PART I.
HOMEOPATHIC PRACTICE
OF
SURGERY.






THE
HOMEOPATHIC PRACTICE
OF
SURGERY,
TOGETHER WITH
OPERATIVE SURGERY,
Illustrated by Two Hundred and Forty Engravings.
B. L. HILL, M. D.,
PROFESSOR OF OBSTETRICS AND DISEASES OF FEMALES, AND LATE PROFESSOR OF
SURGERY IN THE WESTERN HOMEOPATHIC COLLEGE.
AND
JAS. G. HUNT, M. D.,
PROFESSOR OF SURGERY IN THE WESTERN HOMEOPATHIC COLLEGE.
CLEVELAND, O.
J. B. COBB AND COMPANY.
1855.



Entered according to Act of Congress, in the year 1855,
BY B. L. HILL, M. D., & JAS. J. HUNT, M. D.,
In the Clerk's Office of the District Court of the United States for the Northern
District of Ohio.
HUDSON, OHIO:
Stereotyped and Printed by the Hudson Book Company.



PREFACE.
To those who have been desiring the speedy publication of this work
the first on Homeopathic Surgery —some explanation of its tardy
appearance is due.
The reasons may be summed up as follows: —The desire to make the
work as perfect as possible, embracing both that knowledge already
written and that evolved in the clinical experience of the Homeopathic
profession; the difficulty and time consumed in obtaining and condensing
communications from our physicians; the severe labor necessary to prepare the first Homeopathic Surgery; and the interruptions from sickness
and professional life.
The want of a work giving the Homeopathic treatment of what are
called surgical diseases and a description of the various surgical accidents
and operations, with the specific treatment, has been long and severely
felt by the Homeopathic profession. At the urgent solicitations of numerous Homeopathic physicians of Ohio, Dr. Hill (then Professor of Surgery in the Homeopathic College at Cleveland), was induced to undertake
the preparation of such a work. But knowing, somewhat, the magnitude
of the undertaking, he secured, as a co-laborer, Doctor Hunt, his former
partner in professional practice, since elected to the chair of Surgery in
the Western Homeopathic College at Cleveland.  And in order to obtain
that large amount of material necessary to the perfection of this work,
which was contained in the private records of the clinical experience of
our practitioners, the following circular was addressed in January, 1852,
to all the most learned and experienced Homeopathic physicians of America
and a large number in Europe:
WESTERN HOMEOPATHIC COLLEGE,
CLEVELAND, OHIO, January 80, 1852.
DEAR SIR: — I am engaged, with another Homeopathic Physician, in preparing
for the Press a systematic work on the practice of SURGERY, adapted to the
wants of the Homeopathic profession.
(v)



Vi                               PREFACE.
The work is designed as a text book for students, and an aid to practitioners
generally.
Inasmuch as practical experience in our Science dates back but a short time
in this country, it can not be supposed that any one man would have sufficient experience in "Surgical diseases" (a considerable portion of which are of rare occurrence), to enable him alone to furnish the proper material for such a work.
We are well aware that in all our attempts at producing books on the Homeopathic practice, we must, at present, depend very much on the able European
authors.  It is, nevertheless, desirable to incorporate in any new work as much
of recentpractical experience and new discovery as possible; that every new book may
be one step further towards that state of perfection which we firmly believe our
noble science is destined to reach.
For the accomplishment of this purpose, we have determined to ask some favors
of our most learned and experienced practitioners, which, we hope, for the sake of
the cause, will be granted.
We are aware that it is asking much, but we hope, some time, to be able to
render a suitable reward for the favor. We wish you to give us, in as full details
as practicable, any very successful treatment you may have employed for the following affections:
Traumatic Erysipelas, Burns and Scalds, Frost-Bites, Irritable, Indolent and
Varicose Ulcers, Necroses, Scrofulous Swellings and Ulcers, Chronic Rheumatism,
Hip Disease (Scrofulous), Lumbar Abscess, White Swelling, Hydrops Articuli,
Polypus of the Nose and Uterus, Cancer of the Womb, Cancer in general, OsteoSarcoma, Fungus Hsematodes, Scald-Head of children, Fistula Lachrymalis,
Fistula in Ano, Maxillary Abscess, Ophthalmia (Purulent, Scrofulous and Gonorrheal in particular), Amaurosis, Nebula and Leucoma, Ulcers of the Cornea and
Lids, Cataract, Dropsy of the Eye, Enlarged Tonsils, Goitre, Mammary Abscess,
Hernia, Hydrocele, Hsematocele, Orchitis, Hemorrhoids, Prolapsus Ani, Stricture
of the Rectum and Urethra, Spermatorrhea, Gonorrhea, Primary, Secondary and
Tertiary Syphilis.
It would be asking too much to expect an article from your pen on each of
these complaints, but if you can afford to comply with the request to any extent,
please select such cases from your list as you think would be most useful in carrying out the object of the work, preparing what you write for the pages of the book,
or furnishing us the material for preparation, as your convenience will allow.
We further ask that you will allow us the privilege of giving you credit in the
book for what you contribute.
As we wish to incorporate the matter we receive from our friends with our own;
as we proceed in our labors of preparing it for the press, it is desirable that we
have it at as early a day as possible, and hope to hear from you soon, while we
remain,
Very respectfully,
Your co-laborers in the good cause of Homeopathy,
B. L. HILL, M. D.,
PROF. SURGERY, WEST. HOM. COL.
Numerous commendatory letters were immediately received in reply,



PREFACE.                            VU
with the promise of the desired contributions; which from time to time
were received. To those who thus responded we tender our sincere thanks,
particularly to that veteran in Homeopathy, Doctor C. Neidhard, of
Philadelphia, for the number and completeness of his communications.
Had each old experienced practitioner done as well, we have no doubt that
the profession would have had much valuable matter- now lost to them.
In the preparation of this work, in addition to the above clinical experience, we have freely availed ourselves of any matter contained in the
Homeopathic works on practice, or the literature of the profession:
where it could be well done, we have used the words of the author, but
where the arrangement did not suit his ideas, either in his own language
or ours, our aim has not been originality, but condensation of present
medical knowledge upon the subjects treated. Some of the surgical treatment, however, either in whole, in part, or combination, is contained in
no other works, and is original with the authors.
We have not hesitated to give that treatment which we knew, from a
large and successful personal experience, to be the most efficient, even
though it might be objected to by some as not agreeing strictly with their
ideas of Homeopathy; and we trust the day is not far distant when the
superiority of the Homeopathic treatment of surgical diseases and accidents
over any other, will be as manifest, as it now is, in common and epidemic
diseases. The major portion of Part II. (Operative Surgery), and a considerable part of the description proper of diseases in Part I., are copied
from a work of which Doctor Hill is author, published several years ago,
while he was Professor in another school (Lectures on American Eclectic
Surgery, by Benjamin L. Hill, M. D.), and we cheerfully give credit to
that work for the portions above referred to.
Among the physicians who have contributed materials from their experience, of which we have availed ourselves, we would mention, particularly, the names of Drs. C. Neidhard and Prof. Kitchen, of Philadelphia;
Dr. Shipman, Chicago, Ills.; Dr. Prowell, Lexington, Ky. ] Drs. Tifft
and Beckwith, Norwalk; Dr. S. M. Cate,' Augusta, Maine; Drs. Babcock
and Foote, Galesburg, Ills.; Dr. Rogers, Farmington, Ills.; Dr. Sharpe,
England; Dr. Rosa of Painesville, Ohio; Dr. A. Bauer, Dr. W. Owens,
Dr. Parks, of Cincinnati.






PART 1.
CHAPTER I.
INFLAMMATION IN ITS GENERAL ASPECTS.
Inflammation- Inflammation not a disease, nor "the reparative principle"Etymology - Heat and other vital manifestations - Excess of, vascular or nervous? - Simplistic questions and varied researches - Acceleration or Retardation? — Chemical and Microscopical results- Inflammation not indispensable
to recovery from local injury -Its stages up to "mortification," and particularly of suppuration.
"INFLAMMATION," says the celebrated surgical philosopher of
England, John Hunter, in his great work on the blood (page 205),
" is the first principle of Surgery."  As it is indeed of primary
importance, and has been long customary to begin a book upon
Surgery, with a dissertation upon it, we shall not in this respect
depart from the old path.
Among the conditions of life is a certain range of temperature, above or below which it cannot be maintained. This range
is much wider than might at first be supposed, owing to nature's
wonderful provisions of adaptation. The result is, that the human body has the power of keeping up to about its hundred degrees, in all climates and under all ordinary circumstances. Heat,
then, is one of the manifestations as well as conditions of vitality.
It is one of the most striking manifestations. It is popularly and
poetically expressive of life; its reverse of death.  " Ere coldness
wraps this mortal clay" is the poet's translation of dying; the
chemist's version would only be verbally different. It would show
that the " fire of life" is not a mere metaphor.
The word " inflammation" is derived from  the most striking
phenomenon of the states, -the unusual development of heat accompanying them.   It means that the body is " burning up."
1                                           (PART I.)



2                       INFLAMMATION
Modern chemistry would accept the definition, with the addition
of "too fast."  Liebig has a complete " Theory of Disease,"
founded on and confirming this simple idea. The slow combination with oxygen throughout the body, as well as in the lungs, is
made not only to explain the problem of animal heat, but of the
common morbid increase of temperature.  The degeneration of
the diseased parts, and the subsequent decomposition, of the
whole, are accounted for on similar principles.
Not only has it been speculatively doubted whether inflammation is not an altogether necessary and beneficial operation, or at
least "effort" on the part of nature, of a beneficial tendency;
but it often becomes practically requisite to consider it in some
such light. We speak of it as a desirable condition, though more
often as an evil to be removed or averted. In Carlisle's Notes of
Sir Astley Cooper's Lectures we are taught, without qualification,
that " Inflammation is the process by which local injuries are repaired, and may be considered as the restorative principle." Physiological authors often speak in a similar manner, though at other
times the state in question is discriminated as " abnormal." It is
then contrasted with a reparative process, one of " growth analogous to the natural one," attended with little or no irritation, or
confusion and waste of material, and more complete and permanent in its result.  "It is consequently," says one of the most
esteemed of these writers, the very mode of repair " which the
surgeon should aim to produce; and the means of accomplishing
this aim consists in keeping down the inflammatory process."  In
the other diseased or more " abnormal" mode, a new and distinct
kind of tissue is formed, a merely provisional growth not analogous to the natural and permanent one. And the result of this
"granulation structure," as it is called, "is not so perfect as that
of the simple or non-inflammatory process."
It is, of course, in some sense true, that the " efforts of nature" must be all directed to good ends. We see, however, that
no doubt with the best intentions, "Nature" errs from her presumed end, and works evil instead of good. This may not be a
very respectful way of speaking, but it is inevitable when our individual ends and aims are attributed to "Nature" as a whole.
In a wider sense, Nature can do no wrong; but this, like the cor



IN ITS GENERAL ASPECTS.                   3
responding maxim, " Kings or sovereign bodies can do no wrong"
is to common sense untrue, absurd, and practically mischievous.
As the political doctrine alluded to, the divine right of kings, led
to the servile corollary of "passive obedience," so the divine infallibility of nature points consistently to non-interference, and
letting nature take her course in all cases. Strange as it may
appear, this practical reductio ad absurdum has not daunted some
reasoners. They have accepted it, and founded on it a system of
practice, or no-practice. In fact the views in question cannot be
maintained without arriving at the conclusion of such " Medical
Reformers" as Dr. Jennings, of Oberlin, who really advocate a
simple " faith in nature," discarding all our presumptuous attempts
to interfere with her, since she always aims at the best possible
results under the existing circumstances.
Besides the practical, common-sense objection, to considering
inflammation as a sanatory process, or the reparative principle,
recent researches give us additional reason for doubting it even
in its most abstract and general sense. Microscopic observation
shows us that in the mode of reparation " analogous to the natural growth," in the union of wounds " by the first intention," for
instance, under the most favorable circumstances, there is no evi.
dence of what we call inflammation, or any of the changes always
accompanying that state.  Nature gets through her extra work
of repair, with the same ease, precision and uniformity, as her
regular business of growth and preservation. And in those lower
orders of animals, whose reparative powers are greater than ours,
extending to the reproduction, for instance, of a lost limb, the
process, as we are informed, always takes place without any appearance of inflammation.
The common, convenient distinction, between " healthy" and
" unhealthy inflammation," would seem to imply that the process
may, or may not, be one of disease.  The expressions, however,
may be better understood as characterizing those modifications
whose tendencies are toward health, or toward still greater disorder: "healthy inflammation" thus means health-ward, and
self-limiting, such as takes place, under favorable circumstances,
in an otherwise healthy constitution. John Hunter, who was one
of the first investigators of this subject in a philosophical spirit,



4                       INFLAMMATION
and makes great use of this distinction, speaks also in perfect
consistency of " too much health," or, " health above par." These
expressions would be regarded by most as involving absurdity;
and perhaps " healthy inflammation," though it is hardly possible
to avoid its use, may come to be considered a contradiction in
terms.
Increase of other vital properties, besides that of heat, is so
obvious in inflammation, that the fact has for a long time been
considered a sufficient definition and explanation. The state has
been identified with over or undue excitement. The natural functions of any part stimulated too much, or too long, may, indeed,
run into inflammation; but the latter state is clearly a new one,
and will continue for a longer or shorter time, after the stimulus
causing it has been withdrawn.  Although a stimulus produces
the diseased state in question, we may reasonably suppose that it
never does so except by exhausting the natural and healthful excitability, and substituting morbid irritability, thus depressing,
instead of exalting the vital powers of the part.  After much
controversy on this subject, this seems now to be the general
opinion, or tendency of opinion.
Nevertheless, it once seemed to be the only question — to
which agencies of the system to refer this increased activity. The
blood-vessels appeared plainly most concerned in the business;
but when the implication of the nerves became known, the priority of their action was generally recognized.
The ancient definition of its state was wholly independent of
any idea as to its nature. The "four signs" it distinguished may
still be remembered with advantage. When a part feels " hot and
painful," and looks "red and swollen," it is very apt to be in a
state of inflammation.  These evidences, however, have to confirm
or correct each other. One or two may concur, without proving
the point; and serious inflammation may exist without either being very manifest, and often does run through its course without
manifesting all these symptoms.  " Redness," of course, can only
be observed on the surface of the body, or at the extremities of
mucous openings.  The sensation of "throbbing" is considered
by some as more generally characteristic of the state than " pain."
Perhaps soreness (or tenderness to pressure and other irritants)



IN ITS GENERAL ASPECTS.                   5
would more frequently hold than "pain," if by that be meant
spontaneous sense of suffering, without any external cause.
A change of action tending to, if not, also, resulting from a
change of structure, may be regarded essential to our modern
idea of inflammation. Placing this characteristic tendency first,
as more important than the sensible appearances, Druitt suggests
the following definition as an amendment of one given in a French
Medical Dictionary: " A state in which there is a tendency to
morbid secretion and change of structure, accompanied by increased vascularity and sensibility."
According to this, the blood-vessels and nerves must both be
concerned in the result. Where there are no nerves of sensation,
the organic nerves commonly become such, when the part is inflamed.  In a paralyzed part, however, inflammation appears to
go through its course independently of "increased sensibility."
This, though an exceptional case, might be supposed to prove that
the sensitive nervous system  is not essentially concerned in the
process.  " Increased sensibility" to an intolerable degree, as in
neuralgia, may exist, without necessarily being or becoming inflammation.
Irritation is often spoken of, especially by the French " physiological" or Broussaian school of theorists, as the first stage, or
rather the invariable antecedent, and of course "cause" of inflammation.  There is, however, no more necessity for looking to
the nerves than the blood-vessels, as the primary source of the
evil.  Known causes or occasions of inflammation may act directly on the nervous or vascular system, or even on solid structures of the body, independently of either. Whatever destroys
or depresses vitality to a certain extent, or what only seems to
excite its ordinary manifestation beyond the regular limit, will
equally induce the state in question.
As far, then, as this single question between the nervous and
vascular systems is concerned, it is evident that they are both involved in the ordinary phenomena of inflammation, as the usual
signs, " redness and pain," plainly indicate. It is clear, moreover, that they act and react on each other, and no question of
necessary priority between them  can be maintained, unless by
affirming that every change in the action of a blood-vessel implies



6                        INFLAMMATION
a prior, but almost synchronous change in its innervation, from
the ganglionic system  of nerves.  An active determination of
blood to the brain (for instance) may be for a while quite distinct
from cerebritis, but is very apt to lead to some form of it. A
cupping glass, producing all the external "signs" of inflammation, would actually cause that state, if not removed. Over-stimulation of a part by blood, even in its healthy state and flow, is
itself irritation, the very state of the nerves in question; and
stagnant arterial blood soon proves itself a source or occasion of
a similar state. On the other hand, over stimulation from any
cause, however unconnected, originally, with the circulation, has
in general a tendency to bring about a preternatural determination of blood, according to the old empirical maxim, ubi irritatio,
ibi affluxus.
The functions of the nerves and blood-vessels can as little be
separated, or studied apart, without implying each other, as their
course and structure can be distinctly investigated in anatomy,
and demonstrations made of the one without touching or seeing
the other.
Inquiring more closely into "the nature" of inflammation,
some might, perhaps, be tempted to adopt the favorite philosophical " conclusion in which nothing is concluded," viz., that " we
know nothing at all about it."
The obvious increase of some of the vital manifestations in an
inflamed part, seems for a long time to have so impressed observers' minds, that they made little or no question that this first
view was a full, correct, and sufficient one. Its apparent accordance, in the majority of cases, with successful practice, no doubt
greatly strengthened this first impression. Heat, for instance, is
an ordinary manifestation of vitality; in inflammation the calorific
function is evidently too active; we reduce it, or remove its selfsustaining results, and the case improves. What plainer, therefore, than that heat* is one of the supporting influences of inflammation, as of life, and cold a remedy. The same may be said of
other vital stimuli, — air, food, motion, &c.  Hence, the once
* So influential was this one consideration, that it has, in connection with an
exploded chemical theory of heat, given name to the routine of practical measures:
" anti-phlogistic" still means " anti-inflammatory."



IN ITS GENERAL ASPECTS. 
fashionable, and still too prevalent, confidence in "starvation;"
and at one period, not many generations back in the dark ages,
patients, with certain fevers or inflammations, were absolutely refused fresh air!  As to the great internal stimulus, the living
fluid, or fluid life itself, it is unnecessary to point out to those who
have witnessed the abuse of blood-letting, and wish to learn something better, —how destructive has been the consequence of a
partial and superficial view of inflammation, as consisting merely
in too much blood, or too much activity of the circulatory functions. This simple view has evidently been influential in the popular mind, as well as that of the mass of the profession.  If inflammation were solely vascular excitement and excess of blood,
there would be some excuse for invariably, and as a matter of
course, removing the cause or means of the mischief. It is beginning, however, to be acknowledged by all, that venesection is,
by no means, a panacea, even for pure inflammation. The lancet
is found at last to be no more the best remedy for physical evils,
than the sword for moral. Bloodshed is looked upon with somewhat of the same suspicion, when resorted to for the purpose of
restoring health, as for " conquering a peace."
Speculative men, even when they did not question the prevalent opinion, had many hypotheses about the proxima causa and
causa efficiens. Many of these guesses were, perhaps, not quite
so unworthy of consideration as they have since been considered.
Some have been ridiculed, since solidism became the prevalent
fashion of thought, as belonging to the humoral pathology, and
others as much despised by our exclusive vitalists, as too mechanical.  At one time inflammation and all diseases were explained
by the help of stricteum and laxur; or relaxation on the one side,
and tone or tension on the other.  Spasm of the extreme vessels
once played an important part in these imaginary explanations.
When it was necessary to account for obstruction as well as acceleration of the circulation, and " stricture" did not seem sufficient,
the less mechanical and more chemical-humoralistic speculation
invented a "spissitude," or thickening of the blood. This was
the doctrine of the celebrated Boerhaave, and led to a reliance
on " attenuants."
Our more experimental or carefully inductive mode of philoso



8                       INFLAMMATION
phizing, is no doubt much safer than such hypothetical theorizing,
yet it is in vain to protest against hypothesis and theory. All
men theorize to the extent of their leisure and ability.  The only
question is between good theorizing and bad, reasoning with facts
or without, or with few or many. It is speculation that stimulates observation and directs experiment. Hypothesis anticipates
experience, and is only injurious when mistaken for it. Ideas are
necessary to animate mere matter of fact knowledge.  Thought
is the soul of Fact.
Whether Inflammation really consists in  an acceleration,
rather than in a retardation of the local circulation, has been
much discussed by more recent investigators; and the microscope
as well as experiment has been brought to the aid of observation.
But with all these advantages, this question was not so easily settled as might have been supposed.  Many recorded experiments
seem to contradict each other. As it cannot be supposed that inflammation excited in one frog's foot is different from that in
another's, or from inflammation in any animal body from the same
cause, it becomes necessary to discriminate as to the period of the
process when the observation was made, and also the particular
part of the supposed inflamed part, more especially noticed. With
attention to these points the different statements of facts might
not appear to contradict each other. The result would seem to be
that, according to the means used to excite the inflammation, it
may begin either in apparent acceleration or retardation of the
local circulation; either, however, soon inducing the other to a
greater or less extent. When obstruction is the first state, it becomes a cause of excitement, which again may change, and a future observation find only a feebler circulation. If everything go
on most favorably, there is increased action in the absorbents, and
"resolution" the result.  If the diseased state continue long
enough, there may even be impeded or entirely suppressed circulation at one point, and greatly increased activity or force of the
vessels in another.
Restricting the enquiry to the purely physiological question,
as first put, the answer must no doubt be that of Professor Burns,
of Glasgow, in his work on the " Principles of Surgery,"-" That
neither debility nor increased action sufficiently accounts for in



IN ITS GENERAL ASPECTS.                   9
flammation."  One satisfactory test of the one-sidedness of such
views is suggested by this author- that of availability in practice. Could the morbid state in question be really accounted for
on either hypothesis, or any other " simple idea which fancy might
fix upon," such state, so easily understood, could be as easily
treated. If the question could be settled or arranged as the old
kindred one in nosology, between diseases of increased or decreased excitability, the surgeon might " defy nature to set up
inflammation," with means almost as simple as the Brunonian
physician-armed to encounter all diseases, with the lancet in
one hand and the brandy bottle in the other. Unfortunately, the
war with death cannot be carried on with such weapons.  The
watchwords of sthenic and asthenic have been of little avail in
the day of battle; nor have pathologists, since they ceased to be
nosologists, or mere classifiers of the names of diseases, found
them of much use as mere descriptive words. So with the question under consideration, which, as once regarded, was little else
than the old " sthenia or asthenia" in its local application.
It is by no means necessary, however, on account of the unsatisfactory nature of this limited question, to conclude with the
author above quoted, that of "the peculiar nature of the action
(Inflammation) we know but little, and I fear have in the present
state of science no prospect of knowing more."
This tone of despondency in regard to truth is anything but
philosophical. The history of science contains too many brilliant
triumphs of "impossibilities" and "improbabilities," for any illomened predictions to have much longer any influence.  Fortunately, a different spirit has animated, and always will animate,
some minds.  On the subject in question much light has been
thrown from different, and in some instances unexpected, quarters.
When we find one route of research blocked up, it is only a
reason for pursuing another, with the advantage of already knowing at least that the one abandoned was not the right or best.
When Nature is cross-examined in our experiments, she often refuses to depose merely "yes or no;" and her answers are not
the least significant and worthy of record when they seem to evade
the question.  They furnish hints for other questions, or the same
in other forms, that she will be more disposed to answer directly.



10                     INFLAMMATION
In the investigation as to the nature of inflammation, the advocate
of both sides of "the question" have found it necessary to vary
and modify their enquiry, and make many limitations and discriminations not before thought of.
The subject has not been allowed to remain as a merely curious and limited physiological or pathological question. Comparative Physiology and even Pathology have been brought to bear
upon it.  The enquiry has not been restricted to what we can see
even under the microscope. Chemistry has carried us as much
beyond Optics, as the latter beyond the ken of unassisted vision.
It is now known that the old humoralists were not wrong in the
directions their enquiries took, so much as in the conclusion in
which they stopped and rested. The changes or actions going on
in the blood itself, and other fluids, are at least as important as
the resulting changes of structure or action in the solids. The
contents of the vessels in inflammation, and the discharges from
them, require to be studied, no less than their calibre and contraction.
In fully developed inflammation of any extent, the whole organism sympathizes with the affected part, not only sensibly or
physiologically, but, so to speak, chemically: there is not only
general uneasiness or irritation, and it may be symptomatic fever,
but all the absorbent and secreting functions are modified, and
consequently the constituents of the blood changed, both by what
it receives and what it ceases to give off.
The change called the buffy coat has been long since empirically known, and it may be empirically acted on. The same appearance may be produced by circumstances so trifling as the
shape of the vessel in which the blood is poured. A deeper stratum of the blood, or a greater slowness of coagulation, gives opportunity for the red globules to subside and leave the lighter
colored film at the surface to form this buffy coat. Even the size
of the orifice through which the blood runs may have an influence
on the buffy appearance; and it has been well ascertained that
the buffy coat may frequently be absent in cases of severe inflammation. Yet there are physicians who still bleed to get this evidence of "bad blood," and bleed again because they find it!this buffy coat, so much talked about when bleeding was more in



IN ITS GENERAL ASPECTS.                  11
fashion, appears really to be the result, not perhaps of inflammatory blood, but of a modification of the blood accompanying inflammation.  There is found, on actual analysis, to be nearly as
much as one per cent, more fibrin in the circulating fluid in some
cases of inflammation than in health, and less than the average
proportion in certain typhoid or non-inflammatory diseases. Fibrin appears to be the material of nutrition and of the reparative
process. Its corpuscles indeed exhibit the transition of organizable matter into living atoms, or germs ready to take their place
in any part of the organism.  The corpuscles differ from  the
proper blood globules, in being white or colorless.
According to the chemists "there is a direct connection between the quantity of oxygen introduced through the lungs and
the amount of fibrin in the blood."  The coagulation of blood,
when out of the body, or precipitation of fibrin, seems analogous
to its solidification or assimilation when forming part of the living
organism: just as the brightening of venous into arterial blood
may be effected by the presence of oxygen anywhere else as well
as in the lungs. The red globules or blood discs, according to
chemists, are the parts concerned in oxygenation, and have nothing to do with nutrition. The different degrees of oxydation of
their iron (an element not found in the solid structure of any part)
constitute the principal difference of venous and arterial blood,
and principal source of animal temperature. Hence, perhaps, a
reason for thinking redness and increased heat no necessary concomitants of the merely reparative process; and this view accords
with the aim and result of treatment. The practical object always
is to keep down the temperature of the inflamed part. Observation confirms this opinion: when divided parts unite most favorably " by the first intention," or when a breach of continuity is
filled up with " healthy granulations," no preternatural heat is
noticed.
At the beginning of the true inflammatory process, and afterward in the middle of the inflamed part, as a nucleus of disorder,
there is a greater or less cessation of the ordinary vital functions.
This much seems to be generally if not universally acknowledged.
" The extraordinary tendency to the production of fibrin," previously noticed as the most important character of inflammation, is



12                      INFLAMMATION
said by Carpenter to be " always conjoined with a depressed vitality of the tissues of some part of the body, which indisposes
them  to the performance of their regular nutritive operations;
and this part may undergo a variety of changes, according to the
degree in which it is affected."  This "depressed vitality" is
shown to involve a languor in the movement of the blood, with
which the capillaries are distended. There is nevertheless a determination of blood toward the part, with a special attraction to
it of the "white corpuscles," that is, of the fibrin, which is necessarily in excess from the check to the nutritive process throughout the system.  The " effort of nature" in inflammation, or the
final cause of the process with which it is connected, is evidently
good.  Some degree of, or tendency toward, this state is indispensable to the reparation of injuries, and still more plainly though
less directly to preservation, by limiting the progress of disorganization.
Slight irritation in a part may pass off without much affecting
its vascular functions; and engorgement of vessels, as after cupping, may be gradually removed, and the eddy carried on again
into the general current of the circulation. In these cases, we
do not say there has been any inflammation.
Even where the cause has operated long enough to develop all
the recognized "signs" or symptoms of disease, the reaction of
the " depressed vitality," or that of the surrounding parts, proves
sufficient to overcome all obstruction. The disorder of the part
"resolves itself" into the normal state; and this resolution of
inflammation only differs perhaps from the disappearance of irritation or stagnation last mentioned, in having been preceded by
more or less transudation, for the relief of the distended vessels.
The fine gelatinous fluid long known as "coagulable lymph" is
thrown out, first distending the parts, and then ministering to its
repair. This " coagulable or organizable" fluid, may be familiarly
defined as "white blood," or blood minus its red globules, with,
at this time, an additional amount of colorless ones. These when
naturally coagulated, or, so to speak, vitally precipitated and crystalized, become integral parts of the living solid body. According to common observation and language, the effused lymph (or
fibrin) "becomes organized."  According to the recent micro



IN ITS GENERAL ASPECTS.                  18
scopic, or what may be called, from analogy to chemistry, atomic
anatomy, the colorless corpuscle or molecule of fibrin, becomes a
"primordial cell" or cytoblast.  " Corpuscles" seems a correct
name for these organic atoms, for they appear to have their own
independent vitality, even anterior to being organized, or assimilated to already formed structures. The serous part of the blood
or lymph is the first nutriment of these cell-germs, and hence
called the " cytoblastema."
"The shooting out" of new  vessels, or prolongations of
branches, into the newly deposited fibrinous matter, has long
been investigated, as an interesting process.  We are now informed by microscopists that the cells arrange themselves in rows,
the cavities of which connect into canals, by obliteration of the
transverse surfaces of the cells themselves.  Thus all animal,
as well as vegetable structures, are originally cellular.  In the
proper fibrous formations (including muscles) the cells themselves
undergo a change of form, become fusiform instead of spherical:
the single cells become fibres or fibrillhe. Drawings of this transformation are shown expressly from " plastic exudations."
The red blood, or the proper coloring portion of it, seems to
have nothing to do with the nutritive, nor consequently with the
reparative process. The globules or discs containing iron and
carbon, play a part only in the respiratory or calorific function,
with its necessary consequence  of transformation of tissues
throughout the system. As far then as increased " heat and redness" are developed in inflammation, they may be regarded as injurious.  The development of heat, so far from being proof of
stronger vitality, may be the means of destroying life, and continue after death, as recent researches have shown. It is altogether too common and explicable a result of chemical change, to
be regarded as otherwise than incidentally connected with life.
When there is besides or instead of a mere transudation of
serum as lymph, holding the fibrin in solution, an effusion of complete blood, the process of reparation and restoration will be more
complex and difficult. This is the case, not only in injuries which
open or divide the blood vessels, but, whenever the obstruction
and increased action in the vessels are so great as to cause their
rupture. It is as much from this extravasation or ecchymosis as



14                        INFLAMMATION
from structural injury to the solids, that "contused wounds" are
so troublesome. In "lacerated wounds," the careful surgeon always removes clots of blood, and sponges out all he can that is
yet fluid, as if still living, it must, in that situation, soon die and
become a source of irritation.
When the direct injury causing the inflammation  has been
greater, when the "depression of vitality" amounted more nearly
to extinction, or when the inflammatory process has proceeded
unfavorably, so as to result in at least the death of the fluids,
there must be SUPPURATION.  Pus is dead blood, or fibrin.  The
globules still found in it are larger and apparently partially decomposed, certainly so far changed that they can take no farther
part in the chemistry of life, or be of any possible use, except in
some situations to act as a temporary cuticle and protect the surface of a wound from  the air.  Suppuration is spoken of as a
"secietion" when it takes place from  a mucous surface.  It is
usually accompanied with sensible relief to the distended vessels
and neighboring parts, which then, if not before, throw out good
coagulable lymph, by which the tissues of those parts are consolidated, so as to prevent the spreading of the pus.  When from
"too low a grade of inflammation," constitutional weakness, peculiarity of structure in the part, or any cause, this isolation of
the suppurating part and product does not take place, we have
the very serious result of "diffused inflammation."  In this case
the infiltrated matter not only acts as an irritant, which has long
since been well enough understood, but the decomposition going
on in the pus appears to be of the self-continuing or self-communicating kind, recently investigated with so much interest by the
chemists.   The deleterious agency of pus is rather active than
passive, of a ferment* rather than that of a foreign or'" effete"
substance.  Hence, under the most favorable circumstances, ab* Notwithstanding the ridicule attached by modern purists to the use of such
words, which they consider antiquated, we prefer to retain this word ferment,
which is sanctioned by chemical science.  See Cooper's Surgical Dictionary,
Theory of Suppuration, Vol. II, page 313- where, because the old ideas of the
fermentation of solids into pus are shown not to be the whole truth of the case,
the use of such terms as "acrid or corroding pus" is condemned unqualifiedly as
unworthy of educated medical men.



IN ITS GENERAL ASPECTS.                   15
scesses, though limited by the effused and organizing fibrin,
become ulcers, the pus "eating" its way out.
If the original injury or the subsequent inflammation itself
be so great as to cause the disorganization of a sensible amount
of the solid structures, we have what is called sloughing. The
difference between this result and that of mere suppuration being
that the solid matter is not so easily converted into pus as the devitalized fluids.  In this case the local "depression of vitality"
amounts to a sup-pression or destruction. Hence positive inflammation may seem more Necessary than in simple division or excission of a part.  The question remains, however, whether fibrin
might not be effused for both reparation and protection, as in the
case of mere suppuration, without sensible inflammation,- that
is, without its phenomena.  In actual Mortification, — which, in
the view here taken, only differs in the extent, not the intensity
of the evil, from the preceding degrees of injury, — there is
death throughout a considerable part, both of the solids and
fluids.  Here the sloughing is on a large scale, and inflammation
with suppuration, &c., can only take place in the connected parts,
where the depression has not amounted to a suppression of vitality. This is one of the cases where the apparently beneficial
effect of the inflammatory process is the most striking.  Gangrene, or the dying process, like the simple suppuration, has a
tendency to spread; and is limited by the effusion of fibrin,
which also prevents hemorrhage from the partially destroyed vessels, and sets up the well marked "line of demarcation" between
life and death, -on the one side of which all vital action has
ceased, while on the other it is manifested to the inflammatory
degree.
The tendency of inflammation to diffuse itself is particularly
manifest in ulceration, which is hence sometimes called "destructive inflammation." In this case, a peculiar layer of cells have
been noticed, "which appear to possess the power of drawing
into themselves the materials of the solid tissues on which they
lie, and thus causing their destruction; and this destructive action may take place to an unlimited degree, if no measures be
taken to check it."  The author quoted goes on to explain the
efficacy of the "most successful mode of treatment in these



16                       INFLAMMATION
cases," that of caustics, by the fact of their destroying these
peculiar cells and the adjacent matter partially affected by them;
and thus to draw another argument for the necessity for inflammation.  He speaks of the inflammatory action beneath the surface killed by the caustic, as the only possible mode by which
"fibrin can be effused and preparation made for filling up the
breach of substance."  The treatment he appeals to, is undoubtedly the best in many cases, to which it is not commonly applied.
The burn is more manageable than a phagadenic ulcer.  The
sloughing process, limited by the contiguous inflammatory effusion, is less destructive than the parasitic cells of which he speaks.
But, after all, does this amount to more than saying that one kind
of inflammation is preferable to another, as the lesser of two
evils?   That the excitement of inflammatory effusion is, in all
cases, the only way of arresting the destructive progress of such
ulceration, is contrary to the experience of all who have used
appropriate remedial means or milder caustics, such as the sesquicarbonate of potash, an intermediate between the common pearlash and saleratus. This article is often better than a substitute
for escharotics, destroying morbid growth and arresting morbid
action, without exciting inflammation or acting in any way unfavorably upon sound parts.  In many cases it very evidently allays
both irritability and inflammation.
According to the view here taken, Inflammation, -though
perhaps to be regarded as originating in the healthful function of
reparation, is still an excess of that necessary action, and, therefore, a disease, - a condition which, if carried to a certain degree,
defeats the very object for which it is said to be constituted. If
continued too long, it will more or less transform, or wholly destroy the part; and if extended too far, must certainly be fatal.
That this morbid and dangerous state appears sometimes to be a
relative advantage, like every other general provision of nature,
is no reason for calling physical evil, good. If nature ever cures,
or partially saves by means of inflammation, when she could not
by any other means, this is only saying that nature, like other
intelligent agents, sacrifices a lesser to a greater object, and like
other practitioners of the healing art, sometimes inflicts transient
pain and inconvenience for the sake of permanent benefit.



IN ITS GENERAL ASPECTS.                  17
The slight exaltation of vital action that seems necessary to
the recuperative process, is but that process in operation, the performance of overwork and the making up of lost time, in the
more active resumption of functions that have been impeded.
When the amount of the injury, or the want of steady healthpreservative power in the constitution, is such that this resumption
of increased business on the part of nature cannot be got through
without evident hurry and alarm, and more or less confusion and
damage done to the agents and material concerned, there is, of
course, disorder, disease and danger, - what we call from one of
its obvious symptoms and dangers, the "burning state," or inflammation. If the danger is obviated, the obstructions removed,
and the orderly performance of the functions of the part resumed,
there is a resolution of the inflammation. In this case the depression of vitality was but temporary as well as local: the part
was in a state of "suspended animation," occasioning the subsequent and surrounding "reaction" of excitement.  When the
original mechanical injury, or subsequent chemical or chemicovital one of inflammation, excited in the imperfect effort to repair
the former, has gone to the extent of so altering any of the
living "atoms" of the organism, that their vitality must cease or
become latent, they are discharged from  further service, and
thrown out as "dead matter."  The "secretion" of pus, which
has been the professional doctrine, since the rejection of early
and superficial chemical views of putrefaction, is more properly
an excretion. None will contend that it is the elaboration of
anything positively useful, and therefore the main object of the
process must be to get rid of something which is the reverse.
Suppuration may be regarded as a slower and modified process of
decomposition, if we must not say "fermentation," modified,
" controlled" if you please, for wise ends, by the "vital principle."
If thus a mode of local or partial dissolution, it may still be
the most favorable mode. It often prevents "mortification," or
the quicker and more complete death of a larger amount of the
living mass, already solidified. In suppuration nature expends,
if possible, only her superfluous resources, to save what is more
identified with the permanence of organism, just as nations, to
preserve their vitality or independence, send against an invading
3                                           (PART I.)



18                 INFLAMMATION CONTINUED
foe the portion of society that can best be spared, to preserve the
rest from destruction.  Here, too, the analogy with inflammation
holds strictly. The preservative process or means often turn out
destructive to friends, more than to foes. The arming of society
is often found an "inflammatory" and disorganizing business,a fatal necessity.
CHAPTER II.
INFLAMMATION CONTINUED UNDER ITS MOST PRACTICAL ASPECTS.
" The four Signs" -Constitutional Symptoms- Changes of Function and Structure — Divisions -Common, Specific, "Healthy," &c., Acute and Chronic —
"Terminations," Modifications from circumstances and in different tissues —
Causes- Effects - Adhesion, Suppuration, Ulceration, Cicatrization, &c.
GOING more technically and practically into the subject of
Inflammation, we will revert again to the so-called signs, pain,
swelling, increased heat and redness.
The PAIN  cannot be wholly  attributed  to distension and
"stretching" of the nerves by the engorged blood-vessels, for it
is not proportionate to the vascular distension, and may precede,
being often the first symptom. The tenderness or soreness, which
is often a diagnostic symptom between inflammatory and merely
nervous affections, shows that the sensibility of the nerves is itself
altered or heightened. This is further manifest from the sensation
of heat, which is out of all proportion to the actual elevation of
temperature. Bones, moreover, and other internal parts not naturally sensitive, become intensely so when inflamed.
The pain is always lessened by discharges from the engorged
vessels; and while it lasts, more severe in structures that are hard
and unyielding.  Adhesions also lessen pain, or prevent it altogether. It is generally less in chronic than acute cases, and
in what are called specific inflammations, as scrofulas, than in the
ordinary forms.



