use of the arm Compound fract. of the olec. are very serious accidents When the elbow is going to be stiff place the arm at a little more than right angle Fract. of bones of the carpus From blows etc. effusion very grat yet you can generally feel a crepitus The principal indication is to treat the great infl. Bleed cal. op. etc. warm or cold appl. etc. Keep a splint on to prevent distortion Fract. of metac. bones Ascertain by prying & feeling with the thumb. Apply a splint to the hand. If the pat. insists upon using the hand, apply plaister bandage Compound fract. of the metac. bones are sometimes followed by mortif. of the fingers. Take them off if so Fract. finger Apply a little roller & a splint of basket stuff a roller over it Bend it to the next finger. Sometimes they are so washed that they must be amputated Still however they often recover when exceedingly crushed Fract. of os. innom. In consequence of passage of loads etc. Sir A. C. observes that in fract. of the acetab. the limb will be drawn upwards like disloc into the ischist. notch The most we can do is to apply a strap around the pelvis Purgatives & injections will be needed & a catheter Fract. of the lower extremities We always have much constit disturbance Fract. of body of os femoris Limb is distorted crepitus can be felt unless the ends are too far by each other or too far apart. When broken high up the upper fragment is drawn forwards and upwards Children have the bones oftener broken transversely. To reduce the fracture make extension. Let the assistant take hold under the arms. Great diversity in the mode of treatment exists. Mr. Pott & others advocated the bent position. Mr. S. Cooper changed his opinion & gave up the bent position Prof H has succeeded very well with 3 splints one on each side and one in front especially with children putting a pillow under the knee [Amesby’s] splint exhibited. The limb will shorten under almost any treatment in oblique fractures of adults The fractures commonly unite by bony union In children the cure is perfect Fract. of neck of os femoris An obscure subject. illustrated best by Sir A. C. who 1st wholly within the caps. lig. 2nd through the neck at the root of the great trochanter 3d through the body of the bone & the great trochar 1st This sort occurs oftenest in the aged & in aged females often from very little force the foot perhaps catching & causing a fall. (The neck of the os fem. undergoes a considerable change in advanced life Sometimes not shortened until often the lapse of several hours. The foot is turned outwards the heel resting in the hollow beside the tendon achillis Desault gives a good diagnostic mark of all the 3 kinds viz. the trochanter in rotation does not describe an arc upon a circle You can generally feel some crepitus Most apt to be confounded with dislocation upon the os ilium but in the latter the head of the bone can generally be felt & the toes turn inwards In pract. there is little pain except on motion & the pat. is liable to sudden starts in sleep. Splints and bandages are of no use Pass however a broad band around the pelvis to bring in the trochanter Place a pillow under the [illegible] sometimes a bolster under the whole limb confine the foot with rolls of cloth or billets of wood so as to prevent the turning out of the toes 2nd Fract. without the caps. lig. Occurs at all ages. Toes turned out limb shortened about an inch. Occurs from falls etc. Trochanter appears to be somewhat sunken in a swelling about it. Appears less like a dislocation Pain is often entirely in the knee hence the accident is sometimes mistaken Dr Physick advises treatment for a fracture whenever there is a suspicion of a fracture This fract. is treated by A., Coop. with a long splint extending from the knee up above the hip etc. etc. Prof. H. has treated them very successfully with Desault’s long splint He pulls the foot down & keeps it down the cross piece by means of a wooden gaiter 3d Fract. through the trochanter Not so much shortening The lower part of the trochanter seems to project too much outwards the broken end may frequently be felt Caused by falls on the trochanter Fract. below the trochanter are treated with a double inclined plane Separation of the epiphysis of the head of the bone sometimes occurs We cannot distinguish it before death. Indeed in all these cases we must be cautious in our prognostication. Sometimes excessive pain and long confinement occur without any apparent fract. and the pat. recovers completely without distortion 4 rules given 1st a roller & 3 splints are enough for children 2nd in fract. within it caps. lig. in very old persons depend principally on position. 3d in fract without the caps. lig. depend on Smith’s splint or Desault’s long splint 4th in fract. of the body use Smith’s splints or Amesby’s or Desault’s long splint & Prof. H. generally applies another splint on the inside Fract. of condyles of os [com.] Caused by falls Distinguished by distortion the lower end is drawn backwards and the patella seems below the joint Generally there is much tumefaction & injury Often the fract. is oblique & the upper end pierces the rectus muscle & perhaps the skin. Distinguished from disloc. by greater mobility, greater tumefaction etc. Treat for the infl. etc. in the first place Treatment by Smith’s splint or two lateral pasteboard splints applied wet 1st a roller then the pasteboard & splints then a roller over them. Compound fractures here are very serious accident we must consider about amputation Fract. of patella Caused by direct violence or by muscular exertion, when the foot slips The fragments separate They unite by ligamentous union A.C. directs to apply two straps & draw them together etc. Prof. H. applies a thick narrow compress fig. 8 bandages also above and below keeping them wet with a lotion to reduce the infl. Swollen along the thigh will in all cases be proper to keep the muscles from acting Keep the foot higher than the hip. If there is no tumefaction Prof. H. applies straps of sticking plaister. In all cases apply a splint we may use a bit of board with notches to keep it from slipping up and down. Give no violent motion even after the joint begins to have strength We may commence exercising the limb by motion made by another person, or by setting on a table and swinging the legs. Secondary fractures are apt to occur they are troublesome but not dangerous they may make the ligamentous union longer let the pat. walk with a splint Fract. of tibia & fibula Broken by blows or by falls on the feet or by slips of the foot. The two bones may be broken at different places, when the accident results from falls etc. The notion of a fracture in two places is generally a mistake caused by the overlapping of the bones In compound fractures it may be necessary to to cut off a projecting point of bone Compd fract. near the ankle joint are dangerous, especially when as is often the case compounded with a compound dislocation. Amputation will generally be needed Fract. of the lower end of the fibula with compound disloc. internally are not so dangerous. In fract. of the upper portion of the tibia the upper fragment sticks directly upwards there is a difficulty in keeping the fragments in contact Smith splints are best put a pillow under the [illegible] In every other fract. of the leg the best position is decidedly preferable by a double inclined plane or what is often better by placing the limb on the outside In fract of the tibia the upper fragment is generally forced inwards Apply a compress over the projecting end of bone bandage the whole limb. Apply a splint in the inside with a hole for the malleolus bandage over the whole Counterextension Prof. H. thinks of little use in fract. of the leg Smith’s splint is advantageous for preserving the foot in a proper position The time of keeping in the splints in simple fractures is 6 or 8 weeks the surgeon must examine & there is a certain consciousness of strength in the limb. If upon attempting to walk the pat. feels a pain in the part & a sense of giving way, he must lie by longer & perhaps have the dressings reapplied Sometimes the tibia alone is fractured distinguished by rotating the limb by passing the fingers along etc. Some think confinement is all that is needed but Prof. H finds it advantageous to treat as for fracture of both bones Fract. of Fibula Pat. will continue perhaps a long time lame and wonder what is the matter Examine with the fingers for a tenderness by moving the foot, etc. Prof. H. has had great satisfaction expresses with his treatment Apply a roller bandage and then a slender splint and another roller Compound fract. of leg more frequent than those of other parts First cut off the boot, stocking etc. Replace the bones if possible. Let one assistant grasp the thigh above the knee and make counterextension extension to be made by another at the heel the surgeon attempts to force the fragment into their place. Perhaps you can introduce your finger into the wound and lift up the skin Saw off a long sharp & projecting point an inch or two a spatula, or piece of sheet lead or tin being placed under the bone. It may be necessary to dilate aa little with a probe pointed bistoury. Do not use much force in removing fragments Dress carefully. Place a series of [slips] one over another each [indricated] lapping about half Extend the limb in both directions & thus left up the limb and place it upon the slips. Cross one set of the slips. Then equalize pressure by compresses, place a splint over then cross over the splint and limb both with the other set of slips Put a bridle around the foot & pin it up towards the knee to keep the foot from being permanently extended It will often be advisable to have another splint on the outside. Wetting the bandages will be advisable to prevent infl. It is well to stay by a patient a little while to see whether the bandages are too light or give uneasiness from other causes Great const irr generally follows it will be necessary to bleed a strong robust man op. cal etc. Spasm often occur the greatest relief for the time will be afforded by compressing the muscles with the hands Infl. of cell. memb. may come on Collections of pus may occur requiring [illegible] opening If every thing goes on well do not remove the dressing for some days It will be well however to call the next day Sometimes there is a deep seated collection of matter, which will require to be opened by a deep incision If the abscesses continue to form with great suppuration sloughing of periosteum looseness of the bones etc. the patient’s strength failing we must amputate. In the worst cases of shattered limbs they have been treated simply by placing them in a trough and covering them with bran crowding it down around them probably limbs may be saved by this mode If the great blood vessels are too much injured immediate amputation will be necessary Fract. of tarsal bones Generally they are compound but sometimes simple. 1st of the os calcis Dress by a roller & compresses then a broad splint along the bottom of the foot & bandage If the upper end is broken off and drawn up by the tendo achillis keep the foot permanently extended by bandages and a splint & endeavour to keep down the fragment. Apply warmer cold applications, or poultices for the infl. Splints give great relief in fract. about the joints by preventing the motion If the bones are too much broken in the tarsus, amput. must be performed but better in the leg than at the ankle It has been proposed to amputate in some cases at the astrag. & os. calcis Fract. metacarp. bones Press by pasteboard or other splints or in slight cases by plaister bandages Fract. of toes The best splint generally is the other behind the two together A plaister bandage will often be serviceable Fract. which do not unite by bone Imputed to motion [illegible] to want of nutrition 2d to effusion of serum. But there are cases where none of these causes operate & yet the union is ligamentous Gunshot wounds sometimes terminate thus but do not always. The frequent motion of the limb has been considered as a cause of these accidental cases but animals go with their broken limbs dangling about and yet the union become [illegible] An epileptic man broke both femurs the fits continued nothing could be done for the limbs yet they united firmly Also it is best in first dressings of fracture to make extension it gives relief Interposition of muscles has been assigned also old age & pregnancy yet none of these reasons are satisfactory The causes may be conjectured to be accidental in the particular limb not constitutional & perhaps another bone in the same person might unite Mr. Amesby cured a great many a great many cases he found also that many of the incurable cases exhibited an artificial joint & a pseudo-serous membrane The best plan of cure seems to be to keep the bones as firmly pressed together as possible binding the limb as firmly as can be endured Dr Physick has effected a cure by keeping a seton through the limb which produced either inflammation or granulation. This method has been extensively tried since that time both in Europe and in this country it sometimes fails A Mr. Burke of St. Thomas cured by electricity but then he used also an apparatus Dr White Sen. of Cherry Valley cut down & bored repeatedly into the bones with an awl he cured but then he used an apparatus Counterirritation has been extensively used As a last resort an incision has been made down to the bones & the ends of the bones. [Let] the operation has been fatal & has often failed Prof. Smith tried it once he had to saw off again on account of overlapping the bones about 10 days after The case was successful. But he declared that he never would again perform the op. Prof. H gives the preference to the plan by setons. Keep them in a long time Dr Physick kept his in at first 6 or 8 weeks. Probably some cases have failed from the short time during which the seton is kept in Dislocations It is of the highest consequence to be thoroughly acquainted with dislocations so as to be able to set a bone at once Failures are peculiarly unfortunate Dislocations may be caused by direct violence, by disease of the joint, by muscular action as in epilepsy. The swelling at first and the infl. afterwards may render the diagnosis obscure. The immediate swelling must be from effused blood. Van Swieten thought dislocation of the hip could not occur Many have believed this. Indications are 1st restoration 2nd retention in place 3d obviating of the effects of the accident The principal obstacle to restoration is muscular action which is overcome by for e applied with sufficient strength at first or by gradual force The British surgeons apply the extending force to the bone itself. The French apply it at the end of the member Splints etc. are often necessary to keep the bone in place Prof. H. has never seen simple dislocation compounded with simple fracture. But such cases may perhaps occur. Compd disl. & fract. may occur e.g. at the ankle But a short time only shd be allotted to the previous reduction of inflammation We may bleed largely etc. [Ganglinoid] joints can seldom be reduced [illegible] a month Orbicular joints have been reduced after 5 or 6 mo even. But the axillary artery has been ruptured in these attempts upon the shoulder Constit. means to facilitate are 1st bled ad deliq. 2d tart. ant. 3d warm bath continued as long as the patient can bear it. Begin with tart. ant. (say) then warm bath then bleeding. Tobacco has been proposed but it is too dangerous. Opium cannot be depended [illegible] Intoxication is a favorable state but it cannot be managed at pleasure. If you find a man drunk take immediate advantage of the oportunity Partial dislocations can only occur in ginglynoid joints Desaults notion about rupturing adherent (or new) ligaments in old luxations by moving the limb in every direction is perhaps a good one, but is not much attended to. He supposed that the bone was often girt about by the ligaments Luxation of lower jaw Occurs in one or both sides the condyle is thrown forwards & the chin is oblique except when both are dislocated Does not occur in children Prof H’s first case was that of a young man courting! about midnight In one case epileptic fits caused a continual recurrence of luxations The teeth will be 1 or 1 ½ in. apart. It is a mistake to suppose that the mouth must be wide open. Some cases have been mistaken for spasm & treated accordingly Place the pat. in a low chair Put the thumbs as far back on the jaw as possible bear down with the thumbs & upwards with the fingers, upon the chin If this fails place a lever of wood bark & then press down with one hand upon that & up with the other at the chin and reduce one side at a time Place the pat. on his back in bad cases. Bandage for awhile Luxation from epilepsy are apt to recur Sir A.C. mentions a sub luxation caused by relaxation producing a snapping while eating Push the jaw upwards N.B. when you use a lever of wood make the upper jaw the fulcrum At the same time pullup the chin with your fingers Luxation of the Clavicle When at the sternal end, it is caused by a blow on the shoulder & the end of the bones project outwards. Reduce by putting the shoulder backwards (by an assistant) & pushing in the end of the bone Dress as for fract. clav. Great difficulty is found in keeping the part in place A tumour forms Sir A.C. mentions one case of an internal dislocation of the sternal end of the clavicle About an inch of the bone was sawed out The fracture of the scapular end may be treated by raising the shoulder bandaging as for fract. clav. putting a compress on the part etc. They are not readily restored to perfect soundness Luxations of Vertebrae Prof H. has known persons fall (as from a load of hay) upon their heads & their heads be permanently bent forwards & depressed. He has not ventured to interfere, but if he should have another case he would endeavour to brace the head back Luxation of shoulder Said to be equal in frequency to all other dislocations hardly so When unreduced the arm remains permanently extended from the side & is almost useless sometimes a semiparalysis of the arm occurs This luxation can only occur when the arm is removed from the side Boyer thinks the luxation forward is always consecutive this is denied by others The general signs are depression above, the head of the bone percesptible etc. the arm is directed obliquely Sir A. C. speaks of subluxations but Prof. H. coincides with Abernethy in thinking this impossible Two classes of modes of reduction 1st manual 2 by machinery Prof. H. has never used the latter. No account of fatal accidents has been given from manual reductions In recent cases Sir A.C. reduces by the heel in the axilla. Dr Wells, formerly of N. [Stonington] succeeded in one case by placing the other foot in the acremium & thus making additional counterextensions Prof. Smith’s mode Prof. H.’s mode Generally press the scapula down After sufficient extensions, lower the arm & the bone will go into its place If possible divert the attention of the patient so as to relax the muscles Sometimes constitutional means are necessary vide supra Sometimes a reduction is effected by first fatiguing the muscles, by long continued extension Compound dislocation of the shoulder occasionally occur case of Sir A.C.’s in which the bone projected through the pect. muscle The suppuration caused anchylosis ultimately Compd disl. occur by the arm’s being caught in machinery Displacement of the long head of the biceps. This is probably what Sir A. C. called partial dislocation After reduction of the shoulder, in these cases there will be [lameness], pain etc. which is removed by raising the [illegible] & rotating it outward Prof. H. has frequently seen this affection when there had been no dislocation The [elevation] of the arm about 45 [degrees] gives great pain after however a higher elevation gives no pain. Rotations of the arm gives no pain. Often great pain is felt during sleep say Prof. H thinks that the displacement is backwards generally Prof. H. diverts the attention & then suddenly rotates the arm. If necessary repeat the process frequently & make the pat. do so likewise Luxation of elbow 1st both bones backward. The arm is shortened the bones project backward & a depression is felt on each side of their ends Frequently caused by a fall on the hand Most apt to be confounded with a fract. of os. hum. just above the condyles But in fracture all the marks of displacement are immediately he removed by extending the limb We can also move the joint more & can feel the crepitus. In children luxation does not occur so often as the fracture of the os hum. Prof. H has an assistant grasp the arm firmly above the elbow for the counterextension & then he grips with his fingers the ends of the bones, pulls down & forwards & then suddenly bends the arm. Dress with the arm bent in a sling. The inflammation will be considerable Sir A.C. applies his knee, or puts the elbow across the back of a chair 2nd Radius and ulna laterally If internally the head of the rad. is in the posterior fossa of the humerus 3d dislocation of the ulna alone backwards distinguished by the projection of the ulna & the turning of the hand inwards Caused & cured in a similar way 4th Radius forwards its head upon the coromoid process. The arm is partly prone the elbow cannot be completely bent. There will be no contusion & now swelling & a mistake is apt to be made in the nature of the accident the shoulder being considered in fault Clap your right thumb on the head of the radius press with it make extension with the left hand then turn the arm supine & immediately flex the elbow For adults an assistant or two may be needed in order to exert greater force Prof. H. has seen many cases & has known many cases of mistake Bandage & sling 5 Radius backwards Sir A. C. met with a case in a subject brought into the dissecting room Smith’s splints Fract. of corp. proc. of ulna Caused by falls Keep the arm in a sling Sir A. C. Union by ligament Fract of neck and rad. Sir A.C. has never met with a case Luxations of wrist 1st both bones either forwards (palmar) or backwards (dorsal) Generally discovered easily may be confounded perhaps with effusions of the bursae mucosa but in this case the projection will be only on one side May be confounded with fracture of lower ends but we can generally discover the lower end of the radius the arm is more bent in fract also the lower projecting end is lower down in dislocation Let an assistant hold the arm place your thumbs in the back against the projecting ends of the forearm your fingers in the palm extend press & bend the wrist up so as to make the hand straight Smith’s splints 2nd Radius forwards easily reduced 3d Rad. backwards set in the same way Always apply splints 4th ulna alone Prof. H. has seen it the end projects forwards reduce in the same way let the hand hang down in the sling to keep the ulna up next to the radius Luxations of the Carpal bones Rare accidents reduce them as the above cases Great infl. generally attends Apply Smith’s splints If the tumour is only from effusion, it will feel soft. Luxation of metacarpal bones caused only by passage of heavy bodies by # bursting of [illegible] etc. Generally compound We may if necessary remove any one or a majority of the metacarpal bones Sometimes a luxation of digital extremity of a metacarpal bone occurs. It feels like a dislocation, but gives a crepitus Generally in most such cases put a round body in the hand, to dress upon Luxation of metacarpal bone of the thumb forwards & backwards Make extension & carry the bone into its places. Pat. are generally impatient of dressings & will come to you with a sort of sub luxation. Then apply a plaister bandage Luxat. of first phal. of thumb backwards easily recognised difficult to reduce difficult to et the bone over the projection of the met. bone The thumb has been torn off in attempts to reduce Sir A. C. directs to soak the parts then apply a piece of soft leather then a piece of tape with a clove hitch Let the assist. pull on this while the surgeon pulls inwards. If this fails he recommends a [illegible] the elbow being around a bed post Mr. Hey recommended divis. of lig Boyer failed in one 10 days old The disl the other way is easily [illegible] The second phal. is easily reduced After all dist. of fingers & thumbs splints give great relief they will relieve pain Luxations of hip joints 4 directions 1st upwards upon the dorsum of il. knee & toes turned inwards [illegible] 2 in. short. head of the bone can be felt Buttocks flattened Trochanter higher up & pointing inwards forwards Dist. from fract. of [illegible] of fem. by the bone being fixed not easily moved no crepitus by the toes not turned inwards This is the most common kind Prof. H. has succeeded by Dorseys mode Pass a sheet around the perinaeum make [illegible] by a handkerchief around the limb just below the bent knee one assistant pull the thigh outwards by a napkin the surgeon rotates the limb outwards & the bone comes into its place. Two assistants will be needed for adults Sir A. C. advises in the first place const. means by v.s. 10, 20 or more oz. warm bath & tart. emet. Place the pat. between the two strong parts with staples. Pass a strap around the perinaeum & fasten to the first staple another (by a wet roller) above the knee 7 fastened to a pulley make exten. gradually finally when the muscles are fatigued & the head is drawn down, then rotate outwards as above. It may be necessary to lift the bone outwards to get it over the edge of the ilium 2nd Dist. into foram. ovale Limb length 2 in. stands out from the other body bent forwards toes turned outwards Caused by force applied to the upper part of the thigh Sir A. C. Fastens the body firmly to a table & by a pulley pulls outwards the surgeon with his hand on the ankle suddenly crosses the limb over the opposite one 3d backwards into ischemic notch limb ½ to in. shorter troch. mag. projects less & is turned forwards knee & foot turned inwards great toe in the hollow of the other foot toes touch the ground head of the bone can often be felt Reduce (Sir A.C.) about as the first except that the assistant lifts the bone upwards by a towel around his neck 4th on os pubis head of the bone can be felt & rolls foot turned outwards limb shortened caused by falling backwards to a hole Place pat. on the table make ext. backwards & downwards left the head of the bone over by a towel around the neck of an assistant Fract. of ossa immon. have been mistaken In 20 cases [illegible] 5 [in] isch. notch 2 in for. ov. 1 in os pubis Sir A.C. Boyer does not direct pulleys Abernethy [illegible] After reduct. apply a 8 bandage Treat for const. infl. & irrit. Bleed & cath. [illegible] Benedict [Def??st] [not] Shelton Totten Next to Totten The [tabula] vitrea or internal plate may be fractured while the external [illegible] [illegible] These are irregular depressions of [the] internal plate, which the surgeon [illegible] calculate on a generally [illegible] near the longitudinal sinus They are not often found in the young In the youngest [illegible] [there] [are] not [illegible] tables In the very old [bone] the [illegible] is nearly [???ting] In [illegible] [to] [know] in [illegible] [illegible] [for] [this] [illegible] [illegible] 13 Surgery 1 2 3 4 5 Lecture 2nd Inflammation Characterized by heat pain redness, swelling, soreness upon pressure & if considerable a symptomatic fever. If considerable & extensive, constitutional irritation, or irritative fever may be produced. The pain is caused by some affection of the nerves, the swelling by effusion or by distention of the vessels The symptoms above described may occur successively and not all be present at the same time 6. Inflammation has been divided into two kinds Phlegmonous & Erysepelatous 1st Phlegmonous & 1st of that which arises from external injury. The injured part is the centre of the inflammation. The manner in which injury produces inflammation is not well understood. Hunter speaks of both increased and diminished action of the vessels & uses the term healthy inflammation in which there is increased action. Cullen thinks the action increased Wilson Philip thinks there is diminished action. At the present day surgeons consider that there is increased action at first in all cases Hunter thought the vessels were always diluted at first An injury is first followed by pain, caused by laceration & pressure of nerves perhaps. For an example an incised wound is followed by retraction of the lips, by pain swelling redness, heat, 7 and the inflammation spreads over adjacent parts The sense of fullness and the redness is probably caused by increased quantity of blood red blood is carried where it did not exist before as in ophthalmia The venous blood becomes red like arterial The cold stage is extensive inflammation should not be omitted. It is a part of the symptomatic fever & this fever sometimes also has a sweating stage Prof. H. thinks there is always in creased action in the commencement of infl. He thinks also that fever differs from inflammation The heat extends widely perhaps over the whole body It is principally a sensation however, and not much indicated by the [therm.] Inflammation of some parts as stomach & bowels the pulse will not be full & strong. This will also be the case in some constitutions, in which 8 there will be feeble pulse nausea vomiting etc. Prof. H. objects however to the term atonic inflammation Causes of infl. are mechanical & chemical heat, cold etc. Syphilis & some others are attributed to a specific cause & called specific inflammation Cold may cause inflam. by rendering the system or part more susceptible to heat afterwards. A frozen part will irritate as dead matter. The frozen fluids will irritate Prognosis will be dangerous 1st from violence or extent of infl. 2nd from nature of the part affected as the viscera the functions of these parts being suspended or destroyed. joints are dangerous parts 3d const. & habits of the patient Terminations are 1st resolution 2nd adhesion 3d suppura. 4 gangrene. Schirrhus was added by the older writers 9 1st Resolution is where the part is left healthy 2nd Adhesion takes place generally in serious membranes & in the cellular membrane especially in the linings where it is called hepatication Treatment. The cause as [illegible] should be immediately if possible removed Remedies These should be local as much as possible. Much may be done by prophylactic treatment especially in the case of wounds The first indication is to preserve the proper temperature of the part we may apply cold or tepid applications according to the sensations of the patient. If chilliness is produced by cold applications, apply warm ones though in infl. of the brain the production of chilliness is beneficial in many cases IN abdominal infl. fomentations & warm bath will be very useful and the French use poultices extensively in infl. of the lungs substituting them for blisters 10. We may apply cold applications too long. There is sometimes a choice in liquid appl. spts & water ac. pl. 1z to 1 pt. mur. amm. zii to pg. cold water alone ice especially for the brain vinegar & water though this irritates the skin & produces an eruption in some persons mur. amm. in very popular & seems to answer better than ac. pl. for deep-seated infl. Cold water is probably good enough in most cases, if there is no prejudice in the patient. Some surgeons use sulph zinc. Others depend much upon narcotic applications as of stramonium Prof. H. does not use them Blisters are especially useful in chronic & deep seated infl. Prof. H. prefers a repetition of the blisters for keeping up a perpetual discharge The first general treatment is bleeding which is recommended by W. Philip for two reasons to dimin. the vis a tergo & to dim. the quantity of fluid in the part. Those of opposite theories use it 11 There seems to be no doubt about bleeding in phlegmonous infl. and Prof. H. has often found benefit from it in erysipelatous Venesection is the most common the most convenient for several reasons. Prof. H. has thought that drawing blood from a vein near the inflamed part relieves the pain sooner though it may have no effect afterwards. Continue the flow till pain is relieved or faintness is produced patient not being in a horizontal posture. If the pain etc. return repeat the bleeding Blood letting has been objected to in old persons and in the feeble. Brit Prof H. has frequently bled both with advantage Arteriotomy has no advantages Leeches are not fashionable but Prof. H. thinks they have no advantage over venesection. He thinks experiments on their relative advantage have not been sufficiently tried They may be better in some cases of chronic infl. but Prof. H. has used repeated bleedings in such cases with advantage Cupping combines bloodletting & and counterirritation Lecture 3d The next remedy in importance for inflammation is cathartics The saline are recomm. but the merc. are better. As W. Philip says they undoubtedly have a specific effect Antimonials have a powerful effect In Italy many have used them exclusively Beginning with small doses & increasing gradually, they gave a large quantity and depend upon this alone I have known a patient bear 4 gr of tart. em. once in 4 hour Narcotics have been much used It is safe to give opium, contrary to Brown. Dovers powder may be given But perhaps the best article for inflammation which we have, perhaps is calomel and opium. This practice is now much used in G. Br. A little opium is combined in order to quiet irritation. Hyoscyamus has been used. 13 where opium would not agree It has been my practice to give opium enough to quiet the irritation from excessive pain & continue my other treatment at the same time Rest & quiet must be used to relieve pain An elevated position well often relieve pain in paronychia for instance & in pneumonia, & in infl. of kidnies Diet should be light & vegetably an. food to be avoided, including broth also which many consume, in injurious quantities Attention must be paid to the constitution. We must be cautious about bleeding drunkards Often a state of debility succeeds such as to require tonics Opium has sometimes to be continued after recovery Adhesions in the cell. mem. are apt to take place after inflam. of joints These are to be relieved by fiction and motion 14 Chronic infl. will be treated hereafter Often the most Erysipelas is principally confined to the skin though the cell. mem. is generally more or less affected There is a redness in erys. which disappears after pressure. The redness also is exactly defined at the edge. There is a remarkable propensity to spread The redness is of a darker colour then in phlegmon & in the progress of the disease inclines to yell. The skin is shining. The pain is not throbbing as in phlegmon, but burning. Sometimes there is a deep seated part at the same time The infl. frequently leaves one part and spreads over another The eruption disappears in [brawny] scales. There is a slighter swelling of the skin perceptible to the finger, a hard leathery feel of the skin 15 The fever is considerable. Vomiting bitter taste in the mouth bile is thrown up heat very great Old persons frequently have coma When as is sometimes the case erysipelas comes on at intervals or is periodical Its occurrence may be preceded in old persons by come Delirium may be caused by it 1st erys. eff. skin only 2nd erys. aff. cell. mem. which may or may not be accompanied with aff of the [skin] 1st This does not suppurate & terminate in branny scales. Found in all ages 2nd Skin and cell. mem. affected there is swelling suppuration etc. sometimes the fasciae & tendons are involved. It affects principally the old and the intemperate especially the legs Erys. is dist. from phlegmon by col. by circumscription by fixedness Erys. when suppurate does not have a regularly defined abscess like phlegmon 16. Erys. aff 1st nerv. syst. by coma for instance delirium when the head is affected, by burning heat 2nd heart & arteries by a pulse smaller weaker and quicker than in phleg. 