UNDER ITS MOST PRACTICAL ASPECTS.               19
The pain may exist in or be referred to parts distant from the
seat of the inflammation. In the hip disease the first complaint
of the patient is often "pain in the knee."
The character of the pain, as well as the amount, differs in
the different structures and tissues.  Throbbing is the characteristic of proper phlegmon or circumscribed inflammation in the
cellular structure: and a dull heavy sensation that of the substance of most of the internal organs. When the external covering of the body is affected, the pain is generally described as
"stinging or smarting;" when the internal or mucous surface, as
a sensation of " burning and soreness."
The SWELLING may be, in the beginning, from mere increased
flow of blood to the part, though if the "increased vascularity"
meant activity of the veins as well as arteries, the more rapid
current would not account for the rise of the stream, much less
the overflow, without an obstruction at some point. There is always, perhaps, more or less transudation, often effusion of the
blood entire.  When the "coagulable lymph" is thrown out, and
its fibrin deposited, the thin serum permeates the neighboring cellular tissue. These are the chief causes of proper inflammatory
tumefaction, which may be surprisingly great and rapid. It is to
be distinguished, however, from  the sudden swelling of a part
from internal hemorrhage, as well as the gradual development of
a tumor. If the vessels are not sufficiently relieved, fibrin of an
inferior quality is thrown out, often mixed with blood from the
rupture of the vessels. In a more advanced case, the accumulation of pus may be the principal cause of the swelling.
The swelling, in as far as it results from effusion, is a relief
to the distended vessels, and appears to enable them to resume or'
continue their proper functions.  As observed before, the less
opportunity for swelling, the greater the pain. The swelling or
effusion may, however, be the very cause of suffering; as beneath
the periosteum, or between the cartilages. It may even become
a source of danger, by pressure on vital parts. Next to loose,
cellular textures, glands are the parts apt to swell most largely.
INCREASED HEAT, though so prominent a symptom, has been
much questioned and debated.  After the thermometer was resorted to, it was a matter of surprise that so little if any change



20                 INFLAMMATION CONTINUED
of temperature was discoverable. Hunter sometimes failed, after
exciting artificial inflammation in animals, to ascertain any definite increase of heat. It has been generally allowed, however,
that in the lower extremities, and other parts distant from the
center of circulation, the inflammatory state raised the temperature a few degrees, -up to that of the heart or lungs; and this
slight change was attributed wholly to the increased quantity, and
more rapid flow of the blood.  "Heat," then, as a symptom, is
referred rather to the morbid susceptibility of the nerves, than to
an abnormal physical or chemical condition of the parts.  A difference, however, of seven or eight degrees, which is allowed to
be not unfrequent, is certainly considerable. That the part is
cut off, as it were, from the general level of temperature, and has
lost any power of regulating its own, is sufficiently important.
The relief from abstracting heat, and after effusion and suppuration, the appearance of the pus globules, and other more manifest
results of molecular action, all seem to favor the idea that "inflammation," after all, may be essentially nothing else than what
the word imports, a "burning up" of the part, -  in the chemical
dialect, a too rapid combination with oxygen. In the theory of
Liebig, before alluded to, it is a too rapid "transformation of
the tissues," not only destructive of itself, but developing other
destructive and superfluous "force," as well as that of heat.
The fact that not only does an inflamed part rise six or seven
degrees, but that some parts of the human body rise as many degrees more after life has ceased (or up to 113 degrees*) clearly
shows that chemical considerations cannot be dispensed with, in
the explanation of morbid phenomena.
The REDNESS is not only owing to more blood being in the
part, but to that blood itself being richer in the coloring matter,
or red corpuscles, in proportion as the serum with the fibrin or
white corpuscles has been thrown out.  There may be also transudation or effusion of the blood, red particles and all. Redness
of surface proves the distension of the vessels, not as was once
supposed by the red globules taking the place of the supposed
smaller lymph-corpuscles, but by their being visible only in mass,
* An important fact long overlooked, and but very recently settled, by the experiments of Dr. Dowler, of New Orleans, and Davy, and others, in England.



UNDER. ITS MOST PRACTICAL ASPECTS.              21
and not in " single file." As the inflammation advances new vessels may also be formed, thus adding to the degree of redness.
This varies with the structure of the part, the kind of inflammation, its amount, stage, &c.  It is greater, for instance, on
mucous membranes than on the skin.  There is said to be " uniform  redness" in Erysipelas, "capilliform" when only some of
the capillaries are rendered visible, as in conjunctivitis.  There
may be only red points or larger spots called maculae, - the latter
from sanguineous effusion. The effusion in most specific or asthenic inflammations becomes of a dusky or even coppery hue.
In chronic cases generally the "redness" is but that of venous
blood.  The more acute and sthenic the action, the more it has
of the bright scarlet hue, or that of the freshly oxygenated blood.
The CONSTITUTIONAL SYMPTOMS of inflammation ought not to
be overlooked.  When the disease is at all severe, or in an important part, the whole system is affected with what is hence called
"sympathetic or symptomatic fever."   This is usually of the
active grade-distinguished as "'inflammatory" even when not
dependent on any known disease of a particular part. Its development is usually preceded by chilliness' and weakness, with a
diminution of the secretions. It may become a source of greater danger than the local affection itself, and greatly retard the
favorable progress of the latter. The nervous system may sympathize, without the circulation reacting to the febrile extent,
constituting general irritability; or be depressed, with a feeble
excitement of the heart, and derangement of the secretions generally, thus changing from the inflammatory to the typhoid character. Lastly, from extensive ulceration or absorption of pus,
hectic fever may set in, with exhausting efforts at reaction.
The ALTERATION of function and structure, in the part affected, is a more important consideration than mere external symptoms.  The " increased sensibility," like the "increased vascularity," may be but temporary as well as partial, even in respect of
the whole part seemingly affected.  It is around the injured part
that inflammation most displays itself.   At the central point
there is probably less irritability as well as less activity of the
vessels.  The change of structure, consequent on the diseased
action, may again reduce both the nervous and vascular system



22                INFLAMMATION CONTINUED
below their average of functional power. The secretion proper
to the part is always modified or checked at the commencement
of inflammation, but subsequently it is often greatly increased and
mingled with the products of diseased action. Structural change
becomes chiefly manifest in chronic inflammation, the acute ending in complete destruction or more or less incomplete restoration.
Increase of weight is often a marked symptom or sensation of the
patient, as when a limb is the part affected. Most parts, however,
are softer in the acute form or stage.  Hardness is the characteristic of chronic inflammation, and may consist with increase or
diminution of bulk and density.
After death redness and swelling may disappear, but often
remain as prima facie evidence of recent inflammation.  It
requires, however, to be corroborated by the presence of pus or
lymph, as well as serum, and softening of the part. After mere
congestion, the larger veins will be found distended rather than
the capillaries. Both serous and sanguineous infiltrations may
occur in the corpse from many other causes than inflammation.
There are many DIVISIONS of inflammation, some of them not
very concurrent or consistent with others.  Some of the least
satisfactory, in a philosophic point of view, are among the most
practically convenient. Such is that into " healthy and unhealthy
inflammation."   The first division that requires attention may
depend either on the exciting cause or modifying circumstances,
giving rise to the distinction of
Common and Specific Inflammation.  The former is such as
arises from mechanical injury, or slight physiological derangement in an otherwise healthy constitution. Its most favorable
form  is seen in what is called "adhesive inflammation," the
healing of a cut finger. It is always to be understood when the
specific is not expressly in question.  This term is almost synonymous with " unhealthy," though common inflammation may lose its
natural tendency to recovery, and would then be called unhealthy
rather than specific.  The latter word implies some particular
known cause for the inflammation being peculiar and generally
unhealthy in its character. This cause may be a contagion, affecting the part directly, or the constitution.  Gonorrhea is an
example of the former, Syphilis of the latter. Or it may be the



UNDER ITS MOST PRACTICAL ASPECTS.               23
result of a dyscrasia, predisposing the individual to inflammation,
or to an unfavorable modification of it, when produced from ordinary causes. Thus, scrofulous swellings or other inflammations in
scrofulous patients, are easily excited, but difficult to reduce.
Their progress is tedious; and a thin fluid, with curdy matter,
takes the place of serum  and healthy fibrin, or of consistent
"healthy pus." After these explanations, it is hardly necessary
to define, very formally,
"Healthy  and  Unhealthy Inflammation."   The former is
"Common Inflammation" in its best or least unfavorable form,
and under favorable influences. Though a morbid action, it may
be under the circumstances of the case inevitable, or even desirable, as where it limits a still worse form  of inflammation or
actual "mortification."  Its tendency is self-limiting and restorative.
The simplest form  of unhealthy Inflammation is that which
tends to self-diffusion, from lack of good fibrinous deposits. Its
products may be deficient or excessive in quantity, as compared
with those of "healthy inflammation," and always differ in quality, if not in sensible appearance. It is, therefore, an essentially
destructive and dangerous state, requiring the interference of art,
in cases where healthy  common inflammation would do well
enough of itself. The differences between them will be noticed
when speaking of particular instances, as well as the general
subjects of abscesses and ulcers.
An important practical distinction is into
Acute and Chronic, which may be plainly translated the quick
and slow, or "active and passive."  The limits between the two
cannot be defined by time alone, and the kind or degree of action
is often a better criterion.  Generally, however, the higher the
inflammatory action and more obvious the symptoms, the speedier
its termination, whether in restoration or destruction.  Hence the
necessity for some word to mark a certain degree of activity,
and amount of immediate danger.  That the distinction in question is not absolute, is shown by the necessity that often arises
for such additional epithets as " sub-acute;" and still more clearly
by the chronic forms being often a result or continuation of the
acute.  The effects of the two modes of action are, however,



24                 INFLAMMATION CONTINUED
often sufficiently distinct. Hence the kind, as well as degree of
danger, is different in the two cases.
Such expressions as "Adhesive Inflammation, Suppurative,
Ulcerative or Gangrenous Inflammation," must be understood as
descriptive, as denoting degrees, stages or accidental tendencies
of the same action, rather than distinct kinds of diseased action.
All these peculiarities may depend on the state of the patient's
constitution, the part affected, and a variety of other circumstances.   They are, therefore, sometimes found  enumerated
among the, so-called
TERMINATIONS of Inflammation.  Almost every result enumerated under this head by one author, is criticised and objected to
by others.  Generally speaking there are but two " terminations"
of the disease in question, as of all others, - convalescence or
death.  These, regarded as local, are technically called Resolution and Mortification.  The latter, however, as well as Transformation or permanent Degeneration of the part, may be classed as
only a modification or result. It seems absurd to speak of inflammation ending in suppuration, and then of the suppurative
process being still an inflammatory one.  So of other "terminations." Still there is a tendency to one or other of the following
results, and the sensible relief accompanying most of them,
accounts for this expression continuing in use. These, then, are
the results or effects of inflammatory action:Resolution, when the increased action of the larger vessels is
supposed to overcome the obstruction or debility in the smaller,
and perfect circulation through the part is restored; - increased
or modified Secretion, from naturally secreting surfaces, as serum
within the cavities and mucus in the outlets of the body; — Effusion, which may be of three kinds, merely serous, sanguineous
or of "coagulable lymph,"-serum containing plastic fibrin, and
necessary to Adhesion; — the discharge of devitalized fluid in
the characteristic form of " pus," the "secretion" or transformation being called Suppuration;- and finally Gangrene or rather
its termination, local death or mortification.
Among the circumstances that will render one or other of
these tendencies more probable, the most important is the state of
the patient's constitution.  Health might be measured by the



UNDER ITS MOST PRACTICAL ASPECTS.             25
vigor and freedom from aberration of " the restorative principle,"
i. e., by recovery from local injury without, or with little, inflammation. It is a familiar observation, that " some people's flesh
will not heal like others." Some are in danger of bleeding to
death from  the smallest wound, and are hence said to be of a
hemorrhagic diathesis. Others, it might be also said, have a suppurative or gangrenous or at least inflammatory diathesis. "A
full habit of body," however, is not to be mistaken for the best
possible health. Plethoric persons are in danger from too high
inflammatory action, as are debilitated and emaciated ones from
too low. Habitual beer drinkers are obliged to submit to amputation, for injuries that could easily be cured in others, not saturated with such a blood-making beverage.  Inflammation is of a
higher grade, and more rapid in its course in the young than in
the old, and in parts nearer the source of circulation than in the
extremities.
The structure affected exerts a marked influence.
Inflammation in the cellular tissue is favorably situated for
effusion, after which absorption and consequent resolution can
often be effected. When it is not, suppuration follows, constituting an " abscess."  When the disease is not properly circumscribed
as the true "phlegmon," and the pus, then sure to be unhealthy,
is infiltrated through the cellular structure, a form of inflammation more or less resembling erysipelas ensues. When near the
surface, the healthy abscess is the common boil. This, though
the very type of "healthy inflammation," may degenerate, some
even believing it, in constitutions at the same time weak and irritable, to become the carbuncle. (For a different view, see Lecture
on Carbuncle, &c.)  Cellular inflammation, when it becomes
chronic, may produce various tumors, and even schirrus, or the
malignant induration that precedes cancer.
Inflamed Glands resemble the cellular structure in tendency
to swell; but they are more apt to suppurate, and in chronic
cases to harden.
In the skin, inflammation tends to spread, and by its effusion
separates the cuticle, producing what is called vesication.  The
effusion is usually merely serous, but in some cases contains fibrin,
occasioning a thickening. After removal of the cuticle, the ex4                                          (PART i.)



26                INFLAMMATION CONTINUED
posed cutis is liable to suffer from cold air; from which, however,
it is protected, if not artificially, by a thickening of the matter
effused into what is called a scab. Small and distinct elevations
of the cuticle are called " vesicles." If they contain pus instead
of serum, they are distinguished as "pustules," and the process
of their formation "pustulation."  Pimples, rashes, &c., might
perhaps be mentioned as peculiar results of cutaneous inflammation. The skin is more disposed to ulceration and gangrene than
many other tissues.
The mucous membranes have a strong tendency, when inflamed,
to relieve themselves by suppuration; this process appearing to be
substituted for the ordinary secretion of mucus.  When the inflammatory action is very violent, however, the "coagulable
lymph," which is the common product in other parts, may be
thrown out, as in croup, when it organizes into an additional or
"false membrane."  Were adhesive matter as frequent or as capable of organizing itself in the mucous outlets, as in other parts,
the result would be frequently fatal.  The suppurative "secretion"
is often only partial, and the discharge spoken of as " muco-purulent."  What is called passive hemorrhage is another not unfrequent result of mucous inflammation.  As structural results,
contraction, thickening, and softening, may be named.
In the SEROUS CAVITIES, where the danger is reversed, so is
the relative order of suppuration and adhesion.  The natural
tendency is for the inflamed membrane to coalesce with its opposite fold. The consequence of this "termination" is often of no
appreciable disadvantage.  Chronic inflammation of these investing membranes, however, is liable to relieve itself, though
unfortunately not as a termination of the diseased action, in
serous effusion or exhalation, constituting dropsy of the part, as
hydrocele, hydrothorax, &c. The effusion may be bloody, but is
commonly of a whey-like color and consistency.  The membrane
itself may exhibit ecchymosed spots.  Neither ulceration nor
thickening, except by adhesion, as before mentioned, is frequent
in these parts.
In the FIBROUS STRUCTURES, the characteristic effusion is
gelatinous, within which bony matter may be afterward deposited. Independently of this, their substance is liable to be thick



UNDER ITS MOST PRACTICAL ASPECTS.              27
ened and indurated.  Their liability to ulceration and gangrene
has been disputed.
Tendons and Ligaments are both described by Sir Astley
Cooper as "not very susceptible of inflammation," at least in
healthy persons.  The pain, however, produced by injuries of
the former, particularly punctures, is more than a set-off for this
exemption, oftener producing tetanus than in any other part.
The synovial membranes connected with the ligaments, are very
liable to take on inflammation and advance to the suppurative
stage. When they do not, the substance of the ligaments thickens,
and the joint is greatly enlarged. When matter is formed under
tendons, it burrows far and produces violent irritative fever. The
same may be observed of fasciae, inflammation in which has also
a great tendency to become diffuse.
Within the substance of the muscles, inflammation is characterized by "twitchings," particularly noticeable after comminuted
fractures.
The substance of the vessels or nerves may be itself the seat
of the inflammation.  Phlebitis is more common than inflammation of the arteries, both as a spontaneous disease, and after mechanical injuries. In the latter case the termination is often in
adhesion.  This takes place most frequently at the valves, "gluing
the sides of the vein together and preventing further mischief."
The affected vessel may be traced as a thick hard cord, and is
very sensitive to pressure.  When not thus limited, "phlebitis" is
distinguished as "diffuse," and is then a very serious disease.
The great danger is from  discharge of pus into the current of
the circulation, giving rise to extreme depression, restlessness,
hectic fever, &c., with secondary inflammations in other parts.
The arteries are seldom separately inflamed, except from wounds.
Inflammation from the application of a ligature may extend to
the heart itself.  " This," says Cooper, "I have frequently observed in patients who have died from constitutional irritation,
after an operation where a ligature has been made on an artery."
Gangrene of the affected vessel is an occasional result. Inflammation in the nerves, "though very painful at first, is followed by
little irritation."
Inflammation in cartilage tends to ulceration, and destruction



28                INFLAMMATION CONTINUED
of the joint or bone with which it is connected. All the usual
phenomena of inflammation take place in the BONES; their gangrene and mortification, however, are usually spoken of under
distinct names, as " caries and necrosis."   The result of their
suppuration is often diagnostic, "bone-pus" being so rarely
healthy, that it is synonymous with ichor, generally foetid, and
often quite dark.
CAUSES. - Of the "proximate cause" of Inflammation enough
was said, when speaking of its disputed "nature."  "Exciting
causes" have been divided, like the disease, into "common and
specific," the former affecting more or less all persons,-as exposure to heat and cold; the latter requiring a peculiar susceptibility, as well as producing peculiar results, like the various
contagions.  An obvious division is into those which act directly
on the part, producing structural injury in the first place, and
only affecting the functions or exciting inflammation secondarily,
-such as mechanical violence and chemical corrosion,-and
those which induce visible structural change, if at all, only
through the functional disorder (it may be the proper stimulus of
the part or organ, as volition in the case of excessive exertion).
Thus the structural effect is not only indirect, but often on a different part from that to which the cause was applied, as a current
of cold air. Cold and heat, however, as well as other agencies,
may belong to the direct or indirect class, according to their
intensity.
ADHESION,-or "Adhesive Inflammation," as it is called, in
consequence of generally occurring in connection with inflammation, — is properly the uniting of divided or contiguous parts,
and may occur without any such degree of incited action as
amounts to inflammation.  This is the case, under the most favorable circumstances, in what is technically called "union by
the first intention," when an incised wound or cut heals without
new formation or leaving a cicatrix.  More commonly, however,
the term is applied to the process of union between divided and
other surfaces already inflamed, and also to the coalescence of
tissues by fibrinous matter, as around an abscess, and to new
growths on the surface of membranes, as in croup. It limits cellular inflammation, and is often a result of the state in serous



UNDER ITS MOST PRACTICAL ASPECTS.             29
membranes, appearing to divert the excessive activity or "force"
then generated. This is one reason why it is often spoken of as
a termination.  The pain attending this process is "thrilling,"
while in
SUPPURATION it is dull and throbbing, with a peculiar sensation of uneasiness in the part. When the suppurating tumor is
near the surface, the formation of matter is preceded by flush on
the skin above, and followed by the tumor rising and becoming
softer at some point, where a liquidity or "fluctuation" will be
felt on pressure. The abscess is then said to have "pointed."
The extension of matter will be attended with constitutional irritation, rigors and subsequent febrile reaction. The time usually
requisite for inflamed parts to relieve themselves, by this process,
is from one to two weeks.
What is called "healthy" or "laudable" pus, is a thick bland
homogeneous fluid, nearly white, and of the consistence of thin
cream, with a peculiar smell while warm, and it is said a sickening
taste. It differs from the natural secretion of mucous membranes,
in containing swollen and decomposing globules, and in sinking in
water, and being rendered gelatinous and ropy by the action of
potash, while mucus swims and is readily dissolved by the alkali.
Pus is considered unhealthy whenever mixed with blood, in which
state, usually called sanious, it will often irritate the parts with
which it comes in contact.  The more common variation from the
healthy standard, is by its being too thin and serous, when it is
called ichor or ichorous.  Foetor is another symptom of unhealthy
suppuration.  Healthy pus answers many secondary purposes, besides relieving the system of dead or dying blood. It is nature's
own "healing salve," protecting parts from the air, and promoting granulation.  It is very slow in putrefying or undergoing
further chemical transformation, perhaps from the very fact of
having already undergone a certain degree of decomposition.
When improperly constituted or elaborated, however, it may
possess every variety of bad quality, from the slightly irritating to
the specific poisoning properties of contagia. Even the healthiest
pus seems to communicate the suppurative quality to any other
parts than those discharging it, unless when they are protected
from it, as by cuticle or epithelium. Its injurious effects when



30                 INFLAMMATION CONTINUED
taken back into the blood, and thrown by it on internal parts, are
well known.
Abscess, as a result of suppuration, has been before explained.
The pus is confined by the inflammatory effusion itself.  The abscesses produced by acute inflammation generally run their course,
including the necessary ulceration for the discharge of matter, in
less than three weeks. The situation of the matter has, however,
much to do with the period, as well as the amount of danger, and
will often of itself make the case necessarily chronic.
ULCERATAON has usually been described as an exaggeration or
excess of the ordinary absorbent process, as adhesion or fibrinous
formation is of the ordinary nutritive function. Mere pressure is
well known to stimulate the absorbents.  An unusual flow of
blood has the same effect. In inflamed parts both these causes
concur, the ulceration usually following the effusion or suppuration.  When necessary for the discharge of matter, the ulcerative
action tends toward the surface of the body,- a beneficial provision of nature, "explained," however, by the greater irritability
conjoined with less tenacity of life, in the more superficial textures.  For the same reason, newly-formed parts, the result of
recent " adhesive" organization, and parts at the greatest distance
from the center of circulation, are more liable to ulcerate than
others. Textures, however, that have little vascularity, are proportionably indisposed to ulceration, and more liable to mortify,
as the tendons.  Though the swelling, &c., of ordinary inflammation may be considered a cause of ulcerative absorption, the
latter may go on, when once instituted, where there is no longer
effusion or tumefaction. Certain forms of the ulcerative process
are found to depend on a peculiar order of cells, and to continue
until these are destroyed. (See former chapters.)'The ulcerating part appears and feels worm-eaten, -- as if
insects were about it," The constitutional symptoms are moderate, the fever rather hectic than inflammatory.
Particular parts in a state of ulceration, or "ulcers," will be
more particularly considered hereafter in connection with their
treatment.
GRANULATION is the name given to the process by which lost
parts are reproduced, and to each little fleshy pimple or particle



UNDER ITS MOST PRACTICAL ASPECTS.                 31
of the new structure. These are red in color, and generally-protected by a covering of pus.  They rise in successive layers, as
the fibrin is thrown out, and the vessels from the parts beneath
elongate and branch through them.  After the cavity is completely filled up, and closed over with skin, "the granulative
structure is absorbed and a contracted cicatrix is left." When
divided parts, or the walls of emptied abscesses are not brought
together, healing commonly takes place by means of the granulative structure. Granulations, however, readily unite with each
other, and the requisite contact can be effected after the process
of filling up has commenced. It is by the union or inosculation
of granulations, spoken of, that new skin or
CICATRIZATION is effected, cuticular granulations proceeding,
with their necessary vessels, from the surrounding sound skin, and
uniting with each other as they advance toward the center, as
well as with the granulations beneath.  A  fresh cicatrix is redder and more vascular than the original skin, but afterward becomes less so, the vessels contracting, and that Dart of the surface
having ever after less vitality.
CHAPTER III.
TREATMENT OF INFLAMMATION.
Blood-letting-Objections to Venesection, theoretical and practical-Local
Bleeding -Leeches and Scarifying- Dry Cupping.
THE first thing that occurs to the mind of old-school practitioners, if it is not actually put in practice in all serious cases,
— the first measure directed in all their books, is
BLOOD-LETTING.
It is true there is a great difference in regard to this measure
in the practice of different individuals, and generally speaking,
much less blood is taken now than formerly.  With some of the



32               TREATMENT OF INFLAMMATION,
class of physicians in question, bleeding is now the exception in
cases where it was once the rule. Its direction by the authors is
accompanied with so many conditions and qualifications, that a.
cautious beginner can never be sure when he is warranted in resorting to this once never-failing expedient.  Still it is the remedy
of the books, and sufficiently relied on for other better means to
be habitually neglected, even when that also is omitted. A living
authority, who for more than a quarter of a century has been a
teacher in one of the first schools in America, in attending to the
uncertainty of the signs for omitting or repeating venesection,
concludes that, "perhaps the most certain indication of the presence of inflammation is the continuance of pain," and further
assures us that "so long as this remains severe, we can scarcelygo
wrong in the detraction of blood."*  The insidious relief of pain
has long been the tempting motive for bleeding, and often the
measure of the amount taken; if its existence were indeed made
the criterion for the measure, -as seems to be the design of the
celebrated professor alluded to, —what a sanguinary business
would medicine become!
Local suffering, however, even in connection with other more
decisive evidence of dangerous inflammation, cannot safely be
made our only consideration, when we come to treat a case, or lay
down general rules of treatment.  General disorder is the necessary accompaniment of the local difficulty. The over distension
and over action of the part are necessarily at the expense of the
rest of the body.  If there is "increased vascularity and sensibility" in and about the inflamed part, there is a decrease of both
throughout the rest of the system. This inequilibrium of circulation and sensibility is generally obvious.  A deficiency of blood
in the extremities and throughout the general surface (unless the
inflammation be located in the skin), is manifest in almost all
cases.  " Dryness of the skin and decreased secretion generally"
are laid down among the diagnostic symptoms.
The correction of this inequilibrium  is well known to be one
of the surest means of relief, and signs of the local disease
having ceased.  If you can bring it effectually about, you have
* Gibson's Surgery, Vol. I, p. 28.



TREATMENT OF INFLAMMATION.                   33
secured "resolution;"  if not, suppuration or sloughing must
generally ensue.
Now blood-letting, by merely lessening the general amount
of the circulating fluid, can certainly have no direct tendency to
bring about this desirable result. The amount removed is drawn
in at least equal proportion from all other parts, which then have
an inadequate instead of a superabundant supply. The inequilibrium must therefore be increased instead of lessened. The whole
system must be thus debilitated, and rendered less capable of resisting the morbid influence, or of sustaining the effort necessary
to repair the damage already done. The heart is less capable of
propelling the blood through the extreme vessels, and through the
deranged part; and while that part is weakened in its recuperative resources, it is not proportionately relieved of oppression.
It is not the more energetic flow of blood to the part, but its obstruction there, that adds to the disease and constitutes its danger.
All experience proves that general vascular excitement is not
necessarily of itself a dangerous condition.  Still to lessen the
force, or rather the rapidity of the circulation for a time, is very
desirable when accomplished without weakening the system.
That the loss of blood is debilitating, no one pretends to deny.
It is the most directly debilitating of all measures used in medicine, and its weakening effect is generally proportionate to the
amount of blood taken.  It is only in cases of "oppression,"
that is, of apparent weakness, that the pulse rises and the patient's vigor revives after a bleeding.  The patient is nevertheless
debilitated in reality from the loss of blood, though apparently
stronger than when the vital powers were oppressed.  The removal of the oppression may more certainly be accomplished by
other means without any risk of debility.
Nor can it be urged that venesection has any tendency to reestablish the cutaneous function. When, indeed, it is carried so
far that the debility approximates prostration, ad deliquium
animi, as the books say, then there is perspiration enough, or
rather deliquium  enough of the blood as well as of the senses;
for it is not a real perspiration from the proper stimulation of the
secreting organ, but a mere exudation from its collapse, just as
the fainting also results from a similar deficiency of stimulus on
5                                         (PART I.)



84                 TREATMENT OF INFLAMMATION.
the brain.  It is a cold, clammy death-sweat.  In  the natural
action of this function, the whole surface of the body is in the
active condition, warm and red, and the pulse full and soft.
Experience confirms physiology in showing that blood-letting
cannot effect the object for which it is practiced. It is now, indeed, sometimes said that the bleeding is rather a preventive than
a curative measure; that it is chiefly useful as a means of gaining time or facilitating the cure. In other words, it is found that
this measure does not facilitate the cure of inflammation, without
the aid of others,-which other measures, we contend, would
have accomplished the object in a far better and safer manner.
Even if the desired results were as unquestionably attained  as
might be supposed, from the long prevalence of the practice, still
the risk of other results is sufficient to make it doubtful whether
it ought in any case, or ever, to be resorted to. It could be
easily shown, that no one can bleed in any given case without a
violation of some or other of the rules laid down for the use, or
rather the disuse of the measure.*   The exceptions to bleeding
* "Of all the therapeutical appliances," candidly remarks Professor Flint, of
Louisville, in a note to Druitt (where he seems to regard bleeding, at least in
case of internal inflammation, rather as a preventive than curative means, - a distinction he tells us to be always borne in mind by the surgical practitioner, in
order to determine the extent to which he may safely carry the means of depletion
and depression; concluding that of all measures this of direct " depletion and depression," is the most dangerous and presumptuous: or in his own words, which
I began to quote)   "Of all therapeutical appliances, there is none in which art
ventures on such extreme liberties with nature as in this of blood-letting; and unfortunately there are few in regard to which the principles that are to regulate its
administration are so unsettled and contradictory." Among the principles or rules
"most approved" of by " the authorities," he refers us to the text (Modern Surgery, page 49 et seq.), where, among other	hings, we find the following: 
"As a general rule, the blood should be permitted to flow" (" as quickly as
possible," "from a large orifice," &c.) "till paleness of the lips, lividity about
the eyes, sighing, nausea, fluttering pulse, and relief of the pain indicate the approach of syncope."  Diseases in which bleeding "is most injurious and worst
borne are putrid fevers and diseases of debility." (Page 50.)
" But the junior practitioner must bear in mind that he may occasionally meet
with some thin bloodless patients, whom it would be very injurious to bleed. but
who nevertheless, from some peculiarity of constitution, do not faint, even though
bled to excess."  Yet we were told on the previous page that, "it is often absolutely
necessary to bleed persons in acute disease, who are extremely debilitated."
Not only is the bleeding of eertain thin persons doubly dangerous, as we have



TREATMENT  OF  INFLAMMATION.                          35
for inflammation are now so many, that they will no doubt become
the rule, even among Allopaths. It is well known that Homeopathists have always proscribed blood-letting.
TOPICAL BLEEDING
is a very different measure from  venesection, but this is liable to
many of the same objections,. The same quantity of blood, taken
just seen, from their systems not knowing when to give the fainting sign of "hold,
enough!" but the fat and some of the fleshy are also expressly exempted — "it
will be borne worse when the muscles are large and flabby, and the pulse habitually
open, soft and full."  "Fat people generally bear bleeding worse, and contain
in fact less blood, proportionally to their bulk, than those of a spare lean habit
and rigid fibre."  " It will be borne worst of all, when the complexion is sickly and
pale,   the pulse quick, small and feeble, - the lips, conjunctiva and tongue pale."
" If there should happen to be a state of passive dilatation and weakness of
the heart, syncope would most likely be instantly fatl; and if there should be any
organic disease which impedes the formation of blood, its loss is liable to be followed by irrecoverable sinking and exhaustion."  (Pages 50 and 51.)
Yet with all these dangers and exceptions, " the first and most important measure" in inflammation is still "general blood-letting; which, if caried far enough,
induces a state of insensibility and suspended circulation, to which the name syncope or fainting is given." (Pages 48 and 49.)
It is true, we are afterwards told to stop short of this desirable state, and the
" approach to syncope" is made "the general rule;" "because, after the depressing effects of bleeding there naturally ensues a degree of reaction; the pulse rising
in frequency and the local pain returning: and this reaction will be the greater if
the venesection has been carried to the extent of producing full syncope." If
this reaction (with "rising pulse and returning pain!") exhibit " well-marked inflammatory symptoms, the bleeding must be repeated till the disease is vanquished
provided that the strength permit."
" The propriety of the second bleeding must in a great measure be determined
by the effect which the first has had on the pulse; for if that be more frequent and
quick, or more sharp and jerking, instead of slower and softer, it would seem that
the bleeding had diminished the strength more than it had reduced the disease."
Not only is the degree of this " tolerante' of bleeding, as it is technically
ealled (varying, as it has beet ezperimentalty discovered, it does, with the different
diseases as well as classes of patients for which it is nevertheless said to be indicated), made the criterion for a repetition of the measure, but for other measures
also, and even an " aid to" or test of diagnosis itself!  " If faintness occurs from
the loss of a very small quantity of blood, it will be certain that it is not an inflammatory but nervous" disease, "or that if inflammatory, it must be treated by
other measures than blood-letting."  So that even in inflammation, syncope, with all
its confessed evil of aggravated reaction, may ensue on but slight loss of blood.
The danger is still greater of not fainting when the operation is not conducted
exactly secundum artem (as well as sometimes when it is, "owing to some peculi



36                 TREATMENT OF INFLAMMATION.
slowly and gradually from  the small vessels of the part, will not
produce the same  immediately dangerous effects.  There is no
shock produced upon the general system, the vessels having time
to contract so as to reduce their calibre to the amount of fluid
contained. Still, if much blood be taken, even in this way, evil
consequences must ensue.
But the great objection to local bleeding is, that the necessary
applications cannot be made directly to the part affected; and
any partial attempt near it is likely to draw the blood in that direction, and add to the congestion already existing. Unless the
vessels of inflamed parts can be "entirely drained," and the surarity of constitution"), "the bleeding may be continued almost to death, without
the occurrence of syncope."  (Page 49.)
" Tolerance" is generally represented as greater, and the necessity for bleeding
more urgent, the more vitally important the organ affected. But this again depends on the time when it is resorted to, our author's American annotator assuring
us that, "after violent reaction," in other words, when there is actual inflammation, "the utmost discretion is necessary, in the use of this potent means."  With
respect to the disease or injury, "bleeding is not well borne," continues Druitt,
when there is great depression of the vitality, whether from the peculiar nature of
the morbid cause, or the inflammation excited, " nor in the case of an injury requiring great constitutional efforts for its restoration, as a compound fracture; nor
if the disease be advanced toward suppuration or gangrene."
To vary these quotations with one from a writer of a very different character,
supported, however, too strongly, by less popular and more professional authority.
After showing that the diseases of the poor in Europe arise in a majority of cases
from defective food and impure air, creating a deficiency of blood; "yet," continues
Dr. Dickson, "enter the crowded hospitals of England, and see how mercilessly
the lancet, the leech and cupping-glass are employed, in the diseases of the poor.
What a contrast to the eager pupils and attendants thronging around their beds, 
those attendants with bandage and basin, ready at a moment's notice to take from
the poor creatures whatever quantity of life-blood solemn pedantry may prescribe,
as the infallible means of relieving their sufferings."
How well does this "rhetoric" agree with the confessed results.  " Patients who
have been apparently cured by large bleedings," which according to Dr. Rutherford,
of Edinburg, "have conquered pain in the first instance, remain eventually longer
in the hospitals than those who have not been so speedily relieved (other more efficient means not having been resorted to): moreover, you will find them return
again, with dropsy and chronic affections."
"One objection to venesection," says one of Great Britain's most distinguished
surgeons, "is that, after frequent and copious venous hemorrhage, the internal
vessels become gorged with blood, and a disposition to apoplexy is induced." (Liston, page 26.



TREATMENT OF INFLAMMATION.                         37
rounding ones nearly exhausted also, it is confessed that little or
no good can be done.
LEECHES are, in some countries, and by some practitioners in
this country, the most approved means of local depletion.  But
of these agencies in surgery it may be said, as of blood-letting in
general, that the cautions necessary to be observed in their use,
nearly amount to a prohibition.* Besides, they must not be applied directly to the part inflamed; and their sucking off blood
from any other part can have little influence, except as it lessens
the general circulation, or acts as a " derivative or counter-irritant." In the latter case, their poisonous effects are often more
to be dreaded than the original disease. Fatal hemorrhage frequently results from applying leeches to children, and adults do
not always escape injury. It is impossible to know beforehand
what bad effects will follow their use; and, inasmuch as all cases
to which they are applied, can be cured by other means, we would
never recommend a resort to them.
Scarifying is only less objectionable than leeching. Scarification of the inflamed part, in acute disease, aggravates the disease, and renders it more troublesome to heal. We do not mean
to say that scarifying is never beneficial; but that the benefit in
addition to that of the cupping used at the same time, is due to
the additional local counter-irritation, and not to the amount of
blood taken away.  The revulsion and counter-irritation are, perhaps, more complete and permanent after the scarifying; but
according to our observation, the amount of good done is never
in direct proportion to the quantity of blood drawn, but rather in
the inverse proportion.
* " LEECHES," we are told in a recent work, "should not be applied in females
where the cicatrix would be unsightly. In children large superficial veins should be
avoided. Nor should they be placed on the eye-lids, since in this situation they are
apt to cause sedema and ecchymosis in the part; nor where cutaneous nerves abound,
as erysipelas is apt to follow. They should not be applied directly to the inflamed
part, for the reason that the stimulus of their bites adds to the existing inflammation; nor should they be applied near an acute ulcer, for their bites are apt to degenerate in this case into ulcers: if the ulcer be of a specific character, the bites become
inoculated, and thus extend, instead of decreasing the ulcerated surface. Neither
should they be placed where bandages are of paramount importance, as in fractures,
for in such cases the bites are apt to inflame and ulcerate, and thus cause the removal
of the apparatus at a critical period." (Hasting's Practice of Surgery, page 42.)



38              TREATMENT OF INFLAMMATION.
Dismissing the subject of abstracting blood, together with cathartics, &c., as measures not only unnecessary, but highly injurious, since healthy organs are attacked in order to relieve
diseased, the vital force is impaired, and the means employed
have no special adaptation to the end proposed,-we will speak
briefly of the
SPECIFIC OR HOMEOPATHIC TREATMENT.
Its simplicity, its harmlessness, is in as strong contrast to
other modes, as it is superior in efficacy. It could never yield
such wonderful results were it not in accordance with a divine
law.  The charge is sometimes made against Homeopaths, that
they neglect the causa occasionalis of disease; but if we observe
the difference between them and others, in the treatment of inflammation arising from different causes, it will be seen at once
that the charge is not only false, as against us, but is true against
those who make it. Instance a person who has received a severe injury upon the head, and inflammation of the brain is present, apart
from attention to the wound, in what respect would the Allopath
treat this case differently from one of cerebral inflammation from
another cause, — venesection, or if not in favor of that, active
cathartics, &c. Would the fact that the difficulty was the result
of a mechanical injury determine, or have any influence in the
selection of the medicaments to be given? not at all!
But with the Homeopath, that fact would be most significant,
and direct his mind to a remedy, which he would not have thought
of employing in inflammation of the brain from other causes.
The great remedy with which the Homeopathic Surgeon has to
combat inflammations, the result of external violence, is
Arnica Montana, the specific for diseases from mechanical injuries. Its timely administration, and local application, upon the
occurrence of an accident, would, in a large majority of cases,
prevent the rise of inflammation, which under different medication
would be attended with great danger. Calendula offic., Rhus. Tox.
and RRuta are equally valuable in special cases, but clinical experience has not assigned to either of them so large a sphere of
curative action. When the inflammation is very high, Aconitum
Napellus, that general " anti-phlogistic" of the Homeopath, so



TREATMENT OF INFLAMMATION.                39
superior to the depleting means usually employed, will be needed,
and in some cases, Belladonna, Bryonia, Cantharis, Mere, &c.,
are useful. (For the particular indications for each remedy, see
WOUNDS, ABSCESS, DISLOCATIONS and FRACTURES.)
The local applications will be spoken of in connection with
the different classes of injuries, but we would state here the general rule for their use. Immediately upon the occurrence of an
injury, and until considerable inflammation is present, and in
chronic inflammations, cold or cool applications should be applied.
Cloths kept constantly wet with cold water are usually employed;
but by means of arnicated water, or aqua calendulae, we not only
obtain all the advantages derived from the cold water dressings,
but, in addition, we have all the benefits that flow from the direct
applications to the injured part, of a remedy that is specifically
adapted to the prevention of inflammation: we would, therefore,
recommend that the Tincture of Arnica, or the appropriate medicament, be added to the water, cold, cool or warm, as may be
proper, in all cases of injury, and that where poultices are applied, they should be mixed with a dilution of the remedy; but
in all high grades of inflammation, hot applications should be employed.  Carpenter speaks in the highest terms of the efficacy
of hot steam in removing local inflammation. Had not empirical
experience long since proved their superiority, their homeopathicity would have suggested their use. (For Haemastasis in subduing inflammations, see note to CONCUSSION AND COMPRESSION
OF TEE BRAIN.)