3d al. can. by bitter taste dryness of mouth diarrhoea vomiting From the bilious vomiting yellowness of skin & of the affected part Some have supposed the liver to be aff. but this takes place from sounds merely & from the bit of the rattlesnake Caused by wounds ulcers etc. and in erys. the infl. is not necessarily near the part injured The causes operating upon the constitution are malaria and the crowded air of hospitals, feebleness and intemperance etc. In Pomfret after draining the [meadow] one summer there was more erysipelas (St. Antonys fire) than in 10 years In the Mass. hospital Heated air produced this effect. The violence of erys. is generally proportioned to that of the local aff. 17 Sometimes however it affects internal parts Sometimes erys. alternate with other diseases Prognosis depends upon the violence of the infl. upon the cell. membranes being affected upon the head & face being aff. upon the constitution age and habits of the patient The indication is to promote a resolution and prevent suppuration if possible Though some suppose that suppuration never occurs Resolution is to be accomplished 1st topical 2nd by general app 1st Many object to topical applications Though S. Cooper and Lawrence do not object to them Ac. pl zi to pt. is the best Milk & water or cold water is good Use the cold or warm acc to choice of pat. mur. amm. zii to pt. corr. sub. 10 to 20 gr. to pit. will often be good Narcot as 6 p. zi to pt water or op. zi ac. pl. zi mercurial ointment has been 18 celebrated as a catholicon Another however though lard a catholicon Prof. H. has derived much benefit from lard or tallow alone In violent or extensive infl. I have found ointments inferior to liquid applications Though ointments are very agreeable when the cuticle is peeling off A new remedy is not silv. moisten a stick and sub it over the part (Mr Higginbottom) There is considerable testimony in favour of this mode of treatment. It is said to prevent the spreading. Mr. H. trusted to this alone without internal remedies. Prof. H. has used it but has not trusted to it alone he recommends however Blisters have been proposed by Dr Rush & used by Dr Physick Dr Rush recommended them for gangrene Prof H. has used them with the greatest benefit Case of a man’s face so swelled as to blind him. Prof. H. blistered the whole face & cured the patient Blisters are not t be applied to every extensive erysipelas 19 When the cell. mem. is affected blisters undoubtedly ought to be used Undoubtedly erysipelatous inflammation may affect the cell. mem. without the skin It has been called erys. phlegmonode Dissection [illegible] are in Prof. H.’s opinion are of this nature. The propriety of treating erysipelatous infl. like phlegmonic has been very much questioned but Prof H. has often bled and reduced with great success. It is often very difficult to cure returning after an apparent cessation Purgatives have probably been more used on account of the notion that there was bile in the skin and on account of the humoral pathology Bark opium etc. will be proper when the pulse is very feeble etc. but not when the tongue is dry, skin hot etc. etc. (Thomp) Infants have erysipelas sometimes caused apparently by irritation from improper tying of the navel string. I have 20 also seen if affect the pudenda and sometimes be very dangerous The cause of the latter I do not know. I have treated erysipelas in children with cal. ipecac & rhubarb etc. and the same ext. appl. as in adults Erysipelas of cell. memb. the skin not being affected. It usually attacks old, intemperate broken down persons commences with chills skin feels doughy pits on pressure Generally there is much derangement of stomach, vomiting etc. Sometimes delirium & even del. tremens Lotions are not of so much use Prof. H resorts immediately to blisters Narcotics are generally strongly indicated. Suppuration is to be expected and promoted. In this kind incisions are proper. Pus will collect in a day or two and should be let out. The pus will collect in parts & the skin have a boggy feel. 21 Treatment of erys by incisions. Considerable blood may flow & in one case Mr Hutchinson the inventor lost a patient from haem. owing to the negligence of the dresser Tinct. myrrh is an old article, formerly much used for injection into erysipelatous absceses (Dr Ives) Chronic inflammation. This is generally a sequel of acute inflammation Some constitutions are predisposed to it For instance an injury of a joint will being it on in some persons Scrofulous persons are more subject The gland and joints are the most common parts affected Treatment Bleeding should be local rather than general. Blisters cupping etc. Mercury in small doses narcotics as opium & conium. Deobstruents are very important. Vide Mat. Med. 22 Suppuration Infl terminates in suppuration when it resists the usual means used for discussion & increases & swells more Phlegmonic infl. has a soft part in the middle more or less pointing & in a round or oval form Erysipelas does not suppurate in a circular pointing abscess and the us collects more suddenly. Nothing perhaps distinguishes an experienced surgeon more than tact in discovering matter An abscess always tends to [illegible] the skin Pus is not now thought not to be formed from coagulated blood neither from the solids but to be a secretion Properties globules in a fluid cream coloured sweetish coagulated by mur. amm. Putrifies upon exposure to the air, & may rust a silver probe Delpect maintains that it is secreted from a membrane Pus is detected by placing the two thumbs at some distance from 23 each other & pressing alternately. In the thigh do not place the thumbs transversely upon the limb. lest you be deceived by the slipping of the muscles on the contrary place the thumbs up and down the limb S. Cooper thinks it is often better to suffer many abscesses to burst themselves thinking that the cavity will gradually contract & the healing will be more favorable. Prof. H. dissects entirely from this and always lets pus out by an incision It abscesses open themselves, the pain is often excessive at the close, just before opening feeling like the cutting of a knife There are no advantages to be derived Erysipelatous pus should always be evacuated immediately. If not, it may become acid and fetid Sometimes fetid gas will issue & fill the room Abscesses are opened with the abscess lancet, or with a bistoury. Large ones with a double edged knife Prof. H. knows of no medicines which promote suppuration unless it be warm applications fomentations etc. which 24 soften the skin and allow it to distend They are very comfortable and may be allowed An abscess after opening should not be violently squeezed, but pressed a little and afterwards, pressed again, or subsequent days. When there is difficulty in getting out all the matter bandage so as to make constant pressure leaving a hole for the pus to issue Do not attempt to discuss deep seated abscesses & those about the joints. The pus is often contained in a bursa mucosa & will not evacuate itself and patients often are suddenly in such cases Abscesses continued. It may be advisable to keep a small slip of linen in the opening at first to prevent [closure] of the cavity If the healing is slow, touch with nitrate silver. Sometimes inject corrosive sublimate 25 If these things with bandaging fail to cure, look out for the constitution be careful to keep up a strick rest of the part. The fore arm may often be healed in this way, when other means failed before applying a splint As illustrations of abscesses take these of the female mammae. 1st We have simple phlegmonic infl. & abscess. Treat just like any other inflammation pro re nata Robust women may be bled. Sling the breast. The skin always adheres over an inflamed gland 2nd erysipelatous infl. of the breast pus in the cell. memb. sometimes the ducts are laid open by # suppuration Inf. of the bursa mucosa under the gland commencing like rheumatism constit. disturbance considerable The breast is not hardened but the whole of it is pushed out. Suppuration takes place within, and points below. Open the abscess and keep it open by a bougie keeping on a bougie as long as you can & then introduce a probe. If these means all fail Introduce a seton and take out a thread a day until the abscess heals. Dr Physick invented this practice Hey advises to lay open the whole breast & calls them chronic abscesses Finally bandage the breast The seton may be introduced by Acute inflam. of hip joint [illegible] supervenes upon an injury violent pain inability to use the limb const. irrit. violent fever convulsions death in a few days if not opened. Prof. H. has not with several cases. We must not hesitate about opening the joint, to evacuate pus in these cases Case of erysipelatous abscess Hard drinking patient infl. of leg below the knee del. tremens came on opium 175 drops & more a day Abscesses repeatedly opened until the whole leg was open under the skin pus collecting very quickly recovered Cases in which pus collects in the cell. memb. in various parts & finally 27 death or loss of a limb. The treatment must be very much varied Opium bark etc. Bark is of little use when the tongue is brown, dry etc. In the early part of his practice Prof. H. gave much more bark than at present Chronic abscesses Limits not very well defined. They are merely those which are long in collecting. Bryer divides into acute chronic & congestive or those where the pus is found in a different place You will be called & sometimes [& be] told of a fever, sometimes previously at other times there is no apparent cause Often the pain is in a different part. Case of a child treated for aff. of the knee is hip had an abscess It was opened & cured Much is said about absorption of pus. But Prof. H. has never known cases completely cured without opening Prognosis is very difficult in chronic abscess Sometimes death ensues in a few days after opening sometimes only 28 after months Prof. H has never opened with caustic Lumbar abscess caused sometimes by strains & bruises sometimes no apparent cause Scrofula is given as a cause but it is necessarily Most common in the young though it is found at middle age Commences like rheumatism without much severity of symptoms A peculiar bending forwards & to one side characterises the walking pain on pressure Prof. H. thinks it is seated in the bursa of the psoas muscle The pus points below [illegible] ligament or lower down on the thigh even on the outside of the thigh It is sometimes mistaken for aneurism & for inguinal hernia It is easily distinguished The pus is described in the books as pointing always in the groin Prof. H. has seen it point in the loins If pointing in the groin let this patient stand up when you 29 open the abscess It may be necessary to introduce a probe to bring out the coagula which are numerous & sometimes large but be cautious in using a probe, lest you excite internal hemorrhage Make the opening keeping the surface tense about the width of the lancet (into the cyst) for the size of the opening Evacuate all the pus & heal by the first intention. When pus collects again make a second opening in another place because it would not heal so soon in the first place and evacuate & heal up as before. After a few such openings the pus will ulcerate out & then a modification of treatment is required “The patients may recover in the country but in cities & hospitals” Old surgeons introduced tents with great mischief Prof H has read of no lumbar abscesses cured by absorption where the patient ultimately recovered an abscess of the lungs is apt to occur as a sequel & take off the patient 30 Hectic fever may be acute and violent, soon 2 or 3 days or even 24 hours after opening lumbar abscess or hip joint heat fever nausea vomiting great local pain inability of motion of the part from pain These symptoms appear so like an attack of common fever that they are sometimes falsely accounted for in this way. This hectic may occur after the bursting of an absc. It is different from confirmed chronic hectic though called by the same name vide “acute hectic” A lumbar abscess opened by a large incision gives rise to more violent symptoms. Though they may occur often a spontaneous opening or a small incision Case of a young woman who feel from a horse was somewhat lame finally there was a pointing in the groin patient was about the abscess burst violent symptoms took to her bed lay a year & died The doctrine of absorption of pus was first denied by J. Hunter. 31 Some have attributed the bad effects upon a free opening are owing to admission of air others to cold air But Baron Larrey dressed wounds below zero When a lumbar abscess becomes permanently open. Prof H. injects corrosive sub. 10 gr. to a pint. 2 or 3 times a week taking pains to have the solution touch the whole internal surface of the abscess, by turning the patient stroking up the part etc. If after continuing the injection about a fortnight discontinue it if no benefit is derived we should increase the strength until some sensation is produced. Sometimes the injection will produce a slight ptyalism but this is of no consequence Prof. Smit injected the cavity immediately upon first opening Prof H. has tried this, but prefers Abernethy’s mode. The injection generally somewhat increase the discharge The constitutional treatment shd be with opium especially conjoining calomel. Tonics also as bark. prof. H. cannot think that lumbar abscess proceed from an affection of 32 the vertebrae because the disease often arises from injury to the muscles merely & is cured more readily than we could expect if the vertebrae were affected he has examined the vertebrae also, when about to make the opening & could not find them affected. Languid scrofulous abscesses take on an oral form & are to be treated like others. Do not wait until the skin becomes very thin and of a purple colour If we wait too long the skin will form loose flabby granulations so that the skin will perhaps have to be cut away Quality of the discharge from abscesses Sometimes is is pure pus, sometimes thick or curdy But before the abscess closes the discharge becomes whey like, thin, watery. This is not noticed by writers. It must not be mistaken for a bad action of the abscess 33 Furunculus or boil Called an instance of phlegmonous infl. Still it differs much. For in common phlegmonous inflammation there is a cavity for the pus or no cure Furunculus commences with a pimple and a small vesicle which when pricked yield a serum. Hardness purple colour pointing is not always in the centre. One or more small holes out of which the pus issues The pus is apparently contained in the cells of the cell. memb. The boils do not heal until the core [illegible] which is rotten cell. mem. Treat sometimes by bleeding if const. infl. is great at other times give calomel. Poultice or plaisters They may be cured more speedily by opening than by suffering then to burst So says Prof. H. Sometimes they contain clots of blood (called blood boil) Where there have been very many on a limb Prof. H. has enveloped the whole limb in ac. plumbi 34 Anthrax (burning) or carbuncle most commonly found on the face neck or back found also on the hands and feet and in other parts Often preceded by violent pains and heat in the part. A malignant fever may be the cause. Sometimes it is preceded by a sort of anomalous [illegible] [illegible] [illegible] [illegible] of health. It may commence with a broad inflamed spot on the skin Begins differently in different localities. Generally with several points Begins with a fiery pimple which gives a burning pain & often Begins on the hand with one pimple cause considerable const. irrit. Colour of the skin around not bright like furunculus but dark like erysipelas a hard cake in the cell. mem. equally around the centre. lymphatics affected becoming hard & red cords much const. irrit. chills, flashes of heat, nausea, restlessness etc. Small holes appear & keep occurring in a fresh part of the swelling A piece of skin mortifies & comes off often The pimples emit a yellowish fluid More dangerous about the head generally but not always fatal there Sometimes 35 very rapid gangrene ensues Case of a man who observed a small pimple while shaving a few days after Prof. H. was called, he died of gangrene Occurs oftenest on the old & in the intemperate Coma & delirium often ensue in the old where the gangrene is near the head Authors differ as to treatment The French use the actual cautery at a white heat The pains [illegible] is said not to be great Prof H. blisters at first It relieves the burning pain & heat. Then he applies an emollient poultice If the burning heat returns apply another blister. Apply ac. pl. [illegible] & cerate Sometimes where the fever is high bleeding has been beneficial in Prof. H’s practice. Always give calomel Dr Physick recommends caustic kali he says it relieves the pain Prof. H. has not tried it. He has always found blisters promote suppuration When pus collects squeese it out, and pull out the slough of dead cell. mem. which gives great relief If necessary in order to extract the pus & 36 sloughs in incision if sufficient size may be made Incis. at first though highly recommended are not approved of by Prof. H. Various affections of the hand called felons, whitlows etc. & paronychia Paronychia The term is applied to a variety of sores upon the fingers & hands sometimes upon the toes. Four kinds 1st a superficial suppuration around the root of the nail cured by nit. sil. 2nd suppuration in the cell. memb. of the fingers or hands a real anthrax 3d Inflamm. in bursae mucosae 4 deep suppuration between periosteum and bone & leading to necrosis 1st Commences with heat, [burning] pain, redness finally yellowness The nail is best unless properly treated These are commonly located with poultices They are comfortable. Mr. Higginbottom recommends nit. sil. If suppuration takes place open through the cuticle & clip off as much as possible of the skin The suppuration extends around and you 37 must continue to clip off skin. To stop this continually spreading ulceration, inject corr. sub. or sprinkle on cal. Finally dress with cerates or with saturnine cerate Sat. cer. Rx ac. pl. zii sulph. sod zfs sim. cerate ziifs. 2nd Is an anthrax & to be treated as such by blistering at first etc. Generally the tendons when laid bare continue white and glistening & do not turn yellow and die. If they are laid bare in this state by sloughing of cell. mem. they will generally become covered afterwards. 3 Of bursae mucosae They are excessively painful Generally common at a point & feel for some days as of a splinter was sticking there We can do little better than to continue to poultice until suppuration comes on. Then open thoroughly & keep the abscess if necessary open by a piece of linen. Pencil with caustic. It will not readily burst [illegible] through the bursa 38 4th The periosteum covers the pus. Treat by an incision in the first place without [reacting] for the formation of pus keep the part [illegible] This is a necrosis and is to be treated as such. There is much pain long before the swelling & much const. disturbance It may be necessary to extract a dead phalanx. The finger will heal up well afterwards This kind affects perhaps the canellae of the bone in some cases, producing complete necrosis Mortification. Conversion into a dark ash coloured mass, which is cold & if kept dry becomes black & finally fetid. It is said that mortif. for gangrene may commence without previous inflammation. This doubtful Two kinds acute & chronic 1st acute, takes place, by becoming orange coloured forms livid or purple vesications, containing bloody serum Bloody serum is a diagnostic, unless proceeding from ecchymosis Pulse becomes weak sometimes intermitting A mortified part is always insensible to a prick or cut, by a pin or knife 39 Chronic mortification takes place without any apparent inflammation though often preceded by severe burning j& pain A good example is that of old mens toes which commences with small vesicles & extends over the whole foot & the leg There generally precedes a severe pain in the part Two circumstances will always distinguish a mortified part, 1st an insensibility 2 fullness of blood vessels in the parts adjacent? Mortific. may be caused by injury, especially if violent enough to destroy the vitality of the [part] in the skin for instance by obstruction of the bloodvessels leading to the part by malignant diseases suddenly destroying a whole limb without any previous inflammation occasionally also from palsy in this way Cases 1813 pneu. typh. Infl. especially, erysipela & anthrax & in the old & intemperate is the most common cause fire frost bite The pathology of mortification 49 is very obscure. Sometimes excessive action There is sometimes a predisposition to mortif. & in such cases it will follow trifling injuries e.g. in broken down const. Prognosis is often difficult. All causes are dangerous. Prognosis depends upon constitution, part affected, & rapidity of progress It is very dangerous to have mortification succeed a trifling injury Chronic mortific. is always dangerous and especially if the tendons & fasciae are affected, when there is [little] probability of a cure for tendons are very slow in healing If possible dissect out dead portions of tendon etc. Sometimes the patient is suddenly carried off by a new attack of erysipelatous infl. or an infl. of one of the viscera especially the lungs Indications are 1st to moderate the violence of infl. 2nd remove sources of irritation 3d to prevent spreading 4th support sonstit 41 According to the opinion that the line of demarcation instituted by nature should be [initiated] and promoted by art it was formerly proposed to apply stimulating articles as hot oil of turpentine, etc. but these do injury. Cutting down for the purpose of separating the sphacelus does not stop the spread The const. sympt attend are sudden sinking of pulse, great anxiety of mortal restlessness cold sweat etc. If the mortif. comes on gradually these symptoms may be gradual in their occurrence. Sometimes however their attack is sudden The indications of treatment were 1st To moderate violence of reaction If the pulse is strong & the pain very great so that there is danger of mort. we may bleed. But the period for it is short. Where bleeding cannot be admitted leeches are recommended by some. There will be a dry tongue & the secretions are to be improved, by full doses of cal. when there is constip. but 42 small alterative doses when there is diarrhoea. Prof. H was in the habit of using it before he saw Sir A. Cooper’s remarks Bark is not how much relied on and is ever objected to b y many when there is fever. Mr. Pott found it useless for toes of old men & relied on opium instead For local application, use mur. amm. & ac. pl. either cold or warm according to the sensations of the patient Some object to cold applications Poultices are useful [Yest] poultices are merely useful. Prof H thinks by correcting fetor Bark poultices he thinks useless and if they are used are better made by a decoction than by powder 2nd In old men; to remove cause of irritation. be careful about splinters etc. Be careful to open abscesses to prevent irritation Remove sloughs if it can be done readily Continue opium all along beginning with cal. if bow. are costive but continue opium long after ceasing with cal. To prevent the spread 3dly It is very difficult to stop the spread 43 of gangr. Sometimes it will extend in the cell sub. under the skin, producing a crackling feel. Bark was formerly relied on’ but it is not now valued Blisters must be our great reliance. (Dr Phys. introduced them) but be cautious not to blister too near the gangrenous part. In case of chronic mort. as of old toes this is [illegible] Dr Phys & Dors. disputed Nitrous acid is now much applied 1, 2, or 3 or drops to a pint of water As for the const. treatment 4th This ind. is answered partly by the 2nd Besides this where the bowels are good etc. & it will do well give bark. Give wine, porter, etc. and indulge, but do not force the patient to generous diet In the suppurative stage give poultices & sat. cerate. Sometimes relief will be great from removing sloughs. Case in which the whole [gastrocnemius] muscle [illegible] removed, with relief & a cure Death from mort. even if external is sometimes very sudden. In 44 some such cases I have suspected phlebitis might have been the cause Hiccup has been called a fatal symptom, but I have seen it occur in the suppurative stage & yet the patient recover When the patient sinks, vomiting diarrhoea hiccup etc. comes on sinking of the pulse, cold sweat mortal restlessness etc. As to amputation in these cases, it must not be done if the whole limb is affected, but must be in cases of dead toes not spontaneous and other such for we must not expect a good separation, spontaneously to occur. As to time it was long considered as a certain axiom to wait until a complete line of demarcation is formed Baron Larrey was the first to change the practice Others here imitated him Prof. H. was at first driven to the practice by a hemorrhage of the post tibial art. He has never known a case where the limb has separated of itself. Though it has occurred undoubtedly 45 When mort. takes place spontaneously & from const. causes it will be of no use to amputate, but it should be done when preceding from fire, frost or erys. infl. Prof H. has always found the arteries of the toes, in such cases, ossified Sometimes in such cases it will be proper to amputate high up upon the thigh. Chronic mortification requires amputation occasionally especially of the limb is amputated high enough. In general however we cannot expect much success from amp. in chron. mort. Prof H. has known many deaths are often very sudden in such cases, and unaccountable. The line of demarcation is at first red, and afterwards whitish 46 Hectic fever. This was formerly thought to arise from suppuration but it occurs from irritation in chronic infl. of joints etc. when there is no suppuration. Prof. H. thinks it has always a local cause & is never idiopathic Unless it attacks suddenly and violently as after opening a lumber abscess it generally comes on insensibly It may be divided into acute & chronic acute when sudden and violent chronic when coming on gradually and continuing a long time, as in phthisis tubercularis Commences with a chill, and a hot fit In the midst of a hot fit a chill may occur. This was considered pathognomonic by Heberden. Considerable cough & expectoration of purulent matter may occur when the disease is produced entirely from a local cause & one not seated in the lungs & may be removed by amputation as of white swelling. Parox 2 in 24 h. pulse sharp Sweating generally occurs 47 only after an abscess is open as in disease of the hip joint, lumbar abscess etc. A good constitution is no safeguard neither is youth, where a cause, as an abscess exist. The chance of restoration of the local part is greater in the young, but the rapidity of the hectic is much greater in the young It is in them that we have galloping consumption” Indications are 1st to remove the cause 2nd allay & abate symptoms irritation 3d support strength 1st Open abscesses etc. We may warm the [illegible] when about to open an absc. that we esp. the sym. will be [illegible] for a time. 2nd to abate the symptoms restore the secretions by calomel relieve irrit. by opium not. but op. will stop the diarrh. whch often occurs Relieve thirst by acid cool drinks Keep the bowels soluble by cal. at first, afterwards by rhubarb etc. or if cath. exhaust too much use injection 3d To restore strength use opium also This procures sleep etc. Give bark also. Sulphuric acid has been much used but Prof. H does not think it anything more than a pleasant article Give nutritious 48 food. if the patient will take no stronger food, he may sometimes be kept along for sometime or milk porridge & similar articles Be very particular in searching out the cause. Case of young married woman with hectic. The unsuspected cause was the breasts cured by opening Wounds. Solutions of continuity in a soft part. There is a great variety in their nature & the part affected Symptomatic, or inflammatory fever usually follow considerable wounds This in good constitutions & when the wound is not too severe is generally short & easily subdued Six kinds 1st incised 2. punct. 3 lacer. 4 contusa 5 poisoned 6 gun shot 1st Incised wounds. The edges immediately retract but the first thing is to stop the haemorrh. by pouring or cold water by a short compression with the finger or lint. sometimes 49 by elevating the limb, as in wounds of the foot by the dressing merely if the wound is slight by exposure to the air. If a large artery is divided, it must be tied, but in small arteries completely dividing the art. will often answer as a substitute for tying. Tying should be by pulling out with forceps if possible, if not with tenaculum. Use a surgeon’s knot for large arteries. It is convenient else in the 1st knot from not slipping Leather ligatures shd be made of French kid (with the epidermis peeled off) & rolled round. Buckskin will answer. Leather tanned with bark will not be absorbed. Small ligatures are now used, in order to cut the int. & middle coats. Lec. haem. is now less common Mr. Lawrence recommends silk ligatures, cut close off. The knots however sometimes suppurate out. Prof. H. has no experience of this method The old method of tying with a needle is not now used if it can be avoided Other mode of stopping haemorrage 50 are by styptics, by compression. The best mode of applying pressure is by placing a [illegible] of lint on the artery & holding it there with the thumb Fungus as lycoperdon, agaric astringents as alum act. cautery The latter is especially convenient in the mouth. It is used in other cases also by the French. Re Remove foreign bodies Bring the edges together After cleaning the wound of blood & coagula. bring the edge carefully together, & apply adhesive plaster. Mode of applying them Begin at one angle etc. Leave about a quarter or an eighth of an inch between the strips. In the large town they use plaster spread by machinery & plaster cloths but they do not hold so well as if recently spread Mr Liston recommends glazed [ribands] smeared with a solution of isinglass & brandy 51 The main indication for a strong plaister, and made of material which will not irritate the skin Do not dress a second time at all unless there is some indication for it not under 3 or 4 days Where artery has been tied, do not dress under a week or 10 days Dress as seldom as possible unless called upon to do so by accumulation of pus, or offensiveness of discharge etc. When you dress, do it after carefully washing and softening the old dressings and if the wound is large and open apply a new strip of plaister after removing one so as to have but one strip off at a time Inflammation should be guarded against thought it is the fashion with many to make no applications but the dry dressings. Prof. H. has been led by experience of both methods to prefer wetting the dressing with cold lotions in the robust, & [illegible] tepid nor the feeble & 52 delicate, if they prefer it Where it is of consequence adhesive straps be sure to hold wait a few hours before you wet the dressings In longitudinal wounds of the limbs the rolling bandage, with one end drawn through a slit in the other will be a very useful adjuvant Splints also may be necessary. A proper posture is of great consequence Haemorrhage continued. Jones found that small ligatures cut the inner coats and thus promote the closures. Vide his work on haemorrhage. Torsion of arteries another mode & may be useful in the [orbit] of change for instance When called to a wound, if the hemorrh. has been already stopped by dressing, the cautious about removing them for fear of reproducing the haemorrh. Generally let the first dressings remain about a week Secondary haem. may occur Prof H. has been obliged to tie arteries 6 weeks after the wound An artery should not be tied in an old wound. The wound shd be 53 dilated It will not always answer to be the artery at a distance on account of the anastomoses In the first place where a limb is bleeding freely, apply a tourniquet Much has been said about the reunion of parts totally separated. Prof H. has never succeeded, where the separation has been total Yet othes have succeeded The diet shd be attended to We expect more or less fever, and of course a moderate and generally vegetable diet shd be prescribed. Sometimes also bleeding & cath. may be needed Generally [illegible] the fever subsides readily Sometimes pus forms underneath and must be let out Punctured wounds Shd be dressed & the attempt made to heal them in the same was as incised wounds They are more difficult to heal however much const. irr. may ensue 54 Suppuration is apt to come on It is necessary to dilate if the symptoms are very severe and the local pain and inflammation are very severe. Case of a lady in convulsion from a prick on the toes relieved by dilating the wounds to the bottom (Dr Phys.) Where other means fail of relieving the symptoms, then dilate freely. Tetanus is oftenest a consequence of punctured wounds The cases of idiopathic tetanus which Prof. H. has seen differed much in the symptoms from traumatic tetanus & he thinks the dis. is different Pathology of tet. is very obscure. Some have thought the spinal marrow the [illegible] other can find no disorganizat. there Tet. takes place about 10 days after the injury Wounds producing it are less liable to inflam. and may have healed up & from their insignificance have been forgotten entirely by the patient Commences with stiffness of the jaws, as if patient had taken cold 55 The stiffness increases. Spasms in the jaws & neck come on which increase and affect the dorsal pectoral and abdominal muscles The pat. is drowsy after a spasm and requests to be allowed to sleep The bending generally is backwards. Prof. H. has never seen a case of [empusthotonos] The spasms grow more violent & the patient generally expires in one. An effort to swallow may bring on one. A good constitution is no security. If the pat. is to recover the species grow less violent. After recovery a stiffness remains of the jaw for some time I have known a stiffness of the muscles of the back remain for a year. Treatment 1st local open and dilute the wound endeavour to excite inf. (according to Dr Rush’s plan) by corr. sub. in the wound Baron Larrey recommends act. cautery 2nd const. treat. Sometimes Prof. H. bleeds always gives cal. Some bleed enormously and have cured 56 Dr Phys. applies mercurial ointment until salvation is produced. All give opium largely some by injection Chapman gives injections of antimony & succeeds Arsenic has been strongly recommended, in large doses All remedies must be in large doses, for small ones do not affect the system. The bowels are costive & not however in consequence of opium Cath. must be given. Croton oil promises well Hamilton’s cases tetanus cured by cath. were merely idiopathic cases arising from irritation of al. can. Amputation has succeeded where there were spiculae of bone have irritated (with thumb) Prof. H. tried it in the case Bark & wine have cured (Hosack) Alcohol (Rush) Case of a young man who had cut his foot with glass. When he first began to have tetanus he would fall on the blood & his mother thought him rheumatic. Cured 1st large bleeding [illegible] cal. spasm continued laudanum beginning 57 with 25 or 30 drops (any strong SS) increasing to 40 & eventually a teaspoonful frequently reputed. After recovery his neck was bent back for a long time. Case in London Cal. grs 6 once in 6 hours Ol. turp zii – zj ol. oliv. by injection gave the most relief & first checked the disease They were given 3 times a day. Opium seems to do no good & was relinquished. The woman was long in recovering So that his case was not the most violent Lacerated wound have been supposed to require a peculiar treatment not to attempt the union by first intention There is little or no hemorrh. Prof. H. however brings the edges together & keeps them in contact by adhesive plaster keeping the dressing wet He has had much better success Often they heal principally by the first intention. The injection of the cell. memb. with lymph, and swelling etc. is prevented The only systematic writer who has as yet recommended this practice is Mr. Mann. 58 Poisoned wounds The bite of the rattlesnake is an instance Some persons seem to suffer very much from the stings of bees & wasps It is a question whether the bite of a rattlesnake is injurious by absorption or by an affect upon the nervous system merely Some late exper. seem to prove the former opinion Symptoms of phlebitis have appeared to show themselves in some of these cases The tendency to gangrene is very strong Remedies At first excision caustic ligature. The French use muriate of ammonia as a strong caustic (old butter of ant.) After the first stage apply blisters and treat as for erysipelatous inflammation. For the const. shock & exhaustion ammonia seems to be best article opium also Cordials and stimulant are strongly indicated Case of a man in St Lucie [colub???] [illegible] stupid in ten min. amput. of finger which was not felt 8 grs arsenic in 4 hours cordials mint water laudanum spts terp. amm. & ol. oliv. in a liniment for 59 the hand Cured in 10 hours Several persons had previously died of the bite of this serpent Case of a woman stung near the eye Cured by bleeding & calomel A young woman died in 20 m. after being strong with leg [illegible] Hydrophobia. Prof. H. has always cut out the part. It seems to answer Prof. H. has performed excision 6 days after the accident no hydroph. followed Dissection wounds A wound seems to be necessary. Various circumstances are supposed to predispose, but Prof. H. thinks they are not necessary & that the most we can say is that the inoculation does not always take Symptoms infl. of the wound redness of lymphatics all along the arm Const. sump. very severe from the first, great prostration, restlessness etc. Suppuration forms along the arm in the axilla or under the pectoral muscle or within the pleura Or the patient may recover with a suppuration of the finger, & perhaps 60 a loss of the finger Prof. H has seen the same symptoms take place to the greatest extent from wounds of simple puncture e.g. from [illegible] of fist in N. Haven from a fish spear the latter case related wounded the tendon of the gastroc. while wading suppurat. all along the leg in the axilla finally in the pleura Prof. H. has had his own fingers very sore & for a long time after dressing gangrenous ulcers & has known women effected in this way from washing bandages losing the nail etc. Caustic should be applied to the very bottom of the puncture & not merely on the top. Contusions. Injuries of the vessels & a rupture of their contents without breaking the skin. Ecchymosis or “black & blue” In favourable cases the extravasated fluids will be absorbed In others the colour changes becomes mottled and yellow etc. The effused fluids often descend in the direction of gravity & produce discoloration in another part 61 In dicutions 1st to prevent further effusion by keeping cloths constantly moistened with ac. pl. or cold water. 