40           THE DIFFERENT KINDS OF WOUNDS, &C.
CHAPTER V.
THE DIFFERENT KINDS OF WOUNDS, ERYSIPELAS, TETANUS, AND
HYDROPHOBIA.
DEFINITIONS - Simple, &c. - Cuts, Bruises, &c. - their respective importance,
pain, bleeding and danger - TREATMENT - Incised Wounds and HemorrhageCompression, Styptics and Ligatures -Punctured and Penetrating Wounds -
Suppuration - Lacerated and Contused - Irritation, Gangrene, &c. - Gunshot Wounds - their varieties and peculiarities - Probing, &c. - Calendula
- Poisoned Wounds - Wasps, Snakes, &c. - Remedies, general and topical -
TETANUS-successful and "experimental treatment"-list of "hopeless
measures"   ERYSIPELAS- HYDROPHOBIA, preventive and curative measures.
WHAT may be termed  artificial maladies,-derangements,
chiefly local, produced directly by external agents, - constitute
the special and characteristic province of the surgeon.  Men's
more frequent indulgence, in former times, of their "organ of
destructiveness" on each others' bodies, gave rise to a separate art
of surgery.  The German name for its practitioner is still " wounddoctor" - wundartz.  The reaction, however, of the organism
against injurious influences of all kinds, is of more importance
than the peculiar nature of those influences, —the study of cure,
than  that of cause.  Hence, Surgery has become a branch of
medicine? and while there are general diseases called surgical,
the local derangements that are external and make a breach in
the bodily substance, have been  spoken of by some surgical
writers as wounds, though not occasioned directly by outward mechanical force.  In this sense an ulcer will be a species of wound!
A WOUND is defined as a recent solution of the continuity of
the animal structure, always accompanied with more or less violence done to the vitality of the parts.
Still the formal classification of wounds now to be considered,
depends on the nature of their external causes.
The most general DIVISION is into simple and complicated.
A simple wound is a mere division of a particular part under
the necessary conditions for healthy restoration. Any departure
from this definition, either as to extent of injury or amount of
vital reaction, constitutes a complicated wound.
Five or six classes of wounds require separate consideration:



THE DIFFERENT KINDS OF WOUNDS, &C.            41
— the incised; the punctured and penetrating (distinguished by
their depth); the contused and lacerated (often connected); those
occasioned in any way by explosion of gun-powder, and called
for convenience "gun-shot wounds;" and lastly, those that, besides the mechanical injury, are the means of introducing into
the body some poisonous substance.
1. An Incised Wound is, in plainer English, "a cut" — more
precisely defined as a "solution of continuity by a sharp-cutting
instrument."  " A simple incised wound" is further distinguished
as made "by a clean, sharp-cutting instrument," and in a healthy
individual. A scrofulous or syphilitic taint makes it complicated,
no less than a bruising in addition to the cutting. A simple incised wound is always one that heals, or might heal, by the first
intention: whatever prevents it, is a complication.
2. A Punctured or Penetrating Wound is one made by a
sharp-pointed instrument, thrust to a greater or less extent below
the surface. A needle "punctures," a bayonet "penetrates," —
perhaps into the great cavities, on which circumstance the distinction is, by some, made to depend. These wounds are not apt to
heal by the first intention; hence more or less suppuration.
3. A  contused wound is inflicted by some blunt instrument,
that injures the parts underneath, without any breach of the
surface.
4. A Lacerated Wound, on the other hand, is generally occasioned by a rough as well as blunt instrument, tearing the integuments.
5. Gun-shot Wounds require no definition, except to repeat
that they are made to include all injuries occasioned by the explosive force of gun-powder.  Scorching by powder belongs, of
course, to the subject of "burns." Stones and other substances
thrown by explosion, often strike with the force of balls; and
balls often kill when it is very difficult to know whether they have
struck or not. The cases called by the old surgeons " wind-contusions," are no longer spoken of, under that name; and most
modern writers seem disposed to question the whole subject of
" windage," -without, however, bringing forward any hypothesis
more tenable.  There is not any sufficient reason4 for doubting
that the violent concussion of the atmosphere, by the passage of
(PART I.)



42             HEMORRHAGE, PAIN AND DANGER.
a ball, may inflict severe injury. The stratum of air impelled before the ball, or contained between the ball and the skin, is doubtless sufficiently condensed to impart a decided impulse to the
surface that is grazed.
The subject of cannon balls will be found more curious than
practically important, except to surgeons in the navy or army.
The rifle or pistol balls, with which the surgeon is more likely
to be concerned, generally make at once a punctured and a lacerated wound; and require particular attentions, which we shall
point out when speaking of treatment.
6. Poisoned Wounds are inflicted by some instrument that inserts a virus into the wound it makes. The bite of a rabid dog,
some kinds of serpents or other reptiles, and the stings of various
insects are familiar examples.   Commonly the wound itself is
trifling: the poisoning of it makes all its importance.
The first striking circumstance attending most wounds is the
flow of BLOOD. This, when not externally visible, is called simply' extravasation;" and is then often more dangerous than "the
bleeding," so alarming to patient and friends.  The amount of
hemorrhage is no criterion of the importance of the wound, unless it is so great as to endanger life by its mere loss. It depends
not only on the size and situation of the wound, but on its nature
or mode of infliction, and sometimes on the constitution of the
patient. A liability to profuse bleeding on slight injuries, constitutes the "hemorrhagic diathesis."*   Gun-shot wounds often
bleed but little; and the severest contusions, if merely such, none
at all.
The PAIN is another circumstance that frequently deceives.
It bears, in many cases, no relation to the danger, unless that of
inverse proportion. It is only in the extreme degree, threatening
tetanus, that it becomes itself a consideration of vital importance.
Nature generally ceases her alarm of pain, where the injury is already irretrievable. The general rule is, that parts well supplied
with nerves, are the most susceptible to painful irritation. The
skin is a vast net-work of nerves, while many vital parts are
nearly insensible in their normal condition. In amputation, it is
* See remarkable case under Ligating Carotid Artery, Part II.



THE DIFFERENT KINDS OF WOUNDS.               48
the superficial cutting that hurts most. The back is much less
sensitive than the front of the body, the feet than the hands.
Wounds in the knee occasion little suffering in proportion to their
danger.
The DANGER of wounds depends on many circumstances, besides the obvious ones of depth, direction, &c.; among which,
those of the patient's constitution and habits are especially important.  With the same kind of wound, in the same part, you
must be careful not to give, as a matter of course, the same prognosis.. Some persons have an irritable temperament, and their
slightest injuries require great caution and attention.
AGE, also, makes a difference.  Young persons suffer more,
when wounded, from the first shock and reaction, than the old;
but their danger is much less, and they recover more quickly.
TREATMENT OF WOUNDS.
It is especially in connection with the first class of wounds,
the incised, that the subject of hemorrhage requires our consideration. The first thing that arrests the surgeon's attention, and
excites the alarm  of the patient and spectators, is the bleeding.
This should be stopped as soon as possible. We effect this object
by the application of cold, - tourniquet, - compression, styptics,
and the ligature.  Arnica, Diadema and Phosphorus, internally
and externally, have been strongly recommended.
If no large arteries or veins have been cut, a lint compress
and bandage will be sufficient. If not, the continued application
of cold arnicated water, or exposure to cold air, will arrest the
hemorrhage, except when large arteries are injured.  Should
these means fail, styptics may be used, such as pulverized galls,
lint steeped in the tincture of the same article, or in a solution of
alum, or strong decoction of white oak bark, or (what is better
than either of these articles) we would recommend to scrape off
and use the fleshy side of a piece of spongy, oak-tanned soleleather. This presents a very soft, unirritating surface, while it
is strongly astringent, and may be strengthened in that respect,
by wetting in any styptic liquid. It may be pressed firmly into
the wound, so as to give the additional advantage of compression.
If these means fail, or. are not considered sufficient, recourse



44             TREATMENT-  LIGATURE OF ARTERIES.
must be had to the ligature. Its use should, however, if possible,
be avoided.
When  an  artery has to be tied, it should be done at the
wound, if it can be reached by the forceps.  When the end of
the vessel has too far contracted, the arterial needle may be
used, and a portion of the surrounding parts included in the ligature. If this measure does not answer the purpose, the wound
will have to be dilated, or an incision must be made at some other
point. Dilatation should, if possible, be avoided. It is frequently
attended with serious consequences; and is altogether unnecessary
in a simple incised wound. If a large artery is even wounded,
it must be tied, otherwise there is danger of aneurism, and the
surgeon must be careful not to mistake a wounded artery for a
vein, and thus not employ the ligature.*
Dangerous hemorrhage from  any large arteries must be first
guarded against by the tourniquet, or some other mode of applying pressure. If the bleeding is from the lower extremity,
compress the femoral artery, just below Poupart's ligament; if
from the upper, restrain the brachial artery in like manner, somewhere above the middle of the arm, if the wound be below this
point.
* It would seem entirely superfluous to give this caution against the commission of so gross a mistake, but an important case that fell into our hands, while
practicing together in Cincinnati, would show it is not.
A boy, aged about 14, son of Mr. J. D, Flour Merchant, while cutting a
stick with a long-bladed knife, wounded the inside of the thigh, puncturing the
femoral artery. The blood was of a bright red color, and came from the wound in
spirts, and not in a continuous stream (generally regarded as pretty sure indications
of an artery being wounded), and yet two prominent Allopathic physicians of the
city (one of whom made considerable pretensions as a surgeon, and the other has
since been made a professor in one of the colleges), diagnosed a wounded vein,
bound it up, and notwithstanding it afterwards bled, upon three different occasions, the last one being five days after the accident, they persisted in the simple
bandage.  The result was an aneurismal tumor. This they endeavored to cure by
compression, assisted in council by the most distinguished surgeon in the west; -
result, for the surgeons, a most glorious exhibition of ignorance; for the boy, "a
dozen deaths " —mortification of the foot, and " amputation at the thigh, with one
chance out of ten, or death inevitable."  We were called, and the boy is now
(without amputation), attending the college at Delaware, Ohio. Had a ligature
been applied at the time of the injury, the boy would have been saved over a
year of severe suffering, and had an uninjured limb.



TREATMENT   LIGATURE OF ARTERIES.              45
There is some choice in ligatures. The best is made of animal membrane.  Whatever substance is used, it should not be so
thin as to cut through the coats of the arteries, on being tightened. If silk or linen is used, one end should be left hanging
out of the wound, the other cut off close to the knot. Learn to
tie the " surgeon's knot" - one that won't slip. When ligatures
of animal fibre are used, both ends may be cut off close, and the
wound allowed to heal by the first intention; the ligature being
absorbed after having done its office.
In taking up arteries, great care must be observed, never to
tie up a nerve with them. Important nerves frequently accompany arteries, and are attached to the same sheath.  In such
cases they must be carefully separated. Neuritis, neuralgia or
fatal tetanus, may be the consequence of neglecting this precaution.
After having suppressed hemorrhage, bring the parietes of
the wound together, and secure them as nearly as possible in their
original position, by adhesive strips, collodion,* or sutures. The
edges of the wound, and the neighboring surface, should be made
perfectly dry, or the adhesive plaster or collodion will not adhere.
An excellent mode, when you wish to effect exact apposition, is
that recommended by Mr. Skey: -" two narrow strips of adhesive plaster should be cut, and warmed, if necessary; each should
be applied by one-half of its length to the opposite surfaces of the
wound: when thoroughly adherent, the other ends of each strip
should be drawn simultaneously but slowly across the fissure, and
as soon as the edges are brought into perfect contact, and even
drawn closely and pressed together, the plaster should be fixed on
the skin beyond."  Avoid sutures if possible.  When they must
be used, have very few, -two or three may often suffice in the
largest wounds - relying on the other means in the intermediate
spaces; though in some cases a larger number will be required.
After these things have been attended to, nothing more locally
is necessary than simple dressings, such as will shield the wound
from the action of the atmosphere.  Cloths kept constantly wet
with cold weak arnicated water (one teaspoonful of the Tincture
* See Arnicated CoUodion, Appendix.



46            THE DIFFERENT KINDS OF WOUNDS.
to a pint of water), are excellent. A dose of Arnica, 3d, should
be given internally, and repeated once in five or six hours, if there
are any indications of sympathetic fever. Should this rise high,
Aconite should be alternated with the Arnica once in two or three
hours.
If the patient has lost much blood, China should be alternated
with the Arnica from the first.
If severe syncope, with deadly paleness of the face, is present,
or the countenance assumes a livid appearance, and there is subsultus tendinum, China is indispensable.  If the patient does not
speedily rally, use a stimulant until reanimation takes place.
The China should be continued until the patient has recovered
from the effects consequent upon the hemorrhage.
Staphysagria has been recommended as a remedy for severe
incised wounds.
Momordica Balsamina will, we think, be found valuable in incised as well as lacerated wounds.
Calendula Offic. is recommended by Dr. Thorer, of Gorblitz,
as preferable to Arnica, in incised wounds. (See his remarks,
after gun-shot wounds.) We have succeeded so well with Arnica
in this class of wounds, that we have found it unnecessary to resort to any other agent.
Direct an unstimulating nourishing diet; food highly spiced
or seasoned to be, of course, avoided under all circumstances.
PUNCTURED WOUNDS, when slight, do not commonly give the
patient much inconvenience. This depends very much, however,
on their situation and the constitution of the patient. The prick
of a needle may bring on tetanus.  Any puncture through tendons, nerves or fasciae may produce excessive pain and distress.
Matter may infiltrate into the cellular tissue, and occasion extensive inflammation. Swelling of the lymphatics is a frequent consequence of punctured wounds. When the injury is in the foot,
for instance, we may have buboes; or swelling of the sub-maxillary glands, from a punctured finger. In such cases a red line
may nearly always be traced from the point of injury along the
course of the lymphatics to the glands.
A variety of punctured wounds has been distinguished, as the
penetrating, the generic term being restricted to shallow punctures.



TREATMENT — LIGATURE OF ARTERIES.             47
PENETRATING WOUNDS, then, are such as enter the great cavities,
Their diagnosis and prognosis are very doubtful (as will be seen
when we come to treat of particular wounds). A large instrument may pierce the cavities of the vital organs, and the patient
recover: a very slight entrance in another direction may cause
death.  The result depends not only on the extent and position
of the wound, but on the constitution and habits of the individual.
In treating these wounds, as all others, the bleeding, if any,
must be first attended to. Next, the extraction of any foreign
matter that may have been thrust and left in. When any is suspected, you must ascertain by probing. The finger is the best instrument, when the wound is large enough, and not too deep. If
there be any poisonous substance introduced by the instrument or
otherwise, such fluids should be injected as will, if possible, nettralize it, and cleanse out the wound. If you can apply pressure, so that the sides of the wound can be brought in apposition
throughout its entire length, do so, and dress with Calendula.
But if you cannot be certain of doing this, the lips of these
wounds should be kept apatt, as there is always a liability to their
uniting, while suppuration is going on actively within. If the
matter is not allowed a free exit, it will spread and aggravate the
injury.  There is always considerable danger of inflammation
from this source. Hence a tent should be kept in the external
orifice, and often removed; and the wound should be kept covered
with cloths constantly wet with cool Aqua CalendulE. If, however, much inflammation should rise, an emollient poultice, made
of the ulmus fulva flour, wet with the Aqua Calendulw, will be
the best dressing for the wound.
As the pus that accumulates should be allowed to escape as
quickly as possible, it is proper to renew your dressings two or
three times a day, pressing gently on the part, but not so as to
give pain. Never allow the outside to heal before the interior.
Internally, give Calendula once in from three to six hours. We
prefer drop doses.  (For an interesting case of penetrating
wounds treated with Calendula, see WOUNDS OF THE ABDOMEN.)
When the abdomen is penetrated, give Aconite immediately.
For punctured wounds caused by splinters, Aconite, Cicuta,
Nitric Acid, Silicea or Hepar are recommended.



48           THR DIFFERENT KINDS OF WOUNDS,
From credibly reported cures of punctured wounds by the
first intention, with the application of the freshly-bruised root of
the common table beet, we should suspect that beets possessed
some specific virtues in the treatment of this class of wounds,
and that they were worthy of experimentation.
LACERATED WOUNDS differ from  incised, in being generally
unaccompanied with hemorrhage.  Large arteries may be ruptured without bleeding.  The only danger in this respect is that
of "secondary hemorrhage."
The constitutional effects are often very great. Chills, spasms,
and tetanus frequently occur. There is great liability, also, to
erysipelatous inflammation.
Diagnosis is not difficult, the condition of the injury being
generally very apparent.
Prognosis is more questionable, depending much on the habits
and constitution of the patient.  On this account the practitioner should be guarded in his opinion.
There is often great injury done to parts not directly involved
in the laceration, and much foreign matter adhering to the
wound.  If the parts are so lacerated as to produce any insensibility, or a partial loss of vitality, it may be necessary to use
stimulants, such as brandy and warm water, for a short time.
Supposing, then, that there is no hemorrhage, the first thing
to be attended to, is the removal of all foreign substances. But
be very careful about too much handling. After clearing and
cleansing, bring the torn parts as nearly together as possible,
and fix them, either by adhesive straps or bandages, that the
wound may heal by the first intention. As these wounds, under
the ordinary treatment, heal by granulation, the surgeon is frequently careless about bringing the torn parts into entire apposition. Bransby Cooper says of contused and lacerated wounds:
"they are not to be treated in the same manner as incised ones,
for there are no hopes of union by adhesion, until the injured
parts have been removed, either by slough or disintegration."
We would, therefore, caution the Homeopath particularly on this
point, as many badly lacerated wounds would heal by the first intention, even under the cold water dressings, if the parts were
brought and confined in complete juxta-position, and kept at rest;



TREATMENT - LIGATURE OF ARTERIES.                 49
much more when dressed with Aqua Calendulx. The dressing of
these wounds, as well as all others, should be done as expeditiously
as will admit of being thorough.  They should be frequently
changed, and this should be done with great carefulness, lest you
tear the imperfect adhesion that may have formed, and prevent
healing by the first intention. The violent manner in which some
surgeons remove "dressings," would indicate either a want of
sympathy for the feelings and disregard for the speedy recovery
of the patient, or ignorance of the injury that such violence may
do, and cannot be too strongly reprobated.  Sometimes sutures
are needed. It is better, however, to let the wound gape considerably, than to cause much irritation by them.
After arranging the wound, one of the best local applications
for this class of wounds, in all cases where the surgeon is called
immediately upon the occurrence of the accident, is cloths.or
lint kept constantly wet with aqua  Calendule.*  If there is,
however, a great deal of irritability present, before it is dressed,
apply an emollient poultice of the flour of the ulmus ful. and
Aqua Calendule.
In treating lacerated wounds, it is certainly more desirable to
heal them  by the first intention, if possible; if not, to so control
the morbid action, that healthy granulations shall form, and cicatrization take place, with but slight suppuration. No one will
question the importance of accomplishing these results; although
those only who have witnessed the frightful sloughs, excessive exhaustion, and almost entire extinction of the vital powers, that
sometimes result, under the ordinary treatment, from these and
contused wounds, even in healthy subjects, can fully realize it, or
the blessing that would be conferred upon mankind by those who
should give the surgeon the knowledge of a remedy exerting a
* The preparation of Calendula we have used is prepared differently from that
of Dr. Thorer; about one-third alcohol, two-thirds rain water, poured over the
flowers, and permitted to stand till medicated; diluted with water, when used, in
an inverse proportion to the extent of the injury. This dilution we have called
aqua calendulce; whether it is equal to the aqua calendulce.of Dr. Thorer, as a
dressing to wounds, we leave others to determine. Internally, we have generally
given drop doses of the above preparation, or put a few drops in water, and given
in teaspoonful doses.
7                                             (PART I.)



50           THE DIFFERENT KINDS OF WOUNDS.
specific action in their accomplishment. No school but our own
propose any such remedial agent —the language of a distinguished Allopathic surgeon has been already quoted  the Eclectic Surgery says, "these wounds must heal by granulation."
Calendula Offic., both by its provings and clinical use, is clearly
shown to exert a preventative and controlling influence over the
suppurative process, and should consequently be given internally,
as well as applied locally, in all lacerated wounds. Dr. Thorer
employed it only locally. (For cases, see his remarks, after gunshot wounds.)
The Momordica Balsamina, Balsam Apple, employed as a dilute tincture, for lacerated wounds, may yet rival the Calendula.
Mr. J. J-, bricklayer, had one of his fingers crushed, and the
nail torn entirely off; he immediately replaced it, and bound it
up with Balsam of Fir. It soon became painful, with signs of incipient suppuration; he removed the dressings, applied a bandage, and kept it wet constantly with a diluted tincture of the Momordica Bal.  Inflammation left, and the nail firmly united,
without suppuration.
Should there be much contusion with the laceration, Arnica
Mon. should be alternated with the Calendula, and if considerable irritative fever should arise, an occasional dose of Aconite
should be exhibited.
When tendons or ligaments are injured, Rhus. Tox. should be
alternated with Calendula, except where the tarsal or carpal
joints are involved, when Ruta should be preferred. (For those
cases where there is copious suppuration or gangrene, see CONTUSED WOUNDS. For tetanic symptoms, see TETANUS.)
Lacerated wounds, occurring in compound fractures or compound dislocations, are very frequently connected with incised
ones, by our Allopathic friends.  Their ignorance of specific
means to control the disastrous inflammation, so likely to arise,
if at all excusable, is an excuse for their too frequent resort to
amputation.  As Homeopaths are better informed (at least upon
this point), we hope they will have a higher opinion of the integrity of the human form - a firmer reliance on the curative resources of nature, especially when aided by specific medication,
and be chary of the use of the knife. We are heartily glad to



TREATMENT - SECONDARY HEMORRHAGE.             51
hear one of the latest Allopathic writers on the other side of the
great water, teach upon this point a course so opposed to the
bloody path of some of his distinguished brethren out our way.
We hope his teachings may soon reach their ears, and himself not
only trust more to nature, but aid it by specific medication.
After reducing the dislocation, or adjusting the fracture, and
applying the splints and bandages, so that the wound may be
dressed, treat as in other lacerated wounds. Those occurring in
compound dislocation require especially Rhus. Tox., as the ligaments are ruptured, and it has a specific relation to their injury.
Amputation is only indispensable in lacerated wounds upon
healthy subjects, when, after attending to the limb, its temperature continues to become lower, and the sensibility to lessen,
showing that circulation and innervation are both cut off, and
that there is no hope of restoration.  (See AMPUTATION.)
If, however, the patient's arm or leg is of no consequence,
amputation may be resorted to in other cases. An incised wound
heals more quickly, and the treatment requires less skill than a
lacerated one. (For an interesting case, see FRACTURE OF THE
HUMERUS.)
A VERY IMPORTANT POINT, not to be lost sight of in the treatment of lacerated, as also contused wounds, is the necessity of
guarding against secondary hemorrhage.  Although the wound
may be at considerable distance from  any large arteries, and
there may have been very little bleeding in the first instance, yet
we never know to what extent the injury may have gone. Deepseated arteries may inflame, sloughs take place, and dangerous
hemorrhage set in, weeks after the original injury.
CONTUSED WOUNDS. -These wounds are more tedious than
any other. In many cases there is great suffering, though but
little injury. There may, on the other hand, be no pain at all
when the case is serious: in fact, the more extensive and severe
the contusion, the less the pain; when the vitality of the part is
completely destroyed it must slough.
If there be extensive extravasation of blood, forming a tumor,
it may be let out by puncture.  This, however, if done at all,
should either be done early, or after the subsidence of inflammation. If neglected till severe inflammation has set in, your new



52                    CONTUSED WOUNDS.
punctured wound will do more harm than the blood.  It will occasion the occurrence of gangrene; or it may itself be the cause
of tetanus.
The danger is of extensive inflammation, with mortification,
sloughing, hectic fever, &c.
The great aim in treatment is to prevent these results. The
usual means, in the old school, in milder cases, are to apply cold,
to prevent inflammation, but in all severe ones, warmth, as emollient poultices, to facilitate suppuration or sloughing. In some
cases local depletion is recommended, and, if need be, the usual
antiphlogistics.
While we can realize all, and even more advantage from local
treatment, we are not under the necessity of endeavoring to remove the effects of contusion by indirect means: deranging still
more the action of organs already impaired by the shock to the
nervous system.  We have remedies, Arnica Montana in particular, that we can apply locally as well as give internally, that act
directly in removing the effects of the shock, prevent, in a great
measure, the sympathy of the general system with the local irritation: restore tone to the injured tissues and vessels, capacitating them for the discharge of their former duties: excite the
absorbents to the removal of any extravasated fluid, thus preventing inflammation, suppuration, and all the injurious consequences
of contusions.  We do not claim that they will reanimate parts
where vitality is destroyed, or prevent the injurious effects that
follow contusions in persons of cachectic habits; but that they
have a specific effect in removing and preventing the consequences
resulting from contusions, as is shown by the provings upon their
healthy and extensive clinical use, and that they will yield superior results, in all cases, to the usual or any other remedial means,
prescribed upon a different principle.  In all cases of contused
wounds, therefore, as soon as possible give Arnica Montana internally, and repeat, according to circumstances, in from three to six
hours, until all danger is obviated. Locally, apply cloths, or
rather a moderately tight bandage, and keep it constantly wet with
Arnicated water;* the temperature of this is to be determined by
* When there is much extravasation of blood, except in persons of an irritable
habi, or who have very irritable skins, and are liable to be affected with erysipe



TREATMENT   SECONDARY HEMORRHAGE.                  53
the severity of the injury; if not very severe, it should be cool,
but if the vitality of the part is much impaired, it should be tepid.
The difference between Arnica Mon. and Calendula is that
the former is adapted to wounds without laceration —the latter
to open wounds.
Hypericumperforatum (St. John's Wort) has been used (though
not yet thoroughly proven), by some eminent practitioners as a
substitute for Arnica, with excellent effect.
Cynoglossum Officinale (Hound's Tongue, not regularly proven)
appears to resemble Arnica in its efficacy in removing the effects
of contusions.
Rhus. Tox. is particularly beneficial when the joints, synovial
membranes, or tendons are injured by contusion.
Silicea, given daily, or at intervals of four to eight days, in
susceptible habits, is a most important and eminently successful
remedy, when, from  contusion, any of the bursse mucosx is inflamed, causing swelling, with considerable pain, and inflexibility
of the joint (as in house-maid's knee, bunion, &c).
Ruta is serviceable when the periosteum  or tarsal and carpal
joints are injured.
Arnica is the best remedy for recent contusions of glandular
organs, but when induration has taken place, Conium  is more
efficacious.
Aconite is required, should much symptomatic fever be present or arise, as also in wounds of the eye, for which it is the
specific. We prefer to alternate it with the Arnica.
When we are called too late, or are unable to prevent suppuration, and an abscess is about to form, our aim should be to
cause it to point as soon as possible.  (See SUPPURATION, p. 29.)
Warm emollient poultices should then be applied, as they assist
in forwarding the suppurative process; we prefer one made of
the fine flour of the Ulmus Fulva, with a small portion of ground
flaxseed. This forms a complete soothing shield from the action
of the atmosphere, and retains its warmth and moisture for some
las, more of the Arnica Tr. should be put in the water. Arnicated water should
be discontinued whenever it causes a decided aggravation of the pains, redness,
and inflammation in the injured part, and a lotion of another medicament be employed, such as Hypericum, Cynoglossum, Heleanthus, Wc.



54                   CONTUSED WOUNDS.
considerable time.  Bread and milk, frequently recommended,
soon dries, and crumbles, and the crumbs become an irritant to
any inflamed surface, especially to an open wound. As a good
poultice is a very important thing, when needed, we will give
directions for making what we think a good one: Take of the
Ulmus Fulva flour three-fourths, of ground flaxseed one-fourth,
knead into a moderately stiff poultice, with hot milk and water;
let the vessel in which it is mixed stand in hot water for half an
hour - this will prevent any lumps - spread this upon a cloth,
about half an inch thick; then keep adding a small portion of
water at a time, to the face of the poultice, and working it in,
until the surface is quite soft. (A little sweet, or Arnica oil may,
at pleasure, be spread over the face of the poultice.) This furnishes a soft, soothing application, in contact with the inflamed
surface, while the outer portion, being firm, prevents the poultice
from slipping down to the most dependent part, as it will do, if
it is all made thin, often leaving the most important part exposed, or else so thinly covered that it soon becomes dry. It also
remains of a more uniform thickness, and thus we have a more
even temperature and moisture and a complete shield from the
action of the air -important considerations.
Some might object, that it would be too heavy. A proper
position and support to the affected part will obviate any difficulty
upon that point. We prefer to apply them  directly to the
inflamed surface, except we have a fine piece of open lace to
spread over them.  No difficulty need be apprehended about
getting them off, if they are not left on too long. The gentlest
way to remove poultices or adhesive plasters, is to loosen one
edge, then evert it, and draw carefully backwards, instead of
raising it perpendicularly.  These are small matters, but the
patient will feel their importance. When it is not necessary to
remove these poultices, on account of suppuration, they may be
kept fresh for some time, by occasionally pouring a little fluid
under one edge, so that it can permeate between them and the
inflamed surface.
We do not, however, depend upon the local means, to forward
the suppurative process. Again, the specific method comes to our
aid with remedial agents; having a direct influence in hastening



TREATMENT- PARTICULAR INDICATIONS.             55
the formation and expulsion of healthy pus.  As soon as it is
evident that an abscess is about to form, after employing Aconite,
Chamomile, Belladonna, Bryonia, or Ledum, if necessary, for
the removal of severe constitutional disturbance, give, to facilitate
the pointing of the abscess, Hepar. Sul., in repeated doses, in
alternation with Silicea; when, however, a considerable portion
of the skin has been much distended, by the large accumulation
of pus, and is of deep red or bluish appearance, Lachesis is to be
preferred; when there is induration, Mercurius, Carbo. Ac., or
Baryta, is useful —Baryta, when there is considerable surrounding swelling, as well as induration, even after the opening of the
abscess.  If there are violent burning pains, or chills, fever,
clammy sweats, restlessness, and great prostration, Arsenicum is
the proper remedy; it will often so ameliorate the symptoms, and
sustain the patient, as to render severe cases comparatively mild.
After the opening of the abscess, if the matter is unhealthy
and offensive, Arsenicum will generally remove these symptoms,
even when gangrene is strongly threatened.
Asafoetida is indicated, when the matter is thin and discolored,
and the parts affected highly irritable.
Belladonna, when the pains are burning, pressing, and tearing,
with a discharge of curdled, flaky matter.
Calcarea, when the pain and swelling have much diminished,
and the pus becomes thicker and whiter than at first.
Calendula, when the suppuration has a tendency to become too
profuse, and the granulations are slow in forming.
China, for the exhaustion consequent upon a copious discharge
of pus; this may be advantageously alternated with Calendula or
Arsenicum.
Mezereum, in cases affecting fibrous and tendinous structures,
or in those laboring under mercurial poison, and when there are
stinging and throbbing pains in the ulcer and its border.
Pulsatilla, when the abscess bleeds easily, or with severe itching and stinging pains, particularly when the veins are varicose.
Rhus. Tox. is most useful in suppuration of the glands, particularly the axillary and parotid, with a discharge of ichorous
matter.  (See also ULCERS, TUMORS, SCROFULA, HIP DISEASE,
PsoAs ABSCESS.)



56                    CONTUSED WOUNDS.
Generally, after the opening of an abscess, if a few doses of
Mercurius be given, and followed by Hepar, Sul. and Silicea, or
Calc. and Phosphorus, or Calendula, healthy granulations will
form, and the abscess heal.
An important point, especially in the treatment of acute
abscesses, is to prevent the air from  entering their cavities.
Therefore, shield them  with the Elm  poultice; and if healthy
granulations are slow in forming, syringe them out once or twice
a day, with aqua Calendulx, or a dilution of such other remedy,
as the totality of the symptoms may indicate, as a constitutional
remedy.
As to the opening of acute abscesses, Homeopathic writers
have recommended to abstain entirely from the use of the lancet,
and to rely upon the evacuation of the matter by appropriate
medicines, "except when the pus, by its extensive diffusion or
pressure (especially when seated under ligamentous or tendinous
expansions), is liable to injure important parts: or when, from its
situation, there is reason to apprehend its discharge into any of
the cavities of the body."  The reason assigned is, that "the
subsequent treatment is generally more easily conducted, and
the healing of the cavity more speedily effected, when the matter
has been evacuated by the aid of appropriate medicine, instead
of the lancet."  This we regard as an assertion only partially
true; while the direction is incomplete, and fallacious, and liable
to do injury. It is an extreme, begotten by the formerly too
prevalent practice of plunging a lancet into everything which
simulated the appearance of an abscess.
There is a period when the suppurative process is being set
up - a period when that is fully completed, and then follows the
ulcerative (not the suppurative) stage, when the cellular tissue is
being destroyed, for the evacuation of the pus. That any advantage can be derived from the presence of pus, a moment after the
completion of the suppurative process, we cannot imagine, and
that this process is never complete until the completion of the
ulcerative stage, we think none will contend. Once set up, suppuration continues, and when the opening is effected slowly, more
or less pus is absorbed, and this tends to produce constitutional
irritation. It also, by its pressure upon the surrounding parts,



OPENING THE ABSCESS.                   57
as well as the cutaneous surface, tends to cause absorption of the
granulations, and thus to cause the abscess to degenerate into an
ulcer. Its evil effects are more evident upon the cachectic or
debilitated.
That our remedies exert a most salutary influence in maturing
the suppurative process, and completing the absorption necessary
for the exit of the pus at about the same time, as well as warding off constitutional irritation, we are happy to admit; but not
that they consummate the two at the same moment.  We would
therefore recommend, as soon as it is evident the suppurative
process is matured, i. e., the abscess has pointed, or there is the
least symptom of constitutional disturbance from the absorption
of pus (especially in the debilitated), that the abscess should be
opened with the lancet, so as to allow a free exit to the pus. In
the case of the healthy, where no unpleasant symptoms have
made their appearance, we can if we choose, with safety, permit
the abscess to open of itself. After opening, apply, as before
directed, the Ulmus poultice, to prevent the entrance of air and
to absorb the pus as fast as it is discharged.  If the aperture
seems disposed to close, keep a small tent in it to prevent this
from taking place. The incision should, if possible, be made at
the most dependent portion of the abscess.
The diet should be regulated by the degree of inflammation
present, and the constitutional vigor of the patient. In inflammation from plethora, it should be abstemious and antiphlogistic;
but in the inflammation of debility, as also during the suppurative
stage, it should be nutritious.
We cannot, however, in lacerated or contused wounds, always
have so favorable a termination even as suppuration.
Mortification will sometimes occur, notwithstanding the efforts
of the best surgeons. Sometimes the vitality of the part is entirely destroyed by the extent of the injury; at other times, in
consequence of constitutional debility, the inflammation cannot be
controlled. Whatever the remote cause of mortification may be,
the immediate one is interruption of the circulation. Thus, in
the aged, we frequently have gangrsena senilis (dry gangrene),
from  an abnormal deposition of the phosphate of lime in the
coats of the larger arteries.  Gangrene, as has been before stated,
8                                           (PART 1.)



58                    CONTUSED WOUNDS.
is the dying, or state of the part preceding the actual death,
mortification. The latter condition is also designated by the term
sphacelus.
If symptoms of gangrene arise, and we cannot remove them,
mortification is the result, of which the only favorable termination
is limitation; which is known by the formation of what is called
the line of demarcation.  This is a white line, constituting the
structures between the dead and the living portions; on the outside of it, coagulable lymph is thrown out by the parts in a state
of vitality, and granulations are being formed; while on the inside there is naught but death and desolation; the parts have lost
their natural temperature and sensibility, serum transudes, and
the blood is extravasated. It is in an intermediate state, between
life and death, and, within its limits, all the tissues ulcerate,
except the bones and blood-vessels; the latter usually fill with coagulated blood, as high up as where the first branch is given off;
this excites an inflammatory action, coagulable lymph is thrown
out, the vessel closed, and hemorrhage is prevented. Should the
artery be not thus closed, hemorrhage will occur on its division.
This is always an unfavorable indication. The character of
the granulations will materially aid us in forming our prognosis,
by interpreting the constitutional symptoms.
Formerly it was thought expedient to amputate before this
line of demarcation was formed; but as the stump generally became gangrenous, in those patients whose constitutional powers
were unable to limit the gangrene, the best surgeons now recommend to always wait until it is formed. What necessity is there,
then, of amputation? Might not the additional shock and irritation to the nervous system, consequent on amputation, or the
depressing influence of the anaesthetic agents, if they are used,
and the loss of blood, so impair the vital powers as to cause, in
some instances, the stump to become gangrenous and the case to
terminate fatally, that would have recovered if nature's restorative process had been aided, and not interfered with?
The approach of gangrene is indicated by an increase of the
sensibility and pain in the inflamed part; the latter is sometimes
of a pungent, burning character; the inflammatory tint becomes
of a darker color. (If it is a suppurating wound, the pus changes



TREATMENT OF GANGRENE.                   59
to a sanious or ichorous character, and the granulations begin to
look darker, and finally to ulcerate.) The skin is dry, with
thirst, but inability to take large draughts of water; pulse quick
and irregular; small vesicles filled with serum and red particles
of blood, make their appearance, frequently at some distance from
the wound.  Soon, however, the blood ceases to circulate and coagulates; the color of the inflamed part consequently becomes of
deep purple or livid hue; the temperature and sensibility, which
was before augmented, rapidly diminishes; the pain is no longer
located in the affected part, but in the surrounding tissues-the
parts are in a state of gangrene.
If not arrested at this stage the result is mortification or
sphacelus. The affected part becomes of a dirty brown or black
color, sometimes grey or greenish; the vesicles become larger and
more numerous; the portion begins to decompose, and we have that
peculiarly offensive, cadaverous odor, pathognomic of mortification.
If not limited, the pulse becomes more feeble, and finally sinks;
the skin, at first hot and dry, is frequently cold, and covered with
a clammy sweat; the tongue and teeth become coated with
sordes; the breath frequently fetid; the countenance cadaverous;
the feces sometimes involuntary. Hiccough, low delirium, coma,
and death, close the scene.
Cinchona should be given, as soon as any symptoms of gangrene are noticed in wounded parts, before the skin has begun to
turn black; but if not followed by a speedy improvement, it
should be alternated with Arsenicum. If these have the desired
effect in arresting the gangrene, the circulation will become more
active around the circumference of the diseased part; th'e coagulated blood gradually separates and passes into the circulation;
the effused fluids are removed, more or less rapidly, by absorption,
and the natural temperature and sensibility are restored. But if
not, and the skin begins to assume a dark, livid appearance, Lachesis should be alternated with Arsenicum, once in two or four
hours, which will generally cause a favorable termination. Should
these fail, resort may be had to Carbo. Veg., Crotalus, Ophiotox, Secale Cor., Viper. Redi., or Vipera Torva. We would recommend,
also, Sulphureted Hydrogen. It is well known that the bites of some
serpents are peculiarly liable to become gangrenous, and also,



60                   CONTUSED WOUNDS.
that the Sulphureted Hydrogen evolved in the decomposition of
a slough seems to be absorbed, enter into the circulation, and frequently, in itself, to produce gangrene. Seeale Cor. is particularly
beneficial in dry gangrene (Gaangrtena Senilis), and will, we well
know, cause it.
Besides the administrations of the appropriate medicines, it is
very important to sustain the constitutional powers; to keep the
limb of a uniform, natural temperature until the line of demarcation has formed. Then, to facilitate the separation of the slough,
correct the fetor, and prevent the absorption of the putrid fluids.
The diet should, therefore, in the incipient as well as the advanced stages, be nutritious (not stimulating); roast beef, eggnog, &c. When the digestive organs have been disposed to receive
but little solid food, we have derived great benefit from the white
of eggs beat up until they are light, but not frothy, mixed with
cold water, and sweetened with loaf sugar, to suit the taste of
the patient. This may be used as a common drink, is universally
acceptable, and will not soon cloy the appetite.
The natural temperature, also, may be best maintained, by
wrapping the entire limb in "carded wool," as soon as any symptoms of gangrene are noticed. This casing should be continued
until the gangrenous symptoms have been removed, or a welldefined line of demarcation is formed. In contused wounds, no
other application may be necessary to the injured part; though
sometimes benefit may be derived from a poultice made of the
green root of the Althese Officinalis, bruised, and boiled in milk,
which has acquired considerable reputation as a preventative of
gangrene.
In suppurating wounds, lint, saturated with a dilute preparation of the appropriate medicament, should be applied to the
wound, or such as are niildly stimulating in their character. The
pus should be carefully removed. (See ULCERS.)
When, however, mortification has taken place, and the line of
demarcation has formed, the local applications should be such as
to facilitate the separation of the slough, and correct the fetor.
The putrid fluids of mortified parts should be carefully removed,
as fast as formed, otherwise, their absorption will produce very
deleterious effects.  Poultices of the Ulmus Fulva, frequently



GUN-SHOT WOUNDS.                    61
changed, will best accomplish the latter object, particularly where
there is much fluid. Pulverized Carbo. may sometimes be incorporated with them, and will at least, absorb a large portion of
the Sulphureted Hydrogen that is evolved.
Where Arsenicum is indicated, by the totality of the symptoms, a saturated solution of the same should be frequently
applied. (See cases under CARBUNCLE, and CANCER OF THE
LIP.)
We have also applied in some cases, with advantage, the
Sesqui-Carbonate of Potash, and the Sulphate of Zinc, in solution
or powder, and pyroligneous acid diluted.  The'Sesqui-Carbonate
has the peculiar power of dissolving dead portions of tissue or
bone, while it simply stimulates to healthy action the living
portions. The Sulphate of Zinc will dissolve the slough, and.
correct the fetor, but will also destroy the healthy tissue. Prof.
Newton (in vol. i. of the Eclectic Medical Journal), speaks highly
of it, as efficacious, prompt, and unattended with any danger to
the patient. The pyroligneous acid is excellent to correct the
fetor.
GUN-SHOT WOUNDS. -The orifice of these wounds is no
guide to the course of the ball.  For example; a bullet may
strike the middle of the forehead, and emerge from the occiput,
just as if it had passed through the center of the brain, yet the
patient be almost uninjured, the ball having simply whirled round
the skull under the integuments. One of the authors witnessed
a still more remarkable case, where the ball seemed to enter the
thorax near the sternum and fifth rib, and passed out behind at
the junction of the spine and the rib, along which it had slid,
doing no material damage. The direction of the shot does not
even require bone to change it: cartilage, intermuscular ligament,
and even fascia, have been found sufficient.
The orifice which the ball makes in entering, is always much
smaller than that of its emergence.  The latter has ragged,
everted edges; and the parts contiguous to its course are always
more or less contused or lacerated. When bones are broken, the
fractures are generally comminuted. Injury done to nerves is
apt to occasion tetanus, sometimes even after the wound has
healed. Primary hemorrhage is rare; the secondary more dan



62                   GUN-SHOT WOUNDS.
gerous.  Diagnosis and prognosis must therefore be regarded as
difficult. An individual in Erie county, of this State, had a rifle
ball pass directly through the belly, from side to side, yet scarcely
endured a minute's suffering, and in three weeks was perfectly
well.  The ball entering just below the false ribs, must have
passed along in front of the colon, so as to avoid both the intestines and any considerable blood-vessel. In other cases, a small
squirrel shot, entering the abdomen, has caused speedy death.
The treatment depends much, of course, on the site and direction of the wound. The union, it should be noticed, must always
take place by granulation. In your examination, use your finger
as far as possible. It is the best of probes, causing less pain and
injury than any other, and giving the most reliable information.
Remove the ball, shot, clothes, or any other substance it may
have introduced.  If, however, the ball be so situated as to be
got hold of with difficulty, and do not interfere with recovery, let
it alone. Many persons carry shot in their flesh without any inconvenience. If it is near the surface, and cannot be removed,
via the wound, it is better to cut through to it, than to dilate the
original wound.  After cleansing, proceed as with a punctured
wound.  We may here mention an accident that occurs occasionally in this class of wounds.  A nerve of considerable size
may be inclosed in the cicatrix, and give rise to neuralgic or tetanic affections. In such an event the cicatrix must be excised,
and a new one allowed to form.
Dr. Thorer, of Gorlitz, strongly recommends Calendula Officinalis, in preference to Arnica, in wounds of every description,
but especially incised, punctured, or lacerated wounds, and those
with considerable loss of substance. The sphere of the latter, as
a traumatic remedy, he confines to contusions, sprains, bruises
without abrasion of the surface, or lacerations of the soft parts.
Dr. Thorer speaks, moreover, in favorable terms, of the effect
which Calendula appears to exercise over the process of granulation and cicatrization. Very frequently, even after amputations,
the cure, under the employment of this remedy, was effected by
the first intention, and in almost every instance where it was impossible to avoid suppuration, the extent to which it occurred was



CALENDULA.                       63
comparatively insignificant. He employed two different preparations of this remedy as lotions; the one to which he gave the
name of Aqua Calendule Officinalis, he prepared as follows: "I
filled one-third of a clean bottle with the petals or leaves of the
flowers, the remaining two-thirds with pure spring water, corked
it well and exposed it for two or three days to the warm rays of
the sun.  The water was by this process, rendered aromatic, and
having been poured off from the leaves, it was put into a bottle
well sealed up like wine bottles; then immediately placed in the
low temperature of the cellar. Whilst the bottle, with the mixture of the leaves and water, is exposed to the higher temperature
of the sun, it should be narrowly watched, and the moment that
any signs of incipient fermentation make their appearance, measures must be taken to arrest it. The second preparation was a
Spiritus Calendulae, for which I employed the same quantity of
leaves of the flowers, as in the preceding instance, and pure rectified spirits of wine in place of the water. I employed the latter
preparation only on one occasion, very much diluted, in order
that the spirit of wine might not exercise a detrimental influence
on the injured parts.  Its effect was equally beneficial."  We
give the following cases, as instances in which Dr. Thorer applied
Calendula as a lotio vulneraria Homeopathica, with success:
1. R. K-  had the under lip much bruised and lacerated from
the kick of a horse. The lips of the wound were brought together,
and retained there by means of a strip of adhesive plaster; in
addition to this the patient was furnished with a phial containing
Aqua Calendule, and desired to keep the wound covered with a
compress saturated with the lotion. Already, after an interval of
three days, healthy cicatrization began to set in, without suppuration. The process of healing went on quickly and uninterruptedly,
per primam intentionem, and the scar of the divided lip is now
scarcely perceptible.
2. M. A-   had the misfortune to fall down a flight of stairs,
and in addition to several contusions on the chest, two extensive
wounds were inflicted, one on the forehead and the other along
the ridge and at the point of the nose, producing great disfiguration.  In this case also, the healing process proceeded most



64                     CALENDULA.
rapidly and favorably, without suppuration and without leaving
any disfigurement, such as a wound of so severe a character might
reasonably have led me to anticipate.
3. This case was of infinitely greater importance than the
above. Floder, a boy 16 years of age, while engaged at his occupation in a cloth manufactory, had the misfortune to become
entangled in the machinery, in consequence of which the following injuries were sustained: 1, compound fracture of the left
arm, the sharp extremities of the broken bone protruding through
the integuments; 2, a deep wound at the bend of the elbow;
3, the bones of the left forearm completely stripped of their
muscles, and laid bare to the extent of six inches; 4, the hand
torn off, being only kept adhering to the stump by a slip of skin;
5, the skin, and portions of the muscles of the exterior surface
of the right leg were torn off, leaving a large and deep wound
extending down to the bone; 6, face and chest severely contused
and exhibiting many small flesh wounds. The unfortunate patient
was reduced to a state of extreme exhaustion by loss of blood and
excessive suffering; amputation of the left upper arm was, nevertheless, rendered imperative, and was accordingly performed.
Compresses, saturated with Aqua Calendult, were applied to the
exposed lacerated muscles of the right leg, up to the period of
recovery of the patient, and it was striking to observe how dry,
and without suppuration, incarnation proceeded in the parts to
which the Calendula was applied, in comparison with the extensive
suppuration, and slow curative process, which took place in the
stump of the amputated arm, treated according to the ordinary
surgical rules. I was not at this time aware of the peculiar properties of Calendula; but, in consequence of the striking beneficial
effects which it produced on the injured lower extremity of the
patient, I subsequently applied it to the wound of the stump, and'
was gratified by the peculiarly favorable granulations which soon
ensued there likewise. All the wounds henceforward filled up and
healed in so satisfactory a manner, that it was scarcely possible
to conceive that they could have been of so serious a character,
and attended with so much loss of substance, as they in reality
were.  The patient was restored to perfect health, and I have no
hesitation in attributing his recovery to the very favorable process



CALENDULA.                       65
of granulation and cicatrization which took place under the employment of the Aqua Calendule.
4. C. in G. lost his footing, when in his mill, and had the
third phalanx of the left index-finger, the second and third phalanx of the ring-finger, and the flesh of the middle finger torn
off. A small portion of the bone of the second phalanx of the
ring-finger remained, but was entirely bared and exposed; the
patient was desirous that this remnant of bone should be removed.  I refrained from doing so, however, in the hope that it
might become covered by means of favorable granulation.  And
so the result proved. After the hemorrhage had been arrested,
by the application of cold water dressings, Aqua Calendule was
employed, two days from the occurrence of the accident; the
wounds thereupon assumed a drier aspect, incarnation went on uninterruptedly, and a perfect cure was rapidly accomplished. On
the ring-finger alone, a very minute exfoliation came off from the
exposed bone.  Mr. Surgeon Schulze, to whom I had recommended the Calendula as a remedy in wounds, and who had employed it extensively, with much satisfaction to himself, for the
past two years, recently favored me with the following cases,
amongst others, in which he had used it with success:
5. A laborer received a comminuted fracture of the right
index-finger, while engaged in lifting a heavy stone. The splintered and more or less loose pieces of bone were removed, and the
Aqua Calendulse applied as a lotion. The cure followed rapidly,
and without any particular suppuration.
6. A miller's apprentice had two of his fingers so completely
crushed, that, as in the foregoing case, it was necessary to remove the shattered particles of bone; the Calendula effected an
equally rapid cure, with a very trivial degree of suppuration.
7. In a case of complicated fracture of the leg, with a wound
nine inches in length, from which the tibia was laid bare, Arnica,
largely diluted, was employed for a few days, in consequence of
the accompanying extensive suggillation.  The Calendula was
then brought into requisition, and produced a speedy cure, without
extensive suppuration.
I could quote a multitude of other cases, in which the Calendula alone was employed, and with singularly successful and sat9                                         (PART I.)



66                   POISONED WOUNDS.
isfactory results; but I shall content myself with adding, that in
all instances where there is extensive loss of substance, and where
it is found impracticable to bring, and retain the lips of the wound
together by means of adhesive plaster, &c., I consider the Calendula to be the best aqua vulneria. It has long been occasionally
employed by the lower orders, in form of an ointment, made of
fresh butter mixed up with the ground or powdered leaves of the
flower, and sometimes, though rarely, in the form of infusion, and
taken internally. Its homeopathicity in wounds, as well as several
other affections, has, moreover, been demonstrated and confirmed
by the provings of Dr. Franz."
POISONED WOUNDS.
Of these the most familiar are the bites and stings of insects
and reptiles.
The sting of a wasp or bee, though very painful, is generally
attended with no serious consequence. Yet in some individuals it
occasionally produces alarming, and even fatal results. We have
for some years past been in the habit of making one and only one
prescription. If this prove as successful in other hands as it has
in ours, no one need ever suffer more than a few minutes. Cut in
two a raw onion, and apply a section to the part affected. It has
in every case relieved the pain, and in most, prevented or reduced the inflammation. Dr. Hill applied this simple remedy, in
one case, where the nose had been stung three days before. The
countenance was completely disfigured by the swelling; eyes
closed, and lips and tongue so much envolved, that the individual
could not articulate. There was violent sympathetic fever, with
pain in the head, amounting almost to delirium.  All these severe symptoms subsided in a few hours, and the tumefaction went
down in the course of twenty-four.  In fact, the pain was relieved in a few moments. The onion is to be changed every fifteen
or twenty minutes.
Inasmuch as this convenient application has proved a specific
in so many cases, we have not found it necessary to try other
means. Is not the onion the antidote to Apis Mellifica?  Dr.
Pulte recommends to cover the injured part immediately with
damp earth, and keep it wet with arnicated water. Internally,



SCORPION -RATTLESNAKE.                  67
Arnica and Camphor every three or four hours. Irritation from
the bite of gnats, musquitoes, &c., we have relieved by directing
the patient to chew the common plaintain leaf, and rub the spittle
on the bite.
We will mention the poison of the scorpion, on account of the
very simple isopathic remedy which, we are informed, both prevents and cures.  The common people in Italy, who are much exposed, rely with perfect confidence on the application of a little
olive oil, from a bottle they carry about with them, and in which a
scorpion is kept. On the coast of Barbary, where many persons
go nearly naked, and sleep in the open air on the sand, they ate
in the habit of anointing the whole body with such a preparation
of scorpio; after which the live ones run over them without stinging.  Of the immunity enjoyed through this article, we are assured by eye-witnesses.
The only dangerously poisonous reptiles we have in this country, are the moccasin, copperhead, and rattle snakes. The effects
of their bite are so much alike as not to require separate notice.
The person bitten is seldom at a loss about the cause of his
sufferings. He feels a smarting pain at the wound, extending up
the limb, which swells, and in the case of the rattlesnake, turns
spotted.  Nausea soon comes on, with dizziness.  The swelling
continues, extending to the other limbs, and sometimes over the
whole body.  One of the authors saw a case where the tension
was so great, that the skin burst open in several places. The patient often becomes delirious, &c.
A course of treatment which has proved successful where we
have known it to be tried, is to make the patient drink freely of
a strong decoction, in milk, of common plantain and horehound,
and apply a poultice of the same articles to the wound. Speedy
and permanent relief follows. It is best, however, to continue
the prescription, in smaller quantities, for several days, when a
complete cure may be relied on. An old practitioner, Dr. Baldridge, states that he has succeeded by this means, in a great number
of cases, with brute as well as human patients. We have other
testimony to the same effect. The plantain, we think, is the remedial agent, and will be found to possess specific properties in
antidoting the poison of serpents.  The Uvularia grandiflora,



68                   POISONED WOUNDS.
prepared in the same way, is said to be equally efficacious.  The
successful administration of sweet oil and scorpion was mentioned
when speaking of the scorpion. Would not Crotalus be equally
beneficial? An unfortunately more accessible and popular remedy
in many parts of this western country is whisky, rum, or brandy,
applied externally and internally, ad libitum, or in quantities unlimited, and almost incredible.  Of the success attending this
course we have been assured by many professional as well as nonmedical persons.  The quantities stated to have been given to
those who had been bitten, without producing intoxication, or
leaving any bad effects, are almost incredible. Of course this
cerebral insensibility to the article is an indispensable condition
for its prescription; and people need not be made dead drunk for
fear of being poisoned.
In India, where the poisonous Cobra de Capella abounds, the
most successful treatment reported, is the immediate application
of a tight ligature above the bitten part; the extraction of the
poison by a cupping-glass, or by the patient himself, or some one
else sucking the poison from the wound; the administration of
large doses of Ammonia internally, and the thorough washing of
the wound with a solution of the same.
In conclusion, with our present information, we would say,
that we think the best and most successful treatment would be,
immediate application of a tight ligature above the bite; excision
of the wound, and the radiating heat    afterwards a poultice of
plantain to the wound. Internally, a free use of the plaintain
decoction or the spirits, whichever is the more convenient. After
difficulties to be prescribed for by the totality of the symptoms.
(See ULCERS.)
Dr. C. Hering, the best Homeopathic authority on this point,
speaks as follows:
".Envenomed Wounds. —The best domestic remedy against'the bites of venomous serpents, mad dogs, &c., is radiating heat.
This should be done by the readiest means at hand, —a red-hot
iron, or live coal, or even a lighted cigar, for instance, must be
placed as near the wound as possible, without, however, burning
the skin, or causing too sharp pain; but care must be taken to
have another instrument ready in the fire, so as never to allow



DR. HERING'S TREATMENT.                   69
the heat to lose its intensity. It is essential also that the heat
should not exercise its influence over too large a surface, but only
on the wound, and the parts adjacent. If oil or grease can be
easily procured, it may be applied round the wound, and this
operation should be repeated as often as the skin becomes dry;
soap, or even saliva may be employed when oil or grease cannot
be obtained.  Whatever is discharged in any way from  the
wound ought to be carefully removed. The application of burning
heat should be continued in this manner, till the patient begins to
shiver, and to stretch himself; if this takes place at the end of a
few minutes, it will be better to keep up the action of the heat
upon the wound for an hour, or until the affections produced by
the venom are observed to diminish.  Internal medicines must be
judiciously administered at the same time.  In the case of a
BITE FROM A SERPENT, it will be advisable to take, from time to
time, a gulp of salt and water, or a pinch of kitchen salt, or of
gunpowder, or else some pieces of garlic.
" If, notwithstanding this, bad effects shew themselves, a spoonful of brandy or wine, administered every two or three minutes,
will be the most suitable remedy, and this should be continued
till the sufferings are relieved, and repeated as often as they are
renewed.  If the shooting pains are aggravated, and proceed
from  the wound toward the heart, and if the wound becomes
bluish, marbled, or swollen, with vomiting, vertigo, and fainting,
the best medicine is Arsenicum.  It should be administered in a
dose of three or four globules in a tablespoonful of water, and if
the sufferings still continue, the dose should be repeated at the
end of half an hour, but if, on the contrary, the state remains
the same, it should not be repeated till the end of two or three
hours. If there is an amelioration, a new aggravation must be
waited for, and the dose ought not to be repeated before its appearance.
" In cases in which Ars. exercises no influence, though repeated
several times, recourse must be had to Bell. Sen. also frequently
proves efficacious.
" Against chronic affections, arising from the bite of a serpent,
Phos. Ac., and Mere. will generally be most beneficial.  (For
the bite of a mad dog, see HYDROPHOBIA.)



70                     HYDROPHOBIA.
" For wounds that are envenomed by the introduction of animal
substances in a state of putrefaction, or of pus from the ulcer of
a diseased man, or animal, Ars. is generally the best medicine.
" Lastly, as a preventative against bad effects, when obliged to
touch morbid animal substances, envenomed wounds, or ulcers of
men and animals, under the influence of contagious diseases, the
best method that can be pursued is the application of dry burning
heat at a distance.  To effect this purpose, it will be sufficient to
expose the hands for five or ten minutes to the greatest heat that
can be borne, and after this it will be proper to wash them with
soap.  The use of of Chlorine and Muriatic Acid in similar cases
is well known."
Of the efficacy of radiating heat we cannot speak from our
experience, never having used it but in one case, of the bite of a
mad dog. Dr. Hering's recommendation, however, is a sufficient
guarantee.
HYDROPHOBIA.
The bite of the rabid dog is by far the most serious species of
poisoned wounds, on accountfof the inoculation of the hydrophobic
virus into the bitten part. The treatment should be applied early,
and be such as is calculated to remove, destroy, or antidote the virus,
and thus prevent the development of hydrophobia, although the
major part of those bitten would never exhibit any symptoms of
the disease. Such is Dr. Hering's confidence in the absolute efficacy of distant heat as an antidote to this, and all other animal
poisons, that he simply recommends "to apply distant or radiating
heat to the recent wound, as described under envenomed wounds;
or until shudderings appear, and continue this practice three or
four times a day, until the wound is healed without leaving a colored cicatrix.
" At the same time the patient should take, every five or seven
days, or as often as the aggravation of the wound requires it, one
dose of Bell., or Lach., or of Hydrophobin, till the cure is
completed."
We should however prefer, immediately after the bite, to cord
the limb above the wound, so as completely to cut off the returning



SYMPTOMS OF HYDROPHOBIA.                  71
circulation; to excise the bitten part, and then apply the distant
heat, &c.*
If any small vesicles should make their appearance under the
tongue, between the seventh and fourteenth days, puncture them,
and rinse out the mouth with salt and water. This course will
generally, if not invariably, prevent the development of HYDROPHOBIA.
Symptoms of Hydrophobia. — The first symptoms generally
manifest themselves between the seventh and fortieth day after
the bite; there are said to be cases, however, where the poison
remains latent in the system for years.  The precursory stage
frequently lasts from two to twelve days. The wound heals very
shortly, as every other slight wound. If the wound should not
be completely healed while the precursory symptoms are developing themselves, it assumes a livid and spongy appearance, and
secretes an ichorous humor. If the wound has closed, it inflames
again, and breaks open; the patient complains of itching pains,
striking from the wound or cicatrix along the nerve to the neck
and trunk; the bitten limb frequently feels numb, or as if it had
gone to sleep, or it becomes rigid, or is convulsively moved.
General Symptoms: anxiety; melancholy; tendency to start; excessive apprehension about his condition and future; he wants to
be alone; his sleep is restless, interrupted by dreams (about dogs),
and starting as if in affright, or he is completely sleepless. The
patient complains of languor, drawing pain in the nape of the
neck and back, burning sensation in the fauces and stomach, sensitiveness to cold and draughts of air, alternative heat and chilliness. Frequently we observe vertigo, ringing in the ears, obscuration of sight, nausea, vomiting of green bile.  The face is
frequently distorted, pale; the eyes faint; the voice hollow and
trembling; breathing oppressed; pulse small; urine pale. Many
patients manifest an uncommon desire for an embrace, and a
constant urging to urinate, the urine being discharged drop by
drop.  Symptoms of the disease when fully developed. -We term
this the convulsive, hydrophobic or furibund stage.
The patient shows the most frightful aversion to liquids, in
* For some interesting remarks on this subject, see Dr. Hering on Psoricum,
in N. A. Homo. Jour., Nov. 1852.



72                     HYDROPHOBIA,
spite of his violent thirst; he cannot swallow, nor see, nor hear
the noise of any thing fluid; whenever he attempts to swallow a
few drops of water, his throat and chest become constricted, and
the most violent suffocative convulsions of the facial, cervical,
thoracic, and abdominal muscles take place; they are excited
even by merely swallowing saliva, or by thinking of drink.  The
patient experiences a most violent sensation of oppression of the
chest, and has to sigh frequently. In some cases the convulsions
are excited by the least draught of air, the motion of the curtain
in contact with the body; the eye dreads the light; shining objects, looking-glass, a burning candle, are painful to the patient,
and excites his spasms; every kind of noise is unpleasant to him;
hence it is that frequently, without any apparent cause, periodical
paroxysms of spasmodic oppression, constriction of the fauces
and larynx, set in. At first there is a constant secretion of a
thick tenacious, frothy saliva; hence slavering and spitting, for
fear the saliva should have to be swallowed. At last, rage breaks
out, and tetanic or epileptic convulsions take place; periodically
the patient is attacked with furibund delirium, during which his
muscular strength increases to an enormous extent, and he can
scarcely be controlled; at the same time he spits about, bites, endeavors to escape from his attendants, tears clothes and beds,
howls, barks like a dog, and endeavors to destroy himself; his
blood-shot eyes roll wildly in their sockets, and fright is depicted
in the features of the patient. He is frequently attacked with
epileptic convulsions, or tetanus. The attacks last a quarter or
half an hour.  During the intervals the patient is entirely
exhausted.
He is generally conscious of himself; warns his attendants of
the danger to which his rage might expose them, and prays them
to terminate his frightful sufferings. Sometimes vomiting takes
place; and men are attacked with priaprism and seminal emissions, and women with furor uterinus.  The pulse is up to 130
or 150 beats, small and irregular. As the disease increases, the
paroxysms become more frequent and violent, until death ensues
after twenty-four hours, two or three, and less frequently five to
eight days: generally by exhaustion (apoplexia nervosa); towards
the end the patient sometimes becomes quiet, is even able to



CAUSES OF.                        73
drink, and dies quite composedly in a state of sopor, or in a
violent paroxysm of convulsions, suffocated. Modifications occur in this disease as in any other; but the symptoms are
the same, except more or less intense. For instance, in some
cases the patient is able to swallow; in others he is able to swallow
coffee, beer, or solids, but no water; or the hydrophobic symptoms only occur during the paroxysms; or the patient is able to
swallow water, provided he does not see it, and his nose is kept
closed. There are cases where the disease did not break out, but
the cerebral affection was confined to anguish and sensitiveness;
this is probably the case when the patient, after being bitten by a,
dog, is tormented by the fear that he will be attacked by the disease; this might be termed an imaginary hydrophobia.  Anatomical changes. - The bodies of hydrophobic subjects generally
decay very rapidly; the blood is dark, fluid, and is rapidly imbibed by the tissues; the veins are engorged.  Air is frequently
found in the larger vessels, and  emphysema develops itself
rapidly.  The whole surface of the body is blue-red; the epidermis very dry; all the muscles are dark red, and, like the tendons,
they are rigid and tight.  Causes. - This disease develops itself
spontaneously among the canine and feline races. Spontaneous
rage has been observed among every species of those races,
wolves, foxes, jackalls and cats. The virus can be transferred to
men and to all sorts of warm-blooded animals, horses, cattle,
sheep, swine, goats; but animals that live on vegetables do not
seem to reproduce the virus.  The same remark applies to man,
and all the observations which have been gathered on that subject
go to show that the bite of a man is not dangerous. The primary
cause of this disease is not known. It is supposed that it can be
excited by excessive heat or cold, unsatisfied sexual instinct, decayed food, deprivation of fresh meat, want of water in very hot
weather.  The rage of dogs is either raving or silent.  Formerly
it was supposed that a mad dog dreaded the water; that he had
foamed at the mouth; that he took his tail between his hind-feet,
and went straight on his course. All this is either false, or only
partially true.  We now know that dogs, even in the last stage of
the disease, do not always dread the water; on the contrary, real
hydrophobia only attacks man.  Foaming at the mouth and slav10                                       (PART I.)



74                      HYDROPHOBIA.
ering occur only among dogs attacked with silent rage, &c.
Other and more important symptoms of hydrophobia among dogs
are; alteration in their conduct, restlessness, constant roving
about, escape from their masters, loss of appetite, devouring of
things which are not natural food for them, such as wood, straw,
dirt, &c.; constipation, vomiting, a peculiar rough, hoarse, howling bark, disposition to attack and bite people, hasty snapping at
inanimate objects, altered, lean, shaggy, sleepy appearance, redness of the conjunctiva, photophobia; in dogs attacked with silent
rage, the lower jaw is moreover depressed, as if paralyzed; they
slaver, the tip of the tongue is protruded between the teeth, and
finally the hind-legs are paralyzed. Dogs attacked with rage die
after six or eight days, and sometimes even before that time, in
an apoplectic fit. The following anatomical alterations have been
discovered in the bodies of mad animals: dark, tarry blood; inflammation of the pharynx, tonsils, epiglottis, larynx, and mucous
membrane of the stomach; pieces of undigested food in the
stomach.  Sometimes the duodenum  and jejunum  were found
inflamed; the trachea and bronchi were filled with a tenacious,
bloody foam; congestion of the brain and spinal marrow.  The
hydrophobic virus is transmitted by the saliva or slaver being applied to a sore or a part covered with a very delicate epidermis.
Contact is necessary to establish the infection. The flesh, spleen,
or the substance of the nerves do not contain any virus.  It has
no poisonous effect when received into the stomach. A peculiar
predispositiou on the part of the poisoned subject is likewise
necessary to create hydrophobia.  Not every bite of a mad
animal is contagious, if the necessary susceptibility be wanting.
Hunter relates that four men and twelve dogs were bitten by a
mad animal: all the dogs died, but the men remained uninjured.
In another case, twenty individuals were bitten by the same dog,
but only one was poisoned. It is probable that the virus loses its
intensity, whenseveral animals or men are bitten in succession,
and that those only who were bitten first are poisoned.  Age,
sex, or constitution do not modify the action of the virus. The
hydrophobic virus retains its infectious power for a long time; it
attaches itself to straw, wood, clothes, and other substances,
covered with the slaver of the mad animal; in this way the dis



TREATMENT.                       75
ease may be communicated a long time after a mad beast had
been seen on the spot. Physiologists differ as to the period how
long the virus can remain latent in the organism, before manifesting its destructive agency. This rarely takes place before the
tenth day; according to some it has remained latent for months
and years. This, however, may be an illusion, for hydrophobic
symptoms may supervene while some other disease exists, and
may thus lead to the belief of hydrophobia having set in.
Spasms of the pharynx, and dread of swallowing liquids, are
observed in hysteric patients, individuals afflicted with typhoid
and other fevers, local disease of the pharynx, esophagus, nervus
vagus. The development of hydrophobia in man can be hastened
by excesses, emotions, and passions: anger, fear, fright, sexual
intercourse (Canstatt).
Prognosis: * Tolerably favorable.
Treatment. - Hahnemann says in his preface to Belladonna:
"A small dose of Belladonna every three or four days is the
best preventive of hydrophobia; one or two doses of Belladonna
will cure it." Belladonna, however, not being the only remedy
for this disease, it may break out, even though Bellad. should
have been taken as a preventive; but it will probably be very
much modified in intensity, and will then be easily combated.
The preventative treatment has been  before mentioned.
Should a cicatrix have formed, and the hydrophobic symptoms
not speedily yield to internal remedies, we should advise to get
up a free discharge from  the original wound. The internal
treatment must be conducted in accordance with the state of the
patient. If the patient had already been treated with the plaster
of Cantharides, or had been salivated, the homeopathic remedies
have to be chosen with reference to the results of that treatment.
It should be observed that under homeopathic treatment, the
patients experience no pain from the treatment, whereas the allopathic treatment inflicts upon them untold tortures.
The principal remedies for hydrophobia are: Belladonna,
Hyoscyamus, Stramonium, Cantharides, Hydrophobin, Lachesis.
Belladonna is principally indicated by the following symptoms:
* "Hydrophobia may still be considered an incurable disease." - Gibson's Institutes of Surgery.



76                      HYDROPHOBIA.
ineffectual attempts at sleep, anxious breathing, frequent desire
to drink, though the patient rejects every drink which is offered;
burning sensation in the throat, with great dryness, red, bloated
face, and glistening eyes; excessive thirst, with suffocative constriction of the throat on attempting to swallow liquids (this constrictive sensation in the throat does not exist continually, but
only at the commencement of every new attempt to swallow a
liquid); inability to swallow, fear, alternating with a desire to
snap and spit at those present, or to escape from the attendants;
constant restlessness of the whole body, and jactation of single
muscles, particularly the muscles of the face.
Though Belladonna is not counter-indicated by convulsions of
the extremities, yet Hyoseyamus is preferable when the convulsions are more permanent, when the spasmodic constriction of the
throat is less violent, and there is not so much a desire to snap
and spit at the attendants as to injure them in some other way.
Hyoscyamus is particularly adapted to the following symptoms:
The patient complains of great dryness and burning heat in
the throat, with stinging in the throat, and a suffocative constriction of the throat when swallowing; he has a dread of drinks,
because he is unable to swallow them, and if he does succeed in
swallowing a liquid, he is attacked soon after with spitting, and
with convulsions that deprive him of his senses. He is constantly
delirious, even when there is no paroxysm; or he is taciturn, and
exceedingly fearful, or he has paroxysms of rage, during which
he endeavors to injure others, and is so strong that he can scarcely
be controlled; frequently excessive anguish alternates with startings, as if in affright, trembling convulsions; he shows a peculiar
fear of being bit by animals; at times the upper and lower extremities are only slightly convulsed, at others the extremities are
spasmodically curved, and the body is tossed off the bed; during
such attacks the patient is often drenched with sweat. His face
is red and bloated. There is some sleep, but it is disturbed by
starting, and by anxious visions and dreams.  In this respect,
Hyoscyamus is distinguished from Belladonna, which has ineffectual attempts to go to sleep.
Stramonium is indicated by the following symptoms: restlessness, violent convulsions (of a rather tonic nature), during



TREATMENT - CANTHARIS.                  77
which the patient becomes so frantic that he has to be tied; he
has no sleep, and tosses about his bed, uttering hoarse screams;
he is delirious, without memory or consciousness; his pupils are
very much dilated; violent desire to bite and to tear every thing
with his teeth; excessive dryness of the inner mouth and fauces;
the sight of a candle, of a mirror, or of water, throws him into
frightful convulsions, with irresistible aversion to water, constriction
and convulsions of the pharynx, slaver at the mouth, and frequent
spitting; loquacious mania, with gesticulations, dancing, singing,
laughing."   Lachesis may be advantageously alternated with
Belladonna or Hydrophobin, in the raging state.  Hydrophobin,
however, from the experiments of Dr. Hering, we should regard
as the best prophylactic, and most valuable remedy for every
stage of Hydrophobia.
Drs. Hartlaub and Trinks recommend Cantharides as a preventive of hydrophobia.  Dr. Hartmann thinks it should be recommended for the following symptoms: alternate paroxysms of
rage and convulsions; the convulsions can be excited by touching
the larynx, which is painful in the region of the thyroid cartilage;
by making pressure on the abdomen, and by the sight of water;
the eyes look fiery and flashing, and roll about in their sockets in
the wildest manner. The patient is scarcely able to swallow, especially liquids, on account of a burning and dryness of the
mouth and pharynx.  There is an excessive desire for sexual intercourse, with constant painful erections, or constant itching and
burning in the internal sexual parts. The oppression of breathing and anguish are less striking than in cases for which Bellad.
and Hyoscyam. are indicated; the covulsions, however, are sometimes frightful. In general, Cantharides seems to be more indicated when the inflammatory symptoms are more prominent, and
when the impeded deglutition does not proceed from spasmodic
constriction of the fauces, but the spasm proceeds from the inflammation of those parts, or from  the pains caused by the
swallowing.
It is said that a strong decoction made of the bark of the
roots of the white ash (Fraxinus accuminata), drank freely, will
cure hydrophobia.  It is also stated as a fact, which we omitted
to mention when speaking of snake bites, that rattlesnakes can



78                      HYDROPHOBIA.
be made more easily to crawl over live coals than white ash leaves,
and that they are never found in forests where the white ash grows.
We will conclude this subject (treatment of real Hydrophobia),
with the interesting case of M. Buisson, as reported by himself
to the Paris Academy of Sciences, as it suggests to the Homeopathic Surgeon a valuable auxiliary means, which he may employ
at the same time that he is administering his internal remedies.
" He had been called to visit a woman, who for three days was
said to have been suffering under this disease. She had the usual
symptoms: constriction of the throat, inability to swallow, abundant secretion of the saliva, and foaming at the mouth.  Her
neighbors said that she had been bitten by a mad dog about forty
days before.  At her own urgent entreaties, she was bled, and
died a few hours after, as was expected. M. Buisson, who had
his hands covered with blood, incautiously cleansed them with
a towel which had been used to wipe the mouth of the patient.
He had then an ulceration upon one of his fingers, yet thought it
sufficient to wash off the saliva that adhered with a little water.
The ninth day after, being in his cabriolet, he was suddenly
seized with a pain in his throat, and one still greater in his eyes.
The saliva was continually pouring into his mouth, the impression
of a current of air, the sight of brilliant bodies, gave him a painful sensation; his body appeared to him so light that he felt as if
he could leap to a prodigious height; he experienced, he said, a
wish to run and bite, not men, but animals and inanimate bodies.
Finally he drank with difficulty, and the sight of water was still
more distressing to him than the pain in his throat. These symptoms recurred every five minutes, and it appeared to him  as
though the pain commenced in the affected finger, and extended
thence to the shoulder. From  the whole of the symptoms he
judged himself affected with hydrophobia, and resolved to terminate his life by stifling himself in a vapor bath. Having entered one for this purpose, he caused the heat to be raised to 420
(107~ 36' Fah.), when he was equally surprised and delighted to
find himself free from all complaint. He left the bathing room
well, dined heartily, and drank more than usual.  Since that
time he says he has treated more than eighty persons bitten, in
four of whom the symptoms had declared themselves, and in no



SYMPTOMATIC.                      79
case has he failed, except in that of one child, seven years old,
who died in the bath."
Symptomatic hydrophobia is much less dangerous than the
real disease; it is not contagious, and is not always attended with
violent symptoms; the frightful anguish is likewise wanting, nor
is there any slavering. It is not caused by virus; frequently
by fright or anger, or it is a symptom of some inflammatory, nervous, or hysteric disease, or attending a very acute eruption, or
some other spasmodic or malignant disease. Fear and imagination, after an innocent bite, may, in very sensitive persons, cause
the disease.  The allopathic preventive treatment, with large
doses of Belladonna, Cantharides, and Mercurius, may likewise
lead to a medicinal hydrophobia, which ignorant physicians might
mistake for symptomatic hydrophobia.
To cure this disease, it is of the utmost importance to find out
its cause. If it was caused by the continued use of large doses
of Belladonna, large quantities of black coffee should be administered by the mouth and rectum, to be followed by one, two,
three, or four doses of Hyoscyamus. Repeated doses of Camphor
may likewise be required, particularly if the disease was occasioned by the abuse of Cantharides. If there should be symptoms of poisoning by Mercury, Camphor, Opium, Belladonna,
Electricity, or some other of the above-mentioned remedies will
have to be given, according as indicated.
If, however, the symptoms should point to the existence of a
more general and more deep-seated disease than symptomatic hydrophobia, in this case the physician will have to select one of the
remedies mentioned in the preceding paragraphs; and this will
be so much easier, as the hydrophobic symptoms constitute the
more prominent symptoms of the patient's illness.
TRAUMATIC TETANUS.
It will be proper in this connection to speak of tetanus as
connected with wounds. When the jaws only are affected, it is
called trismus.
It arises in consequence of the violent pain, or nervous irritation, immediately after a wound, when it is fatal in a short time;
or in the first few days after the wound, during its inflammatory



80                   TRAUMATIC TETANUS.
stage; or eight or ten days afterwards, while the wound is in the
best process of healing and suppuration, without any inflammation
and pain.  Here the wound is apparently the predisposing cause,
increasing the sensibility of the nervous system.
In some cases the attack occurs suddenly with great violence,
but generally it comes on gradually.
The first symptom is a sensation of soreness and stiffness in
the muscles of the neck and face. This rapidly increases; the
forehead wrinkles; and the countenance assumes a ghastly appearance.  Swallowing becomes difficult, and soon impossible.
The jaws are locked fast, and the whole body is rigid. There is
often a cold and clammy perspiration, accompanied in general
with costiveness. The pain is extreme, but somewhat remittent.
Though every muscle in his body seems in painful contraction, the
patient still retains his consciousness. The pulse is at first strong
and full, then small and rather feeble. Death results from suffocation or apoplexy.
The most dangerous cases are those arising from wounds in
tendinous and aponeurotic parts, as in the palm of the hand, or
sole of the foot. Exciting causes are the presence of foreign
bodies in the wound, mental affections, taking cold, impure air, or
tension and distraction of single fibers in the wound from suppuration.
A sad summary and just estimate of a common practice may
be seen in the following extract, from  a quite recent work.
Under the head of " Treatment," in Hasting's Practice of Surgery,* we are informed that "this" (the treatment) "has been,
as yet, but experimental —no form is settled on as rational and
hopeful practice- remedial means, as comprehended in the present
day, seem to hold forth but a slender chance of success - therefore nothing more can be done than to give a catalogue of remedies that have been employed" (with little or no success!).  "The
following means have been constantly tried, and it is said of each,
occasionally with success; amputation, division of the nerves, cupping the part, the incision being deep enough to cut off all nervous communication (!) - the actual cautery- cold bath - hot
* Published in Philadelphia, in 1850.