2nd prevent inflammation, by const. rem. if necessary 2d to promote absorption, by fomentations & [sometimes] application camphor and soap etc. It may be necessary to let out the effused fluid Sometimes these “bloody abscesses” as they are called by the French shd be opened at first. Case of a man whose foot had been crushed in a saw mill pain absolutely intolerable relief was given by letting out about ½ just of effused blood Prof. H. can derive no rule from the coagulation of the blood The blood is generally dark fluid tar like If means for absorption fail we must make an incision. This will oftenest be the case in the old and especially when the effusion is in a bursa as that of the patella. Prof. H. has often been obliged to open the bursa of the patella open on the outside of the tendon of the rectus 62 On the olecranon also the same state of things occurs absorption here is uncommon. Serous effusion is apt here and elsewhere to follow the letting out the blood If the abscess does not heal, inject corr. sub. & probe the abscess every day Often a part of the skin is killed if this is the case, puncture through the dead part. Contusions of abdomen kick of a horse The peristaltic motion is suspended the abd. immediately swells constant vomiting great anxiety of continuance etc. mortal restlessness no sleep etc. Blood may or may not be united Vomiting may be of blood and immediately. Bleed at first the pulse will rise after it repeat it bleeding gives great relief the patient will call for it [illegible] Apply cold lotions bandages to the abdomen. Purge with large doses of calomel & injection until relief is obtained. Blister early if there is great pain 63 In the progress of the treatment a blister may be applied to the abdomen The thirst will be very great and is to be relieved with cold water These cases are very severe The abdomen will infl. up suddenly after the blow, before there is any time for inflammation & immediately vomiting of blood may supervene Case A young man in Prof. Brown barn yard. Vomited blood all day warbled 2 or 3 times Large quantities of calomel In two or three days was able to be removed A phys. who had received such an injury called for repetitions of the bleedings saying that they afforded his great relief After the first stage cordials etc. may be necessary on account of the shock of the system. Or at the first where there is no vomiting etc. Blows on the pit of the stomach may extinguish life 64 Strains Hardly known to writers except Boyer Extension of ligaments with rupture. Joints subjet are those with but little motion and strong ligament viz knee ankle, wrist, fingers & toes. Shoulder & hip very rarely At first the joint can be moved freely in all directions enquire after this to distinguish from fract. & disb. Very soon affus. takes place perhaps a sac of burs-mucosa Dieting from cont. by nature of accident by being treated Sometimes however it may be doubtful or both may be combined The treat however is the same for both Dieting from disloc. (this is of great consequence) Prognosis doubtful Bayer remarks that the ligam. become lengthened Constit. makes great difference rending some more liable (delicate persons) ternia rate in white well. perhaps is scrof . persons Treat like contusion Boyer 65 advises cold water at first. Use tepid water for a very delicate fem. perhaps) For consid. infl. use ac. pl. Some are afraid o fit Prof. H. has seen no injury A bandage moistened will give actual relief instead of pain & will promote absorption Opodeldoc also For great pain apply fomentation or a steam bath. After infl. is subd. apply frict. Give the attendants some camphor perhaps to encourage them in using friction When the proper time arrives use motion & exercise passive at first afterwards by the action of the [muscles] There is a golden time for exercise. A plaister bandage around the joint applied so as to keep the whole joint at rest & firm when pat. first begins to walk let him have a shoe or boot with a stiff sole # Burns Infl. or destruct. of parts by heat No part of surg. more empirical No advantage in dividing into species. It must be remembered that a burn or scald when slight is merely a blister just as from canth. or hot water and shd be treated as a blister, by excluding # not bundled up in blankets more motion 66 the air. Case of a child blistered over the whole body by cantharides & vinegar died If the cuticle peels off immediately after the barn, we may be sure that the injury is very extensive The highest danger is from the shock Often perhaps the [glaze] is inhaled, when the clothes are on fire. Prof. H. has not however with nothing more than a hoarseness from this cause & dissections have not shown much of this kind Sometimes the viscera immediately under the skin are inflamed vide Journals It has been remarked also that child. often die some weeks after the burn unaccountably 3 weeks is the critical period when the suppuration Convulsions often occur in children when after the first shock reaction begins to come on When any application apparently comfortable has been made do not disturb it. Sir James Earle contended for 67 cold water, ice, bleeding & cathartics [illegible] [illegible] on the other hand contended for spts turp. & intern. stim. Prof. H. thinks truth lies in the mean Where the shock is very severe the const. must be supported The best application for the vesicles a simple cerate prick but do not clip off the vesicles. Always have your dressings ready when you take off the old one when the cuticle merely is separated the granulations will be very small and no scar will be left But when the true skin is separated the ulcer will be long in healing & leave a scar The best dressing in the latter case is a mixture of spts turp. & cerate. Rx common basilicon of the shops & basilicon or cerate equal parts Prof. H has seen all sorts of applications. He at first tried Ben. Bell’s plan of ac. pl but it does not promote healthy suppuration. Poultices are very inconvenient requiring frequent exposure 68 to air and being [heavy] Besides they do not promote suppuration When supp. is established the spts turp. cerate will cause smarting and should not be continued then dress with simple cer. Keep on the first dressing as long as you can dress as seldom as possible. Keep the air of the room equably warm [illegible] keep in cold weather a warming pan near the body In the latter stages especially if the sores heal over & break out again use sat. cer. Before this Prof. H uses Turner’s cerate & cer. ox. zinc If granulations do not proceed well use nitrate of silver to touch the ulcers. This is a most valuable surgical remedy. Mr. Higginbottoms plan of applying it to infl. though it produces smarting at first, alleviates irritability & promotes resolution Case which Prof H treated with nit. sil. & simple [cerate] did well Sometimes for the fungus sulph. 69 cupri is better than nit sil. The shock is very severe coma excessive coldness of extremities etc. Ben. Bell advises opium. Be careful how you give opium in coma. Prof. H. gives one dose of SS & follows up with alcohol ext. heat etc. When infl. comes on depend especially upon cal. cath. keeping the bowels loose vide [Motherby] Considerable fever may ensue which is to be treated with cal. cath. Generally the pain is so great as to require op. When supp. is extens. & strength fails give bark Cotton will do well enough for superficial burns excluding the air Prof. H has seen much inconvenience from it in deep burns Case A man fell into a [kettle] of boiling potatoes about half of the cuticle from the head to the feet came off He drank a large quantity of spts. Prof. H. applied spts turp. & basilicon, as above. Next morning fever high bled him cal 70 Afterwards treated with cal. & according to symptoms Supp. came on Barks Finally bark injured & was [emitted] & cal. given ulcers touched with nit. sil. Recovered well & has the use of his limbs Distortions from burns The growing together of the fingers may be prevented by separate dressing. The tendons also may be burnt and contract Then keep the fingers straight by splints The object is to keep them straight they can be bent well enough after healing. So also of the feet and toes Case of a man with a ridge of scar extending along the back of the leg up the thigh like a [illegible] finally a growth of [horn] began finally had his thigh amputated. Cicatrices shd be cured by cutting out the whole scar not by dividing it & suffering it to heal up. This las way fails Case 1 ft long 1 inch wide 71. Frost bites Long continued cold produces a degree of torpor in the system tendency to sleep. Case of Prof. H’s instructor warned his companion not to stop; was the first to stop & endeavoured to conceal himself & rest was very torpid when brought to the fire. So Dr Solander The treatment of a limb partially frozen shd be by rubbing with snow or better by putting into cold water afterwards gradually warming the water A limb thoroughly frozen cannot be successfully managed in this way so as to prevent inflammation The infl. resembles that of burns It may be moderated at first by ac. pl. or spt. & wat. When suppuration comes on treat with cerate etc. When the whole limb is thoroughly frozen, gangrene will come in, beginning as usual with dark & ash coloured spots vesicles etc. line of demarcation etc. Prevent this by amputation The const. not being effected the operation will succeed. Do not delay the operation too long 72 Case Gent. in Brooklyn thrown from a wagon lay the whole of a very cold night when found in the morning was able to tell his name When carried into the house blood could not be obtained When Prof. H. found excitement coming on & bled him “with relief” Soon coma came on Thought the man must die But eventually amputated the fingers very bad leg etc. Recovered The amputation was delayed much too long Prof H. has had many cases of frozen toes He always amputates as soon as possible Case at our Almshouse 73 Tumours Varieties are very numerous 1st encysted 2nd sarcomatous 3 medullary Also malignant & non malignant The former may change into the latter We know little of their origin Abernethy thinks they arise from an extravasated clot of blood Sir E. Home has lately advanced a similar opinion It is undoubtedly true that the nature of the part alters the nature of the tumour as Abernethy thinks (The growth of tumours is somewhat similar to chronic infl.) Near the scalp we often find hairs in tumours. In glands the tumours will have a glandular appearance. In the adipose membrane, adipose tumours Yes there are many exceptions Some suppose tumours arise from hydatids (which are decided to be living beings). But this explains nothing The growth may be rapid or very slow or slow & then suddenly very rapid In general their increase seems to be in geometrical ratio 74 As a general rule when it can be done they shd be extirpated before arriving at large size 1st Encys. tum. are 1st atheromat (curdy) 2 vellic (honey) 3 steaton. (fatty) The cyst is generally firm & opaque Tumours that have no cyst or a very [thin one] are generally sarcom. or medull. There is a kind of tumour of a bluish colour [illegible] within cyst, which appears upon the lips and is considered cancerous Cyst very thin filled with matter like the white of an egg extirpated immediately is the remedy (by dissecting around) Often upon the head encysted tumours are very numerous and keep reappearing Discutient applications have been much tried. They do no good, and often change the tumour into a cancer Caustics may be a successful substitute for the knife in small tumours Such small encysted tumours are [illegible] away by the cancer doctors and add much to their reputation These tumours sometimes inflam. of themselves and this in a few rare instances 75 cure themselves. Generally however the part eaten by the caustic heals up and the tumours continue The only remedy is extirpation. This was formerly directed to be done without wounding the cyst this is difficult without cutting away much flesh Sir A. Coop. mode of [illegible] open the cyst and then everting it with heat The cyst is easily distinguished by its appearance Sometimes from an injury the tumour [inflam.] and suppurates of itself. Then Prof. H. introduces a little caustic kali upon lint Lately however he has often succeeded in such cases in pulling out the cyst Sometimes membranous bands have to be cut Sarcamatous tumours are of very various consistence fatty with fat in large cells fleshy & others Extirpate, by removing [illegible] skin as may be advisable remove as much as possible by the fingers cutting membraneous bands if any removing very carefully from their adhesions to muscles & tendons Sometimes an infl. comes on accidentally and very bad ulcers are 76 formed, and the tumours must be removed even from very old persons to whom they have previously given no trouble Arteries do not generally require to be tied. Then after appear about the perineum and the art. may require tying 2 cases in females of Prof. H. Sometimes these tumours are very vascular case in which from are about the size of a goose egg after the first incision a gush of blood by which the tumour was much reduced in size and was extirpated The largest tumours are adipose even 40 50 & 70 pds Tumours of the scrotum seem to be an enlargement of the nat. parts in whole or in part. Adipose tumours feel like a bag of cotton are very irregular in shape and when the skin is pushed along it rises in ridges, from its adhering in some parts and not in others This last is pathognomic Prof. H. believes the shole parotid gland has been extirpated McClellan Glandular enlargement are apt to be called tumours Enlargement of the mammae will often subside after child bearing 77 malignant tumours are these liable to return Medullary Tumours substance resembles that of the brain Called fungus haematodes may spring from any texture even as Prof. H. believes from the bones They have an elastic feel when under a fascia they may be mistaken for [aneurism] or abscesses They were formerly called cancers Their growth is very rapid Prof H has known one is large as a milk pail upon the thigh. They are most common in the young, but are found even in the very aged. They may spring up in the testicle, in the eye & in every part of the body. They have often been mistaken for abscesses and opened. The only marks of distinction are 1st they are at first deeply seated and do not arise from the cell’ memb. under the skin, but from deep seated part apparently, in many cases from the muscles. 2nd not powerful in themselves only so by pressure & distention of surrounding parts and the pain is generally in a distant part, and will often be 78 attributed to hreumatism 3d Great const. disturbance & hectic The only remedy is extirpation but the tumour generally returns, and others often spring out in other parts of the body. So that the prognosis must be very doubtful. In the progress of the tumours the patient will suffer nausea vomiting & will grow sallow. The patients generally recover rapidly after an extirpation and are much pleased with the success of an operation. Yet the tumour soon returns. From some late accounts Prof. H. is inclined in future to persevere in extirpating. They may be distinguished from chronic abscesses by an elastic [illegible] instead of the fluctuation of pus The skin over them is not tender and sore, as when an abscess [illegible]. Distinguished from scrof. etc. by not beginning in the lymphatic glands If we are in much doubt we may make a very small incision without danger closing up immediately 79 When they reappear you will see at first a small gelatinous vesicle which swells and grows very rapidly Many cases related in which they returned in the same [illegible] other parts Schurrhus or Cancer They are different states of the same affection Schirrhus is a hard cartilaginous malignant tumor. Cancer is the same tumour in a state of open suppuration It has been said that infl. may terminate in schirrhus not so. It seems to result from peculiar action we see that tumour improperly tampered with may terminate in cancer. Most commonly found in the female mammae. Found also on the mucous membranes Cancer of the skin will be treated of under the head of cancerous tubercle of the skin Cancer of the breast for an example Begin with an uneasiness soon a small hard tumour finally 80 inflammation of the skin and the skin adheres the nipple retracts afterwards perhaps an ichorous fluid issues next small knobby tumours next a vesicle which bursts and we have suppuration and an open cancer The suppuration does not always begin on the outside but frequently within the substance of the schirrhus. All this while the pain keeps increasing About this time or sometimes before ulceration, the lymphatic glands begin to be [illegible] appearing like inflamed cords giving the skin a hard puckered appearance. Then inflamed and enlarged glands appear not only in the axilla but in all directions The mamma and the pectoral muscle adhere to the ribs and sternum. The affection may extend to the other breast. The swelling of the glands in the axilla may cause so great an edema of the arm that the skin must be punctured. Effusions take place in the pleura or tubercular 81 consumption comes on. It is not true that the cancer “eats through” as they ] say. Hydrothorax is the most common termination. Prof. H. has thought from the supervention of pains in the back etc. that the disease becomes transferred to the uterus Various other symptoms may occur sometimes a paralysis of a part or all of the limbs sometimes the bones break easily Distinguished from fungus hematodes by being an affection of advanced life by ulcerating and destroying the skin by not beginning in the muscle or bones by being not smooth but knobby by lancinating pains Cancer destroys adjacent parts fung. haem. grows through them Above all cancer is always hard to the feel. As to the great question whether cancer is a constitutional or local affection Other tumours and even simple ulceration of the lip may terminate in cancer. Cancers are very liable to return and most so of their previous progress has been very rapid Schirrhus tumours in old persons give 82 perhaps little pain project little, are very insensible, and the old patients converse to their removal As to curing the Prof. H. does not believe in its practicability Mercury seems to be injurious. Storck introduced conium. Carmichael Smith made iron especially the phosphate, fashionable The London Cancer institution has been abandoned from want of success No remedy seems to promise anything but extirpation by the knife Small ones may be eaten away by caustic but the process is very slow and painful Caustics applied to a large cancer produce great and highly injurious irritation Prof Smith never knew a female with cancerous breasts survive caustic for a year It is impossible to say how long it may be before the return in one case 7 years intervened Much is said about the incurability of them after they have become open ulcers. This distinction is not a good one. When you extirpate be sure 83 to cut out all the diseased parts including the infected glands Persevere in extirpating as long as they return, if complete extirpation is practicable in each case. Never amuse the patient with the prospect of a cure by any mode of treatment Prof. H. has extirpated one hard cartilaginous schirrhus of 4 pounds weight Patient recovered for the time Superficial cancer Occurs oftenest in the lip Generally commences with a small crack in the lip which is neglected A scab forms, and upon examination at this time we shall find a hardness beneath The glands under the chin or under the side of the jaw, swell & harden Ultimately the lip becomes excavated, with an ulcer which has cartilaginous edges Finally the whole lip, jaw etc. are eaten away & the patient dies miserably Caustics are generally very injurious. Excision is made by taking out a v0shaped piece Richerand advises to take 84 off the whole lip the lip afterwards elongating This mode not so good As to cancer in other parts Prof. H. has known ulcerated leg terminate in this way and once case of necrosis With respect to the cancerous diathesis or a disposition in the constitution there may exist something of the kind but the practice of telling patients that they have a cancerous humour in the blood is very reprehensible making them very unhappy Extirpation is not necessarily followed by reappearance Cutaneous cancerous tubercle of MR. Lawrence. Commence with a small insignificant tubercle, hard, resemble seeds of mallows called warts often by the patient but they are vascular they finally ulcerate they may become extensive cancers Old men are subject to them about the face. Women have them in the pudenda Men have them upon the glands penis Prof. H. has seen them about the pudenda 85 in cases of amenorrhoea emit blood periodically at the menstrual periods. These cancerous tubercle may occur about the eye and the nose. The success of extirpation is far greater in these cases than in common cancer. Be careful to cut far enough with two semilunar incisions They leave no scar. These cases are different from noli metangere. Noli metangere Intermediate as it were between cancer and common ulcers. Appear about the face and nose An ulcer forms 7 becomes covered with a scab. The ulcer is often irregular & oblong. They are often converted into cancers by caustic In the course of time the scab comes off permanently and an open ulcer continues The ulceration of noli metangere may affect the cell. memb. or the cartilage of the nose or they may not even penetrate the true skin. The best remedy is arsenic The most common form is an oint. of which arsenic zi to zi cerate. Apply a plaister 86 of this one day and then a plaister of common cerate or satur. cer. for a few days. Inflammation S. Cooper uses 4 gr. to 4 oz mint water & 1 oz spirit applied in lint. Sir E. Home applies a solution made by boiling A powder also of arsenic & tapis caliminaris Others apply sulphur & arsenic Fowlers solution also. It seems that any form of arsenic will answer. Prof. H. has cured also by nit. sil. also by red precipitate ointment Occasionally touch with nit. sil. to promote the healing in the latter stages There seems to be little need of the old plan of giving constitutional remedies A disease similar to this if not [proceeded] to far If the cartilage has become affected cut out a piece. If the eye has become affected extirpate the eye. There seems to be nothing specific in the cure of noli metangere other ulcers also are to be treated by exciting an action in this way. 87 Prof H has known the experiment of low diet also of a diet of [illegible] thoroughly in use of cancer but without benefit Subcutaneous tumour in the cellular membrane It may occur in any part covered by acutis vera not on lips They are about the size of a walnut excessively hard First mentioned in Cheselden’s anatomy (calling them a tumour of the nerves) Described by Mr. Wood in the Ed. Journ. also & by Mr. Lawrence in his lectures Very painful skin is emaciated and adheres looking like a cicatrix painful when the cloths rub over them, or when they are struck or examined. Not dangerous but troublesome May continue many years (20 Mr Wood) without charge. Extirpate them 88 Ulcers A solution of continuity which gives out pus. Absorption goes in faster than deposition opposite to the process of healing a wound by granulation Caused by wounds opened abscesses, injures caustics, acids irritation of foreign bodies Constitutional causes are syphilis scurvy scrofula and a predisposition in some families to sore legs Varicose veins, oedema, dropsy, phlegmasia dolens are causes 1st simple 2 irritable 3 indolent 4 varicose 5 specific 1st simple an open sore after a time a bluish skin covers the sore & becomes a cicatrix This is cuticle not true skin. The part underneath is hard cartilaginous In simple ulcers as much benefit may be derived from adhesive straps to approximate the edges as in [wounds] 89 Place over them a compress & bandage If the granulations rise too high (proud flesh) touch with nit. sil. or sulph. cupri. Another advantage of bandaging is to prevent the swelling. Bandage a whole limb. Irritable ulcers painful the adjoining parts sore granulations absorbed bitter smooth Often irregular in shape sometimes however round and cup shaped. On the shins small sized These ulcers do not bear bandaging Frequently touch them with nit. sil. Sometimes however they will not bear this. in this case then apply a solution of nit. sil. 3 or 4 grs. to 1 oz. or corr. sub. 10 gr. to 1 pt or the yellow wash lime water 1 pot corr. sub [illegible] ? or sprinkle on calomel or black wash which is milder than cal. z2 cal. to 1 pt lime water or apply the blacker oxide this generated Also zjfs op. to 1 pt water. Also saturine 90 cer. Also ac. pl. zj to 1 pt of mucilage of slippery elm, when parts are excoriated Warm fomentations and poultices shd not be continued long they are too relaxing We are obliged often to try a variety of applications Indolent ulcers Usually large granulations lax and flabby discharge serous a substance like curd white or yellowish or brown lies upon the surface. Ulcer excavated as if cut out with a knife surface smooth no granulations edges swollen making the ulcer appear deeper surrounding cell. memb. hard Very insensible Patients will continue to labour as usual they apply spirits salt and vinegar urine etc. with no effect In the species also apply nit. sil. 2 or 3 times a week corr. sub. dilute nit. ac. 100 drops to 1 pt. is a good application red precip zi 91 to zi of cerate is an old application Above all other modes is to be recommended the plaister bandage Take common adhesive plaister or dyachylon having a plaister soft enough to spread & yet adhesive soften with tallow or lard if necessary Apply the strips of plaister so as to approximate the edges Then apply a compress & bandage the whole limb. Leave a little interval for pus to escape, or cut a little hole for the escape of the pus Leave the dressings on as long as possible say 3 or 4 days in hot weather it may be necessary to dress every day the sore becoming offensive You may let the patient walk about during the cure, if in this mode Sometimes an erysipelas commences in the neighboring parts And sometimes the ulcerations suddenly spreads with rapidity Surgeons speak of a sloughing 92 ulcer But all ulcers may exhibit this appearance After the erysipelatous infl. suppuration sometimes takes place in the cell. memb. Varicose ulcers Varicose veins accompany them either in neighborhood or over the whole limb May be cured by proper bandages They are ulcers from injury of varicose veins Bandage the whole limbs In the hospitals the patients can be cured of ulcers more speedily than in private practice but they are very liable to a relapse When pat. apply to Prof. H. with a high state of infl. & irritation in consequence of an ulcer, he bleeds But if pat. is cold in extremities feeble etc. he gives cal. & op. as recommended by A. Cooper Prof. H. had however given them long before seeing his work 93 For varicose ulcers cutting the vena saphena is practiced in the Mass. Hospit. (cut inside the skin) In the Penns. Hosp. they cut out a piece after emptying the vein by means of a bandage Mr [illegible] destroys the vein by caustic kali Tying the vein is not to be recommended Cases in which sore legs have become cancerous from tampering with them Propriety of drying up old ulcers The prejudice probably has arisen partly from the drying up of old ulcers after and attack of fever Prof. H. has been in the habit of healing or attempting to heal every old ulcer. He has never either known or heard of a well authenticated case of injury resulting They frequently however break out again If plethora arises it would be much better to bleed etc. as directed by A. Coop. 94 Specific ulcers are syphilitic noli metangere scrofula etc. etc. Some ulcers cannot be classed Sir E. Home speaks of a peculiar sore upon the ankle which yield a serous discharge and covered with scabs Apply after softening the scabs with a poultice and washing them off, cal. or nit. sil. or corr. sub. or ac. pl. with slippery elm or poultices with narcotics cerate sat. or dyach. S. Cooper mentions fungated ulcers upon the calf of the leg nit. sil. or sul. cup. And to prevent apply ac. pl. Occur in corpulent young women especially ‘ those who work in factories and stand much on their feet & live pretty well. Prof. H. has known several females affected with varicose veins & ulcers after phlegm. dolens. Scrofulous ulcers are long in bursting flabby fungous granulating overhung by the think skin upon the edges of the 95. ulcer skin sometimes purple. Apply nit. sil. under the skin and if necessary clip off this skin at the edges. Sometimes there is only a very small orifice in the skin. In this case if they do not heal lay open the ulcer & touch with nit. sil. They will then soon heal. Introduce a stick of nit. sil. upon a quill through the opening and touch all around Diseases of Mammae Vide A. Coop. Lect. by Tyrrel Hydatid or encysted tumour not the hardness of schirrus, skin not discoloured after a while a fluid is felt when upon puncturing serum issues but soon collects again. The tumour may be even 13 lbs in weight not painful Generally a dis. of advanced age sometimes attacks at 20 yrs Upon dissection, one or more cysts are formed the body of the breast not being much affected Sometimes the cyst inflames & 96 suppuration may come on and destroy the patient. Tents and stimulating injections shd not be used they may prove fatal. Diagnosis absence of pain const. not affected swelling smooth firm & hard fluid clear. Cure by extirpating It will not return Simple chronic tumour of the breast. Not hard like schirrhus appears superficial (schirrhus feels deep seated) grows slowly not very painful. Extirpate. Does not return. The tumour seems composed of lobes like the sweet bread (pancreas) Cause unknown though by some to arise from pressure of cloth Adipose tumour of breast Seated sometimes under the gland occasionally of enormous size 14 or 15 pds. The large tumours called cancers which are extirpated are Irritable breast Lobe of the breast slightly swollen and 97. tender pains in the shoulder amenorrhoea irritability of nervous system Do not think of extirpation Bleed the plethoric give sub. & opium etc. Apply spt. & wat. or lard & laudanum or sometimes litharge plaister. Often what is better than all is a piece of soft fur or cotton wool The main thing is to quiet the alarm about cancer. These cases occur in a neighborhood where an operation has been performed Ossific tumour Extirpat Lacteal tumour Soon after parturition Caused by an obstruction of a lacteal tube Introduce a lancet and let out the milk & then pencil with lunar caust. to stop the flow of milk Abscesses of breast that let out milk, by sloughing off a part of a lacteal tube. Touch with nit. sil. Some women are subject to abscesses when the child is 6 mo. old Wean Enlarged breast Generally diminishing upon child bearing. Suspend 98 the breast The breast sometimes enlarges and is painful during pregnancy Bleed. Calomel etc. Operation for taking off the breast. Always remove the whole glandular tumour of the breast except in the case of the simple [uremic] tumour. Instruments 2 or 3 scalpels 1 tenaculum needle ligatures, sponge a broad bandage to pass around the body straps to go over the shoulder [illegible] compresses cordials a pitcher of cold water Place the patient on a table with the feet in a chair An assistant holds the arm at right angles to the body Make the first incision in the longest direction or otherwise in an oblique direction Make two incisions to include diseased skin if necessary and always include the nipple which shd never be left Be careful to make the incisions long enough If two incisions are to be made make the 99 lower one first Then dissect down first on the lower side then on the upper & finally at the bottom The most painful part of the operation is the cutting through the skin The glands in the axilla can frequently be borne out and always when you have fairly cut down to them pull them partly out and then divide the membranous bands this is much safer than to cut around them in the dark Prof H. removes the lymphatic glands first and makes a handle of them instead of making a handle of the breast as recommended by Gibson Wait awhile before you dress the French surgeons say ¾ hour. It is very unfortunate to be obliged to [illegible] the wound. Give but little medicine, as a general rule after the operation Usually in about 4 days the wound must be dressed with dressings become offensive. Dress as at first The nervous irritation and the shock 100 to the system is great in proportion to the length of time taken up in the operation Be careful not to move the arm before the healing of the wound After the healing of the wound remedy the stiffness of the arm by motion Other tumours are extirpated in a similar way. It is too much the fashion to tie the large arteries (as to carotids) at the present day and the plan of tying an artery for the sake of stopping the growth of a tumour fails Fistula Lacyrymalis This name has been given to nervous affections which obstruct the nasal duct. 1st Enlargement of lac. sac is most common 2nd Suppuration of lac. sac. 3d an open ulcer of the lac. sac 4th ulcer with aff. of [illegible] or with nasal polypii Prof. H. has never seen a case of obstruction of the canals leading to the sac which is a 5th kind. 1st Obstruction of nasal duct by enlargement of the sac. May be of 15 yrs standing without going further Most common in females who work over the fire & live in smoke Generally the duct is only partially obstructed Tears flow over the cheek sometimes a gelatinous fluid issues & glues the eyelashes together. There will be a sense of fullness and the patient will press the corner of the eye & a fluid will issue into the eye & down the nasal duct. Tears flow more freely with smoke & in cold air (Sometimes the distention of the sac is large as large as a hickory nut and is mistaken for a tumour (encysted) Some patients in this stage are unwilling to have any thing done Prof. H. has often succeeded in curing the disease in this stage by remedies for infl. sol. nit. sil. dropped into the eye anoint the edges of the lids with red precipitate sat. cer. or citrine ointment ac. pl. Give calomel Prof H. has never used either the probe or the injecting syringe He has seen no account of cure, performed in this way. Mr. Liston disapproves of them. Prof. H. has not used them because the diseases cured by the above means or passes into the second kind 2nd Suppuration Open the abscess and introduce a stilette 3d An open ulcer with complete obstruction. Introduce the stilette. And generally make a new orifice with a small round edged scalpel just below the tendon of the orbicularis. Sometimes Prof. H. has not been able to introduce the stilette at first and has first used a sharp steel knitting needle. Some introduce in gold silver or lead canula Mr. Liston condemns it The stilette will not completely obstruct the passage the tears will pass down Prof. H. has never found it necessary to pierce the os unguis a practice which Mr Liston condemns the hole closes again Let the stilette be worn about 6 mo. occasionally cleansed little syringing is necessary Sometimes a fracture of the nasal bones is the cause. Treat as others 4th Prof. H. has seen no cases of affection of the bones (e.g. venereal) If polypus is the cause cure it The treatment of fistula lach must be varied according to the degree of the aff. its cause & the constitutional health Sometimes, says Mr Liston, the gland and sac & duct are wholly obliterated without inconvenience to the eye Aneurisms 1st true 2 false 3 varicose 4th an. from anastomosis In the true all the coats are not ruptured but all of them are distended equally forming a tumour with an orifice communicating with the artery which is smaller. It is maintained however that the arterial and middle coats are ruptured Begins with a small tumour pulsating externally & when small all the contents may be pressed back into the [illegible] artery. When lager the disposition of lymph prevents this As the tumour increase the pulsation is disagreeable more or less pain numbness from pressure on the nerves obstruction of the progress of the blood which [last] often causes hemorrhages in distant parts as, abdomen [heart] etc. Absorption of soft parts or of bones may be caused Cartilage however being the most indestructible parts of the body resist the absorption In aneurisms near the surface the pointing is towards the skin & ultimately a slough is formed [illegible] the patient dies of haemorrhage. Internal aneurisms besides pointing to the skin point towards a mucous or serous membrane in the latter they make a rent. Causes; wounds, injuries, mistakes in bleeding. From the latter cause The 2nd species or false aneurism arises from a wound of an artery by mistake for a vein the blood is contained in the cell. memb. 3d Varicose aneurisms happen from mistakes in bleeding, the lancet being carried through the vein into the artery The blood at every stroke of the heart issues into the vein (which has adhered to the art.) with a whirring noise & feel. By pressing upon the artery above, or on the cicatrix this whizzing may be stopped Causes of aneurism are very obscure There seems to be a disposition in the circulating systems of many persons. It has been found in many instances that the coats of the arteries in the neighborhood are diseased being brittle etc. [Postillions] & cavalry soldiers are thought to be more liable to aneurisms in the lower extremities Porters who lift heavy burdens are thought to be more liable. Old persons also Occasionally they have spontaneously cured themselves probably by the filling up of the cavity, and the subsequent absorption Treatment. Valsalva’s