TRAUMATIC TETANUS.                    81
bath -feneral bleeding - active purgation - enormous doses of
opium- tobacco  enemata - large and repeated draughts of
brandy- counter-irritation over the spine, with the endermoid
(endermic?) use of morphia, aconite, belladonna, &c., -the/external application of cold, stimuli being given internally at the same
time, and salivation by mercury" (!!)
The prognosis under our treatment is far more favorable.
The treatment must be both internal and external.  If the disease arises from a puncture, the wound should be enlarged, either
with a knife or caustic (the latter is frequently preferable, allaying irritability, by the destruction of all sensibility), and.a warm
emollient poultice applied, to promote suppuration as soon as possible. If the wound is lacerated, cleanse it, and remove all irritating substances, and then apply the warm poultice. Ligatures
around the thighs or arms may be of service, if the injury is upon
the extremities. (See different classes of wounds.)
Arnica is doubtless the most important remedy in traumatic
tetanus.  It should be given internally, and at the same time applied to the wound in dilution. It is better to keep the poultice
constantly moistened with the Arnica lotion. If after the use of
Arnica for several hours, the patient does not improve, and is
afflicted with frequent shiverings and faintness, use Lobelia in the
same manner, both internally and externally.  This, in large
doses, under the Eclectic practice, used to be our great reliance.
Calendula, applied to lacerated wounds in the early stage, before
the tetanic symptoms are fully developed, will often prevent any
further progress, and restore a healthy action in the wound.
Whether it will prove as valuable after their development in that
class of wounds, is yet to be seen. Should the disease prove still
unyielding, Angustura, and Cocculus, or Opium and Hyoscyamus
will prove serviceable.
Belladonna, though particularly beneficial in idiopathic tetanus, has been useful in the traumatic variety, when there is a
sensation of constriction in the throat, spasmodic clinching of the
jaws, foaming and distortion of the mouth, the paroxysms being
excited or made more severe by attempting to drink. It is frequently advantageously alternated with Lachesis.
Nux Vomicais also a valuable remedy in idiopathic, and will
~I~~1 ~(PART I.)



82                 TRAUMATIC ERYSIPELAS.
often be found useful in traumatic tetanus, especially inscases of
drunkards.
Where a nerve has been injured, Hypericum will be useful.
Rhus. is valuable when the disease arises from  contusion of
the joints, synovial membranes, or tendons.
Stramonium is also indicated in the latter stages, when the
other remedies have not relieved the symptoms, and there is delirium. If, however, the delirium occur in the early stage, Opium
is the most important remedy. Other remedies, as Acon., Ign.,
Bry., Cicuta, Camphor, Mere., Mosch., Sulphur, or Verat., may
sometimes be indicated. When it is impossible to introduce the
medicine into the mouth, moisten the lips and nostrils with it, dissolved or diluted in water, and administer the same as an enema.
TRAUMATIC ERYSIPELAS.
This is a species of inflammation with eruptions, which sometimes occurs on the margins, and around wounds which themselves
have degenerated into an unhealthy, and more or less irritable
condition. It is an evidence that the vital powers are much impaired. The surface affected has a dark purple appearance, with
vesicular eruptions around, and is very irritable and painful. The
pain is often of a severe itching and burning character. A sanious fluid exudes from it. Tlie remedies are, Bel., Arren., Rhus.
Tox., Lach.,  aust.,, arb. Veg., and Phytolac. Dec.
Bel. and Rhus. will be found very valuable when there is
severe local inflammation, partaking of the erysipelatous character.
If the pain is burning, with chilliness and thirst, Arsenicum
or Lachesis is the proper remedy.
Carbo. Veg. is to be used when the wound bleeds easily, discharges sanious and corrosive matter, with burning pain.
Rhus. Tox., if the pain is more of the itching character, but
if the itching and burning both be severe, Causticum.
The surface of the affected part should be cleansed often.
The pus will, if allowed to remain, act as a contagious, corrosive
poison. A solution of the same remedy that is given internally
should be applied externally to the affected surface by means of
lint. We have sometimes applied, with very great advantage, as



WOUNDS AND INJURIES.                    83
a detergent and mild local stimulant, a solution of the sesquicarbonate of potash, before spoken of. It did not, as we could
perceive, interfere with the action of the specific remedy. It
should be applied once or twice a day, and will cause, for a few
moments, a slight smarting. But should any case remain obstinate, and resist treatment, we should not hesitate to cautiously
touch each vesicle with the pure caustic potash, so as to disorganize them, following this with an Elm poultice, to promote
suppuration.  We have relieved some cases by the simple application of the Tr. of Phytolacca Decandria.  (See ULCERS.)
CHAPTER.VI.
OF WOUNDS AND INJURIES LOCALLY CONSIDERED.
Scalp-Peculiar Dangers and Precautions -Face and Eyes-Concussion and
Compression - Haemastasis - Treatment for, and Cases — Throat-cutting —
Wounds of the Chest and Venesection - Of the Abdomen and Intestines-Peculiarities of Treatment- Of the Joints, Anchylosis, &c.
WOUNDS OF THE HEAD.
THE scalp is much exposed to cuts and contusions, and the
more liable to be seriously injured by them, inasmuch as it is
abundantly supplied with nerves and vessels, some of which communicate directly with those of the membranes investing the
brain within the cranial cavity. Erysipelatous inflammation may
be easily excited in this part, and extend over the whole head and
face. A trifling blow may occasion effusion of blood between the
scalp and bone, which may form a tumor and remain stationary
for a long period. This tumor will take on inflammation from a
very slight additional injury, and this inflammation may extend
within the cranium, producing meningitis; or the pressure on the
bone, without any violent action, may occasion caries. Such tumors sometimes appear on the heads of new-born infants, being
occasioned by pressure against the parieties of the pelvis.
Months, and in rare instances even years, after the scalp has



84                 WOUNDS OF THE HEAD.
been injured, troublesome nervous symptoms may ensue    twitchings of the muscles of the face — sometimes paralysis of the
limbs, or convulsions resembling epilepsy, occur.
Gun-shot wounds of this part are more dangerous than other
kinds; though recovery is not impossible, even when the skull has
been fractured and the brain itself injured. Both tables of the
skull may, however, be fractured, without affecting the brain. A
ball will often take a circuitous course for a considerable distance
between scalp and skull.
Wounds of the face are no more to be dreaded than those of
other parts, except in as far as the organs of sense are involved,
or permanent disfigurement becomes a consideration.  Another
peculiarity that may be noticed, is closure of the salivary ducts,
giving rise to fistulous openings. (See Second Part.)
The sight is generally more or less injured by any wound
near the eye, - though a ball has been known to enter the socket,
and lodge between the eye and orbital plate, without obstructing
vision. The destruction of one eye may cause paralysis of the
other. When the eye-ball has been so injured that it must evidently be destroyed, it will save the sufferer much pain to puncture it and let the humors out.  This, however, should not be
done merely because the sight is irretrievably lost. Save the
eye to look at, if not to look through. The external ear may be
lost altogether, without any loss of hearing.
In treating wounds of the hairy scalp, the first thing you have
to do is to turn barber. Shave off the hair for a considerable distance around the wound. Neglect of this, by preventing proper
examination as to the extent of the injury, may lead to the death
of your patient.  Remove any foreign substance or coagulation of
blood. Then ascertain, with scrupulous care, whether or not the
bone has been injured. The mere fact of fracture does not authorize trephining. (The symptoms requiring it will be noticed
when speaking of that operation - see Second Part.) Carefully
adjust any portions of the scalp that may have been torn loose.
Fix them by adhesive straps and bandages, if possible, -if not,
the interrupted suture may be used. Then treat as other incised
or lacerated wounds. Symptoms of concussion may be present.
(See CONcUSSION).



CONCUSSION AND COMPRESSION.                 85
The diet should be light, unirritating, and unstimulating.
Regard must be had to this rule for several weeks.
If the head has been simply bruised, without laceration of the
integuments, but with sensible effusion below the surface, it is
customary to open the tumors and let out the extravasated blood.
This should never be done, unless in the three following cases: —
immediately on the receipt of the injury, before any soreness or
sensible inflammation comes on; or after it has entirely passed
off, and a large tumor continues stationary for a long time; or,
finally, when a large blood-vessel is ruptured, and requires to be
tied.  In ordinary cases, any extravasated blood is soon absorbed
under the use of Arnica.  (See CONTUSED WOUNDS.)
The scalp, after healing, under the common treatment, will in
some instances remain tender for a long period; the Arnica will
prevent, and generally cure this. If necessary, however, resort
may be had to Ars., Bovis., Carb. An., Phytolac. Dec., Silic. or
Sul.
Should erysipelatous inflammation at any time supervene, resort must be had to Rhus., Bel., Phytolac. Dec., &c.
CONCUSSION AND COMPRESSION OF THE BRAIN.
A sudden and violent blow on the head, whether organic injury be occasioned or not, generally stuns the person.  That
common word expresses a degree of concussion. In severer cases,
the patient is found in a state of entire insensibility; the face is
pale, the hands and feet cold, and the pulse weak and fluttering:
even the function of respiration being for a while suspended.
This returns, and with it a gradual restoration of the senses.
The mind, however, is still for some time wandering.  At this
stage the pulse is nearly natural, but if you attempt to rouse the
patient his breathing is disturbed, and the action of the heart
quickened.  He may try to get on his feet, but falls again, like a
drunken man.  This inability to move will sometimes continue
after the person has become conscious of all that is going on
around him.  Nausea and vomiting are frequently concomitant
symptoms.
Concussion, as observed, is a "stunning,"-a shock to the



86                      COMPRESSION.
very center of the nervous system, occasioning a slight temporary
or entire suspension of consciousness, and has no necessary connection with compression, contusions or extravasation.
In some instances this shock is so severe that the patient dies
very soon after the injury. The brains of those who have thus
died show, on dissection, no organic lesion; though Mr. Collins, of
Dublin, thought that those he examined were diminished in size,
and did not completely fill the cranium.
It is usually divided into three stages: depression or insensibility, already described — reaction, or the return to the normal
action, and lastly, inflammation, or excessive reaction.
Compression, frequently an attendant or sequence of concussion after injuries to the head, may arise from direct pressure of
the bone upon the brain —from extravasation of blood, effusion
of serum, or the formation of matter.
In compression there is a loss of all consciousness, sensation,
and volition. The pupils are dilated, and do not contract under
the stimulus of light. This is, however, not invariable, as there
is sometimes contraction of both pupils, or contraction of one and
dilatation of the other. The respiration is laborious and stertorous.  The pulse is small, hard and laboring: usually irregular,
and occasionally intermitting. Paralysis, generally on the side
opposite to the one injured, is sometimes present.
When compression is the result of depression of the bone, it
comes on immediately after the accident; but if from extravasation of blood, effusion of serum, or formation of matter, the symptoms come on gradually.  In the case of extravasation of blood,
or effusion of serum, should the ruptured vessel be small, or the
inflammation not very violent, several hours or even days may
pass before the symptoms are fully developed; the time may be
extended even to weeks when it is the result of the formation of
matter. In the latter case the symptoms frequently come on insidiously, though they are usually preceded by pains, rigors, &c.,
such as result from the formation of matter in other parts.
When the skull is fractured, and one edge is depressed, the inequality may easily be detected by pressing the finger for a few
moments firmly upon the edges of the fracture; sometimes, however, the internal plate is fractured and depressed, while the



TREATMENT.                        87
outer one is uninjured; and occasionally the fracture occurs upon
the side opposite to the injury.  The last two cases would render
the diagnosis difficult; but in either of these, as also when it is
the result of the formation of matter, the scalp will become puffy;
if raised, the periosteum will be easily separated from the bone,
and the skull itself be dry and of an ashy color. When there is
an external wound the edges become glossy, and the matter thin
and ichorous, when matter forms under the cranium.
The prognosis, except in those cases of concussion where the
patient dies in a few hours after the accident, is favorable under
our treatment.  Formerly it was the plan to bleed people back to
life in these cases of suspended animation; but it was as mischievous as absurd.  The brain is not inactive from too much
blood, but too little, as the pallid face plainly shows; the loss of
an ounce or two of blood in such a state of the system may be
the loss of life; indeed all modern authorities are against bleeding until reaction is established. Sir A. Cooper, seeing that reaction was frequently preceded by vomiting, was in the habit of
ordering an emetic to excite it; although it was successful in his
hands, surgeons generally have been fearful of causing effusion by
the rush of blood to the brain in the act of vomiting. The common practice now is to resort to stimuli (more or less active, according to the views of the surgeon) till reaction is excited, then
to bleed; or if not in favor of venesection, to catharticize to control it.  The danger of subsequent inflammation resulting from
the use of stimulants, has made the most judicious surgeons favor
the let-alone treatment.
The Homeopathic treatment is, however, unattended with the
hazard of the stimulant or the let-alone, or the debilitating effects
of bleeding or purgation. The remedies used to excite, also control the reaction; they not only arouse but sustain the constitutional powers; and should inflammation arise, we have remedies
specifically adapted to control it.
Treatment.-In all severe cases of concussion, place the patient
in a horizontal position in a dark room; keep the body warm, and
do not let him be disturbed by questions, conversation, or any noise,
as perfect quietude is the most favorable state for the brain to recover its normal action; and for some time after all unpleasant



88                      CONCUSSION.
symptoms have subsided the patient should be kept free from all
excitement, and the diet should be very light and simple.
At the same time Arnica Mon., dissolved in water, should be
given once in two hours, until reaction is beginning to be established; then not so often.  Should the patient have been frightened very much at the time of the accident, a dose of Opium
should precede the Arnica.  If no symptom of reaction appear
soon after the administration of the Arnica, wet the nostrils occasionally with a dilution of the Arnica Tr.  The beauty of the
Arnica is that it has a specific power in removing the effects of
the shock upon the nervous system, restoring it to its normal con.
dition, thus preventing violent reaction, arresting hemorrhage, and
exciting the absorbents to the removal of any extravasated fluids.
It is thus admirably adapted to the, treatment of concussion and
compression.
One or two doses of Aconite should be alternated with the
Arnica as often as once in three hours, when the reaction threatens
to terminate in inflammation. The patient's hands and feet should
be immersed in water as hot as he will bear, for twenty-five or
thirty minutes; the temperature being kept up by constant additions of hot water, and the head kept cool by cloths frequently
wet with cold water. If the inflammation should not yield, recourse must be had to Belladonna, almost a specific for inflammation of the brain and its membranes, which is especially indicated
when the head is hot, the face red and bloated, with violent pulsations of the carotids, increase of suffering from the slightest
noise, and intolerance of light, eyes red and bloodshot, with a wild
expression, pupils contracted or dilated, violent and furious delirium, loss of consciousness; sometimes low mutterings, convulsions and vomiting. If necessary, Hyos., Bry., Mere., Op., Stram.,
Cupr. Acet., &c., may be used.  The particular symptoms indicating each remedy may bejlearned from any Homeopathic work
on Theory and Practice. As this work will probably fall into the
hands of some who are inexperienced in the use of Homeopathic
remedies, and who have been accustomed to frequent doses, we
would here caution them especially against the repetition of Belladonna in these cases. It should never be used lower than the
third dilution, nor repeated oftener than once in three or four



TREATMENT.                       89
hours, generally not under six, and as soon as an amelioration of
the symptoms takes place, it should be discontinued until there are
some indications of a return.
Much benefit may also be derived from the use of HEamastasis.
This is no more nor less than mechanically confining the blood in
one or more of the extremities. By applying ligatures around
the arms and thighs sufficiently tight to check the venous but admit the arterial blood, we can in a few minutes remove from the
trunk from one-third to one-half of its usual supply of blood, and
thus break up severe congestions, by keeping the blood away from
inflamed parts.  If the patient is feeble, the application of the
ligatures will cause him to faint in a few moments, when they
should be loosened. The simple ligature is always at hand, and
usually all that is necessary to avail ourselves of the advantages
of Hemastasis; but as Dr. Junod some fifty years ago invented
an ingenious instrument acting upon this principle, which was
highly prized and made use of by Hahnemann, we give, from the
British Journal of Homeopathy, a description of it, as well as
the report of an interesting cure: "The object sought to be accomplished by the ingenious inventor, is to determine a large portion of the blood of the system into a limb, and thus abstract it
from congested or inflamed internal parts. This design he accomplishes by means of a tin boot into which the leg of the patient
is inserted, and from which the atmospheric air is gradually withdrawn by means of a small air-pump, the top of the boot being
kept in air-tight apposition to the leg by means of a broad belt of
vulcanized india-rubber. The effect of thus exhausting the air is
to cause a rush -of blood into the limb contained in the apparatus;
it resembles dry cupping on a large scale, a whole limb in place
of a few square inches of skin being subjected to the action of
the instrument. No pain, but only a slight uneasiness is experienced in the limb inclosed in the boot, which is found on being
withdrawn to be much increased in size, and the blood does not entirely return into the circulation and the leg resume its original size
at first for twenty-four hours; but the oftener the operation is repeated the more transient is its effect. The effect of the operation in the cases for which it is applicable is almost instantaneous
— congested states of internal organs, all the symptoms of acute
12                                     (PART I.)



90              CONCUSSION AND CONGESTION.
local inflammations vanish as if by magic, the pain of many forms
of neuralgia is at once subdued, hemorrhages from the lungs, uterus, &c., cease. In many of these cases the effect is, as may be
imagined, transient, and the diseased states recur as soon as the
blood is restored to the circulation, though the effect may be often
rendered permanent by repeated applications of the boot; still,
even supposing the effect to be transient and palliative, it is for us
a matter of great importance in many cases to procure a suspension
of the dangerous symptoms, in order to gain time for the action
of our specific remedies.  Thus, in threatened apoplexy, in hemoptysis, in violent metrorrhagia, and many other conceivable
cases, the palliation of the paramount and dangerous symptom is
of the utmost importance, and if this can be done by such a simple appliance as that of Mr. Junod, we should be very wrong to
despise it.  In cases of congestion, hemorrhage, &c., we seek to
attain the same object by placing the patient in certain positions,
by the application of cold water, ice, hot foot-baths, &c.; but M.
Junod here presents.us with a much more powerful and certain
mode of effecting our purpose.  By means of one boot he can
draw into the limb four pounds of blood, and the effect of this,
when rapidly performed on a robust individual in the erect position, is so powerful as to produce perfect pallor of the countenance and syncope.  Dr. Junod attended in Paris several cases,
in conjunction with Hahnemann, who had a high opinion of the
utility of the hemostasic apparatus. One case which he attended
along with the founder of Homeopathy deserves to be detailed,
as it illustrates forcibly the value of the treatment pursued.. The
case was that of a young lady, the daughter of a late noble earl,
formerly English ambassador at one of the European courts.
This lady had long been afflicted with a most curious and sad disease; she had entirely lost the use of her limbs, and lay constantly on a couch, her head generally supported by an attendant's arm.  She seemed to be entirely destitute of any power of
volition, never spoke except when roused, lay constantly in a halfcomatose state, the face being very much flushed, and the head
very hot; evidently she labored under severe congestion of the
brain. She was under Hahnemann's treatment; he went to see her
very frequently, in fact was in almost constant attendance upon



HEMASTASIS.                       91
her, but was unable to produce any favorable result, and after
nearly a year of ineffectual Homeopathic treatment, Hahnemann
called in Dr. Junod to his assistance. When they met together
beside the patient, Hahnemann said,'Now, Dr. Junod, you shall
operate on the legs, and I on the stomach.' After the first application of the boot the patient roused up, addressed those around
her, and chatted familiarly and quite sensibly with her friends:
her face assumed a natural color, and to the surprise of all, she
was able to.walk about the room, a thing which she had not done
for a very long time. After ten applications of the boot, on ten
successive days, the patient was perfectly cured, and was able to
travel into the country, where she remained perfectly free from
all symptoms of her former complaint, and was able to take a
considerable amount of walking exercise. It is possible that the
Homeopathic remedies administered by Hahnemann at the same
time, were the cause of the permanent character of the result obtained in this case, though as long as the congested state of the
brain existed, it was evident that the medicines were of no avail.
Dr. Junod's apparatus has been introduced into all the hospitals
in Paris, and is frequently employed by the Parisian medical men
in their treatment of many diseases that were formerly supposed
to require blood-letting; it has also been adopted by almost all
the London hopitals, and letters from London hospital physicians
and surgeons of eminence, testify their satisfaction with the performances of the instrument."
When symptoms of compression are present, if the skull is
shattered, any depressed portions may be removed or elevated
with forceps, Hey's saw, or perhaps, in some instances, an airpump. The trephine should not be used until after our remedial
means have been thoroughly tried without success. The brain, it
is generally conceded, possesses the power of accommodating itself
to considerable pressure, and the Arnica, every Homeopath well
knows, has a good deal of efficiency in increasing that power, and
is unequaled in removing extravasated fluids.
When the internal plate only is fractured, or the side opposite
to that upon which the injury was received, we should rely upon
remedial measures, and if these are insufficient, and the scalp becomes puffy, and being incised and raised, the periosteum is found



92                FRACTURE 0F THE SKULL.
loosened and the skull of ashy color, we can then be pretty certain of the exact seat of the injury, and are justified in the use of
the trephine. Miss B. had fallen and struck the left temporal bone
upon the corner of a bench: inflammation followed. Dr. Hill, at
that time Professor of Surgery in the Eclectic Med. Institute,
being in attendance, called in consultation his partner, Dr. Hunt,
who was in favor of relying solely upon Homeopathy. The Doctor, although partly converted, had not sufficient confidence. He
accordingly subjected her to a thorough antiphlogistic course,
without perceptible benefit. Arnica being then exhibited once in
six hours, cured the patient, and converted the Doctor and the
family to Homeopathy.
A distinguished old-school surgeon says: " If we examine the
history of injuries to the head, we shall find by far the greater
number of successful cases have been those in which there has
been the least surgical interference." We give below two cases,
illustrative of this and of diagnosis.
One of the authors was cognizant of a case where a falling
limb produced a comminuted fracture, — a literal smashing of the
parietal bone.  The patient lay several hours in a comatose condition.  Three physicians agreed that nothing could be done for
him.  His widowed mother, a poor woman, but not so ignorant as
many a wealthy lady, believing in the good old maxim, "while
there is life there is hope," observed, as reaction advanced, that
his head was too warm, while his feet were too cold. On her own
responsibility, therefore, and the suggestion of her common sense,
she immersed his feet in hot water, and kept pouring a cold stream
on the wounded part. She also administered a strong stimulating
injection.  By these "unprofessional" means, he revived and escaped the danger of inflammation. As the cranium  was fortunately, under the circumstances, completely fractured and not
merely compressed (which might have required more surgical skill
than it was worth while giving a poor boy), the elasticity of the
brain set its own bone - more accurately, perhaps, than art could
have done it, and the boy recovered perfectly. In an adjoining
neighborhood, and about the same time, a rich man's son met with
a similar accident.  In his case the trephine was used by one of
the medical gentlemen, whose prognosis was mentioned above,



WOUNDS OF THE NECK.                    93
though not till after the patient had been allowed to lie fourteen
hours —nothing done for him, of course, secundum artem, till' the doctor" could be brought from a distance of sixteen miles;
this patient died.
WOUNDS OF THE NECK
are principally important from the liability to fatal hemorrhage.
Death may quickly ensue from this cause alone, if any of the
larger vessels are wounded.
Suppression of hemorrhage is, therefore, the first point of
TREATMENT, for which purpose it is often necessary to apply the
ligature to veins as well as arteries. It is always best, however,
to check the hemorrhage from veins by compression, rather than
the ligature, to avoid the danger of phlebitis.  When the hemorrhage has been checked, bring the lips of the wound together,
and fasten them by sutures, using precaution to prevent your
dressings from being thrown off. Most cases of serious wounds
in the throat occur in persons attempting suicide, and may require the hands to be tied, as well as the head to be secured in
one position, leaning over toward the wound. This last precaution is proper in all cases. The patient should not even be allowed to talk. Eating and drinking have often to be restricted,
or altogether interdicted for awhile.  These wounds heal very
rapidly, and require but little attention after the first proper
dressing, except from good nurses.
WOUNDS OF THE CHEST.
When the cavity of the thorax is entered, the lungs are, of
course, almost always injured.  When this is the case, air will
pass out through the wound, causing a bubbling of the blood as
it flows. The respiration will be short, and the expectoration.bloody. The patient will often complain of a sensation like a
stitch, at every breath.
The external passage of air must be stopped as soon as possible. Apply a wet bandage firmly around the chest, to prevent
motion of the ribs, leaving an aperture to admit dressing the
wound (for which see the different classes of wounds), and place
the patient in such a position that the wound may be the most de



94                 WOUNDS OF THE CHEST.
pendent part.  Frequently change the dressing, to give exit to
the blood and matter, using, however, no compression.
Venesection is recommended in the books, " to divert," as they
say, "the blood from the lungs."  But surely it is as well to
bleed to death through a wound in the chest as through one in the
arm! We are told that the bleeding "can hardly be carried too
far, for if the patient be not relieved by this measure, no other
can possibly save him." *-(Gibson, vol. i., p. 19.)  The reason
given for bleeding in such cases, is as.absurd as the process itself.
We are told by the same author to " draw blood copiously from
the arm, which will have the effect of diverting it from the lungs,
and thereby save the patient, perhaps, from suffocation." Now,
it is an anatomical absurdity to speak of diverting the blood from
the lungs by drawing it from the arm, as if the lungs and arm
were merely supplied by different branches from the same arteries. The blood going to the arm comes through the aorta from
the left side of the heart. The blood going to the lungs proceeds
from the right ventricle; hence it is obvious that by taking blood
from the arm, we act upon the systemic instead of the pulmonary
circulation, and cannot possibly influence the determination to the
lungs, or produce any diversion.  The only effect that we can
produce is to diminish the amount of venous blood returning to
the right side of the heart, which object could be accomplished by
a loss of venous blood from any portion of the body, and which
can be accomplished with far greater facility and efficiency by the
application of ligatures, without any loss of blood.
As the only object which the surgeon can hope to attain by
bleeding, if he understands anatomy, is not the diverson of blood
from the lungs, but a diminution of the total amount of blood in
the body, common sense would suggest the query, Why should we
make such efforts merely to diminish the total amount of blood,
when this loss of blood is the very evil and danger which is
threatening the life of the patient?
It is desirable, however, that less blood be thrown upon the
lungs.  Any means, therefore, that will retain a larger quantity
*Such expression are frequently used by old-school writers, who seem to
think that when they have reached the limits. of their knowledge, they have exhausted all the resources of science.



WOUNDS OF THE ABDOMEN.                   95
in the extreme vessels, or prevent its return to the heart and lungs
without permanent loss of it, ought to be resorted to without hesitation.  Such a means we have in hemastasis: * cording the
arms and legs so as to partially arrest the returning circulation,
without impeding the arterial flow, or using Dr. Junod's Haemostasic Apparatus.
Should severe inflammation arise, notwithstanding the use of
Aconite, Arnica, Calendula, &c., resort must be had to Bryonia,
Phosphorus, and such other remedies as are appropriate in the
treatment of inflammation of the lungs (for which see some Homeopathic work on practice).
A gentleman lived eleven years after having the chest transfixed by a gig-shaft. Both lungs were transfixed. The anterior
portion of the thorax of this patient is preserved as a specimen in
the Hunterian Museum.
WOUNDS OF THE ABDOMEN
are no less dangerous than those of the thorax. The amount of
danger will depend, of course, on the part and organ injured, but
any penetration of the peritoneum is likely, from its great vascularity and sensibility, to bring on serious inflammation.
When the intestines are wounded, nausea and vomiting generally occur, the matter thrown up, as well as the stools, being
bloody. Faecal matter and fetid wind pass out of the wound. A
portion of the bowel may also protrude. There is often griping
pain about the precordia.  Cold clammy sweats are among the
fatal symptoms.
Wounds of the small intestines present more dangerous symptoms than those of the large. Any part, however, of the intestinal canal may be injured, and recovery take place.
If an intestine has protruded, it will be too late to return it
two days after the injury. The only chance then is to leave it
open as an artificial anus.
The adhesive process goes on very rapidly in the intestines.
If there be no protrusion and no division of the bowel, no sewing
up is required. If it is cut for a considerable distance lengthwise,
and also protruded, one stitch for three or four inches is sufficient.
* See CoNcussION.



96              WOUNDS OF THE INTESTINES.
If it is quite severed, only two sutures are required, one opposite
the other. The smallest thread and needle should be used, with
as little handling as possible. And you need not be very nice about
bringing the edges together exactly in their natural coaptation.
They will unite in any part; and your turning and handling will
do more harm than some degree of displacement.
Keep the wound open and in a dependent position, dressing it
with lint wet with Aqua Calendule, to protect it from the air.
The patient must remain quiet for the first twenty-four hours at
least.  At each dressing, press upon the wound a little, to force
out the matter. After the second day the external wound may
be allowed to heal. For the first day let the patient eat nothing,
and as little as possible for some days after. Let his diet then be
cooling and unirritating. Every thing he takes should be of easy
digestion; solids had better be avoided altogether. Stimulants
of all kinds of course must be proscribed. Constipation should
be avoided by small injections of cold water.
After healing, the intestine may contract so as considerably to
diminish its caliber. This may give rise to colic-like pains in
the passage of its contents. In such a case great strictness of
diet must be observed. All indigestible things, such as raisinseeds, fruit-rind, had better be avoided, and the appropriate internal remedies employed.
In July, 1851, a boy, son of Mr. L., of Berlin, Erie co., aet.
13, while riding a horse, raking hay with a horse-rake, the horse
ran away with him and threw him upon the rake; a tooth, one
and a quarter inches in diameter, entered his abdomen about midway between the umbilicus and left anterior superior process of
the illium, passed through the colon, making a hole two and a half
inches long in it, tore off the peritoneal coat some distance further,
and emerged at the right ischiatic notch, passing through the pelvic cavity, penetrating through the rectum, and severely lacerating the sacral plexus.  The wound was dressed and treated by
Dr. G. S. Hill; -B. L. Hill, consulting surgeon.  The parts
were washed with a dilution of Tr. Calendula - half an ounce to
a pint of tepid water - this was made to run through the whole
course of the wound; the parts brought in contact and kept there
by straps, compresses, and bandages, and kept constantly wet with



WOUNDS OF THIE JOINTS.                 97
the same fluid. Arnica was given internally every four or six
hours for two days; then Calendula was given internally.
At first there was considerable depression in the circulation,
but reaction came on, and the pulse rose but little, if any, above
the natural standard, and the case went on; healing took place
by the first intention in all the parts except the opening at the ischiatic notch. Through this the faeces continued to pass, as well
as through the rectum, as in health. In a few weeks he was able
to walk about; still he suffered much from the soreness and chafing of the wound, by the passing of fecal matter, as well as a
neuralgic affection of the limb, in consequence of injury of the
sciatic nerve. After the healing of the upper wound, no further
medicine had been given for several weeks, during which time no
progress towards a complete cure seemed to have been made, but
the pain and soreness grew rather worse, and his general health
had failed very much; he was evidently fast running down.  Calendula Tr. in drop doses, once a day, was given, and no local application made. He began to improve from the first day, and in
about two weeks the wound had healed, and all symptoms of disease soon disappeared, since which he has enjoyed perfect health
(Oct. 1853).  The Calendula was continued daily for about ten
days.
WOUNDS OF THE JOINTS.
Injuries of the larger joints are almost as dangerous as any
in surgical practice.  The danger consists as usual in inflammation - which it is much safer preventing than trusting to cure.
The limb should be placed in the easiest position that will bring
the lips of the wound together, and be kept there perfectly still,
so as to avoid the necessity for suture. Adhesive straps will be
sufficient, if this point be attended to; but the patient must positively learn what we mean by "rest:" must not be allowed for
several days to move the affected parts at all.
If the KNEE joint is concerned, you should keep the limb extended, that your patient, in the event of anchylosis, may still be
able to walk, though with a stiff leg. The arm, on the contrary,
when it is the elbow that is affected, had better be secured in a
half-flexed position. The- danger in question results mainly from
13                                       (PART i.)



98                   BURNS AND SCALDS.
adhesion between the synovial membranes, on losing their contained fluid.  The joint should not be kept too long motionless.
As the wound improves, it should be gently exercised.
For other treatment see the different classes of wounds, and
consult the pathogenesis of Arn., Alum, Chin, Calen., Led.,
Nat. ML, NuxY Vom., Petr., Puls., Rhus.,  uta., Sep., Silic., Sulph.
The practice of scarifying, blistering and leeching, about the
wound, cannot be too strongly reprobated.
If inflammation should have progressed so far before you are
called that suppuration is unavoidable, it will be proper to make
such local applications as will induce or promote it. Retaining
the limb in an elevated position is an important auxiliary in restraining or preventing inflammation.
In cases of this kind, a most excellent local application to the
joint, for the prevention or moderation of the inflammation, and
one which has been eminently successful alone, in our hands, is
simply pure yellow clay kept moist with water, or dilute Arnica,
Calendula or Rhus. Tr., at the option of the surgeon.
Inflammation alone does not authorize amputation.  A stiff
joint is preferable to an amputated limb. Should the bones and
cartilage be extensively shattered, leaving little or no hope of restoration, while danger of tetanus is imminent, immediate recourse
to the knife and saw is justifiable, without waiting for inflammation. When we must operate, the sooner the better.
CHAPTER VII.
BURNS AND SCALDS
Distinction - Four degrees of Burning- Their respective symptoms and dangers
- Heat - Spirits -Rum and Molasses - Carbonate of Lead - Flour - Soap
- Ulmus Ful. -  ertica Urens - Internal Remedies -Prevention of Deformity.
UNDER this head are usually included all local injuries caused
by the application of heat. Scalds are distinguished from burns
by the mechanical state of the heated and heating substance; the
popular meaning of the words may be considered as the technical



DIFFERENT DEGREES.                     99
one.  All cases, then, caused by hot liquids are "scalds," while
"burns" proper are those produced by solids at a high temperature.  Greater injury may be done by oils and some other fluids,
as they can be heated above 212~, the maximum of temperature
for water under ordinary circumstances.  On this account some
writers would restrict the "scalding" to injuries done by hot or
boiling water. They are all, however, degrees of "burning;"
and the specific difference is better marked by the distinction of
solid and liquid, than by that of the chemical character or temperature of the substance inflicting the injury. The effect of a hot
liquid, or
Scalding, is likely to be more superficial, and is chiefly dangerous from the extent of surface affected.
Burns (including scalds) or the local effects of great heat, are
divided into several kinds or degrees.   Some distinguish four,
some five or six.
The first degree of burning is when there is only a slight irritation produced, with redness of the surface and the stinging or
peculiar pain, but without vesication, or with only.small vesicles,
the fluid in which is readily absorbed.  The inflammation, if any
is excited, terniinates in spontaneous resolution.  At worst, only
asuperficial dry scab is produced, involving little more than the
cuticle. There may, indeed, be considerable tumefaction, produced
by serous effusion in the cellular substance; but the effusion is absorbed, the swelling goes down, and the part returns to its natural
state and appearance, leaving no trace of the injury.
In the second degree, there is more redness of the surface in
the first instance, and this is succeeded by diffused vesication.
The serous fluid is not absorbed; and when the vesicle or vesicles
are broken, a purulent secretion from the surface takes its place.
Still there is no real ulceration, or destruction of parts, further
than the cuticle, and no necessity occasioned for granulation.
The skin is merely converted into a secreting surface, and may
continue to discharge pus for a considerable time. If exposed to
the air, a crust or scab will form, protecting the parts beneath,
and allowing a new cuticle to form there, as appears when the
scab falls off, and presents the surface restored, without a scar, as
in the former case.



100                   BURNS AND SCALDS.
In this form or stage of the burn, if care be taken not to
puncture the distended cuticle until purulent matter begins to be
formed beneath, the pain will be but slight, and the cure facilitated: but if by any accident or officious ignorance, the cuticle is
ruptured, and the raw surface exposed to the action of the atmosphere, the pain is oftenintense, and the danger from irritation
and inflammation may become very great.
In cases, otherwise of this character, where gunpowder or
other coloring matter is forced through, under the surface, it will
remain for a long time, as no sloughing occurs to carry it off.
The third degree is when the heat is so intense as, if not directly to disorganize the surface, to so far lessen its vitality as to
render destructive inflammation inevitable. If, however, the extent of the injury be small, and the patient's constitution good,
the ulcerative process will very generally terminate of itself, granulations form, and the surface heal up, leaving only an ugly cicatrix. But if the burn be large, much constitutional irritation will
generally attend it, and the granulations, instead of healthy, will
be of a fungoid character. The discharge also will be often excessive, and accompanied with an offensive smell. All these bad
symptoms will be worse, if there is much constitutional derangement.  Indeed, serious ulceration may follow the simple vesication, when the general health is very bad, but such a result is rare.
In all cases of ulceration from burns, the cicatrix remains red
and glossy for a long time after, or of a higher color than the surrounding surface, with a puckered appearance, which is permanent.
When the heat is so great as of itself to destroy the skin
(which some make a fourth variety), the pain is very great during
the whole progress of the case, and even continues after the cicatrix has formed.  The patient will be unable to use the part, or
the muscles and tendons passing near it, in consequence of the
preternatural susceptibility, especially if it were a part of a limb
that was burnt, and that be in a dependent position.  The tendons often contract, if near a joint, and when, in addition to this,
adhesions have been allowed to occur, the use of the part or limb
may be lost forever. These contractions and adhesions may not
occur, in some cases, till after cicatrization, the irritation still continning and producing a deposit of coagulable lymph.



PROGNOSIS.                      101
The fourth and last degree (in our scale) is the true or complete burning up of the part; vitality being at once destroyed
and disorganization effected. The cause of this is usually the application of some highly-heated solid substance, as white-hot iron.
The part itself being involved in flame or other burning substance,
will of course have the same effect. If this complete burning be
also extensive, it will be most certainly fatal.
The patient in this case experiences no pain for a time; at
least none after the first touch. The part is so effectually killed as
at once to annihilate sensibility. The burnt part is " burnt to a
crisp," leaving only an eschar. If there is sufficient power in the
system to react, sloughing takes place, the eschar is thrown off,
and a deep ulcer is formed.
The ulcer, in this case as in the last, is liable to suppurate
and excite, also, an unhealthy condition of the surrounding parts.
Not unfrequently abscesses will form there, with sinuses.  The
adjacent bones or joints soon become affected. The inflammation
excited is sometimes immediately followed by extensive mortification.
If the patient does not die before reaction comes on, the constitutional irritation produces hectic, and he soon sinks from exhaustion.
The danger depends much upon the constitutional vigor of the
patient, and upon the locality of the burn, as well as its extent.
Children are not so likely to recover from the effects of a scald
as adults, owing to the greater susceptibility of their nervous system.  Very small children are apt to be thrown into spasms, when
the effect upon the brain frequently proves speedily fatal. Very
old persons suffer much less than any others; but erysipelas occasionally follows, which is very difficult to control.  Erysipelatous inflammation is particularly to be apprehended, when the
head is the part affected.  When it is the abdomen, the inflammation is liable to extend to the vital organs beneath. A burn
or scald on either of these locations is always to be regarded as
dangerous, and proportionally more dangerous as the patient is
younger.  A  slight injury of this kind upon the scalp is to be
looked upon with suspicion; and you should take care to heal as
soon as possible when upon the abdomen.  Burns upon the geni



102                  BURNS AND SCALDS.
tal organs are very hard to cure, and give rise to strong constitutional symptoms, in consequence of their peculiar susceptibility
and great sympathy with all the vital functions. Upon the course
of the tendons, these wounds tend more than any others to produce contraction, and when nerves are also involved in the eschar,
or contraction, there will be danger, for a long time after, of tetanus or neuralgia.
Violent constitutional symptoms follow an extensive burn, let
it be in what part it may. There will, at first, be rigors, disturbed and oppressed respiration, and general depression, with a pulse
for a time low and feeble; but if there is sufficient vigor in the
system for reaction, the subsequent inflammatory fever is often
very violent.
Scalds, —unless when caused by hotter liquids than boiling
water, or unless the part should remain in the hot water long
enough to be itself boiled or cooked, — belong to the second degree in which nothing worse than vesication is the necessary result.  Generally, therefore, their only danger is from the extent
of surface involved. How large an amount of the cutaneous tissue may thus have its function stopped or changed, without thereby causing death, is not known. Some author has stated that life
could not be supported after one-seventh of the surface was vesicated; but we are sure we have had cases in which a much larger
fraction was not only blistered, but " flayed" away with the clothes.
The most important point of
TREATMENT
without doubt, in all kinds and grades of burns, is the keeping of
the surface entirely shieldedfrom the atmosphere.
Numerous applications "for burns and scalds" are in repute
with the profession or the public, some of them are as " specifics."
Many of them are really valuable, and we will mention a few, selecting those whose good effects we have had opportunity of testing, or those which, if not intrinsically superior to others, are oftener to be relied on, because universally accessible.  Not the best
possible, but the best practicable —the best under the circumstances of the case - is the rule for the medical man as well as
the moralist.



PROGNOSIS.                             108
In slight cases when the skin is not destroyed, it is best to ex.
pose the part for a short time to a moderate, dry heat, or apply
water as hot as the patient will bear.  When practicable, this can
best be done by immersing the part in hot water.  In either case
the heat should be constant. Warm spirits have been recommended, but will be  much  more  beneficial with  molasses.*   Prof.
Gross of Louisville (in his notes to the American reprint of Liston's Surgery), strongly recommends the application of carbonate
of lead and linseed oil, mixed as in common white paint; but this
should never be used, since fatal consequences have, and are likely to result from  the absorption of the lead.  Lime water, sweet
oil and soap, have been used with good results (see remarks on
soap). But the applications most beneficial and easiest applied,
are flour, soap (castile) or ulmus fulva.  Of these the flour is
most convenient, and from the testimony in its favor at least as
beneficial. As soon, therefore, as possible, after the accident,
oil the injured surface with sweet, or linseed oil (if the burn or
scald is severe, the linseed oil will be rather too severe), and
then sprinkle, or dredge with a common dredging-box flour over
it until every part is completely and thickly covered. The fluids
discharged, are absorbed by the flour and form it literally into a
" crust," beneath which a new cuticle is concocted, and resolution
readily effected, if the case admits of so favorable a termination.
* Rum and Orleans Molasses is a southern specific, which has been much extolled by several physicians. One of them assured one of the authors that he had
seen it used, with the happiest results, in the most severe cases, both of scalds
and burns. It frequently prevents vesication, and even discusses the inflammation where extensive vesication has previously been caused. In a few instances,
Dr. Hill made this prescription for the grocery instead of the drug-store; and
he says the result of its use has fully answered to its reputation. The spirits and
molasses should be intimately mixed, and applied cool, either by wetting an elm
poultice with the mixture, or saturating raw cotton or Canton flannel with it, and
then applying a covering wet with some article impervious to air, such as a solution of gum arabic.
We are informed by one of the oldest and ablest Homeopaths in Ohio (Dr.
Blair of Newark), that he has been in the habit of prescribing pure molasses for a
long time, as a specific for all forms of burns, with the happiest results. He applies it so as completely to cover the affected surface, and keep it constantly covered by rewetting the dressings with the molasses until all inflammatory action
has ceased.



104                 TREATMENT OF BURNS.
Should the flour fall off, or any part'become exposed, repeat the
application.
In the use of the soap, Dr. Tifft, of Norwalk, O., in a communication to the authors, states one peculiarity which is worthy
of especial notice.  He makes a stiff lather with shaving soap,
which he applies with a brush again and again, till he forms a
thick coat, a complete covering, to all of the injured part; over
this he places linen cloths, spread with a thick layer of soap.
This plan he has found far more successful than any other; it is
best to cut the linen in small strips, as it can thus be applied
more accurately to an uneven surface.  The same course should
be pursued at every subsequent dressing. By means of the brush
and lather, we can bring the soap in contact with every part of
the surface, no matter how uneven, which sometimes cannot be
done when it is spread on cloths. The application of the soap at first
rather increases the pain, but soon mitigates it; it also generally
prevents suppuration and those hideous scars. The frequency of
the removal of the dressings should generally be governed by the
state of the patient.  If there should be an exacerbation of the
pain after being relieved, apply another coat of lather. The ulmusfulva forms an excellent soothing shield from the atmosphere
for the injured surface, is adapted to any stage, and has, in many
cases, in our practice produced admirable results. The best way
is to make it into a poultice with the warm dilute tincture of Urtica Urens (or the dioica seems to have the same effect), and apply over the burnt or scalded surface. From time to time, a little of the liquid may be poured on so as to permeate between the
surface and the cataplasm. This is particularly beneficial where
there is extensive suppuration or sloughing. It allays the pain
and irritation, protects the surface from the action of the atmosphere, promotes the formation of healthy granulations, and is
the best vehicle for the application of the specific Urtica Urens.
After acute symptoms have subsided, simple dressings, such as
simple cerate, are all that is necessary for the ulceration. If high
febrile excitement comes on, give Aconite; also when the system
has received a severe shock from fright at the time of the accident; in this last case Opium is of service. But if the patient sinks
into a low state with feeble reaction, use Carbo Veg. and Arsenicum.



TREATMENT OF BURNS.                  105
If his nervous system is much affected, fever being present,
give Belladonna, or fyoscyamus. Cham. has proved beneficial in
convulsions from burns.  Tr. of Urtica Urens, regarded by some
as a specific, at a low dilution, we have found useful in very bad cases;
we always use it internally when we apply it externally. When
the suppuration is so extensive as to debilitate the patient, it
should be used in alternation with China.  If the ulcer becomes
fungoid, use Silicia, Arsenicum, Antimonium, Causticum, Sulphur,
or Petroleum.  The latter article may be applied with excellent
effect, undiluted to the surface of the sore. It will generally dissipate the fungous growths in a short time. When the fungus
remains obstinate, apply the Sesqui Carbonate of Potash in powder two or three times at intervals of a day or two, until the sore
assumes a healthy appearance.
An important caution for those who are not accustomed to
these cases, is to keep fingers, toes and other contiguous parts,
from coming in contact at the abraded surface. Another cause
of deformity to be guarded against, is the contraction of muscles
and tendons. For this danger you must study the anatomy of the
parts, and resist the tendency with suitable splints or other modes
of applying force, flexing or extending as the case may require.
When this precaution has been neglected, the case is not quite irremediable. The contracted tendons can be divided when necessary,
though we have hitherto only found it necessary in any cases that
have fallen into our hands for repair, to dissect away the adhesions.
Superficial deformity, by irregular formation of the new integument, is best obviated by proper dressing and attention during the healing process. This becomes an important consideration, when exposed parts of the body, as face, hand or neck, is
in question, —particularly in the case of females. A bad cicatrix may sometimes be divided or reopened by blistering, with a
fair chance of improvement.
14                                    (PART I.)



106                    EFFECTS OF COLD.
CHAPTER VIII.
EFFECTS OF COLD.
Frost-Bites and Freezing to Death-Recovery from suspended animationProgress, symptoms and results of Frost-Bites   Liability of particular parts
and persons-Precautions in restoring frozen parts-Efficacy of SnowChilblains- Variety- Liability - Relapse and chronic cases.
Too LOW a temperature is equally inimical to life with too high;
and indeed the ultimate effect of a "frost-bite" is very similar to
that of "a burn."  Some parts of the body will suffer from exposure to cold much sooner than others.  The peculiar stinging
pain of intense cold ceases after a while, and the part becomes
so entirely insensible that the individual knows not that he is partially dead.  Complete freezing to death comes on in a similar
way.  After the first ineffectual effort of the system to bear up
under the continual abstraction of heat, an irresistible sensation
of drowsiness comes on, and the sufferer feels only inclined to
rest and sleep. The sleepiness, however, is death in its most attractive and insidious form of approach. If the exposed person
be aware of his danger, he may bear up a long time by force of
will and muscular motion,  Snow being a bad conductor of heat,
and the surface of the body already reduced to its temperature,
vitality may be preserved longer by wrapping up in that natural
blanket than by resting in any other cold environment. Loss of
voluntary power and of consciousness is soon followed by a cessation of the organic functions: the lethargy becomes the sleep of
death.  This sort of death, however, may be only temporary; from
even this complete and dreamless sleep, the sleeper may be awakened, by a gradual restoration of the vital stimuli.
The essential difference between this sort of death and the
more common is, that it results rather from  a cessation of the
functions than a change necessitated by a greater or less disorganization.  It is a stagnation rather than an evaporation of life, so
to speak.  When an individual is found in this state of



EFFECTS OF COLD.                   107
SUSPENDED ANIMATION
from cold, he should be carefully removed to a cold room, where he
will be protected from the sliqhtest draught of air. If the limbs
have become stiffened, cover him over with snow, to the depth of
several inches, leaving only the mouth and nostrils free. As the
snow melts and runs off, it should be replaced with fresh. Should
there be no snow, the body of the patient may instead, be immersed in an iced salt-water bath for a few minutes. As soon as
all parts have lost their rigidity, carefully remove the clothing,
and rub the whole surface briskly with the snow or iced water with the
bare hands, until the skin becomes red. The patient should then
be well rubbed with dry flannels, wrapped up in a dry blanket,
and laid in a cool bed in a cool room. If he does not soon begin
to revive, small injections of tepid water containing a small portion of camphor may be given, and if necessary, repeated every
fifteen minutes, until symptoms of restoration, when an infusion
of browned coffee may be used instead of the former. As soon as
the patient can swallow, which he will often do instinctively, before perfect consciousness has returned, a little of the coffee infusion may be given, a teaspoonful at a time. A persevering application of the above course has been rewarded by restoration,
even when animation has been suspended for several days. A
person thus resuscitated, should avoid exposing himself to much
heat for a considerable time, as disease of the bones may be thus
induced.
Carbo Vegetabilis should be given in repeated doses for the
severe pains which generally follow a return of animation, and if
not sufficient followed by Arsenicum; Aconite will be of service,
if heat or stinging pains are felt in the head.
When a part of the body only has become insensible, and had
its organic functions suspended, or been, as it is said,
FROST-BITTEN,
the same principle of treatment is to be observed. If much heat
be too suddenly applied to the part, violent inflammation, if not
speedy gangrene, is almost sure to occur. The spontaneous re



108                   EFFECTS OF COLD.
storation of vital warmth, on' entering a warmer medium, is of itself painful and dangerous enough, and to be made as gradual as
possible.
The parts most liable to suffer first from cold, are those at the
greatest distance from the source of circulation, as the fingers and
toes; or most isolated from the general current, as the nose, ears,
&c.  The trunk of the body is not only protected by clothes, but
by its mass and the easy communication of heat from part to part,
in addition to the fact that the heat is conducted or radiated from
a much less proportionate amount of surface. The importance of
this distinction is very sensibly felt in the superiority of mittens
over gloves, for the mere purpose of warmth.  Hence one reason
for the instinctive drawing up of the body when suffering, or, as
it is said with mechanical correctness, shrinking from cold.
The first visible symptom of a part having been unduly exposed
to cold is not paleness, nor the florid redness of over action or inflammation, but a sort of livid or dull red, indicated by the expression, "looks blue."  This is accounted for by the stagnation
of venous blood, and the diminished quantity of arterial blood
attracted to the part.  Certain depressing emotions, or states of
mind, seem to be indicated as having a tendency to produce the
same effect upon the cutaneous capillaries. Shame reddens, but
chagrin or disappointment "looks blue."  The depressing or negative feelings are, as it were, internal cold.  Real physical cold,
however to a mortal degree, is the only thing that produces the
complete blue or "black looks."
If the exposure to cold, or abstraction of heat, still continue,
even the venous blood disappears, all the blood is thrown upon the
internal or less exposed parts, and the surface in question becomes
white, considerably contracted or " shrunk up," and quite insensible and motionless.  The part is in fact killed for the time, as
much as if it had "mortified," —only the process by which the
latter state is brought about is usually the very reverse, and necessarily irremediable. The deadening of a frost-bite is temporary, because it is merely functional, instead of structural. Its danger, after withdrawal of the cause, is, that structural disease, inflammation, and common mortification, will ensue on a too sudden
or on only partial restoration of vital temperature and activity.



EFFECTS OF COLD.                    109
This accident may happen much more readily to some persons
than others.  It is generally supposed that the degree of cold
must be below the zero of our common thermometer (or 320 below the ordinary freezing point of water), in order to freeze a part
of a living body. But the length of time the person or part has
been exposed, must be taken into account, as well as the state of
system at the time, in regard to food or fasting, clothing and exercise or the reverse, the general plethoric or active habit, and in
short, so many other circumstances, that no general rule can be
laid down.  One individual may have a limb or member of the
body frost-bitten, while those about him, exposed to the same
amount of cold and for as long a time, will scarcely suffer at all.
Indeed, the person who is said to "suffer the accident," does not
feel it after it has occurred, or always know what has happened
until he is told of it by others. If, however, it is a foot or hand
that has been frozen, he will discover the fact from the loss of
voluntary motion, as when the nerves are paralyzed. If heat is
not restored to the part, it may be regarded as already in a state
of sphacelus; and a sudden restoration, either of external or internal warmth, is very likely to bring on gangrenous inflammation
around the part.
Hlabit, as well as original vigor of constitution, has much to
do with a person's power of resisting cold. All know that individuals accustomed to wear gloves will suffer, from exposure without that protection, much sooner than those who habitually go
about with their hands bare. Individuals, living on the shores of
our northern lakes, are accustomed to wear boots without stockings, all the year round, and to work out in the open air through
the winter, handling their ordinary implements of labor, or stones
and metals, when necessary, without any covering on their hands.
Notwithstanding the present suspension of vitality, and future
danger in the restoration of a frozen part, it is well known that
not only small parts or members of the body may be restored to
life and health but that whole limbs which have become white and
quite brittle, may recover under a judicious course of treatment.
Though haste, in these cases, is more dangerous than delay,
no time need be lost, after the discovery of the accident. The direct effect of the cold, and the indirect influence of partial death,



110                CHILBLAIN OR PERNIO.
should not be allowed to continue and extend. Wherever the patient may be, the first and most indispensable measure for his
relief can be adopted.  The accident never happens but where
there is ice, if not snow, within reach. First, then, the rule given
by all authorities, and sanctioned by the greatest of authorities,
-universal experience, - is Homeopathic:
Rub the frozen part well with snow (where it is not to be met
with, smooth ice may do for a while). After a while, the snow
may be laid aside, and the part put into cold water, and there
rubbed first with flannel and then with the hand. All this while
the patient should be kept out of any room in which there has recently been a fire, and in an atmosphere not much, if any, above
the freezing point.'These precautions must be observed, and the
means spoken of continue to be used, until the parts become sensible, or feel natural again, which may require several hours of
constant rubbing. The patient will generally be thirsty, and it
will be well to have him drink frequently small quantities of cold
water. By so doing we have frequently seen persons, who were
just before suffering extremely from cold, break out into a warm
perspiration, with a genial glow of the whole surface.
By this management, the patient may experience no bad
effects from the freezing, further, perhaps, than a slight swelling
of the part, or desquamation of the cuticle as from a trifling scald.
In such a case the part should be treated by some soothing application. If the part concerned be a limb, it will generally be found,
though there is little sensible disease or suffering, to be much
weaker for a long time after.
CHILBLAIN OR PERNIO.
This troublesome affection is a peculiar atonic kind of inflammation of the skin, induced by partial freezing, or rather by too
sudden a change of its temperature, such as warming the feet or
hands at a fire when very cold.
Children and very old persons are the most liable to this species
or degree of "frost-bite," though it depends more on the degree
of constitutional vigor than on mere time of life. Scrofulous individuals generally suffer most from these affections, in consequence probably of their tender susceptibility to cold.



CHILBLAINS.                     11l
At first the skin is red or purple, in round spots of an inch or
two in size, and somewhat swollen, with a severe itching sensation,
very much aggravated in moist or damp weather.  In some instances vesications occur in the center, the skin around continuing
to wear the same purple or bluish aspect; at other times the inflammation proceeds to the extent of sloughing. A serous fluid
is generally discharged, or the mere swelling may become indolent,
when it is very difficult to cure.
But by far the most troublesome cases are those in which no
ulceration takes place.  This is most frequently the case where
the surface is protected by thick or horny cuticle, as on the ball
of the great toe, and the sides of the bottom of the foot. When
these parts become once affected, the patient is apt to suffer an
intolerable itching and burning, not only during the cold season
of the year, but still more in the fall or spring, when there is
much moisture on the ground, and whenever the feet get damp.
Although the patient's sufferings may often be palliated by
soaking the feet in hot salt water, and then rubbing them with
palm oil, and holding them for some time to the fire, any relief
obtained by this or other domestic means is only temporary; the
predisposition to the recurrence of the disease must be removed
by appropriate constitutional means.
The remedies most useful are Agar., Ars., Arn., Carb.  eg.,
Cham., Kali Carb., Lye, Nit. Ac., N'ux Vom., Petr. Phos. Puls.,
Rhus. Sulph.
When the inflammation is slight, with bright red swelling,
cracking and bleeding easily, and a burning itching when warm,
Nux Vom. will relieve.  Cycl. will also often be of service.
If the inflammation be caused by bruising or pressing upon the
affected parts, or the swelling be hard and shining, Arnica should
be used. In more severe cases, with severe itching, burning and
redness, Agaricus will be effectual. When the parts are swollen
and blue with itching and throbbing pain, aggravated in the evening or towards midnight, and the patient of a mild or phlegmatic
disposition, Pulsatilla is indicated.
When the inflammation is considerable, not so dark as that of
Pulsatilla, more of a bluish red, with a creeping tingling sensation,
temperament melancholic, at times vehement, Belladonna is to be



112                        ULCERS.
preferred. For these blue-red chilblains, with severe itching, Kali
Carb. is also a valuable remedy.  Sulphur is only suitable when
the violent itching occurs during warmth.
Nit. Ac., Petrol, and Phos., will also be found efficient in very
painful chilblains; the first two, especially, if the inflammation
sets in with very cold weather.
Rhus. when with the burning and itching there is a severe
stinging in the chilblains, obliging to scratch, after which pustules
arise.  When the pains are very violent, with severe burning, or
if blisters should show themselves on the inflamed parts, with a
tendency to gangrene, Arsenicum  alone, or in alternation with
Carb. Veg., should be used.
Should the inflammation degenerate into an ulcer, see Ulcers.
A lotion of the remedy given internally may be advantageously applied to the affected parts.
CHAPTER IX.
ULCERS -THEIR VARIETIES AND TREATMENT.
Definition and division —Boil or healthy Ulcer —Irritable and indolent Ulcers
contrasted- Varicose Ulcers-"  Specific Ulcers."
AN " ulcer" has been defined a chronic purulent solution of
the continuity of the animal texture.
Writers have generally divided them into a variety of classes,
according to their appearance, progress and effects. The division
here adopted will be sufficient for all practical purposes, though
not so minute as may be found in some of the books.
We would distinguish then these five kinds of ulcers: 1st, the
healthy; 2nd, the irritable; 3rd, the indolent; 4th, the varicose;
and 5th, the specific.
This last class includes a great variety, which will be considered separately, as we come to speak of the diseases or causes
which produce them.  As examples, we may here mention the
scrofulous, the syphilitic, the schirrous and the sinuous (or fistulous) ulcers.



THEIR VARIETIES AND TREATMENT.               113
1. As to the HEALTHY ULCER, it may be defined Hiberniee, by
saying it is no ulcer at all. It is a suppurative, but not an ulcerating, i. e., destructive process. The pus discharged by it is a
normal secretion.
Its surface has a florid appearance, without any offensive smell.
The pus is consistent and easily removed. The granulations are
small, and of a uniform size. It heals spontaneously and regularly, leaving little or no trace of having existed. Patches of
granulations may be early noticed, over the top of which is thrown
a delicate membrane or cuticle, which finally thickens and becomes true skin.
An example of the "healthy ulcer" is the common boil,which, if not an evidence of perfect health, is regarded, and no
doubt correctly, as the next thing to it,- a successful effort of
nature to throw off some slight obstruction or impurity. It may
appear on any part of the body, and occasions no difficulty further than the local pain and temporary inconvenience.
Treatment, as every one knows in the case of the boil, is little
more than the "let well enough alone" practice: a little salve to
protect it from the atmosphere, is all-sufficient.  The only true
"healing salve" is that which nature prepares for herself,healthy pus.
II. THE IRRITABLE ULCER
is very sore to the touch, and easily made to bleed. It generally
wears a dark purplish appearance, discharging but little matter,
and that of a thin, ichorous or sanious appearance, and sometimes
very foetid and corroding. Its imperfect granulations are spongy,
of a dark red hue, or having a whitish vesicular look, appearing
at different points, or leaving vacant spaces between them, and
often disappearing again by absorption. It is bounded by a sharp
undermined (or shelving) edge, sometimes ragged, nearly what
would be called in Botany, "serrated."  The parts around the
ulcer are swollen and reddened,- sometimes edematous.
The constitutional effects of this kind of ulcer are often very
great, and manifested by thirst, chills, and great nervous prostratration, as well as irritability. The pain at the part affected,
which is often great, is of a smarting or turning character.
15                                       (PART I.)



114                        ULCERS.
The worst result is, when the irritable ulcer becomes gangrenous.
THE INDOLENT ULCER
is in almost every particular the opposite of the irritable.  Each
can be best studied in contrast with the other.  Reverse the definition of the one, and you have that of the other.  The edges
of the sore, for instance, are now everted, instead of being inverted, as in the former case;. being, moreover, rounded and thick,
somewhat glossy and quite regular.  The granulations, instead of
being red and sensitive, are insensible and of a dull pale aspect,
with round flat heads, and generally located on the bottom of the
excavation: they have, in short, a fungoid character. The pus,
instead of being ichorous, is thick, of a dark yellow color, and so
firmly adherent to the base of the ulcer that it cannot be removed
without considerable force, and causing a good deal of pain (which,
of course, should not be done).
This kind of ulcer is the more important, inasmuch as it is the
most common form of "sore" which you will be called upon to
treat professionally; while it deserves your attention still more,
from the fact that it is an affection as rarely cured by the profession generally, as any that can be named, not in its nature incurable.  You must not think of turning off these "hard cases,"
though you will meet with many persons who have worn their old
ulcers for ten or twenty years, and exhausted in "doctoring" all
their funds, faith and patience, without the least benefit. If there
is in the whole catalogue of human sufferings, any disease in which
the superiority of one form of practice over another is plain and
palpable, it is this: our success in this class of cases, both before
and since embracing Homeopathy, has been truly gratifying.
Indolent ulcers most frequently occur on the lower extremities,
and much oftener in males than females (the latter seldom being
troubled with them, Anless in connection with a varicose condition
of the limb, of which we shall speak further on).
VARICOSE ULCERS
are so named, because always connected with a swollen or varicose
condition of the neighboring veins. In other respects, they may



ULCERS.                        115
present the characteristics of either of the other two contrasted
classes - may be either indolent or irritable. They are, however,
almost always extremely tender to the touch, and often very painful when the part is exercised. The pain indeed is occasionally
excessive, and the nervous system may become involved, even to
the extent of delirium.
Varicose ulcers seldom occur any where but on the lower extremities, and then only below the knee. Nearly all the smaller
veins, adjacent to the ulcer, are involved. The reddish brown
color of the sore extends to some distance around.  The ulcer
itself may be superficial, or deep and burrowing.
SPECIFIC ULCERS,
meaning those that result from some specific inflammation or disease, as scrofula or syphilis, will be considered in connection with
the disease producing them.
Wounds upon the lower extremities often degenerate into ulcers, and ulcers are often rendered intractable, not from any particular dyscrasia, but from the limb not being kept in the horizontal position until perfectly healed. The weight of the column
of blood retards the circulation, the capillaries thus become congested, and are hindered in the reparative process; such wounds
and ulcers, although before intractable, have changed to a healthy
character immediately upon a change of position.
Ulcers are sometimes also rendered irritable by the depending
position.  The minute nervous filaments that are so numerously
distributed upon and connected with the capillaries are put upon
the stretch, and irritated by the congested state of the blood vessels; a few days' maintenance of the horizontal position will remove this, and the use of an appropriate bandage will entirely
prevent its return. Hence the bandage, although usually contraindicated in irritable ulcers, is sometimes useful.
Another fact to be borne in mind, is that the continuity of the
skin is broken, and that it does not exert its accustomed pressure
upon the superficial veins. The value of this pressure may be
suspected from ulcers which have before shown no disposition to
heal, being completely and effectually cured by an artificial cutis,



116                        ULCERS.
i. e., drawing the edges together by means of successive strips of
adhesive plaster: hence one of the advantages of the bandage.
The local treatment of ulcers upon the extremities, consists mainly
in removing these mechanical obstacles to the cure. Whenever,
therefore, ulcers are situated upon the limbs, they should be kept,
as far as circumstances will admit, in a horizontal or even slightly
elevated position. This is particularly important in the irritable,
while they are such. In the majority of chronic ulcers, as it is
impossible for the patient to do this much of the time, a substitute
is provided in the strapping or bandage (for which, see next
chapter).
In all forms of ulcers, it is best to use, as a topical application to the ulcer, a solution or dilution of the same remedy given
internally. This is best applied by means of patent lint, or a soft
sponge.  The sponge is best in indolent ulcers, as by it we may
obtain a slight elastic pressure upon the granulations, which will
tend to stimulate them  to a healthy action.  It will sometimes,
however, be necessary to apply soothing applications to the irritable, exposing the limb'twice each day for half an hour to the
vapor, from a weak infusion of hops, or an effusion of tepid water,
and in the interval dressing with an emollient poultice, ulmus
fulva, linseed or the common carrot. The latter, grated and wet
with scalding water, makes an excellent one.  When the irritability arises from the distention of the capillaries, gentle compression, by means of a bandage wet with tepid, occasionally cold
water, will be very beneficial.  (See also Capsicum.)
Indolent ulcers, when very foul, should be cleansed with a few
applications of a weak solution of the Chloride of lime, or the
sesqui-carbonate of potash, before applying the remedy used internally.  At each dressing, the edges of the ulcer should be
drawn together by means of straps spread upon the ends with adhesive plaster, and over this should be the bandage.
In varicose ulcers, the engorged and enfeebled state of the
veins constitutes the most serious difficulty. To overcome this, the
bandage or strapping (see next chapter) is indispensable; sometimes the principal veins around the ulcer have to be obliterated.
For this, three plans are recommended: tying the veins, destruction
by caustic, and coagulating the blood by means of electro-galvano



ULCERS.                        117
puncture.  The obliteration-of the veins by ligature is much recommended, among other authorities, by Mr. Phillips, Surgeon to
the Marylebone Infirmary (London), but is condemned by Bransby
Cooper, Mr. Skey, and others. It is undoubtedly attended with
much more danger than the caustic. We have applied the potassa
fusa to each vein, from one to two inches from the ulcer. In the
cicatrix which is formed, the vein is effectually obliterated. No
fears need be entertained about the healing of the caustic ulcer
(as there must be in that of the ligature). Such a stimulus is
given to the part that it will only require simple emollient dressings. Mr. Skey, however, recommends three parts lime, and two
of good fresh caustic potash (Vienna paste), made into a paste by
the addition of spirits of wine, at the time of its application. His
manner of applying this is to take three or four layers of good
adhesive plaster, and make holes in them of about the size of a
pea, the number to be regulated by the extent and complication
of the disease; fix these firmly over the veins. Then fill the
apertures with the paste, and over each of them place a piece of
adhesive plaster. After twenty or thirty minutes, the whole may
be removed.
Any number of eschars, he says, may be made on diseased
veins, - that he has had as many as nine on one leg at a time, 
but that they should be all made at one operation. This treatment he regards, after several years' trial, as both efficient and
safe.  He acknowledges, however, that occasionally the ulcers
heal very torpidly, and that in one or two cases the disease of the
veins partially returned at the expiration of three years.  Galvano-puncture is certainly superior to the caustic, if the cures
effected by it prove as permanent. No artificial ulcers are produced, and the cure is less painful and more rapid. The operation is performed by inserting into the vein two fine needles, which
are connected with the positive and negative poles of a moderatesized galvanic battery. This causes the vein to fill with a firm
coagula of blood, without injuring its coats. The needles are best
made of gold or silver, and should always be insulated by being
covered, except at the points, with a varnish of shellac.
The magneto-electric instruments should never be used, as the
interrupted currents produce severe pain. Dr. Restelli prefers a



118                         ULCERS.
pile of many pairs of small plates, since less caloric is evolved,
while the coagulating power is increased.
He also thinks that, by inserting the needle in connection with
the negative pole, in direct opposition to the current of the blood,
its flow will thus be checked, and coagulation accelerated. Cases
will be given with those of ulcers in the next chapter.
Dr. Roth says that the tourniquet, applied for a few minutes
every day, will cure varices.
We come now to the most important part, the internal treatment.  The totality of the symptoms present, of each remedy,
must all be carefully considered in connection with the previous
medication and history of each case and the pathogenesis of the
medicament.  We can only give a few general indications.
The remedies found most generally useful are Asaf., Ars.,
Carb. V., Lach., Lyc., Mere., Puls., Sep., Silic., and Sulph.
For irritable, particularly Asaf., Ars., Bel., Caps., Lach, Lyc.,
Hepar., Graph., Merc., Mez., Acid M., Nit. Ac., Phos., Puls.,
Silie., Sulph.
Indolent-Acid Phos., Carb. V., Euphorb., Sang., Sep., Lach.,
Lye., Ars., Silic., and Sulph.
Varicose —Arn., Puls., Fluoric Acid, Kreos, Lach, Silic.,
and Sulph; also, Ars., and Phos. Ac.
When proud flesh forms in ulcers -  Sang., Sep., Ars., Petr.,
Silic., and Sulph.
Asafoetida. Ulcers with elevated bluish edges, discharging a
thin, ichorous, and fetid pus; painful upon pressure, particularly
those affecting the bones and venereal-mercurial ulcers.
Arsenicum, when the ulcer bleeds easily, is very painful, with
a severe burning, which sometimes changes to a tearing, when the
parts become cold; the edges hard, irregular, and everted; the
discharge is rather scanty, thin, offensive, and bloody, or blackish,
copious, very fetid and ichorous: also old ulcers, with red shining
areola, and a basis, which is either black, blue, or has the appearance of lard, and those with proud flesh and fetid ichor.
Belladonna, when the areola around the ulcer is inflamed
and painful; there is a burning in the ulcer, upon its being
touched, or at night, with lameness of the affected part; discharge
bloody and ichorous.  (See SCROFULOUS ULCERS.)



ULCERS.                        119
Carbo Vegetabilis is indicated by symptoms similar to those of
Arsenicum, except that the ulcer, instead of being inflammatory
in its character, is torpid, and entirely destitute of organic reaction. It is sometimes useful in alternation with Arsenicum, when
the ulcer is disposed to be gangrenous, the discharge very fetid,
and there is much exacerbation of the burning pains towards
evening, or at night.
Capsicum we have frequently used internally and externally
for those obstinate cases, when nothing else affords relief; such as
will be met with in ulcers on the legs of females who have been
affected with phlegmasia dolens.  The pain being of the severest
character and nearly continuous, smarting and burning as though
the part were enveloped in fire; the nervous system much affected;
chills and great prostration, with loss of appetite and great thirst,
being accompaniments.  For the external application, dilute the
tincture, leaving it strong enough to produce severe smarting,
and wash the ulcer freely with it. Though it first aggravates the
suffering of the patient, it will soon allay the burning and smarting.  It may be reapplied upon a return of the pain, and will
soon change it to a healthy ulcer.
Graphites is beneficial when the pain is of the itching and
smarting kind, with a feeling of pressure and sticking, the pain
being very violent, with a sensation as though the bone would be
broken when the limb is moved.
Fluoric Acid, in repeated doses, reduced to one-half their
former size, numerous varicose veins, of twenty years' standing,
on the left leg of an old man.
Kreosotum.  Scrofulous and varicose ulcers, particularly on
the feet of old people, secreting an acrid fetid ichor, bleeding
easily, the edges irregular and raised, looking as if corroded by
insects.  (See GANGRENOUS ULCERS.)
Hepar Sulphuris.  Ulcers with itching, corrosive, gnawing
pain; burning and throbbing at night; bleeds even when slightly
wiped; pus having a sour smell, as old cheese. If on a limb, the
pain is so aggravated by the depending position, that it is insupportable.  Sometimes follows Arsenicum, with advantage,
Lachesis.  Foul, flat ulcers, of various sizes, scattered over the
body with ichorous discharge: old, very painful ulcers, deep, foul,



120                        ULCERS.
uneven at the bottom; edges raised, pad-shaped; a spongy appearance; cannot bear to be touched or moved; burning pain at night,
palliated by bathing with cold water; tightness of the skin around
the ulcer, as if too short.  The leg sometimes of a livid, dark
brownish mottled appearance, enlarged, with numerous small ulcerating pustules around the ulcer.
Lycopodium. - Phagedenic ulcers; edges callous or everted,
with very great itching tearing pain, especially at night in bed,
and pus of a yellowish citron color.
M1ercurius. -Deep ulcers, disposed to spread rapidly, bleed
easily, very sensitive, least touch causing severe pain; base uneven,
of a dirty reddish or lard-like appearance; edges raised, irregular, serrated, varying in appearance, some parts red, shining, others
livid; pus thin and offensive; pains are generally burning with
stitches, sometimes shooting. Should there be also present an unequal quick pulse, restlessness, profuse night sweats, great nervousness and impatience from the slightest causes, it will be more
strongly indicated.
Muriatic Acid. - Ulcers covered with scurf, on persons whose
vital powers are much impaired, and disposed to become dropsical; very painful, with burning, more around than in the ulcer;
exercise causes a sort of throbbing in the ulcer; fetid, ichorous
pus.
Pulsatilla. - Flat, putrid, carious, varicose and easily bleeding
ulcers, surrounded by a hard, shining red areola, which is affected
with severe itching, pain in the ulcer of a stinging, biting-burning character, which is somewhat relieved by the pressure of the
bandage.
Sanguinaria. - Old, indolent, ill-conditioned ulcers with callous borders and ichorous discharge, and those disposed to the
formation of proud flesh.
Silicia. - Old, unclean ulcers on persons who have become
debilitated and cachetic, whether from abuse of mercury or drunkenness. It is often, in obstinate cases, advantageously alternated
with Sulphur or Sepia, and Nitric Ac.  It is useful when granulation takes place slowly and imperfectly, or proud flesh is disposed to shoot up. In ulcers with rough callous edges, the parts
around the ulcer, if on the legs, enlarged, bluish red, and hard,



ULCERS.                         121;
sometimes like bone; pain stitching and burning around the margin, but aching in the ulcer; pus either thick and discolored, or
thin, bloody, ichorous and offensive.
Sulphur, -in most all old ulcers, Scrofulous, Fistulous,
Psoric, Mercurial, &c., when there is a very strong tendency to
the production of proud flesh, and there is no distinct appearance
of granulations.  In the irritable, easily bleeding with raised,
swollen and sensitive edges, discharging a thin, fetid, ichorous or
sanious fluid, as well as those almost destitute of sensibility, surrounded with a dark bluish areola, the base covered with pale-red,
spongy, insensible proud flesh, with a smooth shining surface, and
discharging a thick yellow pus.  The Tincture of Sulphur, first
attenuation, one dose night and morning, is highly recommended
by Hartman for phagedenic and varicose ulcers.  He says it will
remove the itching and burning, and the inflammation around the
ulcer in a few days, though it generally takes a number of weeks
to cure the ulcers.
CHAPTER X.
CHRONIC ULCERS - "OLD SORE LEGS "-" FEVER OR BRANDY SORES."
Chronic Ulcers - Their frequency and supposed incurability — Description-'"Ought old sores to be cured?"  Old School treatment-Bandaging and
strapping-Therapeutic indications from Dr. Boenninghausen-Report of
Cases.
THAT the subject of ulcers may be as complete as possible, we
shall in this chapter call attention to another species or compound
of the ulcer genus, give the peculiarity of topical treatment,
and in addition to the remedies and their indications given in the
preceding chapter, quote from  that valuable work of Dr. Boenninghausen (Therapeutic Pocket Book, translated by Dr. Hempel), his remarks upon ulcers, and in conclusion give the report of
a few cases.
16                                      (PART i.)



122                         ULCERS.
This species we have designated by the truly descriptive, if
not very classical name of
OLD SORE LEGS!
That it is of more importance than any of the others, must
be evident, if for no other reason than for this, that it includes all
the others, -the same limb often producing specimens of the indolent ulcer, the irritable, the varicose, and perhaps, too, at the
same time, one or two in a tolerably healthy condition.
These cases will often be brought under your notice as "fever
sores;" and as they not unfrequently afflict those who are, or
have been, hard drinkers, they are also called, in many parts of
the country, "whisky" or "brandy sores."  Though intemperance, as this name implies, may have been the principal cause,
" signing the pledge," or even the keeping of it, will not always
be sufficient to obtain a remission of.the penalty. Physiological
sins are not pardoned on simple repentance. Medicinal means of
grace have been provided.
But, unfortunately, the sinners, or sufferers, lack faith in the
Old School ministry, and little wonder!  They have often gone
the rounds of the profession, consulted every doctor within their
reach, been treated or maltreated in hospitals and in private
hands; and if their general health, which is often tolerably good,
escapes this great additional danger, the only result is, that they
get resigned to. their original affliction as well as the disappointment, and can hardly be brought to believe there is for them any
"balm in Gilead,"-any hope from  surgery.  Few cases come
into our hands that are not of long standing. We have had them
ten, twenty, and even thirty years old.*
Although the patient is apparently well, and will tell you that
his general health is perfect, he is often more or less lamed (the
ulcers being deep), and suffers much, particularly at night. The
chief suffering is from the heated state of the parts, which is so
great that cold water affords no sensible relief, and you will often
find that, even in the coldest nights, he lies with the limb entirely
uncovered.  But grown accustomed to the evil, and faithless as to
any remedy, the sufferer makes no complaints and calls for no aid.
* In one case of thirty-five years' standing, where thousands had been spent for
medical treatment, a complete cure was effected in a little over twelve months.