plan was by bleeding the lowest diet External application of ice has been proposed Ligature of the arteries has superseded every other plan History of the various modes things necessary 1st a small round cord 2n tied very tight 3d the vessel shd be detected as little as possible 4th the aneurismal tumour shd be touched # as little as possible Vide Coop. Surgs Dict One ligature only is now used The first cause of danger is from interruption of the circulation producing perhaps gangrene The second is from const. disturbance both from the operation & probably also in some cases from the interruption of the circulation. Thirdly from secondary haemorrhage Cut one end of the ligature short. Mr. Lawrence cuts both short and lets the wound heal over the ligatures afterwards finding their way out Warm the limb by hot flannels Take care however not to burn the patient who will be very insensible # Vide Prof. Knight’s lectures Mr Wardrop proposed to tie the artery beyond the aneurism as in the arteria innominated in order to check the circulation The operation seems not to have succeeded Varicose aneurisms are more or less inconvenient but not dangerous and are all pretty much alike After the wound of an artery we often meet subsequently with a small pulsating tumour which occasionally bursts & bleeds and are obliged to cut down above and tie Waevae Maternae In small tumours of a reddish or purple colour & at consist of a congeries of vessels They are called marks and denominated cherries, strawberries, figs etc. according to their colour and the recollected longing Sometimes these enlarge and have a doughy feel or are pulsating and enlarged when the child cries When the skin in the neighborhood is purplish the tumour is called aneurism from anastomosis Sometimes these marks ulcerate and perhaps extensively Sometimes aneurism from anastomosis occurs in adults without any previous congenital affection the vessels enlarge and are tortuous, and the tumour may be even pulsating from a considerable distance distinguished from [fung.] haem. by pulsation from the first by its originating near the skin by freedom from pain unless after ulceration etc. etc. They sometimes grow to a great size and came to a very troublesome ulceration Congenital [illegible] are sometimes fatal from their great size etc. The congenital [naevi] are to be cut off if practicable where they disfigure Aneurisms from anastomosis have been cured by caustic & by spontaneous ulceration We may as Abernethy recommends apply cold lotion constantly, as ac. pl. The most effectual mode of cure is by extirpation. Cut out for the haemorrhages though considerable is for less than if they are cut into. Cut quickly & let the assistants check bleeding with their fingers Another mode which is calculated to avoid haemorrhage, is that of ligatures passed through & around. Marshall Hall has introduced the plan of piercing through with a white hot needle the tumour then gradually sloughs away In cases of ulceration of the tumour Prof. H. has succeeded by the constant application of nit. sil. caustic. Another mode of [illegible] them has been proposed & practiced by inoculating them with vaccine matter Tying the principal artery leading to the tumour has succeeded, but the plan is now going into disease e.g. carotid, art. when the tumours are upon the head Collections in the Bursae mucosae Not abscesses, which have already been treated of These collections may be fluid curdy or (by absorption of the liquid part) solid. “I have seen more than a gill of something like boiled rice” (Prof. H.) in the wrist. On the patella they resemble a half of an orange # The joints of the toes also get sore Old persons have corns Prof. H has also known in chronic cases the serous part be absorbed and several hard bodies are left he has extracted them without injury. He has known a creaking noise from the cause in the wrists of reapers Treat by ac. pl. finally by a succession of blisters. Bandage tightly to promote absorption If they have suppurated in toes of old persons do not amputate but heal with nit. sil. Ganglions which resist these processes shd be opened & squeezed # N.B. There is a bursa between the skin & the patella Classification of Poisons Prof. T’s attention has been turned to the deleterious effects of medicines from the commencement of his practice 1st Exhausting poisons which extinguish vitality almost as soon as lightning in excessive doses e.g. prussic acid. The measles do not contract & the blood does not coagulate (the last efforts of its vitality) Found in the animal kingdom e.g. fish bites & stings They produce no lesion but destroy vitality 2nd Narcotics (simple & pure) 3d Acrid narcotic (not acrid & narcotic but a peculiar sort of narcotic power which produces no coma e.g. veratrum) Those acrid narcotics are evacuants or non-evacuants. The former kill more speedily 4th Irritant poisons which produce irritation & inflamm. e.g. the salts, the acids & the caustic alkalies 5th Composite poisons which possess several or all of the above kinds of power 1st Exhausting poisons are fish, bites, stings There is considerable mystery upon the subject of poisonous fish The same poisons well sometimes be preserved and sometimes escape. Some will be effected & others escape We have abundant evidence of this but cannot explain it. There is equal mistery about poisonous mushrooms probably some can eat every sort. In the north of Europe every kind is eaten Poisonous fish are more common in tropical climates Even the same fish appear not to be poisonous in cold climates Several species of crab & lobster cancer (sea lobster) cancer miricula (land crab) our common lobster is poisonous to some Clopea murina a species of shad mitylis edulis ([illegible]) is apt to be poisonous in tropical climates Vipera verus (European viper) [illegible] several species (the black snake genus) Cobra di capello [illegible] [illegible] which last is however probably not worse than the candisona horridus (rattlesnake) & the candisona durissi [illegible] in the southern states the commencement of the symptoms Commence with languor, headache, [nausea] oppression, pricking in the skin, hands & feet articaria etc. etc. Spams of abdominal muscles, [illegible] etc. convulsions, coma etc. death When recovery takes place the cuticle comes off, the hair comes off. The strength is long in returning etc. Good calls these symptoms colica cibaria They constitute cholera or diarrhoea as much as they do colics. There is no cessation of peristaltic action as in colic The tormina is not caused by it The tropical writers say that it is of very little consequence whether you evacuate the food or not that vomiting at first will rouse the patient but in the latter stages the patient will often die in the act. They recommend stimulants & nervines above all alcohol also capsicum, [ether] [amomum] granum paradisis etc. etc. opium Those are said almost infallibly to cure even if the disease is far advanced The best emetics are mustard distilled water of ranunculus flammula, which vomits speedily & with no nausea the next best is the bi per sulph. copper then sulph zinc then turpeth mineral The common account of the effects of the bites of snakes is also meagre They are said to be in India pain in the wounded part violent acute burning pain with part. tumefac. in the adj. parts in slight cases the effects stop here otherwise the whole limb & perhaps the whole body swells Colour of the bitten part is first crimson then greenish livid etc. Sir E. Home found that these local effects proceed from emission of serum. He found also that the patient might die from the abscess subsequently formed in the part Sometimes the death is too speedy for the administration of any remedy. Sometimes the vomiting is such as to prevent the retention of any medicine The topical affection unites the characters of erythema edematosum & anatomicum & the const. syrup those of a cold malignant typhus Post mortem examinations show no lesion except some infl. near the part bitten. Patients generally recover completely, but they often suffer long after One has been rendered hemiplegic Various circumstances, as the size of the snake, the degree of his irritation, the part of the body bitten, the climate the season of the year, the delicacy & the apprehensiveness of the patient etc. etc. vary the severity and the danger of the symptoms The surgical writers make much of surgical treatment But all the surgical treatment, as excision etc. seems to be useless There is abundance of testimony in the periodicals & even in the newspapers that efficient quantities of alcohol are infallible. Prof. T. has also conversed with Dr McBride & the late Dr Osborn of N.Y. who had practiced at the south. Accounts are to be found in our periodicals of giving a gallon of spirit in 12 hours with success. The alc. however is much more efficacious, when combined with acrids Simple narcotic poisons. Gelsenum nitidum. Helonias erythrosp. Datura stram. hyoscyamus hydrocyanic ac. Cicuta maculata which destroys some every year the most active of our poisonous plants though deobstruents destroys life as a narcotic So also conium digitalis etc. & probably also alcohol Good calls the disease producing by such articles colica cibaria comatosa with no propriety. Another set produce common or epileptic convulsions e.g. oil of tansy [illegible], cinnamon nutmeg etc. these destroy life as narcotics however Another set, as strychnos, actaea etc. etc. produce tetanic convulsions Another set are evacuants, as aconitum delphinium helleborus veratrum sanguinaria etc. Simple irritant poisons as rhus venenata, [pumila], toxicodendron & radicens [Hippona??] manchinella The aroideae, especillia leontia clematides dephne mezereon euphorbia lithysis sedum acre Ranunculus anemone pulsatilla capisicum if it can destroy life Those of animal origin are phosphorus, the acids, cantharis the larvae of phalaena menstora The caustic salts as nit. sil. the antimonials, blue vitriol etc. Red precipitate & corr. sub. Carbonate of barytes & the caustic alkalies etc. Glass Collection in the wrist Prof. H. has succeeded in curing after trying discutients by opening them amply and keeping in a slip of linen & keeping up inflammation Ganglion, if they do not heal after being punctured may be opened & treated with nit., sil. to create infl. These collections are apt to be confounded with encysted tumours but the latter grow gradually from a small beginning and are round the former spread quickly and are flattened. It would only be the mellicerous tumours that could be mistaken for these Wearing plates of metal & various mercurial & other plaisters are sometimes used for their cure Prof. H. has succeeded upon the olecranon & patella, after they had been opened & yet filled again by [illegible] & injecting nit. sil. & creating infl. After puncture the part shd be kept perfectly at rest Sometimes it is necessary to inject a second time Hard & cartilaginous bodies in the joints as in the bursae muc. also The two situations seem to have been confounded together. Prof. H. has seen some of them and thinks they are rather hardened lymph, and that they are not cartilaginous Mr. Hey recommends a laced knee cap. Prof. H. has endeavoured to affect the same purpose by plaister bandages They cease after a while to give trouble. Case related in which very dangerous consequences resulted from removing them If you desire to remove them place the knee horizontally confine the substance & make a free incision directly over it. Vide C. Bell. Mr. Travers relates a case in which Mr. Young Fractures They are solutions of contin. in bones 1st of the differences which are in the part of the bone the mode of breaking etc. Compound fractures are those in which the skin is likewise broken They differ also in the causes of breaking the direction, nature, & [illegible] of the blood Some fractures are complicated with other circumstances Prognosis varies according to the injury the constitution, the treatment, 6thly The formation of calles varies with the treatment. It will be small & quickly formed when the ends of the bones are kept closely in contact. Much is said by natural bone setters about the split bones but according to Prof. [illegible] experience this is a rare occurrence except in case of gum shot wounds Bones are seldom fractured in two places except when a heavy body has passed over the limb and comminuted the bone. Bones are often supposed to be broken in two places in consequence of the overlapping of the ends. Often we are unable to determine for some time the exact nature of the fracture Fractures are distinguished by the distortion, inability to use the limb, & especially by the crepitus. We think we hear but we in fact feel the crepitus The piercing of the skin is in consequence of an exertion subsequent to the fracture It is common when a limb has been shortened for the surgeon to say that the fracture was oblique but in many such cases you can feel the transverse surface of the end Children are subject to partial fractures or bending of the bones. Prof. H. has generally succeeded in straightening them sometimes however you may break them completely while straightening them probably one side of the bone is always broken in such accidents It is only in the thigh and leg that we meet with spasms. Hard labouring men and irritable females are most liable to spasm. Of course compound fractures are mor liable to cause spasm. Old age is a less obstacle to recovery than we might suppose. Delirium trem. is apt to be produced by fractures in the intemperate Callus Dupuytren made many observations 21st a deposition upon the periosteum [illegible] the bones by what he called temporary callus 2nd callus between the bones. S. Hunter thought there were granulations of the ends of the bones The union of the bones is not [illegible] for several months as the patient is [illegible] or unwilling to rest his weight upon the limb goes on crutches and if he falls it is broken again B. Bell says an arm unites in a month a leg in 6 weeks & a thigh in 3 mo. The union however is by no means firm at this time many cases of refractures occur for slight causes after this time The setting of fractured bones is generally a simple business. It is done by extension counterextension and [coaptation] Extensive may be made at the nearest joint or farther off. Coaptation is of far less efficacy and requires far less skill & [illegible] than used to be supposed It is of little use when the muscles are covered by thick flesh as in the thigh By means of his fingers the surgeon can ascertain when the ends are in place Splints are applied by some only after inflammation has gone down. Apply splints as early as you can Do not bandage too tight and wet the bandages with ac. pl. etc. In some cases a partial application of splints and bandages may be made If the limb is excessively swollen you must wait until you have subdued the violence of the infl. Generally however if you are called soon you can dress immediately The symptoms to be attended to are pain spasms inflammation, & constit. irrit. Relieve these by the usual means For const. irrit. give cal. & op. spasms may take the limb and displace the bones give opium for them and in robust men, bleed sometimes Fractures of ossa nasi These are only dangerous as the [ethmoides] may be driven into the brain. Boyer thinks the brain cannot be injured in this way but Prof. H. has known two cases of death from infl. of brain in consequence of a kick of a horse upon the [nose] Treat by introducing something as a direction under the bones and squeesing up with your fingers. If they do not retain’ their place, keep them there by catheters & lint within & compresses on the outside Wet the bandages Fract. of cartilage of the nose nose twisted Keep in place by straps of plaister Fracture of Lower Jaw Onn one or both sides often on both never exactly at the symphisis Use a compress a four headed bandage tied behind & above and then apply a thick bandage over all Fracture of upper jaw [Arise] from blow bones driven into the antrum etc. Fract. of Vertebrae Prof. H. has had perhaps 30 cases only 2 recoveries Paralysis of the lower limbs immediately takes place retention of urine etc. Infl. comes on. They die in a few days or live for several days Fract. of the dentata occasion sudden death It is perfectly absurd to attempt to restore the function of the limb by blisters etc. The infl. of the spinal marrow occasion, enormous irritation restlessness & fever. Although the legs are insensible & perfectly paralytic yet they will sometimes require their legs to be constantly moved by the assistants owing to some irritation at the origin of the crural nerves The urine is always to be drawn off by a catheter which a surgeon shd always carry with him in such cases If the injury abo e the origin of the phrenic nerves the patient cannot expectorate & dies of suffocation The bowels generally puff up and are constipated In robust men you may bleed and you may always give cathartics The urine finally becomes turbid & eventually purulent When the patient survives 10 days or a fortnight he generally dies from infl. If he lives several months he seems to die of fever of irritation. Opium is the principal remedy Extensive sores from in the muscles of the back. The urine has to be drawn off continually Fractures of the Sternum May generally be distinguished by inequality of the surface. You can often feel a crepitus when the pat. breathes. Treat by preventing motion of the part in respiration by a broad bandage around the breast with a compress under it It gives great relief When the fragments are forced in and the circulation & respiration are impeded do not wait for infl. but bleed immediately the pulse will rise after it. Afterwards apply a blister Treat with opium and cal. Trepanning has been recommended It can hardly be necessary. Pus will not be apt to form if the infl. has been properly checked if necessary however we should trepan In many cases the infl. of the thoracic viscera, cough etc. will [combine] often [The] healing of the wound. The case however will not be so dangerous as one of the phthisis pul. Fracture of the Clavicle May result from direct violence or from a fall on the shoulder elbow and hand, and in the former case there will generally be considerable contusion and the fracture will be between the coracoid process & sternum in the latter often between the corac. proc & the acrom. The shoulder falls the patient carries his head on that ride & supports that arm with the other hand his whole appearance is peculiar or he walks very carefully, to avoid motion of the parts In some cases the subclavian artery and in some cases the lungs have been wounded. Fractures of the clavicle are very often mistaken for a dislocation of the shoulder Reduce the fracture by placing one hand in the axilla & the other under the elbow Place a compress under the axilla & confine it there by a strap passing from it The arms are not very perfect in cases of fract. clav. Fractures of the Scapula When the acromion process is broken the arm falls down and the parts may be brought easily into contact by pressing up the elbow and you can feel the motion of the broken parts Treat pretty much as for fract. clavicle. It is said that the union is ligamentous When the body is fractured pass a bandage around the body and support it with shoulder straps Boyer speaks of fract. of coracoid process. Prof. H. has never met with a case It might be necessary to cut down The ligament of the Fract. of the neck of the os humeri So called when within an inch of the head Caused by falls upon the shoulder Distinguished by the mode of receiving the injury. Examine whether the fall was upon the hand. The ecchymosis is upon the top of the shoulder where the injury was received & not in the fore part near the axilla is in dislocation. The deltoid muscle will be shortened instead of lengthened The bony tumour will be of a different shape in the axilla. The upper fragment is drawn outwards by the [teresm] & subsception? The lower fragment is drawn downwards by the pectoralis Distinguished from fract. of acromion by The whole limb generally swells therefore begin to bandage at the hand & bandage up to the shoulder. Apply on the outside of the arm Smith’s splint & bandage over the splint. Keep a compress in the axilla and bandage [aroun] the body and arm Support the forearm, not the elbow with a sling. Let the elbow hang down Fract. rib Sometime the rib is fractured at a place different from that where the injury was received e.g. the neck. Examine by feeling along the rib when you come to the fracture, pain will be produced You may scarify for the emphysema. When the broken point of the rib is caught, & respiration and all motion of the body is prevented Prof. H. has succeeded in affording relief and disengaging the end of the rib by standing behind the pat. placing the knee against the back and embracing the [illegible] with the hands and at the time of a full inspiration jerking in the abdomen Treat the fract. by a broad bandage around the thorax supported by shoulder straps. The most important part of the treatment is that for the infl. of the thoracic viscera by bleeding cal. & opium & in extreme cases by taking off the bandage and applying blisters. Use demulcents for the cough If the blood does not flow put the hand in warm water Fract. of the body of the condyles of the os humeri Generally distinguished [illegible] by the deformity, loss of motion & crepitus. Fract. near or at the condyles of the bone are to be distinguished from dislocation. The arm will be slightly but the fragments will be drawn up there it will be a depression above them Generally by rolling the fore arm you can feel a crepitus. Sometimes the int. cond. is broken off and drawn up, without aff. of the joint. If the init. cond. is broken the arm will be bent inwards if the ext. cond. the arm will be bent outwards make extension with the elbow bent coaptation will not be needed. Bandage the whole arm. Support the fore arm and let the weight of the elbow hang down For fractured condyles we shd use a bent splint and occasionally after a while bend and extend the limb every day in order to secure perfect motion of the joint Prof. H lets the splint stay on but about a fortnight, for the reason. There is great tendency to a permanent pronation of the fore arm especially when the int. cond. is fract. This accident is very common in young children and sometimes arises from a blow [on] the lower part of the humerus Fract. of both bones of the fore arm. Arise from violence Sometime one bone is broken in a place not opposite to the fract. of the other. Easily distinguished by deformity Reduce by taking hold of the hand & pulling counterextension at the elbow To prevent the union of the ulna to the radius dress with two compresses rolled so as to be thicker in the middle & then over then two splints which by pressure upon the compresses keep the bones apart Fract. of the body of the ulna is easily distinguished coaptate if necessary dress with Smith’s splints & sometimes apply another splint on the other side Fract. of the lower end Radius Looks much like a dislocation of the wrist and is often mistaken for it the styloid process looks towards the palm of the hand The upper end of the lower portion of the radius project backward & the lower end of the upper forwards Put a compress on the inside to keep down the lower end of the upper part Bandage apply a splint on the inside & bandage so as to bring the hand back Sling so as the hand fall down towards the ulna. Leave the fingers out Fract. of the olecranon Put a cloth at the back of the olecranon longitudinally Bandage it down letting the ends come out. The assistants in the meanwhile pushing down the muscles pull up and down the ends & pin them. Use a crooked splint or else fill up the cavity of the elbow the arm being a little bent The danger is not of a stiff but of a weak joint. The union is ligamentous Keep the dressings on about 3 or 4 weeks Begin to move the arm however before this period. Exercise the muscles at first passively, in order to restore the use of the arm Compound fract. of the olec. are very serious accidents When the elbow is going to be stiff place the arm at a little more than right angle Fract. of bones of the carpus From blows etc. effusion very grat yet you can generally feel a crepitus The principal indication is to treat the great infl. Bleed cal. op. etc. warm or cold appl. etc. Keep a splint on to prevent distortion Fract. of metac. bones Ascertain by prying & feeling with the thumb. Apply a splint to the hand. If the pat. insists upon using the hand, apply plaister bandage Compound fract. of the metac. bones are sometimes followed by mortif. of the fingers. Take them off if so Fract. finger Apply a little roller & a splint of basket stuff a roller over it Bend it to the next finger. Sometimes they are so washed that they must be amputated Still however they often recover when exceedingly crushed Fract. of os. innom. In consequence of passage of loads etc. Sir A. C. observes that in fract. of the acetab. the limb will be drawn upwards like disloc into the ischist. notch The most we can do is to apply a strap around the pelvis Purgatives & injections will be needed & a catheter Fract. of the lower extremities We always have much constit disturbance Fract. of body of os femoris Limb is distorted crepitus can be felt unless the ends are too far by each other or too far apart. When broken high up the upper fragment is drawn forwards and upwards Children have the bones oftener broken transversely. To reduce the fracture make extension. Let the assistant take hold under the arms. Great diversity in the mode of treatment exists. Mr. Pott & others advocated the bent position. Mr. S. Cooper changed his opinion & gave up the bent position Prof H has succeeded very well with 3 splints one on each side and one in front especially with children putting a pillow under the knee [Amesby’s] splint exhibited. The limb will shorten under almost any treatment in oblique fractures of adults The fractures commonly unite by bony union In children the cure is perfect Fract. of neck of os femoris An obscure subject. illustrated best by Sir A. C. who 1st wholly within the caps. lig. 2nd through the neck at the root of the great trochanter 3d through the body of the bone & the great trochar 1st This sort occurs oftenest in the aged & in aged females often from very little force the foot perhaps catching & causing a fall. (The neck of the os fem. undergoes a considerable change in advanced life Sometimes not shortened until often the lapse of several hours. The foot is turned outwards the heel resting in the hollow beside the tendon achillis Desault gives a good diagnostic mark of all the 3 kinds viz. the trochanter in rotation does not describe an arc upon a circle You can generally feel some crepitus Most apt to be confounded with dislocation upon the os ilium but in the latter the head of the bone can generally be felt & the toes turn inwards In pract. there is little pain except on motion & the pat. is liable to sudden starts in sleep. Splints and bandages are of no use Pass however a broad band around the pelvis to bring in the trochanter Place a pillow under the [illegible] sometimes a bolster under the whole limb confine the foot with rolls of cloth or billets of wood so as to prevent the turning out of the toes 2nd Fract. without the caps. lig. Occurs at all ages. Toes turned out limb shortened about an inch. Occurs from falls etc. Trochanter appears to be somewhat sunken in a swelling about it. Appears less like a dislocation Pain is often entirely in the knee hence the accident is sometimes mistaken Dr Physick advises treatment for a fracture whenever there is a suspicion of a fracture This fract. is treated by A., Coop. with a long splint extending from the knee up above the hip etc. etc. Prof. H. has treated them very successfully with Desault’s long splint He pulls the foot down & keeps it down the cross piece by means of a wooden gaiter 3d Fract. through the trochanter Not so much shortening The lower part of the trochanter seems to project too much outwards the broken end may frequently be felt Caused by falls on the trochanter Fract. below the trochanter are treated with a double inclined plane Separation of the epiphysis of the head of the bone sometimes occurs We cannot distinguish it before death. Indeed in all these cases we must be cautious in our prognostication. Sometimes excessive pain and long confinement occur without any apparent fract. and the pat. recovers completely without distortion 4 rules given 1st a roller & 3 splints are enough for children 2nd in fract. within it caps. lig. in very old persons depend principally on position. 3d in fract without the caps. lig. depend on Smith’s splint or Desault’s long splint 4th in fract. of the body use Smith’s splints or Amesby’s or Desault’s long splint & Prof. H. generally applies another splint on the inside Fract. of condyles of os [com.] Caused by falls Distinguished by distortion the lower end is drawn backwards and the patella seems below the joint Generally there is much tumefaction & injury Often the fract. is oblique & the upper end pierces the rectus muscle & perhaps the skin. Distinguished from disloc. by greater mobility, greater tumefaction etc. Treat for the infl. etc. in the first place Treatment by Smith’s splint or two lateral pasteboard splints applied wet 1st a roller then the pasteboard & splints then a roller over them. Compound fractures here are very serious accident we must consider about amputation Fract. of patella Caused by direct violence or by muscular exertion, when the foot slips The fragments separate They unite by ligamentous union A.C. directs to apply two straps & draw them together etc. Prof. H. applies a thick narrow compress fig. 8 bandages also above and below keeping them wet with a lotion to reduce the infl. Swollen along the thigh will in all cases be proper to keep the muscles from acting Keep the foot higher than the hip. If there is no tumefaction Prof. H. applies straps of sticking plaister. In all cases apply a splint we may use a bit of board with notches to keep it from slipping up and down. Give no violent motion even after the joint begins to have strength We may commence exercising the limb by motion made by another person, or by setting on a table and swinging the legs. Secondary fractures are apt to occur they are troublesome but not dangerous they may make the ligamentous union longer let the pat. walk with a splint Fract. of tibia & fibula Broken by blows or by falls on the feet or by slips of the foot. The two bones may be broken at different places, when the accident results from falls etc. The notion of a fracture in two places is generally a mistake caused by the overlapping of the bones In compound fractures it may be necessary to to cut off a projecting point of bone Compd fract. near the ankle joint are dangerous, especially when as is often the case compounded with a compound dislocation. Amputation will generally be needed Fract. of the lower end of the fibula with compound disloc. internally are not so dangerous. In fract. of the upper portion of the tibia the upper fragment sticks directly upwards there is a difficulty in keeping the fragments in contact Smith splints are best put a pillow under the [illegible] In every other fract. of the leg the best position is decidedly preferable by a double inclined plane or what is often better by placing the limb on the outside In fract of the tibia the upper fragment is generally forced inwards Apply a compress over the projecting end of bone bandage the whole limb. Apply a splint in the inside with a hole for the malleolus bandage over the whole Counterextension Prof. H. thinks of little use in fract. of the leg Smith’s splint is advantageous for preserving the foot in a proper position The time of keeping in the splints in simple fractures is 6 or 8 weeks the surgeon must examine & there is a certain consciousness of strength in the limb. If upon attempting to walk the pat. feels a pain in the part & a sense of giving way, he must lie by longer & perhaps have the dressings reapplied Sometimes the tibia alone is fractured distinguished by rotating the limb by passing the fingers along etc. Some think confinement is all that is needed but Prof. H finds it advantageous to treat as for fracture of both bones Fract. of Fibula Pat. will continue perhaps a long time lame and wonder what is the matter Examine with the fingers for a tenderness by moving the foot, etc. Prof. H. has had great satisfaction expresses with his treatment Apply a roller bandage and then a slender splint and another roller Compound fract. of leg more frequent than those of other parts First cut off the boot, stocking etc. Replace the bones if possible. Let one assistant grasp the thigh above the knee and make counterextension extension to be made by another at the heel the surgeon attempts to force the fragment into their place. Perhaps you can introduce your finger into the wound and lift up the skin Saw off a long sharp & projecting point an inch or two a spatula, or piece of sheet lead or tin being placed under the bone. It may be necessary to dilate aa little with a probe pointed bistoury. Do not use much force in removing fragments Dress carefully. Place a series of [slips] one over another each [indricated] lapping about half Extend the limb in both directions & thus left up the limb and place it upon the slips. Cross one set of the slips. Then equalize pressure by compresses, place a splint over then cross over the splint and limb both with the other set of slips Put a bridle around the foot & pin it up towards the knee to keep the foot from being permanently extended It will often be advisable to have another splint on the outside. Wetting the bandages will be advisable to prevent infl. It is well to stay by a patient a little while to see whether the bandages are too light or give uneasiness from other causes Great const irr generally follows it will be necessary to bleed a strong robust man op. cal etc. Spasm often occur the greatest relief for the time will be afforded by compressing the muscles with the hands Infl. of cell. memb. may come on Collections of pus may occur requiring [illegible] opening If every thing goes on well do not remove the dressing for some days It will be well however to call the next day Sometimes there is a deep seated collection of matter, which will require to be opened by a deep incision If the abscesses continue to form with great suppuration sloughing of periosteum looseness of the bones etc. the patient’s strength failing we must amputate. In the worst cases of shattered limbs they have been treated simply by placing them in a trough and covering them with bran crowding it down around them probably limbs may be saved by this mode If the great blood vessels are too much injured immediate amputation will be necessary Fract. of tarsal bones Generally they are compound but sometimes simple. 1st of the os calcis Dress by a roller & compresses then a broad splint along the bottom of the foot & bandage If the upper end is broken off and drawn up by the tendo achillis keep the foot permanently extended by bandages and a splint & endeavour to keep down the fragment. Apply warmer cold applications, or poultices for the infl. Splints give great relief in fract. about the joints by preventing the motion If the bones are too much broken in the tarsus, amput. must be performed but better in the leg than at the ankle It has been proposed to amputate in some cases at the astrag. & os. calcis Fract. metacarp. bones Press by pasteboard or other splints or in slight cases by plaister bandages Fract. of toes The best splint generally is the other behind the two together A plaister bandage will often be serviceable Fract. which do not unite by bone Imputed to motion [illegible] to want of nutrition 2d to effusion of serum. But there are cases where none of these causes operate & yet the union is ligamentous Gunshot wounds sometimes terminate thus but do not always. The frequent motion of the limb has been considered as a cause of these accidental cases but animals go with their broken limbs dangling about and yet the union become [illegible] An epileptic man broke both femurs the fits continued nothing could be done for the limbs yet they united firmly Also it is best in first dressings of fracture to make extension it gives relief Interposition of muscles has been assigned also old age & pregnancy yet none of these reasons are satisfactory The causes may be conjectured to be accidental in the particular limb not constitutional & perhaps another bone in the same person might unite Mr. Amesby cured a great many a great many cases he found also that many of the incurable cases exhibited an artificial joint & a pseudo-serous membrane The best plan of cure seems to be to keep the bones as firmly pressed together as possible binding the limb as firmly as can be endured Dr Physick has effected a cure by keeping a seton through the limb which produced either inflammation or granulation. This method has been extensively tried since that time both in Europe and in this country it sometimes fails A Mr. Burke of St. Thomas cured by electricity but then he used also an apparatus Dr White Sen. of Cherry Valley cut down & bored repeatedly into the bones with an awl he cured but then he used an apparatus Counterirritation has been extensively used As a last resort an incision has been made down to the bones & the ends of the bones. [Let] the operation has been fatal & has often failed Prof. Smith tried it once he had to saw off again on account of overlapping the bones about 10 days after The case was successful. But he declared that he never would again perform the op. Prof. H gives the preference to the plan by setons. Keep them in a long time Dr Physick kept his in at first 6 or 8 weeks. Probably some cases have failed from the short time during which the seton is kept in Dislocations It is of the highest consequence to be thoroughly acquainted with dislocations so as to be able to set a bone at once Failures are peculiarly unfortunate Dislocations may be caused by direct violence, by disease of the joint, by muscular action as in epilepsy. The swelling at first and the infl. afterwards may render the diagnosis obscure. The immediate swelling must be from effused blood. Van Swieten thought dislocation of the hip could not occur Many have believed this. Indications are 1st restoration 2nd retention in place 3d obviating of the effects of the accident The principal obstacle to restoration is muscular action which is overcome by for e applied with sufficient strength at first or by gradual force The British surgeons apply the extending force to the bone itself. The French apply it at the end of the member Splints etc. are often necessary to keep the bone in place Prof. H. has never seen simple dislocation compounded with simple fracture. But such cases may perhaps occur. Compd disl. & fract. may occur e.g. at the ankle But a short time only shd be allotted to the previous reduction of inflammation We may bleed largely etc. [Ganglinoid] joints can seldom be reduced [illegible] a month Orbicular joints have been reduced after 5 or 6 mo even. But the axillary artery has been ruptured in these attempts upon the shoulder Constit. means to facilitate are 1st bled ad deliq. 2d tart. ant. 3d warm bath continued as long as the patient can bear it. Begin with tart. ant. (say) then warm bath then bleeding. Tobacco has been proposed but it is too dangerous. Opium cannot be depended [illegible] Intoxication is a favorable state but it cannot be managed at pleasure. If you find a man drunk take immediate advantage of the oportunity Partial dislocations can only occur in ginglynoid joints Desaults notion about rupturing adherent (or new) ligaments in old luxations by moving the limb in every direction is perhaps a good one, but is not much attended to. He supposed that the bone was often girt about by the ligaments Luxation of lower jaw Occurs in one or both sides the condyle is thrown forwards & the chin is oblique except when both are dislocated Does not occur in children Prof H’s first case was that of a young man courting! about midnight In one case epileptic fits caused a continual recurrence of luxations The teeth will be 1 or 1 ½ in. apart. It is a mistake to suppose that the mouth must be wide open. Some cases have been mistaken for spasm & treated accordingly Place the pat. in a low chair Put the thumbs as far back on the jaw as possible bear down with the thumbs & upwards with the fingers, upon the chin If this fails place a lever of wood bark & then press down with one hand upon that & up with the other at the chin and reduce one side at a time Place the pat. on his back in bad cases. Bandage for awhile Luxation from epilepsy are apt to recur Sir A.C. mentions a sub luxation caused by relaxation producing a snapping while eating Push the jaw upwards N.B. when you use a lever of wood make the upper jaw the fulcrum At the same time pullup the chin with your fingers Luxation of the Clavicle When at the sternal end, it is caused by a blow on the shoulder & the end of the bones project outwards. Reduce by putting the shoulder backwards (by an assistant) & pushing in the end of the bone Dress as for fract. clav. Great difficulty is found in keeping the part in place A tumour forms Sir A.C. mentions one case of an internal dislocation of the sternal end of the clavicle About an inch of the bone was sawed out The fracture of the scapular end may be treated by raising the shoulder bandaging as for fract. clav. putting a compress on the part etc. They are not readily restored to perfect soundness Luxations of Vertebrae Prof H. has known persons fall (as from a load of hay) upon their heads & their heads be permanently bent forwards & depressed. He has not ventured to interfere, but if he should have another case he would endeavour to brace the head back Luxation of shoulder Said to be equal in frequency to all other dislocations hardly so When unreduced the arm remains permanently extended from the side & is almost useless sometimes a semiparalysis of the arm occurs This luxation can only occur when the arm is removed from the side Boyer thinks the luxation forward is always consecutive this is denied by others The general signs are depression above, the head of the bone percesptible etc. the arm is directed obliquely Sir A. C. speaks of subluxations but Prof. H. coincides with Abernethy in thinking this impossible Two classes of modes of reduction 1st manual 2 by machinery Prof. H. has never used the latter. No account of fatal accidents has been given from manual reductions In recent cases Sir A.C. reduces by the heel in the axilla. Dr Wells, formerly of N. [Stonington] succeeded in one case by placing the other foot in the acremium & thus making additional counterextensions Prof. Smith’s mode Prof. H.’s mode Generally press the scapula down After sufficient extensions, lower the arm & the bone will go into its place If possible divert the attention of the patient so as to relax the muscles Sometimes constitutional means are necessary vide supra Sometimes a reduction is effected by first fatiguing the muscles, by long continued extension Compound dislocation of the shoulder occasionally occur case of Sir A.C.’s in which the bone projected through the pect. muscle The suppuration caused anchylosis ultimately Compd disl. occur by the arm’s being caught in machinery Displacement of the long head of the biceps. This is probably what Sir A. C. called partial dislocation After reduction of the shoulder, in these cases there will be [lameness], pain etc. which is removed by raising the [illegible] & rotating it outward Prof. H. has frequently seen this affection when there had been no dislocation The [elevation] of the arm about 45 [degrees] gives great pain after however a higher elevation gives no pain. Rotations of the arm gives no pain. Often great pain is felt during sleep say Prof. H thinks that the displacement is backwards generally Prof. H. diverts the attention & then suddenly rotates the arm. If necessary repeat the process frequently & make the pat. do so likewise Luxation of elbow 1st both bones backward. The arm is shortened the bones project backward & a depression is felt on each side of their ends Frequently caused by a fall on the hand Most apt to be confounded with a fract. of os. hum. just above the condyles But in fracture all the marks of displacement are immediately he removed by extending the limb We can also move the joint more & can feel the crepitus. In children luxation does not occur so often as the fracture of the os hum. Prof. H has an assistant grasp the arm firmly above the elbow for the counterextension & then he grips with his fingers the ends of the bones, pulls down & forwards & then suddenly bends the arm. Dress with the arm bent in a sling. The inflammation will be considerable Sir A.C. applies his knee, or puts the elbow across the back of a chair 2nd Radius and ulna laterally If internally the head of the rad. is in the posterior fossa of the humerus 3d dislocation of the ulna alone backwards distinguished by the projection of the ulna & the turning of the hand inwards Caused & cured in a similar way 4th Radius forwards its head upon the coromoid process. The arm is partly prone the elbow cannot be completely bent. There will be no contusion & now swelling & a mistake is apt to be made in the nature of the accident the shoulder being considered in fault Clap your right thumb on the head of the radius press with it make extension with the left hand then turn the arm supine & immediately flex the elbow For adults an assistant or two may be needed in order to exert greater force Prof. H. has seen many cases & has known many cases of mistake Bandage & sling 5 Radius backwards Sir A. C. met with a case in a subject brought into the dissecting room Smith’s splints Fract. of corp. proc. of ulna Caused by falls Keep the arm in a sling Sir A. C. Union by ligament Fract of neck and rad. Sir A.C. has never met with a case Luxations of wrist 1st both bones either forwards (palmar) or backwards (dorsal) Generally discovered easily may be confounded perhaps with effusions of the bursae mucosa but in this case the projection will be only on one side May be confounded with fracture of lower ends but we can generally discover the lower end of the radius the arm is more bent in fract also the lower projecting end is lower down in dislocation Let an assistant hold the arm place your thumbs in the back against the projecting ends of the forearm your fingers in the palm extend press & bend the wrist up so as to make the hand straight Smith’s splints 2nd Radius forwards easily reduced 3d Rad. backwards set in the same way Always apply splints 4th ulna alone Prof. H. has seen it the end projects forwards reduce in the same way let the hand hang down in the sling to keep the ulna up next to the radius Luxations of the Carpal bones Rare accidents reduce them as the above cases Great infl. generally attends Apply Smith’s splints If the tumour is only from effusion, it will feel soft. Luxation of metacarpal bones caused only by passage of heavy bodies by # bursting of [illegible] etc. Generally compound We may if necessary remove any one or a majority of the metacarpal bones Sometimes a luxation of digital extremity of a metacarpal bone occurs. It feels like a dislocation, but gives a crepitus Generally in most such cases put a round body in the hand, to dress upon Luxation of metacarpal bone of the thumb forwards & backwards Make extension & carry the bone into its places. Pat. are generally impatient of dressings & will come to you with a sort of sub luxation. Then apply a plaister bandage Luxat. of first phal. of thumb backwards easily recognised difficult to reduce difficult to et the bone over the projection of the met. bone The thumb has been torn off in attempts to reduce Sir A. C. directs to soak the parts then apply a piece of soft leather then a piece of tape with a clove hitch Let the assist. pull on this while the surgeon pulls inwards. If this fails he recommends a [illegible] the elbow being around a bed post Mr. Hey recommended divis. of lig Boyer failed in one 10 days old The disl the other way is easily [illegible] The second phal. is easily reduced After all dist. of fingers & thumbs splints give great relief they will relieve pain Luxations of hip joints 4 directions 1st upwards upon the dorsum of il. knee & toes turned inwards [illegible] 2 in. short. head of the bone can be felt Buttocks flattened Trochanter higher up & pointing inwards forwards Dist. from fract. of [illegible] of fem. by the bone being fixed not easily moved no crepitus by the toes not turned inwards This is the most common kind Prof. H. has succeeded by Dorseys mode Pass a sheet around the perinaeum make [illegible] by a handkerchief around the limb just below the bent knee one assistant pull the thigh outwards by a napkin the surgeon rotates the limb outwards & the bone comes into its place. Two assistants will be needed for adults Sir A. C. advises in the first place const. means by v.s. 10, 20 or more oz. warm bath & tart. emet. Place the pat. between the two strong parts with staples. Pass a strap around the perinaeum & fasten to the first staple another (by a wet roller) above the knee 7 fastened to a pulley make exten. gradually finally when the muscles are fatigued & the head is drawn down, then rotate outwards as above. It may be necessary to lift the bone outwards to get it over the edge of the ilium 2nd Dist. into foram. ovale Limb length 2 in. stands out from the other body bent forwards toes turned outwards Caused by force applied to the upper part of the thigh Sir A. C. Fastens the body firmly to a table & by a pulley pulls outwards the surgeon with his hand on the ankle suddenly crosses the limb over the opposite one 3d backwards into ischemic notch limb ½ to in. shorter troch. mag. projects less & is turned forwards knee & foot turned inwards great toe in the hollow of the other foot toes touch the ground head of the bone can often be felt Reduce (Sir A.C.) about as the first except that the assistant lifts the bone upwards by a towel around his neck 4th on os pubis head of the bone can be felt & rolls foot turned outwards limb shortened caused by falling backwards to a hole Place pat. on the table make ext. backwards & downwards left the head of the bone over by a towel around the neck of an assistant Fract. of ossa immon. have been mistaken In 20 cases [illegible] 5 [in] isch. notch 2 in for. ov. 1 in os pubis Sir A.C. Boyer does not direct pulleys Abernethy [illegible] After reduct. apply a 8 bandage Treat for const. infl. & irrit. Bleed & cath. [illegible] Benedict [Def??st] [not] Shelton Totten Next to Totten The [tabula] vitrea or internal plate may be fractured while the external [illegible] [illegible] These are irregular depressions of [the] internal plate, which the surgeon [illegible] calculate on a generally [illegible] near the longitudinal sinus They are not often found in the young In the youngest [illegible] [there] [are] not [illegible] tables In the very old [bone] the [illegible] is nearly [???ting] In [illegible] [to] [know] in [illegible] [illegible] [for] [this] [illegible] [illegible] 13 Surgery 1 2 3 4 5 Lecture 2nd Inflammation Characterized by heat pain redness, swelling, soreness upon pressure & if considerable a symptomatic fever. If considerable & extensive, constitutional irritation, or irritative fever may be produced. The pain is caused by some affection of the nerves, the swelling by effusion or by distention of the vessels The symptoms above described may occur successively and not all be present at the same time 6. Inflammation has been divided into two kinds Phlegmonous & Erysepelatous 1st Phlegmonous & 1st of that which arises from external injury. The injured part is the centre of the inflammation. The manner in which injury produces inflammation is not well understood. Hunter speaks of both increased and diminished action of the vessels & uses the term healthy inflammation in which there is increased action. Cullen thinks the action increased Wilson Philip thinks there is diminished action. At the present day surgeons consider that there is increased action at first in all cases Hunter thought the vessels were always diluted at first An injury is first followed by pain, caused by laceration & pressure of nerves perhaps. For an example an incised wound is followed by retraction of the lips, by pain swelling redness, heat, 7 and the inflammation spreads over adjacent parts The sense of fullness and the redness is probably caused by increased quantity of blood red blood is carried where it did not exist before as in ophthalmia The venous blood becomes red like arterial The cold stage is extensive inflammation should not be omitted. It is a part of the symptomatic fever & this fever sometimes also has a sweating stage Prof. H. thinks there is always in creased action in the commencement of infl. He thinks also that fever differs from inflammation The heat extends widely perhaps over the whole body It is principally a sensation however, and not much indicated by the [therm.] Inflammation of some parts as stomach & bowels the pulse will not be full & strong. This will also be the case in some constitutions, in which 8 there will be feeble pulse nausea vomiting etc. Prof. H. objects however to the term atonic inflammation Causes of infl. are mechanical & chemical heat, cold etc. Syphilis & some others are attributed to a specific cause & called specific inflammation Cold may cause inflam. by rendering the system or part more susceptible to heat afterwards. A frozen part will irritate as dead matter. The frozen fluids will irritate Prognosis will be dangerous 1st from violence or extent of infl. 2nd from nature of the part affected as the viscera the functions of these parts being suspended or destroyed. joints are dangerous parts 3d const. & habits of the patient Terminations are 1st resolution 2nd adhesion 3d suppura. 4 gangrene. Schirrhus was added by the older writers 9 1st Resolution is where the part is left healthy 2nd Adhesion takes place generally in serious membranes & in the cellular membrane especially in the linings where it is called hepatication Treatment. The cause as [illegible] should be immediately if possible removed Remedies These should be local as much as possible. Much may be done by prophylactic treatment especially in the case of wounds The first indication is to preserve the proper temperature of the part we may apply cold or tepid applications according to the sensations of the patient. If chilliness is produced by cold applications, apply warm ones though in infl. of the brain the production of chilliness is beneficial in many cases IN abdominal infl. fomentations & warm bath will be very useful and the French use poultices extensively in infl. of the lungs substituting them for blisters 10. We may apply cold applications too long. There is sometimes a choice in liquid appl. spts & water ac. pl. 1z to 1 pt. mur. amm. zii to pg. cold water alone ice especially for the brain vinegar & water though this irritates the skin & produces an eruption in some persons mur. amm. in very popular & seems to answer better than ac. pl. for deep-seated infl. Cold water is probably good enough in most cases, if there is no prejudice in the patient. Some surgeons use sulph zinc. Others depend much upon narcotic applications as of stramonium Prof. H. does not use them Blisters are especially useful in chronic & deep seated infl. Prof. H. prefers a repetition of the blisters for keeping up a perpetual discharge The first general treatment is bleeding which is recommended by W. Philip for two reasons to dimin. the vis a tergo & to dim. the quantity of fluid in the part. Those of opposite theories use it 11 There seems to be no doubt about bleeding in phlegmonous infl. and Prof. H. has often found benefit from it in erysipelatous Venesection is the most common the most convenient for several reasons. Prof. H. has thought that drawing blood from a vein near the inflamed part relieves the pain sooner though it may have no effect afterwards. Continue the flow till pain is relieved or faintness is produced patient not being in a horizontal posture. If the pain etc. return repeat the bleeding Blood letting has been objected to in old persons and in the feeble. Brit Prof H. has frequently bled both with advantage Arteriotomy has no advantages Leeches are not fashionable but Prof. H. thinks they have no advantage over venesection. He thinks experiments on their relative advantage have not been sufficiently tried They may be better in some cases of chronic infl. but Prof. H. has used repeated bleedings in such cases with advantage Cupping combines bloodletting & and counterirritation Lecture 3d The next remedy in importance for inflammation is cathartics The saline are recomm. but the merc. are better. As W. Philip says they undoubtedly have a specific effect Antimonials have a powerful effect In Italy many have used them exclusively Beginning with small doses & increasing gradually, they gave a large quantity and depend upon this alone I have known a patient bear 4 gr of tart. em. once in 4 hour Narcotics have been much used It is safe to give opium, contrary to Brown. Dovers powder may be given But perhaps the best article for inflammation which we have, perhaps is calomel and opium. This practice is now much used in G. Br. A little opium is combined in order to quiet irritation. Hyoscyamus has been used. 13 where opium would not agree It has been my practice to give opium enough to quiet the irritation from excessive pain & continue my other treatment at the same time Rest & quiet must be used to relieve pain An elevated position well often relieve pain in paronychia for instance & in pneumonia, & in infl. of kidnies Diet should be light & vegetably an. food to be avoided, including broth also which many consume, in injurious quantities Attention must be paid to the constitution. We must be cautious about bleeding drunkards Often a state of debility succeeds such as to require tonics Opium has sometimes to be continued after recovery Adhesions in the cell. mem. are apt to take place after inflam. of joints These are to be relieved by fiction and motion 14 Chronic infl. will be treated hereafter Often the most Erysipelas is principally confined to the skin though the cell. mem. is generally more or less affected There is a redness in erys. which disappears after pressure. The redness also is exactly defined at the edge. There is a remarkable propensity to spread The redness is of a darker colour then in phlegmon & in the progress of the disease inclines to yell. The skin is shining. The pain is not throbbing as in phlegmon, but burning. Sometimes there is a deep seated part at the same time The infl. frequently leaves one part and spreads over another The eruption disappears in [brawny] scales. There is a slighter swelling of the skin perceptible to the finger, a hard leathery feel of the skin 15 The fever is considerable. Vomiting bitter taste in the mouth bile is thrown up heat very great Old persons frequently have coma When as is sometimes the case erysipelas comes on at intervals or is periodical Its occurrence may be preceded in old persons by come Delirium may be caused by it 1st erys. eff. skin only 2nd erys. aff. cell. mem. which may or may not be accompanied with aff of the [skin] 1st This does not suppurate & terminate in branny scales. Found in all ages 2nd Skin and cell. mem. affected there is swelling suppuration etc. sometimes the fasciae & tendons are involved. It affects principally the old and the intemperate especially the legs Erys. is dist. from phlegmon by col. by circumscription by fixedness Erys. when suppurate does not have a regularly defined abscess like phlegmon 16. Erys. aff 1st nerv. syst. by coma for instance delirium when the head is affected, by burning heat 2nd heart & arteries by a pulse smaller weaker and quicker than in phleg. 3d al. can. by bitter taste dryness of mouth diarrhoea vomiting From the bilious vomiting yellowness of skin & of the affected part Some have supposed the liver to be aff. but this takes place from sounds merely & from the bit of the rattlesnake Caused by wounds ulcers etc. and in erys. the infl. is not necessarily near the part injured The causes operating upon the constitution are malaria and the crowded air of hospitals, feebleness and intemperance etc. In Pomfret after draining the [meadow] one summer there was more erysipelas (St. Antonys fire) than in 10 years In the Mass. hospital Heated air produced this effect. The violence of erys. is generally proportioned to that of the local aff. 17 Sometimes however it affects internal parts Sometimes erys. alternate with other diseases Prognosis depends upon the violence of the infl. upon the cell. membranes being affected upon the head & face being aff. upon the constitution age and habits of the patient The indication is to promote a resolution and prevent suppuration if possible Though some suppose that suppuration never occurs Resolution is to be accomplished 1st topical 2nd by general app 1st Many object to topical applications Though S. Cooper and Lawrence do not object to them Ac. pl zi to pt. is the best Milk & water or cold water is good Use the cold or warm acc to choice of pat. mur. amm. zii to pt. corr. sub. 10 to 20 gr. to pit. will often be good Narcot as 6 p. zi to pt water or op. zi ac. pl. zi mercurial ointment has been 18 celebrated as a catholicon Another however though lard a catholicon Prof. H. has derived much benefit from lard or tallow alone In violent or extensive infl. I have found ointments inferior to liquid applications Though ointments are very agreeable when the cuticle is peeling off A new remedy is not silv. moisten a stick and sub it over the part (Mr Higginbottom) There is considerable testimony in favour of this mode of treatment. It is said to prevent the spreading. Mr. H. trusted to this alone without internal remedies. Prof. H. has used it but has not trusted to it alone he recommends however Blisters have been proposed by Dr Rush & used by Dr Physick Dr Rush recommended them for gangrene Prof H. has used them with the greatest benefit Case of a man’s face so swelled as to blind him. Prof. H. blistered the whole face & cured the patient Blisters are not t be applied to every extensive erysipelas 19 When the cell. mem. is affected blisters undoubtedly ought to be used Undoubtedly erysipelatous inflammation may affect the cell. mem. without the skin It has been called erys. phlegmonode Dissection [illegible] are in Prof. H.’s opinion are of this nature. The propriety of treating erysipelatous infl. like phlegmonic has been very much questioned but Prof H. has often bled and reduced with great success. It is often very difficult to cure returning after an apparent cessation Purgatives have probably been more used on account of the notion that there was bile in the skin and on account of the humoral pathology Bark opium etc. will be proper when the pulse is very feeble etc. but not when the tongue is dry, skin hot etc. etc. (Thomp) Infants have erysipelas sometimes caused apparently by irritation from improper tying of the navel string. I have 20 also seen if affect the pudenda and sometimes be very dangerous The cause of the latter I do not know. I have treated erysipelas in children with cal. ipecac & rhubarb etc. and the same ext. appl. as in adults Erysipelas of cell. memb. the skin not being affected. It usually attacks old, intemperate broken down persons commences with chills skin feels doughy pits on pressure Generally there is much derangement of stomach, vomiting etc. Sometimes delirium & even del. tremens Lotions are not of so much use Prof. H resorts immediately to blisters Narcotics are generally strongly indicated. Suppuration is to be expected and promoted. In this kind incisions are proper. Pus will collect in a day or two and should be let out. The pus will collect in parts & the skin have a boggy feel. 21 Treatment of erys by incisions. Considerable blood may flow & in one case Mr Hutchinson the inventor lost a patient from haem. owing to the negligence of the dresser Tinct. myrrh is an old article, formerly much used for injection into erysipelatous absceses (Dr Ives) Chronic inflammation. This is generally a sequel of acute inflammation Some constitutions are predisposed to it For instance an injury of a joint will being it on in some persons Scrofulous persons are more subject The gland and joints are the most common parts affected Treatment Bleeding should be local rather than general. Blisters cupping etc. Mercury in small doses narcotics as opium & conium. Deobstruents are very important. Vide Mat. Med. 22 Suppuration Infl terminates in suppuration when it resists the usual means used for discussion & increases & swells more Phlegmonic infl. has a soft part in the middle more or less pointing & in a round or oval form Erysipelas does not suppurate in a circular pointing abscess and the us collects more suddenly. Nothing perhaps distinguishes an experienced surgeon more than tact in discovering matter An abscess always tends to [illegible] the skin Pus is not now thought not to be formed from coagulated blood neither from the solids but to be a secretion Properties globules in a fluid cream coloured sweetish coagulated by mur. amm. Putrifies upon exposure to the air, & may rust a silver probe Delpect maintains that it is secreted from a membrane Pus is detected by placing the two thumbs at some distance from 23 each other & pressing alternately. In the thigh do not place the thumbs transversely upon the limb. lest you be deceived by the slipping of the muscles on the contrary place the thumbs up and down the limb S. Cooper thinks it is often better to suffer many abscesses to burst themselves thinking that the cavity will gradually contract & the healing will be more favorable. Prof. H. dissects entirely from this and always lets pus out by an incision It abscesses open themselves, the pain is often excessive at the close, just before opening feeling like the cutting of a knife There are no advantages to be derived Erysipelatous pus should always be evacuated immediately. If not, it may become acid and fetid Sometimes fetid gas will issue & fill the room Abscesses are opened with the abscess lancet, or with a bistoury. Large ones with a double edged knife Prof. H. knows of no medicines which promote suppuration unless it be warm applications fomentations etc. which 24 soften the skin and allow it to distend They are very comfortable and may be allowed An abscess after opening should not be violently squeezed, but pressed a little and afterwards, pressed again, or subsequent days. When there is difficulty in getting out all the matter bandage so as to make constant pressure leaving a hole for the pus to issue Do not attempt to discuss deep seated abscesses & those about the joints. The pus is often contained in a bursa mucosa & will not evacuate itself and patients often are suddenly in such cases Abscesses continued. It may be advisable to keep a small slip of linen in the opening at first to prevent [closure] of the cavity If the healing is slow, touch with nitrate silver. Sometimes inject corrosive sublimate 25 If these things with bandaging fail to cure, look out for the constitution be careful to keep up a strick rest of the part. The fore arm may often be healed in this way, when other means failed before applying a splint As illustrations of abscesses take these of the female mammae. 1st We have simple phlegmonic infl. & abscess. Treat just like any other inflammation pro re nata Robust women may be bled. Sling the breast. The skin always adheres over an inflamed gland 2nd erysipelatous infl. of the breast pus in the cell. memb. sometimes the ducts are laid open by # suppuration Inf. of the bursa mucosa under the gland commencing like rheumatism constit. disturbance considerable The breast is not hardened but the whole of it is pushed out. Suppuration takes place within, and points below. Open the abscess and keep it open by a bougie keeping on a bougie as long as you can & then introduce a probe. If these means all fail Introduce a seton and take out a thread a day until the abscess heals. Dr Physick invented this practice Hey advises to lay open the whole breast & calls them chronic abscesses Finally bandage the breast The seton may be introduced by Acute inflam. of hip joint [illegible] supervenes upon an injury violent pain inability to use the limb const. irrit. violent fever convulsions death in a few days if not opened. Prof. H. has not with several cases. We must not hesitate about opening the joint, to evacuate pus in these cases Case of erysipelatous abscess Hard drinking patient infl. of leg below the knee del. tremens came on opium 175 drops & more a day Abscesses repeatedly opened until the whole leg was open under the skin pus collecting very quickly recovered Cases in which pus collects in the cell. memb. in various parts & finally 27 death or loss of a limb. The treatment must be very much varied Opium bark etc. Bark is of little use when the tongue is brown, dry etc. In the early part of his practice Prof. H. gave much more bark than at present Chronic abscesses Limits not very well defined. They are merely those which are long in collecting. Bryer divides into acute chronic & congestive or those where the pus is found in a different place You will be called & sometimes [& be] told of a fever, sometimes previously at other times there is no apparent cause Often the pain is in a different part. Case of a child treated for aff. of the knee is hip had an abscess It was opened & cured Much is said about absorption of pus. But Prof. H. has never known cases completely cured without opening Prognosis is very difficult in chronic abscess Sometimes death ensues in a few days after opening sometimes only 28 after months Prof. H has never opened with caustic Lumbar abscess caused sometimes by strains & bruises sometimes no apparent cause Scrofula is given as a cause but it is necessarily Most common in the young though it is found at middle age Commences like rheumatism without much severity of symptoms A peculiar bending forwards & to one side characterises the walking pain on pressure Prof. H. thinks it is seated in the bursa of the psoas muscle The pus points below [illegible] ligament or lower down on the thigh even on the outside of the thigh It is sometimes mistaken for aneurism & for inguinal hernia It is easily distinguished The pus is described in the books as pointing always in the groin Prof. H. has seen it point in the loins If pointing in the groin let this patient stand up when you 29 open the abscess It may be necessary to introduce a probe to bring out the coagula which are numerous & sometimes large but be cautious in using a probe, lest you excite internal hemorrhage Make the opening keeping the surface tense about the width of the lancet (into the cyst) for the size of the opening Evacuate all the pus & heal by the first intention. When pus collects again make a second opening in another place because it would not heal so soon in the first place and evacuate & heal up as before. After a few such openings the pus will ulcerate out & then a modification of treatment is required “The patients may recover in the country but in cities & hospitals” Old surgeons introduced tents with great mischief Prof H has read of no lumbar abscesses cured by absorption where the patient ultimately recovered an abscess of the lungs is apt to occur as a sequel & take off the patient 30 Hectic fever may be acute and violent, soon 2 or 3 days or even 24 hours after opening lumbar abscess or hip joint heat fever nausea vomiting great local pain inability of motion of the part from pain These symptoms appear so like an attack of common fever that they are sometimes falsely accounted for in this way. This hectic may occur after the bursting of an absc. It is different from confirmed chronic hectic though called by the same name vide “acute hectic” A lumbar abscess opened by a large incision gives rise to more violent symptoms. Though they may occur often a spontaneous opening or a small incision Case of a young woman who feel from a horse was somewhat lame finally there was a pointing in the groin patient was about the abscess burst violent symptoms took to her bed lay a year & died The doctrine of absorption of pus was first denied by J. Hunter. 