ULCERS.                       123
His cure, however, is not hopeless, though he is past hoping for
it.  Of however bad a character and long standing may be the
case -and though all the "eminent" surgeons and doctors in the
country may have failed, —the Homeopathic surgeon need not
fail, and will not, if he carefully selects his internal remedies, and
faithfully applies the topical treatment as recommended in this
and the preceding chapter.
One peculiarity of these ulcers was alluded to: they are
often from an inch to an inch and a half deep. They often appear deeper than they really are, from the edges being raised, and
hardened by a deposit in the cellular tissue. Sometimes sinuses
are present, and retard the cure. The patient may suffer much
more, however, from the swelling, where there is no open ulcer
at all.
Aside from the character of the ulcers themselves- the condition of the limb is remarkable.  This is hardened as well as
swollen, and in some instances not to be distinguished by the
touch from  bone. Not unfrequently the patient will say that
Dr. somebody or other has pronounced it an incurable "enlargement of the bone," and thrown out a pleasant hint about amputation in prospect! Around the ulcers, and at other points where
ulcers have formerly existed,- sometimes the limb all over, from
ankle to knee,- it is as dark as a negro's leg: where the cuticle
scales off, as often happens, it leaves a shining, bluish or livid surface, which becomes white onpressure with the finger.
It is a popular opinion or prejudice, that if these old sores
could, they should not be cured!  This notable idea is often encouraged too, by professional men!  Is it to conceal their own
want of skill, or because they really have seen bad effects follow
the "cure" of such cases under their practice    Certainly no
physician will consider the mere external closure of a chronic ulcer as a cure, while the diseased state of the system which occasioned it, and which perhaps required it, remains uncorrected.
Physiology does not enumerate among the natural emunctories,
an artificial anus in the leg.  The human mechanism was surely
constructed to be kept in order without such a safety-valve as
that!  Restore the general health by proper constitutional means,
giving due attention to all the functions, secretory and excretory,
and there will be no danger whatever.



124                        ULCERS.
Nature will be able to preserve the general system without the
sacrifice of any particular part. Nor need there ever be any necessity for reopening the unfortunate ulcer, or setting up of a substitute in the shape of an artificial issue in some other part of the
body, as is the practice of some surgeons.  The drainage and
sewerage of the system are better provided for than they can be by
our art. Where, however, constitutional treatment is resorted to
by the old Alleopathic school of practitioners, it is often worse
than useless.  They are informed, indeed, by one of their greatest American lights, that "constitutional means often (!) exert
great influence (!!) over indolent ulcers." And what do you suppose is indicated as the very best of all "constitutional means?"
"In the words of the Philadelphia Hospital," continues the professor quoted,* "I have succeeded in numerous instances by the
use of blue pills, and other preparations of mercury, after most
other means had been tried for months ineffectually."
Iow much, or rather how little is implied by this expression,
"most other means," we may perhaps guess from what follows:
"where the patient's constitution has been prostrated by intemperance and other similar causes, the internal use of carbonate of
ammonia, wine, brandy, opium, &c., will prove of immense service;
indeed, in most instances, chronic ulcers cannot be healed without
the use of such remedies." These eight or ten lines include all
the constitutional treatment recognized as necessary by a distinguished teacher in one of the first Old School colleges in the
world!  The blue pill and other preparations of mercury, with
wine, brandy and opium!! When such a guide as that is blindly
followed by thousands, can we wonder at the consequences to the
tens of thousands whose lives and health are at stake?  Opium
and Mercury!  The former of these never-failing resources is
also recommended by Druitt, the author of a much esteemed
practical compend of English Surgery.  He tells us (p. 85) " to
begin with half-grain doses night and morning, and gradually increase to keep up the impression," —as of course we must to
a Chinese or Turkish extent, and probably never be able to leave
it off again, while it leaves life. Besides this often fatal inconve* Gibson's Surgery, vol. 2, p. 163.



ULCERS.                        125
nience, the use of the article as recommended is clearly contra-indicated by the very state of the system assigned as a reason or
excuse for giving it. We are encouraged to rely on this tempting
palliative, because forsooth "it acts on the surface!" as if its
certain secondary effects on the surface in those large doses, when
long continued, as in this case it must be, were not visibly the reverse of those designed! Who knows not the sear and dried-up
skin of the opium eater?
It is these partial and superficial views of disease, and the action of remedies, that occasion such frequent failures, and even
fatal errors. Not only has the general surface been for years in
a diseased condition, but the system at large is as plainly out of
order.  Yet opium  and mercury are to be prescribed! the former being certain in the end to lessen the healthy action of the
skin and other excreting surfaces, and the latter having a direct
tendency, when used as recommended, to derange the liver and
stomach, and through its constitutional influence aggravate the local difficulties already present. What ulcers are so ill-conditioned
and intractable as mercurial ones?
Not in a single instance is any application recommended for
the skin, - that most important and most neglected of the healthpreserving, and health-restoring organs, -no, not even soap and
water! Is it then surprising, that in these chronic diseases, under the old Alleopathic practice, the rule should be the failure,
and cure the exception? and that, in a large proportion of cases,
such doctoring should prove worse than unavailing - positively and
grossly mischievous?
Homeopathy keeps us from any such empirical practice, by
teaching us to carefully consider the totality of the symptoms
present in each case, and the selection of that remedy whose symptoms correspond most fully.
The peculiarity of topical treatment, consists in making use of
such mechanical appliances as will remove the mechanical obstacles to the cure.  The weight of the superincumbent column of
blood, retarding the circulation, tends to produce congestion of the
capillaries, and consequent tension of the filaments of nerves distributed over them. These difficulties are increased by the division of nature's bandage - the skin.  They are overcome by the



126                        ULCERS.
artificial bandage. It is true that they may also be obviated by confining the limb in a horizontal position. This is, however, impossible in the majority of instances, during the length of time necessary for the cure of these long standing cases, either from the circumstances or unwillingness of the patient. But if it were possible, it would be impolitic; depriving a patient of the advantages
of exercise in the open air, might injure his health. Besides, experience has shown that a cicatrix formed while the limb was kept in
the horizontal position, is not as firm as one formed where the limb
was exercised.  Some Homeopathic writers have said that "the
treatment of chronic indolent ulcers ought to be solely internal at
the commencement."  If the internal remedies are sufficient to overcome the mechanical obstacles, as well as remove the dyscrasia at the
commencement, and convert the ulcer into one of a healthy character, why not let them  complete the cure?  Why is it more improper to remove the mechanical obstacles to the cure at the commencement than at a later period of the treatment?
The bandage, for some time after commencing the treatment,
should be applied once or twice a day by the surgeon himself, so
that he may know that it presses equally upon every part.  Any
part left constantly uncompressed by unskillful bandaging, will
soon become sore, and probably break out in an ill-conditioned
ulcer. The pressure should be gentle at first, and gradually increased according to the feeling of the patient. If it acts favorably, the swelling will decrease, and the pus become thicker, and
more cream-like.
Fig. 1.
To apply the bandage, which should be about two and a half inches wide, begin with it at the extremity of the great toe, so as to
compress it equally all round. At the next turn include the second toe, and so on with the others, one at a time.  Then go on



ULCERS.                       127
smoothly and firmly all over the foot, first placing compresses in
the hollows round the ankle, so as to have equal pressure at every
point. Continue to the knee, or should the state of the limb require it, include even the thigh also. Let each layer of the roller
overlap the preceding for at least two-thirds of its width. Where
the limb is tapering (as just above the malleoli), it will not lie
smooth unless it is folded over itself and slightly changed in its
direction at almost every turn. When it reaches the knee, or as
high as you wish to go, bring it, in the same manner, down to the
foot again, taking care to bind it no tighter than before.
The limb may now be kept wet with cold or warm water, and
covered with flannel or oil silk to prevent evaporation (see preceding chapter).  When there is a hard, callous welt around the edge
of the ulcer, a compress of thin sheet lead over it, will hasten its
absorption.  When there are sinuses, they should be daily injected with a dilution of the internal remedy, after which, lint, wet
with the same, should be pushed into them until they are quite
filled. Where they connect, lay them open with a ligature.
With the appropriate internal and this topical treatment, the
ulcers will soon heal, but the cure is not complete so long as there
is any hardness or discoloration of the limb.
The limb should be daily bathed in cold water, and the bandage continued for some time after all traces of the difficulty have
disappeared.
The diet in these cases, needs generally to be nutritious, not
stimulating. And besides the sponge-bath, which should be universally used, if only for the purpose of cleanliness, a great advantage may be derived from the wet-sheet pack, and other invigorating appliances of Hydropathy.  The bandage has been sufficient in our hands, yet as there are cases in which we think Mr.
Scott's plan of
Strapping may be advantageous, we quote the directions for it
as given by Dr. Critchett in the London Lancet, vol. ix. He
says: "You must seat your patient opposite to you, and support
his foot upon a small stool about a foot and a half in height, and
so constructed as to receive the point of the heel, and leave the
rest of the foot free. You should be provided with strips of plaster, about two inches in width, and varying in length from twelve



128                        ULCERS.
to eighteen inches, according to the size of the limb. The best
material for this purpose is the simple emp. plumbi, of the Pharmacopoeia, spread upon soft, unglazed calico, and free from resin,
which is often introduced to increase its adhesiveness, but which
is very liable to irritate the skin. If the plaster be well made,
and of the best materials, it will adhere perfectly. I have often
found it unmoved for many weeks and even months. It is convenient to provide yourself with a metallic warmer, made with a
flat top, upon which you can lay three or four pieces, heated either
by hot water or by small lamps, which are better, if you require
it for any length of time.  This form of warmer is far preferable
to the circular one, ordinarily in use, saving both time and trouble.
But to proceed. You then take the center of the first piece, and
apply it low down to the back of the heel, and then with the flat
part of both hands, press the plaster along both sides of the foot,
This plan is preferable to taking hold of the ends, and endeavoring
to apply them, as it insures a perfectly smooth adaptation of the
plaster to the part, and also because it enables you to regulate the
amount of tightness, which is a very important point. As you
proceed with the remainder, you must always remember the principle is to make one portion hold on another; you must, therefore,
alternate them  round the foot and ankle. Your second piece
should be placed in a similar manner underneath the heel, then
carried upwards, at a right-angle to the last, so as to cover a portion of each malleolus. The third piece should be again applied
to the back of the heel, overlapping the first by about one-third.
The fourth piece under the foot and carried upward, each piece
being pushed along so as to allow it to take its own course; this
must be continued until the foot and ankle are enveloped. The
strips must then be carried in a similar manner up the leg, increasing
in length as the calf increases, and extending as far as the knee, and
in some few cases even above this. A calico bandage, about three
inches in width, and eight yards in length, varying, however, according to the size of the limb, must now be applied, to keep the
plaster in its place, and the limb is supported in the most complete
and efficient manner that human ingenuity has yet devised." In
small ulcers, situated in the hollow, between the malleolus and os
calcis, he directs, previous to the support just described, to apply



ULCERS.'I29
some pieces of strapping, about six inches in length, and two
inches in width, in a crucial manner, over the wound, so as to
extend a few inches above and below it.
For the selecting of internal remedies, see the remedies spoken
of in the preceding chapter, and carefully consult the following
indications as given by Dr. Boenninghausen.
"Ulcers in general.
Aeon. alum. ambr. amm. anac. ang. ant-crud. ant-tart, arg.
arn. ARS. ASAF. aur. bar. BELL. bor. bov. BRY. CALC. camph.
canth. carb-an. CARB-VEO. caust. chai. chel. chin. cic. cina. elem.
cocc. coff. colch. CON. creos. croc. cupr. cycl. dig. dros. dulc. euphorb. graph. guaj. HEP. hyosc. ignat. jod. ipec. kali. LACH. led.
LYC. mgs. m-arct. m-austr. mang. MERC. mezer. mur-ac. natr.
natr-mur. NITR-AC. n-mosch. n-vom. par. petr. PHOSPE. PHAC.
plumb. PULS. ran-bulb. ran-scel. RHUS. ruta. sabin. samb. sassap.
scill. sec-corn. selen. seneg. SEP. SIL. spong. STAPH. stram. stront.
SULPH. sulph-ac. tar. thuj. veratr. vit. zinc.
bruised, with pain as if.
Ang. ARS. cham. chin. cocc. CON. HEP. hyosc. natr-mur. n-vom.
rhus. ruta. SULPH.
biting (smarting).
Ars. bell. bry. calc. carb-an. caust. cham. chin. colch. dig. EUPHORB. graph. LACH. LED. LYC. mang. mere. mezer. natr. petr.
ph-ac. PULS. ran-bulb. rhus. ruta. selen. sil. staph. SULPH. sulphac. thuj.
-    black, turning.
Ant-tart. ARS. ASAF. bell. carb-veg. con. euphorb. ipec. lach.
mur-ae. PLUMB. sas. rhus. scill. SEC-CORN. SIL. sulph. sulph-ac.
-  -      on the bottom,
ARS. ipec. plumb. sil. sulph.
~- -. on the edges.
ARS. lach. sil. sulph.
-  bleeding.
Ant-tart. arg. arn. ARS. ASAF. bell. CARB-VEG. caust. con.
creos. croc. dros. HEP. hyosc. jod. KALI. LACH. LYC. mgs. MRC.
mezer. natr-mur. NITR-AC. PHOSPH. ph-ac. PULS. rhus. ruta. sabin.
seseon. sep. SIL. SULPH. sulph-ac. thuj. zinc.
17                                       (PART I).



130                         ULCERS.
Ulcers, bleeding on the edges.
ARS. asaf. caust. hep. lach. LYC. MERC. phosph. ph-ac. puls.
sep. SIL. sulph. thuj.
-   with blisters around.
ARS. bel. caust. hep. LACH. mgs. mere. natr. petr. phosph.
rhus. sep.
-  bluish.
Arn. ars. asaf. aur. bell. bry. calc. carb-veg. CON. HEP. LACH.
mang. mere. ph-ac. sec-corn. seneg. sil. staph. veratr.
-  boring.
Arg. aur. bell. calc. caust. chin. hep. kali. natr. natr-mur. puls.
ran-seel. sep. SIL. SULPH. thuj.
-  burning.
Ambr. ARS. asaf. aur. bar. bell. bov. bry. calc. carb-an. CARBVEG. CAUST. cham. chin. clem. coN. creos. dros. graph. HEP.
ignat. kali. lach. LYC. mang. MERC. MEZER. mur-ac. natr. natrmur. nitr-ac. n-vom. petr. phosph. ph-ac. plumb. PULS. ran-bulb.
RHUS. sassap. scill. sec-corn. selen. sep. SIL. staph. stront.
SULPH. thuj. zinc.
---         in the edges.
ARS. asaf. carb-an. CAUST. clem. HEP. lach. LYC. MERC.
mur-ac. petr. phosph. ph-ac. puls. ran-bulb. sep. SIL. staph. sulph.
thuj.
----   in the circumference.
ARS. ASAF. bell. CAUST. cham. hep. LACH. LYC. MERC. mezer.
mur-ac. natr. n-vom. petr. phosph. PULS. RHUS. sep. SIL. staph.
-   as if burnt.
Alum. ant-crud. ARS. bar. bell. bry. calc. CARB-VEG. caust.
ereos. CYCL. hyosc. ignat. lach. n-vom. puls. sabad. sec-corn. sep.
stram.
cancerous.
Ambr. ant-crud. ARS. aur. bell. calc. carb-an. carb-veg. caust.
chel. clem. con. creos. dulc. HEP. LACH. MERC. nitr-ac. phosph.
rhus. sassap. scill. SEP. SIL. spong. staph. SULPH. thuj.
cold, with a sensation of.
Ang. ARS. BRY. mere. petr. plumb. rhus. SIL. thuj.
-    -   with corroding (gnawing) pains.
Bar. bell. calc. cham. cycl. dros. hyosc. kali. led. lyc. mang.



ULCERS.                           131
mere. mezer. natr. phosph. ph-ac. PLAT. PULS. RAN-SCEL. rhus. ruta.
STAPH. sulph. thuj. VIT.
Ulcers, crusty (scabby).
Ars. bar. BELL. bov. bry. CALC. carb-an. cic. clem. CON.
GRAPH. hep. led. LYC. MERC. mur-ac. puls. ran-bulb. RHUS. sassap. SEP. SIL. staph. SULPH. viol-tr.
-    cutting.
BELL. CALC. dros. graph. ignat. lye. mur-ac. NATR. ph-ac.
rhus. sep. sil. sulph-ac.
-  deep.
Ant-crud. ars. asaf. aur. BELL. CALC. carb-veg. caust. chel.
clem. CON. creos. hep. lach. led. LYC. mgs. mere. mur-ac. natr.
natr-mur. NITR-AC. petr. phosph. ph-ac. PULS. rhus. ruta. sabin.
selen. sep. SIL. staph. stram. SULPH. thuj.
- digging.
ASAF. bell. bry. calc. chin. natr. phosph. ruta. sep. stront.
sulph.
drawing. (See Tearing).
- dry. (See Pus too little).
even (flat).
Amm. ang. ant-crud. ant-tart. ARS. ASAF. bell. carb-an. carbveg. chin. LACH. LYC. MERC. natr. nitr-ac. petr. phosph. PH-AC.
puls. ran-bulb. SELEN. SEP. SIL. sulph. thuj.
-    feeling, destitute of.
Anac. ARS. CALC. camph. carb-an. CARB-VEG. CON. dulc.
euphorb. graph. jod. ipec. kali. lach. LAUR. LYC. mgs. mur-ac.
nitr-ac. oleand. oP. phosph. PH-AC. plumb. rhus. sec-corn. sep. SIL.
stram. SULPH. vit. zinc.
-  fistulous.
Ant-crud. ars. ASAF. aur. BELL. bry. CALC. CARB-VEG. caust.
chel. clem. coN. creos. hep. lach. led. LYC. mere. natr. natr-mur.
NITR-AC. petr. phosph. ph-ac. PULS. rhus. ruta. sabin. selen. sep.
SIL. staph. stram. SULPH. thuj.
-- flat. (See Even).
gangrenous.
Ant-tart. ARS. ASAF. bell. carb-veg. con. EUPHORB. LACH.
merc. PLUMB.  ran-bulb.  SCILL. SEC-CORN.  SIL. sulph.
8ulph-ac.



132                        ULCERS.
Ulcers, with gnawing pain. (See Corroding).
-   hard.
Am. ARS. ASAF. aur. bar. BELL. BRY. CALC. carb-an. carbveg. caust. cham. chel. CHIN. cic. cina. CLEM CON. cupr. cycl. dulc.
graph. HEP. hyose. jod. LACH. led. LYC. MERC. mezer. natr. n-vom.
phosph. plumb. PULS. ran-bulb. ran-scel. selen. sep. SIL. staph.
SULPH. thuj. veratr. vit.
-       -- on the edges.
ARS. ASAF. bry. carb-an. caust. cic. cina. elem. HEP LACH.
LYC. MERC. petr. phosph. ph-ac. PULS. ran-bulb. sep. SIL.
staph. sulph. thuj.
~-  -   in the circumference.
Arn. ARS. ASAF, BELL. caust. cham. cina. hep. LACH. LYC.
mere. mezer. natr. n-vom* petr. phosph. PULS. sep sil. staph.
sulph.
with high, hard edges.
ARS. ASAF. bry. carb-an. caust. cic. cina. clem. hep. lach.
LYC. MERC. mur.ac. petr. phosph. ph-ac. PULS. ran-bulb. sep. SIL.
staph. sulph. thuj.
difficult to heal.
Alum. amm. bar. CALC. carb-veg. caust. CHAM. chel. clem. coN.
croc. GRAPH. hell. HEP. kali. LACH. LYC. magn. mang. MERC.
mur-ac. natr. NITR-AC. n-vom. PETR. phosph. ph-ac. plumb. RHUS.
scill. SEP. SIL. STAPH. SULPH.
-   hot. (See Burning and Inflamed).
-  jerking.
Arn. ASAP. aur. bell. bry. CALC. CAUST. cham. chin. clem.
cupr. graph. lye. mere. natr. NATR-MUR. nitr-ac. n-vom. petr.
PULS. RHUS. sep. SIL. staph. sulph.
inflamed.
ACON. ant-crud& asm. ARS. asaf. bar. BELL. bor. bov. BRY.
calc. caust. cham. cina. cocc. eelch. con. creos. croc. cupr. dig.
HEP. hyosc. ignat. led. LYC. m-arct. mang. MERC. mezer. natr.
nitr-ac. n-vom. petr. phosph. plumb. PULS. ran-bulb. RHUS. ruta.
sassap. sep. SIL. STAPH. sulph. thuj. veratr. vit. zinc.
-itching.
Alum. ambr. amm. anac. ant-crud. ant-tart. am. ARS. bar.
bell. bov. bry. calc. canth. carb-veg. CAUST. chain. chel. CHIN. clem.



ULCERS.                         183
con. creos. dros. GRAPH. HEP. ipec. lach. led. LYC. mere. mezer.
natr. natr-mur. nitr. nitr-ac. n-vom. petr. phosph. PH-AC. PULS.
ran-bulb. RHUS. ruta. sabad. sassap. scill. selen. SEP. SIL. STAPH.
SULPH. thuj. veratr. viol-tr. zinc.
tlcers, itching round about.
Ant-tart. ars. bell. caust. clem. HEP. LACH. LYC. mere. mezer.
natr. n-vom. petr. phosph. ph-ac. PULS. rhus. sabin. sep. SIL.
staph. suzph. vit.
-  looking like lard.
Ant-crud. ART. ereos. cupr. HEP. MERC. NITR-AC. sabin.
sulph. thuj.
~-  -~ on the bottom.
Ars. hep. MERC. nitr-ac.
-   with maggots.
Ars. calc. mere. SABAD. SIL. sulph.
old, opening again. (See Cicatrices).
painful. (See Sensitive).
painless.
Ambr. anac. ant-tart. am. ARS. aur. bar. BELL. bov. bry. camph.
carb-an. cham. chel. chin. cic. COCc. CON. croc. graph. hell. HYOSC.
ignat. ipec. laur. led. LYC. mgs. mere. n-mosch. n-vom. OLEAND.
OP. PHOSPH. PH-AC. plat. PULS. rhus. sec-corn. staph. STRAM.
sulph. veratr. zinc.
-  with pressure.
Camph. carb-veg. chin. GRAPH. par. SIL.
-  pricking.
Acon. alum. ant-crud. am. ARS. ASAF. bar. BELL. bov. BRY.
calc. camph. canth. carb-veg. cham. chin. clem. cocc. con. cycl.
araph. HEP. led. LYC. m-arct. magn. mang. MERC. mezer. murac. natr. natr-mur. nitr. NITR-AC. n-vom. PETR. phosph. PULS.
ran-bulb. RHUS. sabad. sabin. sassap. scill. selen. SEP. SIL. spong.
STAPH. SULPH. thuj.
--- -  in the edges.
ARS. ASAF. bry. clem. HEP. LYC. MERC. mur-ac.petr. phosph.
PULS. ran-bulb. sep. SIL. staph. SULPH. thuj.
-   -   in the circumference.
Acon. ARS. ASAF. bell, cham. cocc. hep. lyc. MERC. mezer.



134                          ULCERS.
mur-ac. natr. n-vom. petr. phosph. PULS. rhus. sabin. sep. SIL.
staph. SULPH.
Ulcers, with tingling.
Aeon. ant-tart. ARN. bell. caust. cham. CLEM. colch. CON.
croc. graph. hep. kali. lach. mere. natr. natr-mur. n-vom. ph-ac.
plumb. puls. ran-bulb. RHUS. sabin. sec-corn. SEP. spong. staph.
sulph. sulph-ac. thuj.
-  with flesh in the ulcer.
Alum. ant-crud. ARS. bell. carb-an. carb-veg. caust. CHAM.
clem. creos. graph. LACH. merc. PETR. phosph. sabin. SEP. SIL.
staph. SULPH. thuj.
pulsating.
Acon. am. ars. ASAF. bar. bell. bov. bry. CALC. caust. cham.
chin. clem. con. hep. hyosc. ignat. KALI. LYC. mgs. MERC. mezer.
mur-ac. natr. natr-mur. nitr-ac. petr. phosph. ph-ac. puls. rhus.
ruta. sabad. sassap. sep. SIL. staph. SULPH. thuj.
-pus of the ulcers. (See Suppurating.)
-   with pustules around
Acon. ARS. bell. CAUST. cham. hep. LACH. lye. mgs. mere. mezer. mur-ac. natr. petr. phosph. PULS. rhus. SEP. sil. staph. sulph.
putrid.
Amm. ars. asaf. aur. bell. bov. bry. CALC. carb-veg. caust. chel.
CHIN. cic. con. creos. cycl. graph. HEP. lyc. mang. mere. mezer.
MUR-AC. natr. nitr-ac. n-mosch. n-vom. phosph. PH-AC. plumb.
puls. RHUS. ruta. sabin. sec-corn. sep. SIL. staph. SULPH. sulphac. thuj.
with redness around.
ACON. ant-crud. am. ARS. ASAF. bar. bell. bor. bry. calc.
CHAM cocc. creos. cupr. IEP. hyosc. ignat. LACH. led. LYC. MERC.
mezer. natr. nitr-ac. n-vom. petr. phosph. ph-ac. plumb. PULS.
ran-bulb. RHUS. sassap. sep. SIL. STAPH. sulph. thuj. veratr.
zinc.
-  salt-rheum.
AMBR. ARS. calc. chin. GRAPH. LYC. mere. natr. petr. phosph.
PULS. SEP. sil. staph. sulph. zinc.
- scabby. (See Crusty.)
-  sensitive (painful).
Alum. amm. anac. ang. ARN. ARS. ASAF. aur. BELL. carb



ULCERS.                           185
an. CAUST. cham. chin. cic. CLEM. cocc. coff.. con. creos. croc. cupr.
dig. duic. GRAPH. HEP. hyosc. jod. LACH. led. LYC. MERC. mezer.
mur-ac. natr. natr-mur. nitr-ac. n-vom. petr. phosph. PH-AC. PULS.
ran-bulb. ran-scel. rhus. sabin. scill. selen. SEP. SIL. sulph. thuj.
veratr.
Ulcers, sensitive on the edges.
ARS. ASAF. caust. clem. HEP. LACH. LYC. MERC. mur-ac.
petr. phosph. ph-ac. puls. ran-bulb. sep. SIL. sulph. thuj.
~-  -~- in the circumference.
ARS. ASAF. bell. caust. cocc. HEP. LACH. lye. mere. mezer.
mur-ac. natr. n-vom. petr. phosph. PULS. rhus. sep. 8il.
-   suppurating.
Aeon. ambr. amm. anac. ang. ant-crud. ant-tart. arg. arn.
ARS. ASAF. aur. bar. BELL. bov. bry. calc. CANTH. caps. carb-an.
CARB-VEG. CAUST. cham. chel. chin. cic. clem. cocc. con. creos.
croc. dros. dulc. graph. hell. HEP. hyosc. ignat. jod. ipec. kali.
lach. led. LYC. mgs. mang. MERC. mezer. mur-ac. natr. natr-mur.
nitr. NITR-AC. n-vom. petr. phosph. ph-ac. plumb. PULS. ran-bulb.
ran-scel. RHUS. ruta. sabad. sabin. sassap. scill. sec-corn. selen.
SEP. SIL. spig. spong. STAPH. SULPH. sulph-ac. thuj. viol-tr. zinc.
-   scrofulous, of the glands.
Cistus canadensis.
-  with shocks in them.
Ang. ARN. cic. CLEM. mezer. mur-ac. plat RUTA. sulph-ac.
-   with pain as of soreness.
Alum. ambr. ant-crud. am. ars. bell. bry. calc. caust. cic.
GRAPH. HEP. hyosc. ignat. kali. lye. mgs. m-austr. MERC. mezer.
natr-mur. n-vom. phosph. PH-AC. PULS. rhus. SEP. sil. staph.
SULPH. sulph-ac. thuj. zinc.
spongy.
Alum. ant-crud. ant-tart. ARS. bell. calc. CARB-AN. carbveg. caust. cham. CLEM. con. creos. graph. jod. LACH. lyc. mere.
nitr-ac. n-vom. petr. PHOSPH. ph-ac. rhus. sabin. SEP. SIL. STAPH.
SULPH. THUJ.
---- on the edges.
ARS. CARB-AN. caust. clem. LACH. lyc. mere. petr. phosph.
ph-ac. sep. SIL. staph. sulph. thuj.



186                         ULCERS.
Ulcers, with white spots.
ARS. eon. LACH. phosph. sep. SIL. sulph.
-   speckled.
Arn. ars. CON. ipec. LACH. sulph-ac.
Ulcers, suppurating:
The pus being blackening.
Bry. chin. lye. SULPH.
-  -_ bloody.
Ant-tart. arg. arn. ARS. ASAF. bell. CARB-VEG. CAUST. con.
creos. croc. dros. HEP. hyosc. jod. kali. lach. LYC. mgs. MERC.
imezer. natr-mur. NITIt-AC. jhoph. ph-ac. PULS. rhus. ruta. sabin.
sec-corn. sep. SIL. sulph. sulph-ac. thuj. zinc.
--  - brownish.
Anac. ars. BRY. calc. carb-veg. con. puls. rhus. SIL.
-  -~ cheesy.
Mere.
--- too copious.
Aeon. arg. ARS. ASAF. bry. CALC. canth. chin. cic. creos.
graph. jod. kali. lyc. mang. MERC. mezer. natr. PIOSPR. ph-ac.
PULS. RHUS. ruta. sabin. scill. SEP. SIL. staph. sulph. thuj.
-   corroding (acrid).
Amm. anac. ARS. bell. calc. CARB-veg. CAUST. cham. chel.
clem. con. creos. cupr. graph. HEP. ignat. jod. lach. LYC. MERC.
mezer. natr. natr-mur. NITR-AC. n-vom. phosph. plumb. puls. RANBULB. RAN-SCEL. RHUS. ruta. SCILL. sep. SIL. spig. staph. sulph.
sulph-ac. zinc.
~ — ~fetid. (See Stinking).
-- -   gelatinous.
Arg. arn. bar. cham. ferr. mere. sep. SIL.
-- -- greenish.
Ars. ASAF. aur. carb-veg. CAUST. clem. creos. mere. natr.
n-vom. phosph. PULS. rhus. sep. SIL. staph.
gray.
Ambr. ars. carb-an. CAUST. chin. lye. mere. sep. SIL. thuj.
--      ichorous.
Amm. ant-tart. ARS. ASAF. aur. bov. cale. CARB-VEG.
CAUST. CHIN. cic. clem. con. creos. dros. graph. hep. kali. lyc.
mang. MERC. mur-ac. NITR-AC, n-vom. phosph. ph-ac. plumb.



ULCERS.                          181
ran-bulb. RAN-SCEL. RHUS. scill. sec-corn. sep. SIL. STAPH.
sulph.
The pus being lingering. (See Too Little).
~-     too little (tarrying, lingering, wanting).
Acon. ars. bar. BELL. bov. bry. CALC. earb-veg. caust. chin.
cina. clem. coff. creos. CUPR. dros. DULC. graph. HEP. hyosc. ignat.
ipec. LACH. led. lye. magn. MERC. n-vom. petr. phosph. PLAT.
plumb. puls. rhus. sassap. SEP. SIL. spong. staph. sulph. VERATR.
-   ~-  with maggots.
Ars. calc. mere. SABAD. SIL. tulph.
---   too much. (See Copious).
-- putrid. (See Stinking).
-     ~-. salty. (See Salt-rheum).
--    ~ smelling like old (rotten) cheese. (See Stinking)...-    ~.... like herring brine. (See Stinking).
of a putrid smell. (See Stinking).
----  of a sour smell.
Cale. graph. HEP. MERC. natr. sep. SULPH.
-- ~ stinking.
Amm- ARS. ASAF. aur. bell. bov. bry. CALC. carb-veg. caust.
chel. CHIN. cic. con. creos. cycl. GRAPH. HEP. LYC. mang. MERC.
mezer. mur-ac. natr. nitr-aa. n-mosch. n-vom. phosph. PH-AC.
plumb. puls. rhus. ruta. sabin. sec-corn. SEP. SIL. staph. SULPH.
sulph-ac. thuj.
stinking, like herring brine.
Graph.
---   -- like old (rotten) cheese.
HEP. sulph.
-- -- like tallow.
Mere.
----- thin.
Ant-tart. ASAF. carb-veg. CAUST. dros. jod. kali. lye.
MERC. nitr-ae. plumb. puls. ran-bulb. ran-scel. rhus. ruta. SIL.
staph. SULPH. thuj.
--   tenacious.
Ars. asaf. BOV. cham. CON. MERC. mezer. phosph. ph-ac. sep.
sil. staph. viol-tr.
18                                        (PART I).



138                          ULCERS.
The pus wanting. (See Too little).
--- watery.
Ant-tart. ARS. ASAF. calc. carb-veg. CAUST. clem. con. dros.
graph. jod. kali. lye. MERC. nitr-ac. n-vom. plumb. puls. RANBULB. RAN-SCEL. RHUS. ruta. scill. SIL. staph. sulph. thuj.
--       whitish (like milk).
Amm. ars. CALC. carb-veg. hell. LYC. PULS. sep. sil. sulph.
-- - yellow.
Aeon. ambr. amm. anac. ang. arg. ars. aur. bov. bry. CALC.
caps. CARB-VEG. CAUST. cie. CLEM. con. creos. croc. dulc. graph.
hep. jod. lye. mang. MERC. natr. natr-mur. nitr. nitr-ac. n-vom.
PHOSPH. PULS. rhus. ruta. sec-corn. selen. SEP. SIL. spig. STAPH.
sulph. sulph-ac. thuj. viol-tr.
Ulcers, swollen.
Aeon. arn. ars. aur. bar. BELL. BRY. cale. carb-an. carb-veg.
caust. cham. cic. cocc. con. dulc. graph. HEP. jod. KALI. led. lye.
mang. MERC. natr. natr-mur. nitr-ac. n-vom. petr. phosph.
ph-ac. plumb. PULS. RHUS. sabin. samb. SEP. SIL. staph.
SULPH. vit.
----- round about.
Aeon. ars. BELL. caust. cham. HEP. lye. MERC. natr. n-vom.
petr. phosph. PULS. rhus. SEP. sil. staph.
--   on the edges.
ARS. bry. carb-an. caust. cic. HEP. lye. MERC. petr. phosph.
ph-ac. PULS. SEP. SIL. SULPH.
tearing (drawing).
ARS. bell. bry. CALC. canth. carb-veg. caust. clem. cocc. CYCL.
graph. kali. LYC. imgs. MERC. mezer. natr. nitr-ac. n-vom. phosph.
puls. rhus. SEP. SIL. staph. SULPH. zinc.
tensive.
Arn. ASAF. aur. BAR. bell. bry. calc. carb-an. carb-veg. CAUST.
cham. chin. clem. cocc. CON. creos. hep. jod. kali. LACH. lye.
MERC. mezer. mur-ac. natr. nitr-ac. n-vom. petr. PHOSPH. ph-ac.
PULS. RHUS. sabin. sep. sil. SPONG. staph. STRONT. SULPII.
thuj. zinc.
-  tensive, in the circumference.
ASAF. bell. caust. cham. cocc. hep. LACI. lyc. mere. mezer.