31 Some have attributed the bad effects upon a free opening are owing to admission of air others to cold air But Baron Larrey dressed wounds below zero When a lumbar abscess becomes permanently open. Prof H. injects corrosive sub. 10 gr. to a pint. 2 or 3 times a week taking pains to have the solution touch the whole internal surface of the abscess, by turning the patient stroking up the part etc. If after continuing the injection about a fortnight discontinue it if no benefit is derived we should increase the strength until some sensation is produced. Sometimes the injection will produce a slight ptyalism but this is of no consequence Prof. Smit injected the cavity immediately upon first opening Prof H. has tried this, but prefers Abernethy’s mode. The injection generally somewhat increase the discharge The constitutional treatment shd be with opium especially conjoining calomel. Tonics also as bark. prof. H. cannot think that lumbar abscess proceed from an affection of 32 the vertebrae because the disease often arises from injury to the muscles merely & is cured more readily than we could expect if the vertebrae were affected he has examined the vertebrae also, when about to make the opening & could not find them affected. Languid scrofulous abscesses take on an oral form & are to be treated like others. Do not wait until the skin becomes very thin and of a purple colour If we wait too long the skin will form loose flabby granulations so that the skin will perhaps have to be cut away Quality of the discharge from abscesses Sometimes is is pure pus, sometimes thick or curdy But before the abscess closes the discharge becomes whey like, thin, watery. This is not noticed by writers. It must not be mistaken for a bad action of the abscess 33 Furunculus or boil Called an instance of phlegmonous infl. Still it differs much. For in common phlegmonous inflammation there is a cavity for the pus or no cure Furunculus commences with a pimple and a small vesicle which when pricked yield a serum. Hardness purple colour pointing is not always in the centre. One or more small holes out of which the pus issues The pus is apparently contained in the cells of the cell. memb. The boils do not heal until the core [illegible] which is rotten cell. mem. Treat sometimes by bleeding if const. infl. is great at other times give calomel. Poultice or plaisters They may be cured more speedily by opening than by suffering then to burst So says Prof. H. Sometimes they contain clots of blood (called blood boil) Where there have been very many on a limb Prof. H. has enveloped the whole limb in ac. plumbi 34 Anthrax (burning) or carbuncle most commonly found on the face neck or back found also on the hands and feet and in other parts Often preceded by violent pains and heat in the part. A malignant fever may be the cause. Sometimes it is preceded by a sort of anomalous [illegible] [illegible] [illegible] [illegible] of health. It may commence with a broad inflamed spot on the skin Begins differently in different localities. Generally with several points Begins with a fiery pimple which gives a burning pain & often Begins on the hand with one pimple cause considerable const. irrit. Colour of the skin around not bright like furunculus but dark like erysipelas a hard cake in the cell. mem. equally around the centre. lymphatics affected becoming hard & red cords much const. irrit. chills, flashes of heat, nausea, restlessness etc. Small holes appear & keep occurring in a fresh part of the swelling A piece of skin mortifies & comes off often The pimples emit a yellowish fluid More dangerous about the head generally but not always fatal there Sometimes 35 very rapid gangrene ensues Case of a man who observed a small pimple while shaving a few days after Prof. H. was called, he died of gangrene Occurs oftenest on the old & in the intemperate Coma & delirium often ensue in the old where the gangrene is near the head Authors differ as to treatment The French use the actual cautery at a white heat The pains [illegible] is said not to be great Prof H. blisters at first It relieves the burning pain & heat. Then he applies an emollient poultice If the burning heat returns apply another blister. Apply ac. pl. [illegible] & cerate Sometimes where the fever is high bleeding has been beneficial in Prof. H’s practice. Always give calomel Dr Physick recommends caustic kali he says it relieves the pain Prof. H. has not tried it. He has always found blisters promote suppuration When pus collects squeese it out, and pull out the slough of dead cell. mem. which gives great relief If necessary in order to extract the pus & 36 sloughs in incision if sufficient size may be made Incis. at first though highly recommended are not approved of by Prof. H. Various affections of the hand called felons, whitlows etc. & paronychia Paronychia The term is applied to a variety of sores upon the fingers & hands sometimes upon the toes. Four kinds 1st a superficial suppuration around the root of the nail cured by nit. sil. 2nd suppuration in the cell. memb. of the fingers or hands a real anthrax 3d Inflamm. in bursae mucosae 4 deep suppuration between periosteum and bone & leading to necrosis 1st Commences with heat, [burning] pain, redness finally yellowness The nail is best unless properly treated These are commonly located with poultices They are comfortable. Mr. Higginbottom recommends nit. sil. If suppuration takes place open through the cuticle & clip off as much as possible of the skin The suppuration extends around and you 37 must continue to clip off skin. To stop this continually spreading ulceration, inject corr. sub. or sprinkle on cal. Finally dress with cerates or with saturnine cerate Sat. cer. Rx ac. pl. zii sulph. sod zfs sim. cerate ziifs. 2nd Is an anthrax & to be treated as such by blistering at first etc. Generally the tendons when laid bare continue white and glistening & do not turn yellow and die. If they are laid bare in this state by sloughing of cell. mem. they will generally become covered afterwards. 3 Of bursae mucosae They are excessively painful Generally common at a point & feel for some days as of a splinter was sticking there We can do little better than to continue to poultice until suppuration comes on. Then open thoroughly & keep the abscess if necessary open by a piece of linen. Pencil with caustic. It will not readily burst [illegible] through the bursa 38 4th The periosteum covers the pus. Treat by an incision in the first place without [reacting] for the formation of pus keep the part [illegible] This is a necrosis and is to be treated as such. There is much pain long before the swelling & much const. disturbance It may be necessary to extract a dead phalanx. The finger will heal up well afterwards This kind affects perhaps the canellae of the bone in some cases, producing complete necrosis Mortification. Conversion into a dark ash coloured mass, which is cold & if kept dry becomes black & finally fetid. It is said that mortif. for gangrene may commence without previous inflammation. This doubtful Two kinds acute & chronic 1st acute, takes place, by becoming orange coloured forms livid or purple vesications, containing bloody serum Bloody serum is a diagnostic, unless proceeding from ecchymosis Pulse becomes weak sometimes intermitting A mortified part is always insensible to a prick or cut, by a pin or knife 39 Chronic mortification takes place without any apparent inflammation though often preceded by severe burning j& pain A good example is that of old mens toes which commences with small vesicles & extends over the whole foot & the leg There generally precedes a severe pain in the part Two circumstances will always distinguish a mortified part, 1st an insensibility 2 fullness of blood vessels in the parts adjacent? Mortific. may be caused by injury, especially if violent enough to destroy the vitality of the [part] in the skin for instance by obstruction of the bloodvessels leading to the part by malignant diseases suddenly destroying a whole limb without any previous inflammation occasionally also from palsy in this way Cases 1813 pneu. typh. Infl. especially, erysipela & anthrax & in the old & intemperate is the most common cause fire frost bite The pathology of mortification 49 is very obscure. Sometimes excessive action There is sometimes a predisposition to mortif. & in such cases it will follow trifling injuries e.g. in broken down const. Prognosis is often difficult. All causes are dangerous. Prognosis depends upon constitution, part affected, & rapidity of progress It is very dangerous to have mortification succeed a trifling injury Chronic mortific. is always dangerous and especially if the tendons & fasciae are affected, when there is [little] probability of a cure for tendons are very slow in healing If possible dissect out dead portions of tendon etc. Sometimes the patient is suddenly carried off by a new attack of erysipelatous infl. or an infl. of one of the viscera especially the lungs Indications are 1st to moderate the violence of infl. 2nd remove sources of irritation 3d to prevent spreading 4th support sonstit 41 According to the opinion that the line of demarcation instituted by nature should be [initiated] and promoted by art it was formerly proposed to apply stimulating articles as hot oil of turpentine, etc. but these do injury. Cutting down for the purpose of separating the sphacelus does not stop the spread The const. sympt attend are sudden sinking of pulse, great anxiety of mortal restlessness cold sweat etc. If the mortif. comes on gradually these symptoms may be gradual in their occurrence. Sometimes however their attack is sudden The indications of treatment were 1st To moderate violence of reaction If the pulse is strong & the pain very great so that there is danger of mort. we may bleed. But the period for it is short. Where bleeding cannot be admitted leeches are recommended by some. There will be a dry tongue & the secretions are to be improved, by full doses of cal. when there is constip. but 42 small alterative doses when there is diarrhoea. Prof. H was in the habit of using it before he saw Sir A. Cooper’s remarks Bark is not how much relied on and is ever objected to b y many when there is fever. Mr. Pott found it useless for toes of old men & relied on opium instead For local application, use mur. amm. & ac. pl. either cold or warm according to the sensations of the patient Some object to cold applications Poultices are useful [Yest] poultices are merely useful. Prof H thinks by correcting fetor Bark poultices he thinks useless and if they are used are better made by a decoction than by powder 2nd In old men; to remove cause of irritation. be careful about splinters etc. Be careful to open abscesses to prevent irritation Remove sloughs if it can be done readily Continue opium all along beginning with cal. if bow. are costive but continue opium long after ceasing with cal. To prevent the spread 3dly It is very difficult to stop the spread 43 of gangr. Sometimes it will extend in the cell sub. under the skin, producing a crackling feel. Bark was formerly relied on’ but it is not now valued Blisters must be our great reliance. (Dr Phys. introduced them) but be cautious not to blister too near the gangrenous part. In case of chronic mort. as of old toes this is [illegible] Dr Phys & Dors. disputed Nitrous acid is now much applied 1, 2, or 3 or drops to a pint of water As for the const. treatment 4th This ind. is answered partly by the 2nd Besides this where the bowels are good etc. & it will do well give bark. Give wine, porter, etc. and indulge, but do not force the patient to generous diet In the suppurative stage give poultices & sat. cerate. Sometimes relief will be great from removing sloughs. Case in which the whole [gastrocnemius] muscle [illegible] removed, with relief & a cure Death from mort. even if external is sometimes very sudden. In 44 some such cases I have suspected phlebitis might have been the cause Hiccup has been called a fatal symptom, but I have seen it occur in the suppurative stage & yet the patient recover When the patient sinks, vomiting diarrhoea hiccup etc. comes on sinking of the pulse, cold sweat mortal restlessness etc. As to amputation in these cases, it must not be done if the whole limb is affected, but must be in cases of dead toes not spontaneous and other such for we must not expect a good separation, spontaneously to occur. As to time it was long considered as a certain axiom to wait until a complete line of demarcation is formed Baron Larrey was the first to change the practice Others here imitated him Prof. H. was at first driven to the practice by a hemorrhage of the post tibial art. He has never known a case where the limb has separated of itself. Though it has occurred undoubtedly 45 When mort. takes place spontaneously & from const. causes it will be of no use to amputate, but it should be done when preceding from fire, frost or erys. infl. Prof H. has always found the arteries of the toes, in such cases, ossified Sometimes in such cases it will be proper to amputate high up upon the thigh. Chronic mortification requires amputation occasionally especially of the limb is amputated high enough. In general however we cannot expect much success from amp. in chron. mort. Prof H. has known many deaths are often very sudden in such cases, and unaccountable. The line of demarcation is at first red, and afterwards whitish 46 Hectic fever. This was formerly thought to arise from suppuration but it occurs from irritation in chronic infl. of joints etc. when there is no suppuration. Prof. H. thinks it has always a local cause & is never idiopathic Unless it attacks suddenly and violently as after opening a lumber abscess it generally comes on insensibly It may be divided into acute & chronic acute when sudden and violent chronic when coming on gradually and continuing a long time, as in phthisis tubercularis Commences with a chill, and a hot fit In the midst of a hot fit a chill may occur. This was considered pathognomonic by Heberden. Considerable cough & expectoration of purulent matter may occur when the disease is produced entirely from a local cause & one not seated in the lungs & may be removed by amputation as of white swelling. Parox 2 in 24 h. pulse sharp Sweating generally occurs 47 only after an abscess is open as in disease of the hip joint, lumbar abscess etc. A good constitution is no safeguard neither is youth, where a cause, as an abscess exist. The chance of restoration of the local part is greater in the young, but the rapidity of the hectic is much greater in the young It is in them that we have galloping consumption” Indications are 1st to remove the cause 2nd allay & abate symptoms irritation 3d support strength 1st Open abscesses etc. We may warm the [illegible] when about to open an absc. that we esp. the sym. will be [illegible] for a time. 2nd to abate the symptoms restore the secretions by calomel relieve irrit. by opium not. but op. will stop the diarrh. whch often occurs Relieve thirst by acid cool drinks Keep the bowels soluble by cal. at first, afterwards by rhubarb etc. or if cath. exhaust too much use injection 3d To restore strength use opium also This procures sleep etc. Give bark also. Sulphuric acid has been much used but Prof. H does not think it anything more than a pleasant article Give nutritious 48 food. if the patient will take no stronger food, he may sometimes be kept along for sometime or milk porridge & similar articles Be very particular in searching out the cause. Case of young married woman with hectic. The unsuspected cause was the breasts cured by opening Wounds. Solutions of continuity in a soft part. There is a great variety in their nature & the part affected Symptomatic, or inflammatory fever usually follow considerable wounds This in good constitutions & when the wound is not too severe is generally short & easily subdued Six kinds 1st incised 2. punct. 3 lacer. 4 contusa 5 poisoned 6 gun shot 1st Incised wounds. The edges immediately retract but the first thing is to stop the haemorrh. by pouring or cold water by a short compression with the finger or lint. sometimes 49 by elevating the limb, as in wounds of the foot by the dressing merely if the wound is slight by exposure to the air. If a large artery is divided, it must be tied, but in small arteries completely dividing the art. will often answer as a substitute for tying. Tying should be by pulling out with forceps if possible, if not with tenaculum. Use a surgeon’s knot for large arteries. It is convenient else in the 1st knot from not slipping Leather ligatures shd be made of French kid (with the epidermis peeled off) & rolled round. Buckskin will answer. Leather tanned with bark will not be absorbed. Small ligatures are now used, in order to cut the int. & middle coats. Lec. haem. is now less common Mr. Lawrence recommends silk ligatures, cut close off. The knots however sometimes suppurate out. Prof. H. has no experience of this method The old method of tying with a needle is not now used if it can be avoided Other mode of stopping haemorrage 50 are by styptics, by compression. The best mode of applying pressure is by placing a [illegible] of lint on the artery & holding it there with the thumb Fungus as lycoperdon, agaric astringents as alum act. cautery The latter is especially convenient in the mouth. It is used in other cases also by the French. Re Remove foreign bodies Bring the edges together After cleaning the wound of blood & coagula. bring the edge carefully together, & apply adhesive plaster. Mode of applying them Begin at one angle etc. Leave about a quarter or an eighth of an inch between the strips. In the large town they use plaster spread by machinery & plaster cloths but they do not hold so well as if recently spread Mr Liston recommends glazed [ribands] smeared with a solution of isinglass & brandy 51 The main indication for a strong plaister, and made of material which will not irritate the skin Do not dress a second time at all unless there is some indication for it not under 3 or 4 days Where artery has been tied, do not dress under a week or 10 days Dress as seldom as possible unless called upon to do so by accumulation of pus, or offensiveness of discharge etc. When you dress, do it after carefully washing and softening the old dressings and if the wound is large and open apply a new strip of plaister after removing one so as to have but one strip off at a time Inflammation should be guarded against thought it is the fashion with many to make no applications but the dry dressings. Prof. H. has been led by experience of both methods to prefer wetting the dressing with cold lotions in the robust, & [illegible] tepid nor the feeble & 52 delicate, if they prefer it Where it is of consequence adhesive straps be sure to hold wait a few hours before you wet the dressings In longitudinal wounds of the limbs the rolling bandage, with one end drawn through a slit in the other will be a very useful adjuvant Splints also may be necessary. A proper posture is of great consequence Haemorrhage continued. Jones found that small ligatures cut the inner coats and thus promote the closures. Vide his work on haemorrhage. Torsion of arteries another mode & may be useful in the [orbit] of change for instance When called to a wound, if the hemorrh. has been already stopped by dressing, the cautious about removing them for fear of reproducing the haemorrh. Generally let the first dressings remain about a week Secondary haem. may occur Prof H. has been obliged to tie arteries 6 weeks after the wound An artery should not be tied in an old wound. The wound shd be 53 dilated It will not always answer to be the artery at a distance on account of the anastomoses In the first place where a limb is bleeding freely, apply a tourniquet Much has been said about the reunion of parts totally separated. Prof H. has never succeeded, where the separation has been total Yet othes have succeeded The diet shd be attended to We expect more or less fever, and of course a moderate and generally vegetable diet shd be prescribed. Sometimes also bleeding & cath. may be needed Generally [illegible] the fever subsides readily Sometimes pus forms underneath and must be let out Punctured wounds Shd be dressed & the attempt made to heal them in the same was as incised wounds They are more difficult to heal however much const. irr. may ensue 54 Suppuration is apt to come on It is necessary to dilate if the symptoms are very severe and the local pain and inflammation are very severe. Case of a lady in convulsion from a prick on the toes relieved by dilating the wounds to the bottom (Dr Phys.) Where other means fail of relieving the symptoms, then dilate freely. Tetanus is oftenest a consequence of punctured wounds The cases of idiopathic tetanus which Prof. H. has seen differed much in the symptoms from traumatic tetanus & he thinks the dis. is different Pathology of tet. is very obscure. Some have thought the spinal marrow the [illegible] other can find no disorganizat. there Tet. takes place about 10 days after the injury Wounds producing it are less liable to inflam. and may have healed up & from their insignificance have been forgotten entirely by the patient Commences with stiffness of the jaws, as if patient had taken cold 55 The stiffness increases. Spasms in the jaws & neck come on which increase and affect the dorsal pectoral and abdominal muscles The pat. is drowsy after a spasm and requests to be allowed to sleep The bending generally is backwards. Prof. H. has never seen a case of [empusthotonos] The spasms grow more violent & the patient generally expires in one. An effort to swallow may bring on one. A good constitution is no security. If the pat. is to recover the species grow less violent. After recovery a stiffness remains of the jaw for some time I have known a stiffness of the muscles of the back remain for a year. Treatment 1st local open and dilute the wound endeavour to excite inf. (according to Dr Rush’s plan) by corr. sub. in the wound Baron Larrey recommends act. cautery 2nd const. treat. Sometimes Prof. H. bleeds always gives cal. Some bleed enormously and have cured 56 Dr Phys. applies mercurial ointment until salvation is produced. All give opium largely some by injection Chapman gives injections of antimony & succeeds Arsenic has been strongly recommended, in large doses All remedies must be in large doses, for small ones do not affect the system. The bowels are costive & not however in consequence of opium Cath. must be given. Croton oil promises well Hamilton’s cases tetanus cured by cath. were merely idiopathic cases arising from irritation of al. can. Amputation has succeeded where there were spiculae of bone have irritated (with thumb) Prof. H. tried it in the case Bark & wine have cured (Hosack) Alcohol (Rush) Case of a young man who had cut his foot with glass. When he first began to have tetanus he would fall on the blood & his mother thought him rheumatic. Cured 1st large bleeding [illegible] cal. spasm continued laudanum beginning 57 with 25 or 30 drops (any strong SS) increasing to 40 & eventually a teaspoonful frequently reputed. After recovery his neck was bent back for a long time. Case in London Cal. grs 6 once in 6 hours Ol. turp zii – zj ol. oliv. by injection gave the most relief & first checked the disease They were given 3 times a day. Opium seems to do no good & was relinquished. The woman was long in recovering So that his case was not the most violent Lacerated wound have been supposed to require a peculiar treatment not to attempt the union by first intention There is little or no hemorrh. Prof. H. however brings the edges together & keeps them in contact by adhesive plaster keeping the dressing wet He has had much better success Often they heal principally by the first intention. The injection of the cell. memb. with lymph, and swelling etc. is prevented The only systematic writer who has as yet recommended this practice is Mr. Mann. 58 Poisoned wounds The bite of the rattlesnake is an instance Some persons seem to suffer very much from the stings of bees & wasps It is a question whether the bite of a rattlesnake is injurious by absorption or by an affect upon the nervous system merely Some late exper. seem to prove the former opinion Symptoms of phlebitis have appeared to show themselves in some of these cases The tendency to gangrene is very strong Remedies At first excision caustic ligature. The French use muriate of ammonia as a strong caustic (old butter of ant.) After the first stage apply blisters and treat as for erysipelatous inflammation. For the const. shock & exhaustion ammonia seems to be best article opium also Cordials and stimulant are strongly indicated Case of a man in St Lucie [colub???] [illegible] stupid in ten min. amput. of finger which was not felt 8 grs arsenic in 4 hours cordials mint water laudanum spts terp. amm. & ol. oliv. in a liniment for 59 the hand Cured in 10 hours Several persons had previously died of the bite of this serpent Case of a woman stung near the eye Cured by bleeding & calomel A young woman died in 20 m. after being strong with leg [illegible] Hydrophobia. Prof. H. has always cut out the part. It seems to answer Prof. H. has performed excision 6 days after the accident no hydroph. followed Dissection wounds A wound seems to be necessary. Various circumstances are supposed to predispose, but Prof. H. thinks they are not necessary & that the most we can say is that the inoculation does not always take Symptoms infl. of the wound redness of lymphatics all along the arm Const. sump. very severe from the first, great prostration, restlessness etc. Suppuration forms along the arm in the axilla or under the pectoral muscle or within the pleura Or the patient may recover with a suppuration of the finger, & perhaps 60 a loss of the finger Prof. H has seen the same symptoms take place to the greatest extent from wounds of simple puncture e.g. from [illegible] of fist in N. Haven from a fish spear the latter case related wounded the tendon of the gastroc. while wading suppurat. all along the leg in the axilla finally in the pleura Prof. H. has had his own fingers very sore & for a long time after dressing gangrenous ulcers & has known women effected in this way from washing bandages losing the nail etc. Caustic should be applied to the very bottom of the puncture & not merely on the top. Contusions. Injuries of the vessels & a rupture of their contents without breaking the skin. Ecchymosis or “black & blue” In favourable cases the extravasated fluids will be absorbed In others the colour changes becomes mottled and yellow etc. The effused fluids often descend in the direction of gravity & produce discoloration in another part 61 In dicutions 1st to prevent further effusion by keeping cloths constantly moistened with ac. pl. or cold water. 2nd prevent inflammation, by const. rem. if necessary 2d to promote absorption, by fomentations & [sometimes] application camphor and soap etc. It may be necessary to let out the effused fluid Sometimes these “bloody abscesses” as they are called by the French shd be opened at first. Case of a man whose foot had been crushed in a saw mill pain absolutely intolerable relief was given by letting out about ½ just of effused blood Prof. H. can derive no rule from the coagulation of the blood The blood is generally dark fluid tar like If means for absorption fail we must make an incision. This will oftenest be the case in the old and especially when the effusion is in a bursa as that of the patella. Prof. H. has often been obliged to open the bursa of the patella open on the outside of the tendon of the rectus 62 On the olecranon also the same state of things occurs absorption here is uncommon. Serous effusion is apt here and elsewhere to follow the letting out the blood If the abscess does not heal, inject corr. sub. & probe the abscess every day Often a part of the skin is killed if this is the case, puncture through the dead part. Contusions of abdomen kick of a horse The peristaltic motion is suspended the abd. immediately swells constant vomiting great anxiety of continuance etc. mortal restlessness no sleep etc. Blood may or may not be united Vomiting may be of blood and immediately. Bleed at first the pulse will rise after it repeat it bleeding gives great relief the patient will call for it [illegible] Apply cold lotions bandages to the abdomen. Purge with large doses of calomel & injection until relief is obtained. Blister early if there is great pain 63 In the progress of the treatment a blister may be applied to the abdomen The thirst will be very great and is to be relieved with cold water These cases are very severe The abdomen will infl. up suddenly after the blow, before there is any time for inflammation & immediately vomiting of blood may supervene Case A young man in Prof. Brown barn yard. Vomited blood all day warbled 2 or 3 times Large quantities of calomel In two or three days was able to be removed A phys. who had received such an injury called for repetitions of the bleedings saying that they afforded his great relief After the first stage cordials etc. may be necessary on account of the shock of the system. Or at the first where there is no vomiting etc. Blows on the pit of the stomach may extinguish life 64 Strains Hardly known to writers except Boyer Extension of ligaments with rupture. Joints subjet are those with but little motion and strong ligament viz knee ankle, wrist, fingers & toes. Shoulder & hip very rarely At first the joint can be moved freely in all directions enquire after this to distinguish from fract. & disb. Very soon affus. takes place perhaps a sac of burs-mucosa Dieting from cont. by nature of accident by being treated Sometimes however it may be doubtful or both may be combined The treat however is the same for both Dieting from disloc. (this is of great consequence) Prognosis doubtful Bayer remarks that the ligam. become lengthened Constit. makes great difference rending some more liable (delicate persons) ternia rate in white well. perhaps is scrof . persons Treat like contusion Boyer 65 advises cold water at first. Use tepid water for a very delicate fem. perhaps) For consid. infl. use ac. pl. Some are afraid o fit Prof. H. has seen no injury A bandage moistened will give actual relief instead of pain & will promote absorption Opodeldoc also For great pain apply fomentation or a steam bath. After infl. is subd. apply frict. Give the attendants some camphor perhaps to encourage them in using friction When the proper time arrives use motion & exercise passive at first afterwards by the action of the [muscles] There is a golden time for exercise. A plaister bandage around the joint applied so as to keep the whole joint at rest & firm when pat. first begins to walk let him have a shoe or boot with a stiff sole # Burns Infl. or destruct. of parts by heat No part of surg. more empirical No advantage in dividing into species. It must be remembered that a burn or scald when slight is merely a blister just as from canth. or hot water and shd be treated as a blister, by excluding # not bundled up in blankets more motion 66 the air. Case of a child blistered over the whole body by cantharides & vinegar died If the cuticle peels off immediately after the barn, we may be sure that the injury is very extensive The highest danger is from the shock Often perhaps the [glaze] is inhaled, when the clothes are on fire. Prof. H. has not however with nothing more than a hoarseness from this cause & dissections have not shown much of this kind Sometimes the viscera immediately under the skin are inflamed vide Journals It has been remarked also that child. often die some weeks after the burn unaccountably 3 weeks is the critical period when the suppuration Convulsions often occur in children when after the first shock reaction begins to come on When any application apparently comfortable has been made do not disturb it. Sir James Earle contended for 67 cold water, ice, bleeding & cathartics [illegible] [illegible] on the other hand contended for spts turp. & intern. stim. Prof. H. thinks truth lies in the mean Where the shock is very severe the const. must be supported The best application for the vesicles a simple cerate prick but do not clip off the vesicles. Always have your dressings ready when you take off the old one when the cuticle merely is separated the granulations will be very small and no scar will be left But when the true skin is separated the ulcer will be long in healing & leave a scar The best dressing in the latter case is a mixture of spts turp. & cerate. Rx common basilicon of the shops & basilicon or cerate equal parts Prof. H has seen all sorts of applications. He at first tried Ben. Bell’s plan of ac. pl but it does not promote healthy suppuration. Poultices are very inconvenient requiring frequent exposure 68 to air and being [heavy] Besides they do not promote suppuration When supp. is established the spts turp. cerate will cause smarting and should not be continued then dress with simple cer. Keep on the first dressing as long as you can dress as seldom as possible. Keep the air of the room equably warm [illegible] keep in cold weather a warming pan near the body In the latter stages especially if the sores heal over & break out again use sat. cer. Before this Prof. H uses Turner’s cerate & cer. ox. zinc If granulations do not proceed well use nitrate of silver to touch the ulcers. This is a most valuable surgical remedy. Mr. Higginbottoms plan of applying it to infl. though it produces smarting at first, alleviates irritability & promotes resolution Case which Prof H treated with nit. sil. & simple [cerate] did well Sometimes for the fungus sulph. 69 cupri is better than nit sil. The shock is very severe coma excessive coldness of extremities etc. Ben. Bell advises opium. Be careful how you give opium in coma. Prof. H. gives one dose of SS & follows up with alcohol ext. heat etc. When infl. comes on depend especially upon cal. cath. keeping the bowels loose vide [Motherby] Considerable fever may ensue which is to be treated with cal. cath. Generally the pain is so great as to require op. When supp. is extens. & strength fails give bark Cotton will do well enough for superficial burns excluding the air Prof. H has seen much inconvenience from it in deep burns Case A man fell into a [kettle] of boiling potatoes about half of the cuticle from the head to the feet came off He drank a large quantity of spts. Prof. H. applied spts turp. & basilicon, as above. Next morning fever high bled him cal 70 Afterwards treated with cal. & according to symptoms Supp. came on Barks Finally bark injured & was [emitted] & cal. given ulcers touched with nit. sil. Recovered well & has the use of his limbs Distortions from burns The growing together of the fingers may be prevented by separate dressing. The tendons also may be burnt and contract Then keep the fingers straight by splints The object is to keep them straight they can be bent well enough after healing. So also of the feet and toes Case of a man with a ridge of scar extending along the back of the leg up the thigh like a [illegible] finally a growth of [horn] began finally had his thigh amputated. Cicatrices shd be cured by cutting out the whole scar not by dividing it & suffering it to heal up. This las way fails Case 1 ft long 1 inch wide 71. Frost bites Long continued cold produces a degree of torpor in the system tendency to sleep. Case of Prof. H’s instructor warned his companion not to stop; was the first to stop & endeavoured to conceal himself & rest was very torpid when brought to the fire. So Dr Solander The treatment of a limb partially frozen shd be by rubbing with snow or better by putting into cold water afterwards gradually warming the water A limb thoroughly frozen cannot be successfully managed in this way so as to prevent inflammation The infl. resembles that of burns It may be moderated at first by ac. pl. or spt. & wat. When suppuration comes on treat with cerate etc. When the whole limb is thoroughly frozen, gangrene will come in, beginning as usual with dark & ash coloured spots vesicles etc. line of demarcation etc. Prevent this by amputation The const. not being effected the operation will succeed. Do not delay the operation too long 72 Case Gent. in Brooklyn thrown from a wagon lay the whole of a very cold night when found in the morning was able to tell his name When carried into the house blood could not be obtained When Prof. H. found excitement coming on & bled him “with relief” Soon coma came on Thought the man must die But eventually amputated the fingers very bad leg etc. Recovered The amputation was delayed much too long Prof H. has had many cases of frozen toes He always amputates as soon as possible Case at our Almshouse 73 Tumours Varieties are very numerous 1st encysted 2nd sarcomatous 3 medullary Also malignant & non malignant The former may change into the latter We know little of their origin Abernethy thinks they arise from an extravasated clot of blood Sir E. Home has lately advanced a similar opinion It is undoubtedly true that the nature of the part alters the nature of the tumour as Abernethy thinks (The growth of tumours is somewhat similar to chronic infl.) Near the scalp we often find hairs in tumours. In glands the tumours will have a glandular appearance. In the adipose membrane, adipose tumours Yes there are many exceptions Some suppose tumours arise from hydatids (which are decided to be living beings). But this explains nothing The growth may be rapid or very slow or slow & then suddenly very rapid In general their increase seems to be in geometrical ratio 74 As a general rule when it can be done they shd be extirpated before arriving at large size 1st Encys. tum. are 1st atheromat (curdy) 2 vellic (honey) 3 steaton. (fatty) The cyst is generally firm & opaque Tumours that have no cyst or a very [thin one] are generally sarcom. or medull. There is a kind of tumour of a bluish colour [illegible] within cyst, which appears upon the lips and is considered cancerous Cyst very thin filled with matter like the white of an egg extirpated immediately is the remedy (by dissecting around) Often upon the head encysted tumours are very numerous and keep reappearing Discutient applications have been much tried. They do no good, and often change the tumour into a cancer Caustics may be a successful substitute for the knife in small tumours Such small encysted tumours are [illegible] away by the cancer doctors and add much to their reputation These tumours sometimes inflam. of themselves and this in a few rare instances 75 cure themselves. Generally however the part eaten by the caustic heals up and the tumours continue The only remedy is extirpation. This was formerly directed to be done without wounding the cyst this is difficult without cutting away much flesh Sir A. Coop. mode of [illegible] open the cyst and then everting it with heat The cyst is easily distinguished by its appearance Sometimes from an injury the tumour [inflam.] and suppurates of itself. Then Prof. H. introduces a little caustic kali upon lint Lately however he has often succeeded in such cases in pulling out the cyst Sometimes membranous bands have to be cut Sarcamatous tumours are of very various consistence fatty with fat in large cells fleshy & others Extirpate, by removing [illegible] skin as may be advisable remove as much as possible by the fingers cutting membraneous bands if any removing very carefully from their adhesions to muscles & tendons Sometimes an infl. comes on accidentally and very bad ulcers are 76 formed, and the tumours must be removed even from very old persons to whom they have previously given no trouble Arteries do not generally require to be tied. Then after appear about the perineum and the art. may require tying 2 cases in females of Prof. H. Sometimes these tumours are very vascular case in which from are about the size of a goose egg after the first incision a gush of blood by which the tumour was much reduced in size and was extirpated The largest tumours are adipose even 40 50 & 70 pds Tumours of the scrotum seem to be an enlargement of the nat. parts in whole or in part. Adipose tumours feel like a bag of cotton are very irregular in shape and when the skin is pushed along it rises in ridges, from its adhering in some parts and not in others This last is pathognomic Prof. H. believes the shole parotid gland has been extirpated McClellan Glandular enlargement are apt to be called tumours Enlargement of the mammae will often subside after child bearing 77 malignant tumours are these liable to return Medullary Tumours substance resembles that of the brain Called fungus haematodes may spring from any texture even as Prof. H. believes from the bones They have an elastic feel when under a fascia they may be mistaken for [aneurism] or abscesses They were formerly called cancers Their growth is very rapid Prof H has known one is large as a milk pail upon the thigh. They are most common in the young, but are found even in the very aged. They may spring up in the testicle, in the eye & in every part of the body. They have often been mistaken for abscesses and opened. The only marks of distinction are 1st they are at first deeply seated and do not arise from the cell’ memb. under the skin, but from deep seated part apparently, in many cases from the muscles. 2nd not powerful in themselves only so by pressure & distention of surrounding parts and the pain is generally in a distant part, and will often be 78 attributed to hreumatism 3d Great const. disturbance & hectic The only remedy is extirpation but the tumour generally returns, and others often spring out in other parts of the body. So that the prognosis must be very doubtful. In the progress of the tumours the patient will suffer nausea vomiting & will grow sallow. The patients generally recover rapidly after an extirpation and are much pleased with the success of an operation. Yet the tumour soon returns. From some late accounts Prof. H. is inclined in future to persevere in extirpating. They may be distinguished from chronic abscesses by an elastic [illegible] instead of the fluctuation of pus The skin over them is not tender and sore, as when an abscess [illegible]. Distinguished from scrof. etc. by not beginning in the lymphatic glands If we are in much doubt we may make a very small incision without danger closing up immediately 79 When they reappear you will see at first a small gelatinous vesicle which swells and grows very rapidly Many cases related in which they returned in the same [illegible] other parts Schurrhus or Cancer They are different states of the same affection Schirrhus is a hard cartilaginous malignant tumor. Cancer is the same tumour in a state of open suppuration It has been said that infl. may terminate in schirrhus not so. It seems to result from peculiar action we see that tumour improperly tampered with may terminate in cancer. Most commonly found in the female mammae. Found also on the mucous membranes Cancer of the skin will be treated of under the head of cancerous tubercle of the skin Cancer of the breast for an example Begin with an uneasiness soon a small hard tumour finally 80 inflammation of the skin and the skin adheres the nipple retracts afterwards perhaps an ichorous fluid issues next small knobby tumours next a vesicle which bursts and we have suppuration and an open cancer The suppuration does not always begin on the outside but frequently within the substance of the schirrhus. All this while the pain keeps increasing About this time or sometimes before ulceration, the lymphatic glands begin to be [illegible] appearing like inflamed cords giving the skin a hard puckered appearance. Then inflamed and enlarged glands appear not only in the axilla but in all directions The mamma and the pectoral muscle adhere to the ribs and sternum. The affection may extend to the other breast. The swelling of the glands in the axilla may cause so great an edema of the arm that the skin must be punctured. Effusions take place in the pleura or tubercular 81 consumption comes on. It is not true that the cancer “eats through” as they ] say. Hydrothorax is the most common termination. Prof. H. has thought from the supervention of pains in the back etc. that the disease becomes transferred to the uterus Various other symptoms may occur sometimes a paralysis of a part or all of the limbs sometimes the bones break easily Distinguished from fungus hematodes by being an affection of advanced life by ulcerating and destroying the skin by not beginning in the muscle or bones by being not smooth but knobby by lancinating pains Cancer destroys adjacent parts fung. haem. grows through them Above all cancer is always hard to the feel. As to the great question whether cancer is a constitutional or local affection Other tumours and even simple ulceration of the lip may terminate in cancer. Cancers are very liable to return and most so of their previous progress has been very rapid Schirrhus tumours in old persons give 82 perhaps little pain project little, are very insensible, and the old patients converse to their removal As to curing the Prof. H. does not believe in its practicability Mercury seems to be injurious. Storck introduced conium. Carmichael Smith made iron especially the phosphate, fashionable The London Cancer institution has been abandoned from want of success No remedy seems to promise anything but extirpation by the knife Small ones may be eaten away by caustic but the process is very slow and painful Caustics applied to a large cancer produce great and highly injurious irritation Prof Smith never knew a female with cancerous breasts survive caustic for a year It is impossible to say how long it may be before the return in one case 7 years intervened Much is said about the incurability of them after they have become open ulcers. This distinction is not a good one. When you extirpate be sure 83 to cut out all the diseased parts including the infected glands Persevere in extirpating as long as they return, if complete extirpation is practicable in each case. Never amuse the patient with the prospect of a cure by any mode of treatment Prof. H. has extirpated one hard cartilaginous schirrhus of 4 pounds weight Patient recovered for the time Superficial cancer Occurs oftenest in the lip Generally commences with a small crack in the lip which is neglected A scab forms, and upon examination at this time we shall find a hardness beneath The glands under the chin or under the side of the jaw, swell & harden Ultimately the lip becomes excavated, with an ulcer which has cartilaginous edges Finally the whole lip, jaw etc. are eaten away & the patient dies miserably Caustics are generally very injurious. Excision is made by taking out a v0shaped piece Richerand advises to take 84 off the whole lip the lip afterwards elongating This mode not so good As to cancer in other parts Prof. H. has known ulcerated leg terminate in this way and once case of necrosis With respect to the cancerous diathesis or a disposition in the constitution there may exist something of the kind but the practice of telling patients that they have a cancerous humour in the blood is very reprehensible making them very unhappy Extirpation is not necessarily followed by reappearance Cutaneous cancerous tubercle of MR. Lawrence. Commence with a small insignificant tubercle, hard, resemble seeds of mallows called warts often by the patient but they are vascular they finally ulcerate they may become extensive cancers Old men are subject to them about the face. Women have them in the pudenda Men have them upon the glands penis Prof. H. has seen them about the pudenda 85 in cases of amenorrhoea emit blood periodically at the menstrual periods. These cancerous tubercle may occur about the eye and the nose. The success of extirpation is far greater in these cases than in common cancer. Be careful to cut far enough with two semilunar incisions They leave no scar. These cases are different from noli metangere. Noli metangere Intermediate as it were between cancer and common ulcers. Appear about the face and nose An ulcer forms 7 becomes covered with a scab. The ulcer is often irregular & oblong. They are often converted into cancers by caustic In the course of time the scab comes off permanently and an open ulcer continues The ulceration of noli metangere may affect the cell. memb. or the cartilage of the nose or they may not even penetrate the true skin. The best remedy is arsenic The most common form is an oint. of which arsenic zi to zi cerate. Apply a plaister 86 of this one day and then a plaister of common cerate or satur. cer. for a few days. Inflammation S. Cooper uses 4 gr. to 4 oz mint water & 1 oz spirit applied in lint. Sir E. Home applies a solution made by boiling A powder also of arsenic & tapis caliminaris Others apply sulphur & arsenic Fowlers solution also. It seems that any form of arsenic will answer. Prof. H. has cured also by nit. sil. also by red precipitate ointment Occasionally touch with nit. sil. to promote the healing in the latter stages There seems to be little need of the old plan of giving constitutional remedies A disease similar to this if not [proceeded] to far If the cartilage has become affected cut out a piece. If the eye has become affected extirpate the eye. There seems to be nothing specific in the cure of noli metangere other ulcers also are to be treated by exciting an action in this way. 87 Prof H has known the experiment of low diet also of a diet of [illegible] thoroughly in use of cancer but without benefit Subcutaneous tumour in the cellular membrane It may occur in any part covered by acutis vera not on lips They are about the size of a walnut excessively hard First mentioned in Cheselden’s anatomy (calling them a tumour of the nerves) Described by Mr. Wood in the Ed. Journ. also & by Mr. Lawrence in his lectures Very painful skin is emaciated and adheres looking like a cicatrix painful when the cloths rub over them, or when they are struck or examined. Not dangerous but troublesome May continue many years (20 Mr Wood) without charge. Extirpate them 88 Ulcers A solution of continuity which gives out pus. Absorption goes in faster than deposition opposite to the process of healing a wound by granulation Caused by wounds opened abscesses, injures caustics, acids irritation of foreign bodies Constitutional causes are syphilis scurvy scrofula and a predisposition in some families to sore legs Varicose veins, oedema, dropsy, phlegmasia dolens are causes 1st simple 2 irritable 3 indolent 4 varicose 5 specific 1st simple an open sore after a time a bluish skin covers the sore & becomes a cicatrix This is cuticle not true skin. The part underneath is hard cartilaginous In simple ulcers as much benefit may be derived from adhesive straps to approximate the edges as in [wounds] 89 Place over them a compress & bandage If the granulations rise too high (proud flesh) touch with nit. sil. or sulph. cupri. Another advantage of bandaging is to prevent the swelling. Bandage a whole limb. Irritable ulcers painful the adjoining parts sore granulations absorbed bitter smooth Often irregular in shape sometimes however round and cup shaped. On the shins small sized These ulcers do not bear bandaging Frequently touch them with nit. sil. Sometimes however they will not bear this. in this case then apply a solution of nit. sil. 3 or 4 grs. to 1 oz. or corr. sub. 10 gr. to 1 pt or the yellow wash lime water 1 pot corr. sub [illegible] ? or sprinkle on calomel or black wash which is milder than cal. z2 cal. to 1 pt lime water or apply the blacker oxide this generated Also zjfs op. to 1 pt water. Also saturine 90 cer. Also ac. pl. zj to 1 pt of mucilage of slippery elm, when parts are excoriated Warm fomentations and poultices shd not be continued long they are too relaxing We are obliged often to try a variety of applications Indolent ulcers Usually large granulations lax and flabby discharge serous a substance like curd white or yellowish or brown lies upon the surface. Ulcer excavated as if cut out with a knife surface smooth no granulations edges swollen making the ulcer appear deeper surrounding cell. memb. hard Very insensible Patients will continue to labour as usual they apply spirits salt and vinegar urine etc. with no effect In the species also apply nit. sil. 2 or 3 times a week corr. sub. dilute nit. ac. 100 drops to 1 pt. is a good application red precip zi 91 to zi of cerate is an old application Above all other modes is to be recommended the plaister bandage Take common adhesive plaister or dyachylon having a plaister soft enough to spread & yet adhesive soften with tallow or lard if necessary Apply the strips of plaister so as to approximate the edges Then apply a compress & bandage the whole limb. Leave a little interval for pus to escape, or cut a little hole for the escape of the pus Leave the dressings on as long as possible say 3 or 4 days in hot weather it may be necessary to dress every day the sore becoming offensive You may let the patient walk about during the cure, if in this mode Sometimes an erysipelas commences in the neighboring parts And sometimes the ulcerations suddenly spreads with rapidity Surgeons speak of a sloughing 92 ulcer But all ulcers may exhibit this appearance After the erysipelatous infl. suppuration sometimes takes place in the cell. memb. Varicose ulcers Varicose veins accompany them either in neighborhood or over the whole limb May be cured by proper bandages They are ulcers from injury of varicose veins Bandage the whole limbs In the hospitals the patients can be cured of ulcers more speedily than in private practice but they are very liable to a relapse When pat. apply to Prof. H. with a high state of infl. & irritation in consequence of an ulcer, he bleeds But if pat. is cold in extremities feeble etc. he gives cal. & op. as recommended by A. Cooper Prof. H. had however given them long before seeing his work 93 For varicose ulcers cutting the vena saphena is practiced in the Mass. Hospit. (cut inside the skin) In the Penns. Hosp. they cut out a piece after emptying the vein by means of a bandage Mr [illegible] destroys the vein by caustic kali Tying the vein is not to be recommended Cases in which sore legs have become cancerous from tampering with them Propriety of drying up old ulcers The prejudice probably has arisen partly from the drying up of old ulcers after and attack of fever Prof. H. has been in the habit of healing or attempting to heal every old ulcer. He has never either known or heard of a well authenticated case of injury resulting They frequently however break out again If plethora arises it would be much better to bleed etc. as directed by A. Coop. 94 Specific ulcers are syphilitic noli metangere scrofula etc. etc. Some ulcers cannot be classed Sir E. Home speaks of a peculiar sore upon the ankle which yield a serous discharge and covered with scabs Apply after softening the scabs with a poultice and washing them off, cal. or nit. sil. or corr. sub. or ac. pl. with slippery elm or poultices with narcotics cerate sat. or dyach. S. Cooper mentions fungated ulcers upon the calf of the leg nit. sil. or sul. cup. And to prevent apply ac. pl. Occur in corpulent young women especially ‘ those who work in factories and stand much on their feet & live pretty well. Prof. H. has known several females affected with varicose veins & ulcers after phlegm. dolens. Scrofulous ulcers are long in bursting flabby fungous granulating overhung by the think skin upon the edges of the 95. ulcer skin sometimes purple. Apply nit. sil. under the skin and if necessary clip off this skin at the edges. Sometimes there is only a very small orifice in the skin. In this case if they do not heal lay open the ulcer & touch with nit. sil. They will then soon heal. Introduce a stick of nit. sil. upon a quill through the opening and touch all around Diseases of Mammae Vide A. Coop. Lect. by Tyrrel Hydatid or encysted tumour not the hardness of schirrus, skin not discoloured after a while a fluid is felt when upon puncturing serum issues but soon collects again. The tumour may be even 13 lbs in weight not painful Generally a dis. of advanced age sometimes attacks at 20 yrs Upon dissection, one or more cysts are formed the body of the breast not being much affected Sometimes the cyst inflames & 96 suppuration may come on and destroy the patient. Tents and stimulating injections shd not be used they may prove fatal. Diagnosis absence of pain const. not affected swelling smooth firm & hard fluid clear. Cure by extirpating It will not return Simple chronic tumour of the breast. Not hard like schirrhus appears superficial (schirrhus feels deep seated) grows slowly not very painful. Extirpate. Does not return. The tumour seems composed of lobes like the sweet bread (pancreas) Cause unknown though by some to arise from pressure of cloth Adipose tumour of breast Seated sometimes under the gland occasionally of enormous size 14 or 15 pds. The large tumours called cancers which are extirpated are Irritable breast Lobe of the breast slightly swollen and 97. tender pains in the shoulder amenorrhoea irritability of nervous system Do not think of extirpation Bleed the plethoric give sub. & opium etc. Apply spt. & wat. or lard & laudanum or sometimes litharge plaister. Often what is better than all is a piece of soft fur or cotton wool The main thing is to quiet the alarm about cancer. These cases occur in a neighborhood where an operation has been performed Ossific tumour Extirpat Lacteal tumour Soon after parturition Caused by an obstruction of a lacteal tube Introduce a lancet and let out the milk & then pencil with lunar caust. to stop the flow of milk Abscesses of breast that let out milk, by sloughing off a part of a lacteal tube. Touch with nit. sil. Some women are subject to abscesses when the child is 6 mo. old Wean Enlarged breast Generally diminishing upon child bearing. Suspend 98 the breast The breast sometimes enlarges and is painful during pregnancy Bleed. Calomel etc. Operation for taking off the breast. Always remove the whole glandular tumour of the breast except in the case of the simple [uremic] tumour. Instruments 2 or 3 scalpels 1 tenaculum needle ligatures, sponge a broad bandage to pass around the body straps to go over the shoulder [illegible] compresses cordials a pitcher of cold water Place the patient on a table with the feet in a chair An assistant holds the arm at right angles to the body Make the first incision in the longest direction or otherwise in an oblique direction Make two incisions to include diseased skin if necessary and always include the nipple which shd never be left Be careful to make the incisions long enough If two incisions are to be made make the 99 lower one first Then dissect down first on the lower side then on the upper & finally at the bottom The most painful part of the operation is the cutting through the skin The glands in the axilla can frequently be borne out and always when you have fairly cut down to them pull them partly out and then divide the membranous bands this is much safer than to cut around them in the dark Prof H. removes the lymphatic glands first and makes a handle of them instead of making a handle of the breast as recommended by Gibson Wait awhile before you dress the French surgeons say ¾ hour. It is very unfortunate to be obliged to [illegible] the wound. Give but little medicine, as a general rule after the operation Usually in about 4 days the wound must be dressed with dressings become offensive. Dress as at first The nervous irritation and the shock 100 to the system is great in proportion to the length of time taken up in the operation Be careful not to move the arm before the healing of the wound After the healing of the wound remedy the stiffness of the arm by motion Other tumours are extirpated in a similar way. It is too much the fashion to tie the large arteries (as to carotids) at the present day and the plan of tying an artery for the sake of stopping the growth of a tumour fails Fistula Lacyrymalis This name has been given to nervous affections which obstruct the nasal duct. 1st Enlargement of lac. sac is most common 2nd Suppuration of lac. sac. 3d an open ulcer of the lac. sac 4th ulcer with aff. of [illegible] or with nasal polypii Prof. H. has never seen a case of obstruction of the canals leading to the sac which is a 5th kind. 1st Obstruction of nasal duct by enlargement of the sac. May be of 15 yrs standing without going further Most common in females who work over the fire & live in smoke Generally the duct is only partially obstructed Tears flow over the cheek sometimes a gelatinous fluid issues & glues the eyelashes together. There will be a sense of fullness and the patient will press the corner of the eye & a fluid will issue into the eye & down the nasal duct. Tears flow more freely with smoke & in cold air (Sometimes the distention of the sac is large as large as a hickory nut and is mistaken for a tumour (encysted) Some patients in this stage are unwilling to have any thing done Prof. H. has often succeeded in curing the disease in this stage by remedies for infl. sol. nit. sil. dropped into the eye anoint the edges of the lids with red precipitate sat. cer. or citrine ointment ac. pl. Give calomel Prof H. has never used either the probe or the injecting syringe He has seen no account of cure, performed in this way. Mr. Liston disapproves of them. Prof. H. has not used them because the diseases cured by the above means or passes into the second kind 2nd Suppuration Open the abscess and introduce a stilette 3d An open ulcer with complete obstruction. Introduce the stilette. And generally make a new orifice with a small round edged scalpel just below the tendon of the orbicularis. Sometimes Prof. H. has not been able to introduce the stilette at first and has first used a sharp steel knitting needle. Some introduce in gold silver or lead canula Mr. Liston condemns it The stilette will not completely obstruct the passage the tears will pass down Prof. H. has never found it necessary to pierce the os unguis a practice which Mr Liston condemns the hole closes again Let the stilette be worn about 6 mo. occasionally cleansed little syringing is necessary Sometimes a fracture of the nasal bones is the cause. Treat as others 4th Prof. H. has seen no cases of affection of the bones (e.g. venereal) If polypus is the cause cure it The treatment of fistula lach must be varied according to the degree of the aff. its cause & the constitutional health Sometimes, says Mr Liston, the gland and sac & duct are wholly obliterated without inconvenience to the eye Aneurisms 1st true 2 false 3 varicose 4th an. from anastomosis In the true all the coats are not ruptured but all of them are distended equally forming a tumour with an orifice communicating with the artery which is smaller. It is maintained however that the arterial and middle coats are ruptured Begins with a small tumour pulsating externally & when small all the contents may be pressed back into the [illegible] artery. When lager the disposition of lymph prevents this As the tumour increase the pulsation is disagreeable more or less pain numbness from pressure on the nerves obstruction of the progress of the blood which [last] often causes hemorrhages in distant parts as, abdomen [heart] etc. Absorption of soft parts or of bones may be caused Cartilage however being the most indestructible parts of the body resist the absorption In aneurisms near the surface the pointing is towards the skin & ultimately a slough is formed [illegible] the patient dies of haemorrhage. Internal aneurisms besides pointing to the skin point towards a mucous or serous membrane in the latter they make a rent. Causes; wounds, injuries, mistakes in bleeding. From the latter cause The 2nd species or false aneurism arises from a wound of an artery by mistake for a vein the blood is contained in the cell. memb. 3d Varicose aneurisms happen from mistakes in bleeding, the lancet being carried through the vein into the artery The blood at every stroke of the heart issues into the vein (which has adhered to the art.) with a whirring noise & feel. By pressing upon the artery above, or on the cicatrix this whizzing may be stopped Causes of aneurism are very obscure There seems to be a disposition in the circulating systems of many persons. It has been found in many instances that the coats of the arteries in the neighborhood are diseased being brittle etc. [Postillions] & cavalry soldiers are thought to be more liable to aneurisms in the lower extremities Porters who lift heavy burdens are thought to be more liable. Old persons also Occasionally they have spontaneously cured themselves probably by the filling up of the cavity, and the subsequent absorption Treatment. Valsalva’s plan was by bleeding the lowest diet External application of ice has been proposed Ligature of the arteries has superseded every other plan History of the various modes things necessary 1st a small round cord 2n tied very tight 3d the vessel shd be detected as little as possible 4th the aneurismal tumour shd be touched # as little as possible Vide Coop. Surgs Dict One ligature only is now used The first cause of danger is from interruption of the circulation producing perhaps gangrene The second is from const. disturbance both from the operation & probably also in some cases from the interruption of the circulation. Thirdly from secondary haemorrhage Cut one end of the ligature short. Mr. Lawrence cuts both short and lets the wound heal over the ligatures afterwards finding their way out Warm the limb by hot flannels Take care however not to burn the patient who will be very insensible # Vide Prof. Knight’s lectures Mr Wardrop proposed to tie the artery beyond the aneurism as in the arteria innominated in order to check the circulation The operation seems not to have succeeded Varicose aneurisms are more or less inconvenient but not dangerous and are all pretty much alike After the wound of an artery we often meet subsequently with a small pulsating tumour which occasionally bursts & bleeds and are obliged to cut down above and tie Waevae Maternae In small tumours of a reddish or purple colour & at consist of a congeries of vessels They are called marks and denominated cherries, strawberries, figs etc. according to their colour and the recollected longing Sometimes these enlarge and have a doughy feel or are pulsating and enlarged when the child cries When the skin in the neighborhood is purplish the tumour is called aneurism from anastomosis Sometimes these marks ulcerate and perhaps extensively Sometimes aneurism from anastomosis occurs in adults without any previous congenital affection the vessels enlarge and are tortuous, and the tumour may be even pulsating from a considerable distance distinguished from [fung.] haem. by pulsation from the first by its originating near the skin by freedom from pain unless after ulceration etc. etc. They sometimes grow to a great size and came to a very troublesome ulceration Congenital [illegible] are sometimes fatal from their great size etc. The congenital [naevi] are to be cut off if practicable where they disfigure Aneurisms from anastomosis have been cured by caustic & by spontaneous ulceration We may as Abernethy recommends apply cold lotion constantly, as ac. pl. The most effectual mode of cure is by extirpation. Cut out for the haemorrhages though considerable is for less than if they are cut into. Cut quickly & let the assistants check bleeding with their fingers Another mode which is calculated to avoid haemorrhage, is that of ligatures passed through & around. Marshall Hall has introduced the plan of piercing through with a white hot needle the tumour then gradually sloughs away In cases of ulceration of the tumour Prof. H. has succeeded by the constant application of nit. sil. caustic. Another mode of [illegible] them has been proposed & practiced by inoculating them with vaccine matter Tying the principal artery leading to the tumour has succeeded, but the plan is now going into disease e.g. carotid, art. when the tumours are upon the head Collections in the Bursae mucosae Not abscesses, which have already been treated of These collections may be fluid curdy or (by absorption of the liquid part) solid. “I have seen more than a gill of something like boiled rice” (Prof. H.) in the wrist. On the patella they resemble a half of an orange # The joints of the toes also get sore Old persons have corns Prof. H has also known in chronic cases the serous part be absorbed and several hard bodies are left he has extracted them without injury. He has known a creaking noise from the cause in the wrists of reapers Treat by ac. pl. finally by a succession of blisters. Bandage tightly to promote absorption If they have suppurated in toes of old persons do not amputate but heal with nit. sil. Ganglions which resist these processes shd be opened & squeezed # N.B. There is a bursa between the skin & the patella Classification of Poisons Prof. T’s attention has been turned to the deleterious effects of medicines from the commencement of his practice 1st Exhausting poisons which extinguish vitality almost as soon as lightning in excessive doses e.g. prussic acid. The measles do not contract & the blood does not coagulate (the last efforts of its vitality) Found in the animal kingdom e.g. fish bites & stings They produce no lesion but destroy vitality 2nd Narcotics (simple & pure) 3d Acrid narcotic (not acrid & narcotic but a peculiar sort of narcotic power which produces no coma e.g. veratrum) Those acrid narcotics are evacuants or non-evacuants. The former kill more speedily 4th Irritant poisons which produce irritation & inflamm. e.g. the salts, the acids & the caustic alkalies 5th Composite poisons which possess several or all of the above kinds of power 1st Exhausting poisons are fish, bites, stings There is considerable mystery upon the subject of poisonous fish The same poisons well sometimes be preserved and sometimes escape. Some will be effected & others escape We have abundant evidence of this but cannot explain it. There is equal mistery about poisonous mushrooms probably some can eat every sort. In the north of Europe every kind is eaten Poisonous fish are more common in tropical climates Even the same fish appear not to be poisonous in cold climates Several species of crab & lobster cancer (sea lobster) cancer miricula (land crab) our common lobster is poisonous to some Clopea murina a species of shad mitylis edulis ([illegible]) is apt to be poisonous in tropical climates Vipera verus (European viper) [illegible] several species (the black snake genus) Cobra di capello [illegible] [illegible] which last is however probably not worse than the candisona horridus (rattlesnake) & the candisona durissi [illegible] in the southern states the commencement of the symptoms Commence with languor, headache, [nausea] oppression, pricking in the skin, hands & feet articaria etc. etc. Spams of abdominal muscles, [illegible] etc. convulsions, coma etc. death When recovery takes place the cuticle comes off, the hair comes off. The strength is long in returning etc. Good calls these symptoms colica cibaria They constitute cholera or diarrhoea as much as they do colics. There is no cessation of peristaltic action as in colic The tormina is not caused by it The tropical writers say that it is of very little consequence whether you evacuate the food or not that vomiting at first will rouse the patient but in the latter stages the patient will often die in the act. They recommend stimulants & nervines above all alcohol also capsicum, [ether] [amomum] granum paradisis etc. etc. opium Those are said almost infallibly to cure even if the disease is far advanced The best emetics are mustard distilled water of ranunculus flammula, which vomits speedily & with no nausea the next best is the bi per sulph. copper then sulph zinc then turpeth mineral The common account of the effects of the bites of snakes is also meagre They are said to be in India pain in the wounded part violent acute burning pain with part. tumefac. in the adj. parts in slight cases the effects stop here otherwise the whole limb & perhaps the whole body swells Colour of the bitten part is first crimson then greenish livid etc. Sir E. Home found that these local effects proceed from emission of serum. He found also that the patient might die from the abscess subsequently formed in the part Sometimes the death is too speedy for the administration of any remedy. Sometimes the vomiting is such as to prevent the retention of any medicine The topical affection unites the characters of erythema edematosum & anatomicum & the const. syrup those of a cold malignant typhus Post mortem examinations show no lesion except some infl. near the part bitten. Patients generally recover completely, but they often suffer long after One has been rendered hemiplegic Various circumstances, as the size of the snake, the degree of his irritation, the part of the body bitten, the climate the season of the year, the delicacy & the apprehensiveness of the patient etc. etc. vary the severity and the danger of the symptoms The surgical writers make much of surgical treatment But all the surgical treatment, as excision etc. seems to be useless There is abundance of testimony in the periodicals & even in the newspapers that efficient quantities of alcohol are infallible. Prof. T. has also conversed with Dr McBride & the late Dr Osborn of N.Y. who had practiced at the south. Accounts are to be found in our periodicals of giving a gallon of spirit in 12 hours with success. The alc. however is much more efficacious, when combined with acrids Simple narcotic poisons. Gelsenum nitidum. Helonias erythrosp. Datura stram. hyoscyamus hydrocyanic ac. Cicuta maculata which destroys some every year the most active of our poisonous plants though deobstruents destroys life as a narcotic So also conium digitalis etc. & probably also alcohol Good calls the disease producing by such articles colica cibaria comatosa with no propriety. Another set produce common or epileptic convulsions e.g. oil of tansy [illegible], cinnamon nutmeg etc. these destroy life as narcotics however Another set, as strychnos, actaea etc. etc. produce tetanic convulsions Another set are evacuants, as aconitum delphinium helleborus veratrum sanguinaria etc. Simple irritant poisons as rhus venenata, [pumila], toxicodendron & radicens [Hippona??] manchinella The aroideae, especillia leontia clematides dephne mezereon euphorbia lithysis sedum acre Ranunculus anemone pulsatilla capisicum if it can destroy life Those of animal origin are phosphorus, the acids, cantharis the larvae of phalaena menstora The caustic salts as nit. sil. the antimonials, blue vitriol etc. Red precipitate & corr. sub. Carbonate of barytes & the caustic alkalies etc. Glass Collection in the wrist Prof. H. has succeeded in curing after trying discutients by opening them amply and keeping in a slip of linen & keeping up inflammation Ganglion, if they do not heal after being punctured may be opened & treated with nit., sil. to create infl. These collections are apt to be confounded with encysted tumours but the latter grow gradually from a small beginning and are round the former spread quickly and are flattened. It would only be the mellicerous tumours that could be mistaken for these Wearing plates of metal & various mercurial & other plaisters are sometimes used for their cure Prof. H. has succeeded upon the olecranon & patella, after they had been opened & yet filled again by [illegible] & injecting nit. sil. & creating infl. After puncture the part shd be kept perfectly at rest Sometimes it is necessary to inject a second time Hard & cartilaginous bodies in the joints as in the bursae muc. also The two situations seem to have been confounded together. Prof. H. has seen some of them and thinks they are rather hardened lymph, and that they are not cartilaginous Mr. Hey recommends a laced knee cap. Prof. H. has endeavoured to affect the same purpose by plaister bandages They cease after a while to give trouble. Case related in which very dangerous consequences resulted from removing them If you desire to remove them place the knee horizontally confine the substance & make a free incision directly over it. Vide C. Bell. Mr. Travers relates a case in which Mr. Young Fractures They are solutions of contin. in bones 1st of the differences which are in the part of the bone the mode of breaking etc. Compound fractures are those in which the skin is likewise broken They differ also in the causes of breaking the direction, nature, & [illegible] of the blood Some fractures are complicated with other circumstances Prognosis varies according to the injury the constitution, the treatment, 6thly The formation of calles varies with the treatment. It will be small & quickly formed when the ends of the bones are kept closely in contact. Much is said by natural bone setters about the split bones but according to Prof. [illegible] experience this is a rare occurrence except in case of gum shot wounds Bones are seldom fractured in two places except when a heavy body has passed over the limb and comminuted the bone. Bones are often supposed to be broken in two places in consequence of the overlapping of the ends. Often we are unable to determine for some time the exact nature of the fracture Fractures are distinguished by the distortion, inability to use the limb, & especially by the crepitus. We think we hear but we in fact feel the crepitus The piercing of the skin is in consequence of an exertion subsequent to the fracture It is common when a limb has been shortened for the surgeon to say that the fracture was oblique but in many such cases you can feel the transverse surface of the end Children are subject to partial fractures or bending of the bones. Prof. H. has generally succeeded in straightening them sometimes however you may break them completely while straightening them probably one side of the bone is always broken in such accidents It is only in the thigh and leg that we meet with spasms. Hard labouring men and irritable females are most liable to spasm. Of course compound fractures are mor liable to cause spasm. Old age is a less obstacle to recovery than we might suppose. Delirium trem. is apt to be produced by fractures in the intemperate Callus Dupuytren made many observations 21st a deposition upon the periosteum [illegible] the bones by what he called temporary callus 2nd callus between the bones. S. Hunter thought there were granulations of the ends of the bones The union of the bones is not [illegible] for several months as the patient is [illegible] or unwilling to rest his weight upon the limb goes on crutches and if he falls it is broken again B. Bell says an arm unites in a month a leg in 6 weeks & a thigh in 3 mo. The union however is by no means firm at this time many cases of refractures occur for slight causes after this time The setting of fractured bones is generally a simple business. It is done by extension counterextension and [coaptation] Extensive may be made at the nearest joint or farther off. Coaptation is of far less efficacy and requires far less skill & [illegible] than used to be supposed It is of little use when the muscles are covered by thick flesh as in the thigh By means of his fingers the surgeon can ascertain when the ends are in place Splints are applied by some only after inflammation has gone down. Apply splints as early as you can Do not bandage too tight and wet the bandages with ac. pl. etc. In some cases a partial application of splints and bandages may be made If the limb is excessively swollen you must wait until you have subdued the violence of the infl. Generally however if you are called soon you can dress immediately The symptoms to be attended to are pain spasms inflammation, & constit. irrit. Relieve these by the usual means For const. irrit. give cal. & op. spasms may take the limb and displace the bones give opium for them and in robust men, bleed sometimes Fractures of ossa nasi These are only dangerous as the [ethmoides] may be driven into the brain. Boyer thinks the brain cannot be injured in this way but Prof. H. has known two cases of death from infl. of brain in consequence of a kick of a horse upon the [nose] Treat by introducing something as a direction under the bones and squeesing up with your fingers. If they do not retain’ their place, keep them there by catheters & lint within & compresses on the outside Wet the bandages Fract. of cartilage of the nose nose twisted Keep in place by straps of plaister Fracture of Lower Jaw Onn one or both sides often on both never exactly at the symphisis Use a compress a four headed bandage tied behind & above and then apply a thick bandage over all Fracture of upper jaw [Arise] from blow bones driven into the antrum etc. Fract. of Vertebrae Prof. H. has had perhaps 30 cases only 2 recoveries Paralysis of the lower limbs immediately takes place retention of urine etc. Infl. comes on. They die in a few days or live for several days Fract. of the dentata occasion sudden death It is perfectly absurd to attempt to restore the function of the limb by blisters etc. The infl. of the spinal marrow occasion, enormous irritation restlessness & fever. Although the legs are insensible & perfectly paralytic yet they will sometimes require their legs to be constantly moved by the assistants owing to some irritation at the origin of the crural nerves The urine is always to be drawn off by a catheter which a surgeon shd always carry with him in such cases If the injury abo e the origin of the phrenic nerves the patient cannot expectorate & dies of suffocation The bowels generally puff up and are constipated In robust men you may bleed and you may always give cathartics The urine finally becomes turbid & eventually purulent When the patient survives 10 days or a fortnight he generally dies from infl. If he lives several months he seems to die of fever of irritation. Opium is the principal remedy Extensive sores from in the muscles of the back. The urine has to be drawn off continually Fractures of the Sternum May generally be distinguished by inequality of the surface. You can often feel a crepitus when the pat. breathes. Treat by preventing motion of the part in respiration by a broad bandage around the breast with a compress under it It gives great relief When the fragments are forced in and the circulation & respiration are impeded do not wait for infl. but bleed immediately the pulse will rise after it. Afterwards apply a blister Treat with opium and cal. Trepanning has been recommended It can hardly be necessary. Pus will not be apt to form if the infl. has been properly checked if necessary however we should trepan In many cases the infl. of the thoracic viscera, cough etc. will [combine] often [The] healing of the wound. The case however will not be so dangerous as one of the phthisis pul. Fracture of the Clavicle May result from direct violence or from a fall on the shoulder elbow and hand, and in the former case there will generally be considerable contusion and the fracture will be between the coracoid process & sternum in the latter often between the corac. proc & the acrom. The shoulder falls the patient carries his head on that ride & supports that arm with the other hand his whole appearance is peculiar or he walks very carefully, to avoid motion of the parts In some cases the subclavian artery and in some cases the lungs have been wounded. Fractures of the clavicle are very often mistaken for a dislocation of the shoulder Reduce the fracture by placing one hand in the axilla & the other under the elbow Place a compress under the axilla & confine it there by a strap passing from it The arms are not very perfect in cases of fract. clav. Fractures of the Scapula When the acromion process is broken the arm falls down and the parts may be brought easily into contact by pressing up the elbow and you can feel the motion of the broken parts Treat pretty much as for fract. clavicle. It is said that the union is ligamentous When the body is fractured pass a bandage around the body and support it with shoulder straps Boyer speaks of fract. of coracoid process. Prof. H. has never met with a case It might be necessary to cut down The ligament of the Fract. of the neck of the os humeri So called when within an inch of the head Caused by falls upon the shoulder Distinguished by the mode of receiving the injury. Examine whether the fall was upon the hand. The ecchymosis is upon the top of the shoulder where the injury was received & not in the fore part near the axilla is in dislocation. The deltoid muscle will be shortened instead of lengthened The bony tumour will be of a different shape in the axilla. The upper fragment is drawn outwards by the [teresm] & subsception? The lower fragment is drawn downwards by the pectoralis Distinguished from fract. of acromion by The whole limb generally swells therefore begin to bandage at the hand & bandage up to the shoulder. Apply on the outside of the arm Smith’s splint & bandage over the splint. Keep a compress in the axilla and bandage [aroun] the body and arm Support the forearm, not the elbow with a sling. Let the elbow hang down Fract. rib Sometime the rib is fractured at a place different from that where the injury was received e.g. the neck. Examine by feeling along the rib when you come to the fracture, pain will be produced You may scarify for the emphysema. When the broken point of the rib is caught, & respiration and all motion of the body is prevented Prof. H. has succeeded in affording relief and disengaging the end of the rib by standing behind the pat. placing the knee against the back and embracing the [illegible] with the hands and at the time of a full inspiration jerking in the abdomen Treat the fract. by a broad bandage around the thorax supported by shoulder straps. The most important part of the treatment is that for the infl. of the thoracic viscera by bleeding cal. & opium & in extreme cases by taking off the bandage and applying blisters. Use demulcents for the cough If the blood does not flow put the hand in warm water Fract. of the body of the condyles of the os humeri Generally distinguished [illegible] by the deformity, loss of motion & crepitus. Fract. near or at the condyles of the bone are to be distinguished from dislocation. The arm will be slightly but the fragments will be drawn up there it will be a depression above them Generally by rolling the fore arm you can feel a crepitus. Sometimes the int. cond. is broken off and drawn up, without aff. of the joint. If the init. cond. is broken the arm will be bent inwards if the ext. cond. the arm will be bent outwards make extension with the elbow bent coaptation will not be needed. Bandage the whole arm. Support the fore arm and let the weight of the elbow hang down For fractured condyles we shd use a bent splint and occasionally after a while bend and extend the limb every day in order to secure perfect motion of the joint Prof. H lets the splint stay on but about a fortnight, for the reason. There is great tendency to a permanent pronation of the fore arm especially when the int. cond. is fract. This accident is very common in young children and sometimes arises from a blow [on] the lower part of the humerus Fract. of both bones of the fore arm. Arise from violence Sometime one bone is broken in a place not opposite to the fract. of the other. Easily distinguished by deformity Reduce by taking hold of the hand & pulling counterextension at the elbow To prevent the union of the ulna to the radius dress with two compresses rolled so as to be thicker in the middle & then over then two splints which by pressure upon the compresses keep the bones apart Fract. of the body of the ulna is easily distinguished coaptate if necessary dress with Smith’s splints & sometimes apply another splint on the other side Fract. of the lower end Radius Looks much like a dislocation of the wrist and is often mistaken for it the styloid process looks towards the palm of the hand The upper end of the lower portion of the radius project backward & the lower end of the upper forwards Put a compress on the inside to keep down the lower end of the upper part Bandage apply a splint on the inside & bandage so as to bring the hand back Sling so as the hand fall down towards the ulna. Leave the fingers out Fract. of the olecranon Put a cloth at the back of the olecranon longitudinally Bandage it down letting the ends come out. The assistants in the meanwhile pushing down the muscles pull up and down the ends & pin them. Use a crooked splint or else fill up the cavity of the elbow the arm being a little bent The danger is not of a stiff but of a weak joint. The union is ligamentous Keep the dressings on about 3 or 4 weeks Begin to move the arm however before this period. Exercise the muscles at first passively, in order to restore the use of the arm Compound fract. of the olec. are very serious accidents When the elbow is going to be stiff place the arm at a little more than right angle Fract. of bones of the carpus From blows etc. effusion very grat yet you can generally feel a crepitus The principal indication is to treat the great infl. Bleed cal. op. etc. warm or cold appl. etc. Keep a splint on to prevent distortion Fract. of metac. bones Ascertain by prying & feeling with the thumb. Apply a splint to the hand. If the pat. insists upon using the hand, apply plaister bandage Compound fract. of the metac. bones are sometimes followed by mortif. of the fingers. Take them off if so Fract. finger Apply a little roller & a splint of basket stuff a roller over it Bend it to the next finger. Sometimes they are so washed that they must be amputated Still however they often recover when exceedingly crushed Fract. of os. innom. In consequence of passage of loads etc. Sir A. C. observes that in fract. of the acetab. the limb will be drawn upwards like disloc into the ischist. notch The most we can do is to apply a strap around the pelvis Purgatives & injections will be needed & a catheter Fract. of the lower extremities We always have much constit disturbance Fract. of body of os femoris Limb is distorted crepitus can be felt unless the ends are too far by each other or too far apart. When broken high up the upper fragment is drawn forwards and upwards Children have the bones oftener broken transversely. To reduce the fracture make extension. Let the assistant take hold under the arms. Great diversity in the mode of treatment exists. Mr. Pott & others advocated the bent position. Mr. S. Cooper changed his opinion & gave up the bent position Prof H has succeeded very well with 3 splints one on each side and one in front especially with children putting a pillow under the knee [Amesby’s] splint exhibited. The limb will shorten under almost any treatment in oblique fractures of adults The fractures commonly unite by bony union In children the cure is perfect Fract. of neck of os femoris An obscure subject. illustrated best by Sir A. C. who 1st wholly within the caps. lig. 2nd through the neck at the root of the great trochanter 3d through the body of the bone & the great trochar 1st This sort occurs oftenest in the aged & in aged females often from very little force the foot perhaps catching & causing a fall. (The neck of the os fem. undergoes a considerable change in advanced life Sometimes not shortened until often the lapse of several hours. The foot is turned outwards the heel resting in the hollow beside the tendon achillis Desault gives a good diagnostic mark of all the 3 kinds viz. the trochanter in rotation does not describe an arc upon a circle You can generally feel some crepitus Most apt to be confounded with dislocation upon the os ilium but in the latter the head of the bone can generally be felt & the toes turn inwards In pract. there is little pain except on motion & the pat. is liable to sudden starts in sleep. Splints and bandages are of no use Pass however a broad band around the pelvis to bring in the trochanter Place a pillow under the [illegible] sometimes a bolster under the whole limb confine the foot with rolls of cloth or billets of wood so as to prevent the turning out of the toes 2nd Fract. without the caps. lig. Occurs at all ages. Toes turned out limb shortened about an inch. Occurs from falls etc. Trochanter appears to be somewhat sunken in a swelling about it. Appears less like a dislocation Pain is often entirely in the knee hence the accident is sometimes mistaken Dr Physick advises treatment for a fracture whenever there is a suspicion of a fracture This fract. is treated by A., Coop. with a long splint extending from the knee up above the hip etc. etc. Prof. H. has treated them very successfully with Desault’s long splint He pulls the foot down & keeps it down the cross piece by means of a wooden gaiter 3d Fract. through the trochanter Not so much shortening The lower part of the trochanter seems to project too much outwards the broken end may frequently be felt Caused by falls on the trochanter Fract. below the trochanter are treated with a double inclined plane Separation of the epiphysis of the head of the bone sometimes occurs We cannot distinguish it before death. Indeed in all these cases we must be cautious in our prognostication. Sometimes excessive pain and long confinement occur without any apparent fract. and the pat. recovers completely without distortion 4 rules given 1st a roller & 3 splints are enough for children 2nd in fract. within it caps. lig. in very old persons depend principally on position. 3d in fract without the caps. lig. depend on Smith’s splint or Desault’s long splint 4th in fract. of the body use Smith’s splints or Amesby’s or Desault’s long splint & Prof. H. generally applies another splint on the inside Fract. of condyles of os [com.] Caused by falls Distinguished by distortion the lower end is drawn backwards and the patella seems below the joint Generally there is much tumefaction & injury Often the fract. is oblique & the upper end pierces the rectus muscle & perhaps the skin. Distinguished from disloc. by greater mobility, greater tumefaction etc. Treat for the infl. etc. in the first place Treatment by Smith’s splint or two lateral pasteboard splints applied wet 1st a roller then the pasteboard & splints then a roller over them. Compound fractures here are very serious accident we must consider about amputation Fract. of patella Caused by direct violence or by muscular exertion, when the foot slips The fragments separate They unite by ligamentous union A.C. directs to apply two straps & draw them together etc. Prof. H. applies a thick narrow compress fig. 8 bandages also above and below keeping them wet with a lotion to reduce the infl. Swollen along the thigh will in all cases be proper to keep the muscles from acting Keep the foot higher than the hip. If there is no tumefaction Prof. H. applies straps of sticking plaister. In all cases apply a splint we may use a bit of board with notches to keep it from slipping up and down. Give no violent motion even after the joint begins to have strength We may commence exercising the limb by motion made by another person, or by setting on a table and swinging the legs. Secondary fractures are apt to occur they are troublesome but not dangerous they may make the ligamentous union longer let the pat. walk with a splint Fract. of tibia & fibula Broken by blows or by falls on the feet or by slips of the foot. The two bones may be broken at different places, when the accident results from falls etc. The notion of a fracture in two places is generally a mistake caused by the overlapping of the bones In compound fractures it may be necessary to to cut off a projecting point of bone Compd fract. near the ankle joint are dangerous, especially when as is often the case compounded with a compound dislocation. Amputation will generally be needed Fract. of the lower end of the fibula with compound disloc. internally are not so dangerous. In fract. of the upper portion of the tibia the upper fragment sticks directly upwards there is a difficulty in keeping the fragments in contact Smith splints are best put a pillow under the [illegible] In every other fract. of the leg the best position is decidedly preferable by a double inclined plane or what is often better by placing the limb on the outside In fract of the tibia the upper fragment is generally forced inwards Apply a compress over the projecting end of bone bandage the whole limb. Apply a splint in the inside with a hole for the malleolus bandage over the whole Counterextension Prof. H. thinks of little use in fract. of the leg Smith’s splint is advantageous for preserving the foot in a proper position The time of keeping in the splints in simple fractures is 6 or 8 weeks the surgeon must examine & there is a certain consciousness of strength in the limb. If upon attempting to walk the pat. feels a pain in the part & a sense of giving way, he must lie by longer & perhaps have the dressings reapplied Sometimes the tibia alone is fractured distinguished by rotating the limb by passing the fingers along etc. Some think confinement is all that is needed but Prof. H finds it advantageous to treat as for fracture of both bones Fract. of Fibula Pat. will continue perhaps a long time lame and wonder what is the matter Examine with the fingers for a tenderness by moving the foot, etc. Prof. H. has had great satisfaction expresses with his treatment Apply a roller bandage and then a slender splint and another roller Compound fract. of leg more frequent than those of other parts First cut off the boot, stocking etc. Replace the bones if possible. Let one assistant grasp the thigh above the knee and make counterextension extension to be made by another at the heel the surgeon attempts to force the fragment into their place. Perhaps you can introduce your finger into the wound and lift up the skin Saw off a long sharp & projecting point an inch or two a spatula, or piece of sheet lead or tin being placed under the bone. It may be necessary to dilate aa little with a probe pointed bistoury. Do not use much force in removing fragments Dress carefully. Place a series of [slips] one over another each [indricated] lapping about half Extend the limb in both directions & thus left up the limb and place it upon the slips. Cross one set of the slips. Then equalize pressure by compresses, place a splint over then cross over the splint and limb both with the other set of slips Put a bridle around the foot & pin it up towards the knee to keep the foot from being permanently extended It will often be advisable to have another splint on the outside. Wetting the bandages will be advisable to prevent infl. It is well to stay by a patient a little while to see whether the bandages are too light or give uneasiness from other causes Great const irr generally follows it will be necessary to bleed a strong robust man op. cal etc. Spasm often occur the greatest relief for the time will be afforded by compressing the muscles with the hands Infl. of cell. memb. may come on Collections of pus may occur requiring [illegible] opening If every thing goes on well do not remove the dressing for some days It will be well however to call the next day Sometimes there is a deep seated collection of matter, which will require to be opened by a deep incision If the abscesses continue to form with great suppuration sloughing of periosteum looseness of the bones etc. the patient’s strength failing we must amputate. In the worst cases of shattered limbs they have been treated simply by placing them in a trough and covering them with bran crowding it down around them probably limbs may be saved by this mode If the great blood vessels are too much injured immediate amputation will be necessary Fract. of tarsal bones Generally they are compound but sometimes simple. 1st of the os calcis Dress by a roller & compresses then a broad splint along the bottom of the foot & bandage If the upper end is broken off and drawn up by the tendo achillis keep the foot permanently extended by bandages and a splint & endeavour to keep down the fragment. Apply warmer cold applications, or poultices for the infl. Splints give great relief in fract. about the joints by preventing the motion If the bones are too much broken in the tarsus, amput. must be performed but better in the leg than at the ankle It has been proposed to amputate in some cases at the astrag. & os. calcis Fract. metacarp. bones Press by pasteboard or other splints or in slight cases by plaister bandages Fract. of toes The best splint generally is the other behind the two together A plaister bandage will often be serviceable Fract. which do not unite by bone Imputed to motion [illegible] to want of nutrition 2d to effusion of serum. But there are cases where none of these causes operate & yet the union is ligamentous Gunshot wounds sometimes terminate thus but do not always. The frequent motion of the limb has been considered as a cause of these accidental cases but animals go with their broken limbs dangling about and yet the union become [illegible] An epileptic man broke both femurs the fits continued nothing could be done for the limbs yet they united firmly Also it is best in first dressings of fracture to make extension it gives relief Interposition of muscles has been assigned also old age & pregnancy yet none of these reasons are satisfactory The causes may be conjectured to be accidental in the particular limb not constitutional & perhaps another bone in the same person might unite Mr. Amesby cured a great many a great many cases he found also that many of the incurable cases exhibited an artificial joint & a pseudo-serous membrane The best plan of cure seems to be to keep the bones as firmly pressed together as possible binding the limb as firmly as can be endured Dr Physick has effected a cure by keeping a seton through the limb which produced either inflammation or granulation. This method has been extensively tried since that time both in Europe and in this country it sometimes fails A Mr. Burke of St. Thomas cured by electricity but then he used also an apparatus Dr White Sen. of Cherry Valley cut down & bored repeatedly into the bones with an awl he cured but then he used an apparatus Counterirritation has been extensively used As a last resort an incision has been made down to the bones & the ends of the bones. [Let] the operation has been fatal & has often failed Prof. Smith tried it once he had to saw off again on account of overlapping the bones about 10 days after The case was successful. But he declared that he never would again perform the op. Prof. H gives the preference to the plan by setons. Keep them in a long time Dr Physick kept his in at first 6 or 8 weeks. Probably some cases have failed from the short time during which the seton is kept in Dislocations It is of the highest consequence to be thoroughly acquainted with dislocations so as to be able to set a bone at once Failures are peculiarly unfortunate Dislocations may be caused by direct violence, by disease of the joint, by muscular action as in epilepsy. The swelling at first and the infl. afterwards may render the diagnosis obscure. The immediate swelling must be from effused blood. Van Swieten thought dislocation of the hip could not occur Many have believed this. Indications are 1st restoration 2nd retention in place 3d obviating of the effects of the accident The principal obstacle to restoration is muscular action which is overcome by for e applied with sufficient strength at first or by gradual force The British surgeons apply the extending force to the bone itself. The French apply it at the end of the member Splints etc. are often necessary to keep the bone in place Prof. H. has never seen simple dislocation compounded with simple fracture. But such cases may perhaps occur. Compd disl. & fract. may occur e.g. at the ankle But a short time only shd be allotted to the previous reduction of inflammation We may bleed largely etc. [Ganglinoid] joints can seldom be reduced [illegible] a month Orbicular joints have been reduced after 5 or 6 mo even. But the axillary artery has been ruptured in these attempts upon the shoulder Constit. means to facilitate are 1st bled ad deliq. 2d tart. ant. 3d warm bath continued as long as the patient can bear it. Begin with tart. ant. (say) then warm bath then bleeding. Tobacco has been proposed but it is too dangerous. Opium cannot be depended [illegible] Intoxication is a favorable state but it cannot be managed at pleasure. If you find a man drunk take immediate advantage of the oportunity Partial dislocations can only occur in ginglynoid joints Desaults notion about rupturing adherent (or new) ligaments in old luxations by moving the limb in every direction is perhaps a good one, but is not much attended to. He supposed that the bone was often girt about by the ligaments Luxation of lower jaw Occurs in one or both sides the condyle is thrown forwards & the chin is oblique except when both are dislocated Does not occur in children Prof H’s first case was that of a young man courting! about midnight In one case epileptic fits caused a continual recurrence of luxations The teeth will be 1 or 1 ½ in. apart. It is a mistake to suppose that the mouth must be wide open. Some cases have been mistaken for spasm & treated accordingly Place the pat. in a low chair Put the thumbs as far back on the jaw as possible bear down with the thumbs & upwards with the fingers, upon the chin If this fails place a lever of wood bark & then press down with one hand upon that & up with the other at the chin and reduce one side at a time Place the pat. on his back in bad cases. Bandage for awhile Luxation from epilepsy are apt to recur Sir A.C. mentions a sub luxation caused by relaxation producing a snapping while eating Push the jaw upwards N.B. when you use a lever of wood make the upper jaw the fulcrum At the same time pullup the chin with your fingers Luxation of the Clavicle When at the sternal end, it is caused by a blow on the shoulder & the end of the bones project outwards. Reduce by putting the shoulder backwards (by an assistant) & pushing in the end of the bone Dress as for fract. clav. Great difficulty is found in keeping the part in place A tumour forms Sir A.C. mentions one case of an internal dislocation of the sternal end of the clavicle About an inch of the bone was sawed out The fracture of the scapular end may be treated by raising the shoulder bandaging as for fract. clav. putting a compress on the part etc. They are not readily restored to perfect soundness Luxations of Vertebrae Prof H. has known persons fall (as from a load of hay) upon their heads & their heads be permanently bent forwards & depressed. He has not ventured to interfere, but if he should have another case he would endeavour to brace the head back Luxation of shoulder Said to be equal in frequency to all other dislocations hardly so When unreduced the arm remains permanently extended from the side & is almost useless sometimes a semiparalysis of the arm occurs This luxation can only occur when the arm is removed from the side Boyer thinks the luxation forward is always consecutive this is denied by others The general signs are depression above, the head of the bone percesptible etc. the arm is directed obliquely Sir A. C. speaks of subluxations but Prof. H. coincides with Abernethy in thinking this impossible Two classes of modes of reduction 1st manual 2 by machinery Prof. H. has never used the latter. No account of fatal accidents has been given from manual reductions In recent cases Sir A.C. reduces by the heel in the axilla. Dr Wells, formerly of N. [Stonington] succeeded in one case by placing the other foot in the acremium & thus making additional counterextensions Prof. Smith’s mode Prof. H.’s mode Generally press the scapula down After sufficient extensions, lower the arm & the bone will go into its place If possible divert the attention of the patient so as to relax the muscles Sometimes constitutional means are necessary vide supra Sometimes a reduction is effected by first fatiguing the muscles, by long continued extension Compound dislocation of the shoulder occasionally occur case of Sir A.C.’s in which the bone projected through the pect. muscle The suppuration caused anchylosis ultimately Compd disl. occur by the arm’s being caught in machinery Displacement of the long head of the biceps. This is probably what Sir A. C. called partial dislocation After reduction of the shoulder, in these cases there will be [lameness], pain etc. which is removed by raising the [illegible] & rotating it outward Prof. H. has frequently seen this affection when there had been no dislocation The [elevation] of the arm about 45 [degrees] gives great pain after however a higher elevation gives no pain. Rotations of the arm gives no pain. Often great pain is felt during sleep say Prof. H thinks that the displacement is backwards generally Prof. H. diverts the attention & then suddenly rotates the arm. If necessary repeat the process frequently & make the pat. do so likewise Luxation of elbow 1st both bones backward. The arm is shortened the bones project backward & a depression is felt on each side of their ends Frequently caused by a fall on the hand Most apt to be confounded with a fract. of os. hum. just above the condyles But in fracture all the marks of displacement are immediately he removed by extending the limb We can also move the joint more & can feel the crepitus. In children luxation does not occur so often as the fracture of the os hum. Prof. H has an assistant grasp the arm firmly above the elbow for the counterextension & then he grips with his fingers the ends of the bones, pulls down & forwards & then suddenly bends the arm. Dress with the arm bent in a sling. The inflammation will be considerable Sir A.C. applies his knee, or puts the elbow across the back of a chair 2nd Radius and ulna laterally If internally the head of the rad. is in the posterior fossa of the humerus 3d dislocation of the ulna alone backwards distinguished by the projection of the ulna & the turning of the hand inwards Caused & cured in a similar way 4th Radius forwards its head upon the coromoid process. The arm is partly prone the elbow cannot be completely bent. There will be no contusion & now swelling & a mistake is apt to be made in the nature of the accident the shoulder being considered in fault Clap your right thumb on the head of the radius press with it make extension with the left hand then turn the arm supine & immediately flex the elbow For adults an assistant or two may be needed in order to exert greater force Prof. H. has seen many cases & has known many cases of mistake Bandage & sling 5 Radius backwards Sir A. C. met with a case in a subject brought into the dissecting room Smith’s splints Fract. of corp. proc. of ulna Caused by falls Keep the arm in a sling Sir A. C. Union by ligament Fract of neck and rad. Sir A.C. has never met with a case Luxations of wrist 1st both bones either forwards (palmar) or backwards (dorsal) Generally discovered easily may be confounded perhaps with effusions of the bursae mucosa but in this case the projection will be only on one side May be confounded with fracture of lower ends but we can generally discover the lower end of the radius the arm is more bent in fract also the lower projecting end is lower down in dislocation Let an assistant hold the arm place your thumbs in the back against the projecting ends of the forearm your fingers in the palm extend press & bend the wrist up so as to make the hand straight Smith’s splints 2nd Radius forwards easily reduced 3d Rad. backwards set in the same way Always apply splints 4th ulna alone Prof. H. has seen it the end projects forwards reduce in the same way let the hand hang down in the sling to keep the ulna up next to the radius Luxations of the Carpal bones Rare accidents reduce them as the above cases Great infl. generally attends Apply Smith’s splints If the tumour is only from effusion, it will feel soft. Luxation of metacarpal bones caused only by passage of heavy bodies by # bursting of [illegible] etc. Generally compound We may if necessary remove any one or a majority of the metacarpal bones Sometimes a luxation of digital extremity of a metacarpal bone occurs. It feels like a dislocation, but gives a crepitus Generally in most such cases put a round body in the hand, to dress upon Luxation of metacarpal bone of the thumb forwards & backwards Make extension & carry the bone into its places. Pat. are generally impatient of dressings & will come to you with a sort of sub luxation. Then apply a plaister bandage Luxat. of first phal. of thumb backwards easily recognised difficult to reduce difficult to et the bone over the projection of the met. bone The thumb has been torn off in attempts to reduce Sir A. C. directs to soak the parts then apply a piece of soft leather then a piece of tape with a clove hitch Let the assist. pull on this while the surgeon pulls inwards. If this fails he recommends a [illegible] the elbow being around a bed post Mr. Hey recommended divis. of lig Boyer failed in one 10 days old The disl the other way is easily [illegible] The second phal. is easily reduced After all dist. of fingers & thumbs splints give great relief they will relieve pain Luxations of hip joints 4 directions 1st upwards upon the dorsum of il. knee & toes turned inwards [illegible] 2 in. short. head of the bone can be felt Buttocks flattened Trochanter higher up & pointing inwards forwards Dist. from fract. of [illegible] of fem. by the bone being fixed not easily moved no crepitus by the toes not turned inwards This is the most common kind Prof. H. has succeeded by Dorseys mode Pass a sheet around the perinaeum make [illegible] by a handkerchief around the limb just below the bent knee one assistant pull the thigh outwards by a napkin the surgeon rotates the limb outwards & the bone comes into its place. Two assistants will be needed for adults Sir A. C. advises in the first place const. means by v.s. 10, 20 or more oz. warm bath & tart. emet. Place the pat. between the two strong parts with staples. Pass a strap around the perinaeum & fasten to the first staple another (by a wet roller) above the knee 7 fastened to a pulley make exten. gradually finally when the muscles are fatigued & the head is drawn down, then rotate outwards as above. It may be necessary to lift the bone outwards to get it over the edge of the ilium 2nd Dist. into foram. ovale Limb length 2 in. stands out from the other body bent forwards toes turned outwards Caused by force applied to the upper part of the thigh Sir A. C. Fastens the body firmly to a table & by a pulley pulls outwards the surgeon with his hand on the ankle suddenly crosses the limb over the opposite one 3d backwards into ischemic notch limb ½ to in. shorter troch. mag. projects less & is turned forwards knee & foot turned inwards great toe in the hollow of the other foot toes touch the ground head of the bone can often be felt Reduce (Sir A.C.) about as the first except that the assistant lifts the bone upwards by a towel around his neck 4th on os pubis head of the bone can be felt & rolls foot turned outwards limb shortened caused by falling backwards to a hole Place pat. on the table make ext. backwards & downwards left the head of the bone over by a towel around the neck of an assistant Fract. of ossa immon. have been mistaken In 20 cases [illegible] 5 [in] isch. notch 2 in for. ov. 1 in os pubis Sir A.C. Boyer does not direct pulleys Abernethy [illegible] After reduct. apply a 8 bandage Treat for const. infl. & irrit. Bleed & cath. [illegible] Benedict [Def??st] [not] Shelton Totten Next to Totten The [tabula] vitrea or internal plate may be fractured while the external [illegible] [illegible] These are irregular depressions of [the] internal plate, which the surgeon [illegible] calculate on a generally [illegible] near the longitudinal sinus They are not often found in the young In the youngest [illegible] [there] [are] not [illegible] tables In the very old [bone] the [illegible] is nearly [???ting] In [illegible] [to] [know] in [illegible] [illegible] [for] [this] [illegible] [illegible]