ULCERS.                       139
mur-ac. natr. n-vom. petr. phosph. ph-ac. PULS. rhus. sabin. sep.
sil. staph. STRONT. SULPH.
Ulcers, with indented edges.
Hep. lach. MERC. PH-AC. sil. staph. sulph. THUJ.
with pain as of subcutaneous ulceration.
Amm. anac. arn. ars. ASAF. aur. bar. BRY. CALC. CARB-VEG.
chin. colch. CON. creos. cycl. dros. euphorb. GRAPH. hep. hyosc.
jod. kali. led. natr-mur. nitr-ac. n-vom. par. petr. PHOSPH.
PULS. RAN-BULB. RHUS. ruta. sassap. sec-corn. SIL. staph. SULPH.
valer. veratr. zinc.
Varices.
AMBR. ANT-TART. ARN. ARS. calc. CARB-VEG. CAUST. coloc.
CREOS. FERR. GRAPH. LACH. LYC. M-AUSTR. magn. NATR-MUR.
n-vom. PULS. sil. SPIG. SULPH. sulph-ac. thuj. ZINC.
-   suppurating.
Ant-tart. ARS. creos. LACH. LYC. PULS. SIL. sulph.
-inflamed.
ARN. ARS. calc. creos. LYC. n-vom. PULS. sil. spig. SULPH.
thuj. zinc."
REPORT OF CASES MOSTLY FROM THE BRITISH JOURNAL OF
HOMEOPATHY, AND RUCKERT'S THERAPEUTICS.
Arsenic cured the two following cases as reported by Dr.
Miller (Hygea xi., 108):
" The wife of a rope-maker, aged sixty-five, had been affected
with an ulcer of the foot for eighteen years. A great many physicians and quacks had treated her in vain. I had treated her
myself in 1830, according to the principles of the old school.
The disease began in the left foot, near the ankle, by the formation of small, pustular elevations, which burst, and discharged a
clear, acrid fluid, and formed an ulcerated surface, which gradually encroached on the neighboring healthy skin, till it reached
the size of two hand's breadths.  It grew gradually more foul
and fetid, and the pains, which were at first more tearing and
drawing, became at length sharp and burning.  The patient had
been confined to bed for the last two years; the foot was edematous, and the swelling increased almost daily; and also the foot



140                       ULCERS.
swelled often. The patient was becoming visibly thinner, her appetite declined, and she had a cachetic appearance. I treated
her for nine weeks with Arsenic 8, a dose every other day;
upon this she gained strength daily, and the ulcerated surface
gradually diminished in extent and dried up, the burning pain
subsided, so that in the fifth week she was able to be up half the
day, and at the end of thirteen weeks was able to resume her
usual occupations."
"I treated in the same way a man aged twenty-three, affected with a psoric ulcer on the foot, arising from suppressed itch.
He had been treated for two years with outward and inward remedies, but the disease had at last gained such a height that amputation was proposed. At first the ulcer had been covered with a
scab, from under which oozed an acrid fluid, and the edges were
thick and surrounded by scabious pustules; but latterly it displayed a foul blackish surface, almost insensible, discharging a
fetid ichor, and was in fact sloughing. By the use of Arsenic,
used as above, the patient was quite cured in seven weeks."-B.
J. Hom., vol. iv., p. 356.
"Arsenicum  30, 2 pellets, removed black-blue ulcers, surrounded with a shining red border, one being situated on the
front part of the thigh, one in the bend of the knee. The swelling hindered walking.  The ulcer in the bend of the knee
required two more doses of Arsenic to complete the cure. -A. H.
Z. vii., p. 327.
Arsenicutn 30, one dose, was effectual where the following
symptoms were present:
The whole body, except the face, was covered with small, ichorous ulcers, painful and burning when becoming cold; the pain
is somewhat relieved by warmth. Emaciation; great exhaustion;
every kind of food causes a pressure in the esophagus, as if it
had been arrested there. Restless sleep; fever every day; first
chilliness, afterwards heat, and lastly sweat; mind full of uneasiness and despair. -Arch. p. 156.
Graphites 30, commenced the cure of an ulcer on the foot of
a female, which was completed by Lycopodium.
Symptoms: a flat herpetic ulcer of the skin, in the region
of the ankle, on the whole anterior surface of the tarsal



ULCERS.                       141
joint; it secretes a good deal of ichor, and is bordered with small,
irritable ulcers, penetrating deep into the skin, and looking like
pustules when making their first appearance. Violent itching and
smarting; pains in the whole ulcer, accompanied with chilliness
and extending up to the knee. The ulcer suppurates a good
deal at the time of the menses. Frequent alternation of costiveness and diarrhea.
Graphites 30, and after a long interval Sepia 30. Symptoms: Ulcer on the dorsum  of the foot, covered with impure,
ichorous pus, having a fetid smell; red granulations on the base
of the ulcer; callous edges, very painful to the touch. Constant
lancinating pains in the ulcer, especially in the night and forenoon.
The foot is swollen, blue-red around the ankles and hot, accompanied with a chilly feeling in the foot.
Lachesis, valuable in old ulcers of the foot: one or two doses
of Lachesis 30, brought on a rapid cicatrization of several
ulcers on the leg, having a dirty appearance. -Arch. xiii. 2, p.
102.
Lachesis 12, three times a day, followed in a week by Arsenicum 12, repeated in tfhe same way, produced a rapid healing
of a varicose ulcer of twelve month's standing, after lower attenuations were ineffectual.
The ulcer was over the right ankle joint; the pain accompanying it was intense and burning, preventing sleep at night. -
Brit. J. Horn. vol. x., p. 667.
Lycopodium 27, one-fourth of a drop removed an ulcer on
the leg which came on after a-knock in the region of the inner
ankle; became deeper and deeper; had callous edges; secreting
a fetid, impure ichor; finally occupied the whole of the tarsal
joint, and caused violent burning pains, especially at night. —
Ann. iii., p. 196.
Lycopodium has been beneficial in malignant, inveterate ulcers
of the foot, phagedenic ulcers generally occupying the legs. In
one case repeated doses of the 15th attenuation were given at the
commencement; afterwards one drop of the 30th.  Symptoms:
The left leg was covered with a multitude of ulcers; they are all
of them flat, and do not penetrate through the skin; edges red,



142                        ULCERS.
hard, shining, raised.  The base has a dirty-yellow appearance,
greenish, bluish, pale red. Pus copious, watery, ichorus, fetid,
diminishing when at rest, and yellowish. The ulcers are surrounded with a blue-red, hard, hot, painful border; the leg and
foot are thick and swollen, hard shining, red, inflamed. The
pains are partly tearing, partly lancinating; sometimes there was
a continued aching, which was almost insupportable in the night
and in bad weather. Likewise ulcers on the right leg and forearm.-A. H. Z. v., p. 195.
Mere. Sol., one-twelfth of a grain, cured an ulcer upon the
tongue in sixteen days.  Symptoms: On the edge of the tongue
there is an ulcer of the size of a bean; along the adjoining parts
of the tongue, in the substance thereof, there are several hard
nodosities, and a deepening resembling an incision. The base of
the ulcer looks gray, reddish, uneven, secreting a fetid matter;
the edges are hard, elevated, of a blue appearance; burning in
the ulcer. The tongue is swollen, coated white, speech unintelligible. Ptyalism; fetid odor from the mouth. The edges of the
gums are bright red, inflamed, standing off from the teeth, swollen in'several places, bleeding frequently, tearing toothache at
night. The vermillion border of the lower lip is covered with
small painful pimples having brownish crusts.  Hot water was
used to rinse the mouth.-A. h. Z. v., p. 231.
Psoricum 6, has cured ulcers of the lower limbs, with intolerable itching over the whole body.-A. h. Z. ii., p. 192.
Psoricum 30, and Anthracin in alternation, cured ulcers on
the leg and tibia of an old man.-A. h. Z. v., p. 64.
Rhus 30, four pellets, followed in six days with three pellets, cured
a patient with the following symptoms: Gradually the whole body
except the head, chest and back, became covered with large and small
vesicles, containing a clear, yellow fluid, and itching considerably.
The opened vesicles had become gangrened ulcers, secreting an acrid,
fetid ichor, which was likewise secreted from the inner surface of
the toes. Continual and violent fever; pulse small and quick. The
whole head, especially the face, was bloated and red, with edema
of the lower eyelids and the penis. The throat was somewhat
swollen, making deglutition difficult. Stool delaying, but every



ULCERS.                       143
day.  Urine suppressed, scanty, turbid and brown. Little appetite; much thirst, disposition impatient; out of humor.-Pr.
Cor. i., p. 172.
Silicea 18, smelling, repeated in three weeks, ulcer of the
foot, the original cause of which was congelation.  Symptoms:
Deep ulcer on the dorsum of the foot, with an impure base; the
wound, which secreted a quantity of thick jelly-like mucus, being
covered with a quantity of spongy and readily bleeding flesh.Arch. vii. 2, p. 46.
Silicea 30, one dose, cured an ulcer of the tibia, which was
brought on by a previous violent inflammation; the ulcer secreted
a quantity of fetid ichor. The periosteum appeared injured and
the bone to be affected.-Arch. viii. 1, p. 23.
Silicea 30, two pellets, and in six weeks Sulphur-Ulcers
of the leg brought on by vesicular erysipelas. Symptoms: Swelling of the legs up to the knees; seven ulcers, partly open, partly
bordered with indented crusts, having a bad appearance and secreting a cadaverous ichor; burning pains, especially in the night;
intolerable itching round the ulcers, obliging one to scratch, which
is followed by burning as of hot coal, and bleeding of the scratched parts.-Arch. viii. 3, p. 57.
Silicea 3, one grain —Ulcer on the leg, brought on by a
blow.  Symptoms: Round ulcer below the patella, over the upper
extremity of the tibia; the ulcer had penetrated down to the bone.
The base of the ulcer was dirty bluish-red. Copious secretion of
a sanguineous, thin fluid; stitching pains in the ulcer, especially
at night; the margin and the surrounding parts of the ulcer
were sometimes itching and somewhat burning.
Silicea in repeated doses has proved curative in the following
cases: Symptoms: Unimportant external injuries bring on widespreading, erysipelatous, or deeply-penetrating asthenic inflammations, followed by a troublesome suppuration; a fetid, sanguinolent, badly colored, yellowish ichor is secreted from fistulous
openings; slow separation of dead fetid pieces of cellular tissue,
muscles and tendons, of a dirty color, partly penetrated by tenacious yellow pus. There remain open ulcers penetrating down to
the bone, and surrounded by shaggy callous borders; the ulcers



144                        ULCERS.
refusing to heal, with vanishing of strength; the adjoining soft
parts are swollen, hard bluish-red. —A. H. Z. v., p. 326.
Sulphur, three doses, cured ulcers on the ankle of an old man,
situated at a place which had formerly been occupied by varices,
with stitching pains, especially at night.
Sulphur 30, one dose, cured three psoric ulcers on the tibia
in three persons. —Arch. xi. 2, p. 115.
Sulphur 3Q, three doses, in a fortnight; ulcer on the foot.
Symptoms: Inflammation in the region of the tibia after a bruise;
this results by the formation of a flat ulcer, with raised edges and
secretion of a quantity of benign pus. The ulcer is surrounded by
small itching pimples.  There is a similar, but smaller ulcer in
the region of the left tarsal joint.,-J. d. h. H. i., p. 155.
Sulphur, three doses, removed in five weeks an old, fetid, deep
ulcer, on the inner ankle, secreting a thin ichor, and surrounded
by some swelling. - A. h. Z. iv., p. 15.
Galvano-puncture. - " A miller in good health was received
into the hospital at Varese, with considerable enlargement of the
trunk of the vena saphena above the knee, and ten knotty dilatations, varying in bulk from the size of a bean to that of a nut, below the knee.  The pain and weakness of the limb were so great,
that he had been obliged to give up his occupation.
" August 3d, 1846. M. Milani, having bandaged the leg above
and below the spot chosen for the operation, inserted two steel
needles into one of the dilated knots, and brought them into comr
munication by means of copper wires, silvered, with the two poles
of a voltaic battery of twenty-six pairs of plates, two and a half
inches in diameter.  At first the patient suffered a slight shock;
afterwards, merely a sensation of burning. The needles were left
in the vein for twelve minutes, when a hard clot had formed around
that in communication with the zinc or negative pole, cold water
and vinegar were applied to the part.
August 4th. Needles were introduced into the saphena above
the knee, and into the varicose enlargements below. A battery
of twenty-six pair of plates was connected with the upper needles
(Dr. Milani tried one of thirty-one plates, but the patient could not
bear it;) another of twenty-four plates, with the needles inserted,



OSTITIS.                       145
below the knee.  Hard clots were produced in the veins of the
leg and in the saphena, blocking up the latter for two or three
inches. Subsequent operations upon the remaining varices proved
equally successful.
"In ten days all the varicose dilatations had disappeared.
Although the points of the two needles were never in contact, and
they were covered with a varnish of gum lac, which left only their
points bare, a slight areola of cauterization had taken place round
each puncture, the extent of which was greater around the negative pole.
" In a second patient, still under treatment at the time of the
report, a tumor as large as a goose's egg, near the internal malleolus of the left leg, filled with coagula under two applications,
and diminished two-thirds in volume."   Chapman on Ulcers,
pp. 149-150.
CHAPTER XI.
DISEASE OF BONES.
Inflammation and Ulceration of Bone - "Caries and Necrosis "- Causes, Constitutional and Exciting - Symptoms - Stages - Diagnosis - "Bone-pus "-Probing - Prognosis -Treatment.
BONES in their healthy state are hard, smooth, and destitute of
sensibility. But, like soft parts, they are liable to become inflamed,
and be far more painful and distressing than ordinary inflammation  the pain is deep-seated, worse at night —attended with
swelling, heat, and often redness of the parts. This nightly exacerbation is specially prominent, if the inflammation arises from
syphilis or abuse of mercury.
The inflammation of bones may be developed in an acute or
chronic form, and, if not resolved, may proceed to adhesion, suppuration, ulceration and mortification. It may be located in the
periosteum, or in the substance of the bone. If the periosteum is
the part inflamed, the progress of the disease.is much more rapid
19                                    (PART I.)



146                        ULCERS.
than if the bone alone is affected. The swelling and pain also comes
on then, very rapidly. The latter being caused principally from
the periosteum being put on the stretch by the effusion which takes
place between this membrane and the bone.  An incision into it
will remove the tension, and afford great relief.
In chronic inflammation, generally arising from mercurial poisoning or scrofula, the progress of the disease is slower. The pain,
at first, is dull, heavy and deep-seated, worse at night or upon
pressure; as soon as matter is formed the pain becomes throbbing,
and rigors are felt. The skin over the abscess becomes discolored
when deep-seated, as suppuration takes place and enlarges the
cavity of the abscess, there is a deposit of bony matter on the outside, so that the bone continues to enlarge until an opening is
made for the exit of pus, either by ulceration or mechanical means.
The condition called Caries, is the same as ulceration in soft
parts; while by necrosis and exfoliation are both meant the death
of bone. The former being internal and more complete, usually
arising from inflammation of the medullary membrane; the latter
external but partial, the consequence of inflammation of the periosteum.  Caries may take place in any of the bones or at any
period of life, but most frequently occurs in young subjects. The
tarsus, carpus, sternum, vertebrae and extremities of the long bones,
are usually the ones involved.
The general causes to be noticed in our day, are the syphilitic,
mercurial, and scrofulous affections. Thousands have died from
the two former being confounded.  The pathogenetic power of
mercury has been proved on a tremendous scale.
The admissions of so distinguished a surgeon as Bransby
Cooper on this point, are worthy of careful consideration. He
says, p. 179, " Syphilis is supposed to be a frequent cause of caries,
but it is a matter of question whether the caries so often concomitant with syphilis, does not in fact result from the action of the
mercury given to cure the specific disease."
Again, p. 180, "I have used the term'syphilitic taint' again
and again, but I am not sure that I have done so advisedly, for it
is doubtful if this caries in bone does not result from the use of
mercury, and not from syphilis. Whoever heard of a person having
diseased bones in syphilis, unless mercury had been given? Sailors



ULCERS.                        147
have often been known to become infected immediately before embarkation, to have made a long voyage, and not to have taken any
medicine, what is their condition?  Extensive ulceration of soft
parts, propagated perhaps by inoculation on the thighs and scrotum,
but no disease of the bones. Why then do we recommend mercury
when caries has commenced?  The answer is, I admit, difficult,
I can only say, that this is one of the few instances somewhat corroborative of the truth of the homeopathic hypothesis."  [The italicising is ours.]
Necrosis, or mortification of bone, may involve only a limited
portion of bone, or it may extend to the whole shaft. It generally
affects the tibia, femur, clavicle, humerus, inferior maxilla, radius,
and ulna. It is seldom met with earlier than ten or later than
thirty years of age, except when it attacks the inferior maxilla.
Violent inflammation of the periosteum or anything which affects
the substance of the bone or the medulla, so as to prevent the proper nourishment of the bone, may cause necrosis. A simple fall
on the feet is said to have caused it.
When a portion of bone becomes necrosed, the surrounding
parts throw out lymph, this is changed to cartilage, and the cartilage to provisional bone, by deposition in it of ossific matter.
As in mortification of soft parts, a line of demarcation is formed
separating the dead from the living tissue. The living bone throws
out granulations while the necrosed bone or Sequestrum is gradually dissolved and absorbed, or discharged in the form of pus, through
the openings which nature generally leaves in the provisional
bone.
Pus, from diseased bone, may be easily distinguished by one
who has had any sensible experience of it; its very offensive odor
is quite characteristic. Touch is, however, a better test of diseased
bone than smell. Apply the finger whenever possible, or probe.
If the surface of the bone be felt rough or uneven, with loose pieces,
or can be seen to be either much whiter or darker than natural,
the case is clear. If the suspected part of the bone can not be
reached, by subjecting the pus to a chemical examination for phosphate of lime, it will be easily determined whether the pus is from
diseased bone or not. In healthy pus there is scarcely a trace of
this phosphate, but in that from bone an appreciable quantity will



148                         ULCERS.
be found in an ounce or more of pus. The quantity found will in
part enable us to judge of the extent of the disease. The prognosis
of ostitis, caries and necrosis, under our treatment, is usually favorable; almost all cases, even in their advanced stages, being curable withoutamputation. Diseases of bones, of the upper extremities,
are more favorable than the lower.
IN TREATMENT assist nature and avoid all unnecessary interference.  Here, as everywhere, remove causes and obstructions,
and let nature proceed with her remedial work; when she is doing
well, " let well enough alone."  The patient should be kept quiet,
the limb in a horizontal position, and his diet regulated according
as the constitutional powers are vigorous or enfeebled. General
bathing should be practised daily. If called at an early stage, we
should by all means endeavor to discuss the inflammation. Much
benefit may then be derived from local applications as recommended
for wounds and fractures. Though for a poultice in this and other
scrofulous affections, we have employed, with the happiest effects,
one made of the common white bean pulverized, and wet with hot
water.  But when it is evident that an abscess has formed, and
there is severe constitutional disturbance, make an opening for the
evacuation of pus. This may be done by cutting down to the bone
with a scalpel and using the trephine, or with the potassa fusa.
When there is dead bone or a sequestrum, as it is called, it is
desirable to remove it as soon as it is entirely loose, provided it
can be done without much violence.  On this point there have
been two extremes.  One, trusting entirely to the absorbing powers of nature; the other, to cutting, boring, or chiseling, wherever
dead bone was suspected.  The disintegration of the sequestrum
may be facilitated, and the necessity of an operation for its removal avoided in all cases where it is not too large, and does not
cause too much constitutional disturbance, by daily injections of a
solution of the sesqui-carbonate of potash.*
Bransby Cooper speaks highly of the use of phosphoric acid
diluted with an equal weight of water.  (See wounds-abscess* This article is one not generally known in surgical treatment. The mild
caustic, sesqui-carbonate of potash, has the peculiar property of dissolving dead
bone and destroying morbid growths, without injury, or preventing new granulation.



ULCERS.                        149
mortification.) If, however, the sequestrum causes great constitutional irritation, which threatens to destroy the patient and is entirely loose, it should by all means be removed.  Then lay bare
the provisional bone over one of its openings, and if this is not sufficiently large, enlarge it with a saw or trephine so as to admit a
pair of forceps. Sometimes it will be best to divide the dead bone
into small pieces with a pair of cutting-bone nippers, before extraction.
When a patient has become much exhausted by suppuration
and long continued suffering, and the necrosis has extended so as
to involve a joint, amputation of the limb had better be performed.
The chances of saving the limb will not justify the risk of losing
the life of the patient.
The limbs of necrotic patients should be protected, by the proper splints, from curvature by the action of the muscles. And the
patient should be cautioned against bearing much weight upon the
limb until perfect consolidation of the bone has taken place.
Internal Treatment. —Except where the result of some mechanical injury, inflammation of bone is generally dependent upon
some constitutional taint, which must be removed in order to effect
a resolution of the inflammation. The careful examination of a
patient recommended by Hahnemann, is especially important in
this disease, otherwise we shall overlook the cause, from a very
erroneous estimate of the true nature of the case; and probably
be unsuccessful in the treatment.
When ostitis is the result of external violence, particularly if
the periosteum has been much injured, Ruta, internally and externally, as recommended in the treatment of wounds, is a valuable
remedy.  Arnica and Calendula will also deserve consideration.
Aconite will only be necessary in a few cases of severe inflammation.  Bryon. and Puls. will be found serviceable when the inflammation is not far advanced, the skin being red, with slight
swelling of the bone and extreme sensibility to the touch. The
first for persons of dry, meager habit and of a nervous temperament; the latter for those of phlegmatic temperament, with lymphatic constitutions.
If the inflammation is of an erysipelatous character, Bell. will
be beneficial.  Mangan. Acet. is particularly valuable in perios



150                  DISEASE OF BONES.
titis and inflammation of the joints with excruciating pains. Hartmann also recommends Asa. and Ac. ph. for periostitis.  Where
the disease is not the result of mercurial poisoning, and occurs in
constitutions impaired or enfeebled by scanty or innutritious food,
living in damp, dark, or badly ventilated apartments, or otherwise,
or in persons of the lymphatic temperament, with severe nightly
exacerbations of pain, Mercurius will prove  an  invaluable
remedy.
But where it is the result of that poisoning, Hepar s. and Nitric ac. are the two most important remedies. Aurum, Ac. ph., Asa.,
Mez., Mere. and Silic., are also excellent. For ostitis from syphilis or the combined effects of syphilis and mercury, the most
valuable remedies are: Daphne, Mez., Asa., Staph., Aur., Man.
Acet., Ac. ph., Phos., Sulph., Sil., Gale. c., Lyco., Nit. ac., Sep.,
Bary., and we would suggest Stillingia Sylvatica. If from a scorbutic taint, Carb. v., Merc., Staph., -Dulc., Ac. Nit., are the most
appropriate.
If the disease is located on the shin or superficial bones, Asa.
and Mez. deserve the preference; but if in the facial bones, Aur.,
Phos., Mere. and Staph. The two latter are also useful in inflammation of the iliac bones.
In the earlier stages of caries and necrosis the remedies as
recommended for ostitis will be found serviceable. In the more
advanced there are but few symptoms present. Hence the cause of
the difficulty; the general condition of the patient, and clinic experience, must determine the appropriate remedy. In some cases
it has been found best to alternate two or more of the prominent
remedies, as Sulph. and Gale.; Sulph., Cale. and Silic; or Silic.
and Phos; Aurum has been found very valuable in affections of
the bones, particularly if from Mere., or from a complication of
Mere. and Syphilis.  It has a special relation to diseases of the
nasal and palate bones.
Ac. Nitricum is useful in caries of the assa nasi as well as the
skull bones of children; and to counteract the effects of the mercurial poisoning, Ac. Fluoricum has been employed with excellent
results in some cases of caries, and will probably prove a valuable
remedy in diseases of the bones in general.
Asafetida is very beneficial in diseases of the bones from



DISEASE OF BONES.                      151
scrofula or a complication of syphilis and mercury, the bone being
more than ordinarily sensitive to touch. Calcarea, although used
with advantage in alternation with other remedies, does not seem
to exert so beneficial an influence over the ulcer as over the constitutional depravity. It acts most favorably after the previous
use of sulphur.
Lycopodium is recommended for diseases of the bones from
scrofula, syphilis and mercury, particularly if the discharge is thick
and lemon colored.
Phosphorus has caused necrosis where persons have been
much exposed to its vapor. It will be beneficial when it has not
given rise to the disease. It is also very important in disease of
the bones in persons with impoverished vitality. The experiments
of Noote on dogs show that it exerts a particular influence over
fibrin.
Silicea is perhaps more frequently useful in diseases of the
bones than any other remedy.  It seems to exert a specific influence both over the separation of the sequestrum from the living
bone and the state that follows, when it is loose and there is a
very copious discharge of pus and ichor from the fistulous opening,
as well as controls the attendant nervous excitement preventing
sleep.
Sulphur is needed in diseases of the bone in scrofulous persons,
or in those of a lymphatic or bilious temperament.*
CHAPTER XII.
SCROFULA- ULCERATION.
The SCROFULOUS Diathesis, Tumors, Abscesses and Ulcers —Treatment.
FAMILIAR as we are with this word " scrofula," what is meant
by it is by no means a simple thing. It is a generalization. Va* The following cases are reported by Laurie and Ruckert:
Three cases of caries cured by Hepar s. and Silic. in alternation. Another by
the above with the addition of Mezereum and Rhus. A fifth complicated with mer



152                              SCROFULA.
rious morbid conditions, having a certain general resemblance, are
thus regarded and referred to as one disease. This similarity, it
should be remembered, is not sameness; the things brought together are one rather in our minds than in nature. In cases that we
identify as "scrofulous," we have not the advantage of a casual
unity, as in syphilis and other contagious diseases. It is, then, a
curial disease by Sulphur and Acid nitr. (Perussel.) Caries of the elbow joint,
with fistulous ulcers of the bone; Calc, c., (Rhus.,) Silic., Lycop. and Sulph. Caries
of the thigh bone of a scrofulous boy; Sep. 10 and Ac. nit., a fungous caries of the
hand; Rhus and Arsenic. Caries of the facial bones; Cale., Carb. and Silic. Caries
of the foot with hectic fever; Am., Lycop. and Silic.  Caries of the radius with
bluish red swelling of the forearm and hectic fever; Puls., Mez., Sab., Silic., Cal.
c. and Lycop.  Caries of the tibia and the left forearm, with several fistulous passages, debilitating diarrhea and utter prostration of strength; Sulph., Asafet.,
Ac. nitr. and Ac. phos., accomplished the cure.  Numerous cases of syphilitic
caries of the palate and nasal bones; Aurum. Chronic caries in scrofulous children
Silic. 30, some, however, required lower potencies. Two cases of caries of the
mastoid process, Silic. 30. Recent caries of the tibia, Silic. 10.
Acid Fluoric. -'" A boy became affected, after scarlet fever, with caries of the
temporal bone, which, during a period of five or six years, periodically broke out
afresh, discharged an offensive pus, and then healed again. The entire left side
of the cranium was arrested in its growth and consequently rendered much smaller
than the other side, the left eye also appeared strikingly smaller than the right
one. The intellect of the boy was not at all impaired. Several remedies improved
but failed in curing the caries. After the employment of Fluoric acid, the periodical attack came on earlier and in more aggravated form than usual, but never
returned.  From that time onward, the left half of the cranium  commenced to
grow, and the previous inequality of size between the two sides of the head became
gradually less, and finally imperceptible."
" The first and second phalanx of the left index finger, particularly the former,
were swollen to four times their natural size, so that the finger presented the shape
and appearance of a pear. On the dorsum of the finger an opening sometimes made
its appearance, from which pus and ichor oozed out. The entire tumor was very
hard to the touch; the skin otherwise unaltered. The cause of the affection was
not ascertainable; the pains were intermittent. With the exception of some degree of dyspepsia, the health of the patient was good. Of Silic. 10, two doses were
prescribed. Twelve days afterwards, the patient returned and said that she thought
the finger better, but there were no outward signs of improvement.  Ac. fluor. 10,
in two doses, was next prescribed.  The patient did not come back again until
about twelve weeks after her preceding visit. The affected finger was so much restored, that it differed little or none, in appearance from that of the other hand.
She had merely returned because her digestion, after having been rendered much
stronger, had threatened to become somewhat disordered again." Caries of the
leg, Asa., one dose of one drop. Caries and necrosis, Asa. and Phos. ac., in larger
doses.



SCROFULA.                       153
certain modification of the general system, with peculiar morbid
tendencies, that is now meant by scrofula. This general state,
usually referred to as the "scrofulous diathesis," requires to be
studied, even more than the special "scrofulous diseases,"- which,
for the most part, are obvious enough, presenting no difficulty of
diagnosis.
The SCROFULOUS constitution, or diathesis, is characterized by
a fair and florid complexion, with thin and delicate skin, and generally fine, light hair; a large head (with precocious development
of intellect) but a small chest, defective in depth from the shoulders
to the diaphragm, with feebleness of the whole muscular system,
which is of a relaxed texture and usually of a puny development.
The neck is thin, the eye and other features large, but regular and
well formed. The upper lip especially is very prominent and rosy,
the coloring of the eyes generally light. The emotions are vivid,
"the social sentiments" generally strong, but the more heroic
passions, which impart force of character, are less developed.
The intellectual organs are large and the reflective apt to predominate. There is generally a remarkable deficiency in those portions
of the brain which have been demonstrated, by Prof. Buchanan,
to be the source of muscular power and force of character, and to
be well developed in constitutions of much vital energy - viz., the
basis of the occiput, the region of Firmness, and the occipital organs generally. Hence, the basis of the cranium being often narrow and shallow, the neck is necessarily slender.
The most characteristic peculiarity, perhaps, is the predominance of the lymphatic glandular system. The salivary and lymphatic glands in particular swell from the slightest cold, to which
moreover the individual is very susceptible.
Scrofulous TUMORS are, however, not confined to the lymphatic
and salivary glands.  They may present themselves with the
same general character in any part of the body. They are most
common during childhood.  There is at first a simple
Swelling of the part, without much if any pain or increased
heat.  This may go back, or go on enlarging, until the patient
complains both of the preternatural warmth and compression,
feeling as if something were pressed on the tumor. In this stage
it may continue for a long time, and then disappear. More com20                                          (PART I.)



154                        ULCERS.
monly it at length takes on active inflammation and terminates in
suppuration - the scrofulous abscess or running sore. Occasionally
it runs through all these stages in a few weeks.
Before the ABSCESS breaks, and in some instances for a long
time previous, the skin over it becomes of a purple or leaden hue,
which color it will often retain long after healing.
The matter discharged in true scrofulous suppuration is of a
thin unhealthy appearance, sometimes quite "gleety" and containing occasionally small solid pieces of something like cheese.
This discharge may continue for a considerable time, without occasioning much inconvenience or undergoing much change, for the
better or worse. In other cases, the whole tumor will rapidly be
involved in a process of destructive inflammation, being, in fact,
converted into a malignant ulcer, wearing a peculiar appearance,
which will be described further on.
When the scrofulous abscess is near the lymphatic gland, it not
unfrequently happens that the gland itself is unaffected, except
by distension.  This may be ascertained by the probe, or by the
fact that the tumor does not soften or diminish in size as the purulent discharge becomes free. The matter thus forming all round
it sometimes completely dissects it out; and the gland is then discharged entire.
The large abscesses about the neck, so long well known as the
" King's Evil," very generally involve several glands at the same
time.
The scrofulous ULCER is never very painful unless when irritated by rough handling or some loose portion of carious bone.
Its edges are usually overhanging, thin and smooth, and of a pale
red hue. Loose granulations may sometimes be seen at the bottom,
of a glossy and somewhat rosy tint. The pus discharged is thin,
as in the case of the abscess, but soon becomes offensive. The
whole sore, however, when irritably inflamed becomes fiery red,
with a rough ragged appearance, fungous granulations sprouting
up rapidly, with a greatly increased discharge of watery matter.
The CAUSE of scrofula is a very obscure question. As in other
diseases, there is a concurrence of many causes.  In this case it
is perhaps impossible to fix on any one as the principal. As improper nutrition is obvious, bad living has generally been regarded



SCROFULA.                       155
as the principal source of the evil. The prevalence of the disease
in this country, however, proves that it is not always brought about
by poor living, in the usual sense of the word, -by insufficient oN
innutritious food. Even in Europe it is not confined to the ill-conditioned classes. Aristocratic and even some royal families are not
exempt. Although it is undoubtedly to be classed among hereditary
diseases, it is the tendency only that is inherited. The actual development of scrofula is never inevitable. Hence the utility of
preventive medication. The inborn predisposition may, moreover,
be very slight or altogether wanting, and the morbid diathesis be
acquired. We often have to treat scrofulous children whose parents both possess sound constitutions, and whose ancestry, as far
as we can learn, have been always free from the disease.
Among the causes, a prominent place should be given to bad
doctoring as well as bad diet. Mercurialism may be in a large
portion of cases the whole hereditary cause. If this be so, and it
is a conclusion from  numerous facts falling under our observation, we need be at no loss to account for the perpetuation or
rather perpetual reproduction of the malady in this country. How
frequently have the otherwise healthy mothers of scrofulous
children, been mercurialized while pregnant or nursing, and thus
the infant had to suffer the effects of a poison blighting the very
germ of vitality! - See Hamilton on Mercury - Allopathic Authority.
Another source of scrofula in towns and cities, among the
poor, is living in dark rooms, and especially crowded, damp, and
dark apartments.  Men may vegetate as vegetables grow in the
dark, but like such, they will be feeble and unhealthy. If we
would have our children and our race the most vigorous and capable of resisting disease producing influences, they must have plenty
of pure air and sunlight
THE TREATMENT must have special reference to, 1st: The
removal of the constitutional taint; 2d, the inflammatory condition or tendency of any part; 3d, the abscesses; and, 4th, the ulcerated or, perhaps, scirrhus complication.
Homeopathy furnishes the only means of preventing the development of scrofulous ulcers, disease, and of removing entirely the
hereditary or constitutional tendency. The physician, if called



156                       ULCERS.
upon to prescribe with a view to such prophylactic results while
the patient is in apparent good health may, doubtless, ward off
impending disease, and thus prevent the necessity for any aid
from the surgeon.
Besides the medicines, the proper regulation of the diet, exercises and bathing, are matters indispensable to successful prophylactic treatment.
The patient should have constant, but not over-fatiguing exercise in the open air, in day time, but be free from exposure at
night. Bathing the whole body daily, should be enjoined, but the
temperature of the bath should be so regulated as not to make too
strong a draft upon the vital heat of the system, while they should
not be so warm as to produce relaxation and a sense of debility.
The diet should be always nutritious, but unstimulating. Meats
being too stimulating, should be prohibited. The natural tendency
in such persons is to a too rapid growth and too early maturity;
hence, all diet calculated to over stimulate the tissues should be
avoided;  all stimulating condiments and alcoholic drinks must be
forbidden, as they are directly inimical to the animal economy.
Pure sweet milk should enter largely into the diet of scrofulous
children, and unless the tone of the digestive organs has become
so impaired as that milk will be too indigestible; it is also useful
for adults.
The most reliable medicines, before any painful or inflammatory
symptoms appear, are Sulphur, Calcaria, Conium and Dulcamara.
Sulphur, to be used early, before any enlarged glands are noticed, administered in high dilution at long intervals.
Calcaria, to follow Sulph., where there is a feebleness and a
deficiency in the development of the bones. It should be given at
intervals of two or three weeks at a high attenuation.
Conium, to be used when the lymphatic glands are simply enlarged in young children, administered at a high dilution, and applied to the surface over the enlarged glands, at a low dilution, or
the Tr.
Dulcamara, for persons further advanced in life, after or near
the age of puberty, where the enlargement of lymphatic glands
continue, or is excited by taking cold, without becoming inflamed,
tender, or painful.



SCROFULA.                      157
SCROFULOUS SWELLINGS AND ULCERS.
Sulphur is to be used in the, early stage of scrofulous swellings. It is also one of the best remedies in any stage, where the
patient is affected with eruptions, tetters, swelling and soreness of
lymphatic glands, with a weak sickly appearance and a great.susceptibility to cold.
Arsenicum, for atrophy, hard distended abdomen of children,
glands of the neck swollen, puffy, pale countenance, pains of a
burning character, with dry skin.
Baryta Mur., is an important remedy for scrofulous persons,
especially children, when the glands of the neck are enlarged and
painful or tender to the touch, the appetite poor, bowels costive,
emaciation, abdomen distended. This remedy is especially useful
for scrofulous children affected with rachitis, the spine and limbs
being distended. It restores the patient to health, and by promoting healthy growth corrects the deformity — it has been successful where the deformity existed in connection with extensive
disease and ulceration of the lymphatic glands.
Phosphorus, dissolved in olive oil, (1 gr. to the oz.) may be
applied with benefit to indurated glands about the head and neck.
Belladonna, for hard, engorged and ulcerated glands, with frequent bleedings at the nose, occasional incontinence of urine.
This remedy is best suited for persons with blue eyes and light
hair.
Nitric Acid is to be used where the scrofulous patient is suffering from mercurial affection, has weak lungs, acidity of the
stomach, stinging pains in the affected part, dry skin, pains change
with changes of the weather, great emaciation.
Miezereum, where the pains are aggravated by a slight touch;
the ulcer is easily inflamed. This remedy is especially serviceable
in inflammation and induration, and even suppuration or ulceration of the auxiliary glands.
Sepia, for delicate young females, weak, debilitated persons,
the nails deformed with scirrhus indurations.
The Oleum Jecoris Asselli, is recommended by lartmann as a
valuable remedy in scrofula; but from our own experience, and
the utter impossibility of getting a reliable article, we have no
confidence in it.



158                       ULCERS.
fepas Sulphuris, is best adapted to the tumors when in a
state of suppuration.
Lycopodium, for lymphatic persons where the bones are affected, especially those of the nose, palate, or face.
We have used in numerous instances the Arum Triphyllum
(Indian turnip,) as a local remedy for the discussing of inflamed
scrofulous tumors, which is frequently an important object, and
never have failed of success where it was not clear that pus had
formed before the application was made.
It is best applied in form of a poultice, made by bruising the
green root and wetting it with warm water.  The finely pulverized
dry root will answer the purpose, but is not quite as efficient. It
should be given internally at the same time, eitler in dilute Tr.,
or weak infusion.
The Stillingia Sylvatica, has beyond a doubt great specific
powers in scrofula.
Dr. Hill formerly made much use of the Scrophularia Marylandica in infusions, and in many cases it proved a specific, even in
ulcers of a scirrhus character.  His attention was particularly attracted to its homeopathic effect in this disease, some years ago, by a
physician in Pennsylvania, who stated that he was in the habit of
prescribing an infusion of it to be taken freely until the symptoms
were much aggravated, and the patient begun evidently to sink
under its effects, when he discontinued all medicines, and in a few
days the patient would begin to improve and a rapid recovery to
health would be the result. This physician also applied it to the
sores as a poultice. The last two articles deserve a thorough
"proving."
If the tumor assumes a hardened, scirrhus condition, Arnica,
Conium, Lachesis, Baryta c., Mercurius, Staphysagria, Carbo v.,
Hep. Sul., Cale. Sil., Jodium, Lycopod., Bovista, Belladonna,
Dulcamara, Sulphur, or Sepia should be used according to the
symptoms. The Conium may be applied with good effect to the
tumor. Phytolacca decandria (the root), in form of a poultice, may be applied with success in many cases, while a dilute
Tr. of the same is used internally. It has relieved some of the
most inveterate cases. But if the induration does not yield to any
of these remedies, and it should be very important to remove the



SCROFULA.                      159
tumor, apply caustic potash and completely destroy it if practicable. After the caustic, use emolient poultices until the eschar has
sloughed out, then cleanse the ulcer, thus formed, daily with a solution of the Sesqui-carbonate of potash, and continue the poultice
until it heals.
The Scrophularia may be used internally during this treatment;
or you can use any of the specific remedies for such symptoms as
may arise.
In concluding our remarks on the treatment of ulcers, and
especially scrofulous ulcers, we deem it our duty to record the
results of our experience in the use of the same remedies locally
(to the ulcer) that are given internally. We use a wash, generally
of a lower dilution, of the article that we are giving internally,
and when the internal remedy is changed for another, the same is
done with the external. From a comparison of our success in the
treatment of ulcers with that of those who used the remedies internally only, we are bold to assert that double the success attends this mode, both in respect to the number of perfect cures
and in the time of accomplishing them.
But we derive a still further advantage by the use of remedies
entirely neglected or discarded by a large portion of the profession,
(at least until lately) - we refer to the local and general application of water-either cold, warm or hot.  We are fully warranted
by experience in saying, that all cases of ulcers, and especially the
scrofulous kind, will be cured in a much shorter time with the
combined use of water, properly and scientifically applied, and
other homeopathic remedies, than by any other mode of medication
now known, while it will, we are quite confident, cure some cases
not amenable to any other plan of treatment whatever that has
yet been presented to the profession.
The application of water in the various modes does not, in the
least, antidote or interfere with the action of the specific drugs
prescribed, but rather facilitates their action by rendering the system in many cases more susceptible. It should be applied in the
form of general baths to the surface daily, or oftener as the surgeon
may deem proper, either with the hand alone or by means of a
sponge, accompanied with frictions and sufficient exercise to keep
up the activity of the circulation.  Occasional packing with the



160                 CHRONIC RHEUMATISM.
wet sheet is very useful, and wet compresses to the part affected,
either cold or warm, are highly beneficial. There is too much ignorance in the profession on the subject of water applications in
surgical practice, and this ignorance has been perpetuated by a
few journalists who were themselves entirely ignorant of its value;
never having used it or bestowed any time to the investigation of
its use by others, and who are too conservative and narrow-minded'o venture upon any new field of investigation, however much inducement it may offer, or however unsuccessful may be their present practice. It is an easy matter for journalists to decry any
particular mode of practice and to call it quackery or mongrelism,
while the attempt to prove it such is too serious a task for them to
undertake. It is sufficient for the practitioner to know, that, while
he violates no known law of cure in the use of a particular remedy,
though he may use that which is discarded by others, he is far
exceeding them in point of success.
It is a strange hallucination that causes these journalists to
persist in their opposition to the employment of means so valuable
as hydropathy offers, in the face of the admissions and recommendations of the ablest homeopaths.  Numerous cures are on
record showing the successful results of the water treatment alone,
in cases which had resisted the efforts of the ablest homeopaths.See Hempel, in note on p. 197, Jahrs' Pocket Manual.
We fully endorse the following sentiments expressed by Dr.
Hartmann: -" After all, it matters little whether we adhere to
this or that name or system provided we' cure the patient in the
safest, shortest, and cheapest manner." This is the physician's
duty, and he who fulfills that duty well is the really great practitioner.-See Hartmann, Chron. dis., vol. iii, p. 183.
CHRONIC RHEUMATISM.
This disease, under homeopathic treatment, does not require
she services of the surgeon proper, and we had concluded to leave
it out, though under the allopathic practice it so often requires the
cups and scarifier, the blisters and the scalpel of the surgeon.
But having received from Prof. C. Neidhard of Philadelphia, a
brief article on this subject, so valuable and so directly in point,
we insert it in full:



RHEUMATISM.                     161
"Inasmuch as this general affection often locates itself, producing states of particular parts that require surgical interference,
it is necessary for us to have regard to the general cause as well
as special results.
"The remote cause, as the name implies' is generally an acute
attack -rheumatic fever or inflammation. The acute affection
may, however, be so slight as to be altogether overlooked and forgotten.  There may be long continued inflammatory rheumatism
located in a particular tissue or organ.
" The knee is a joint very frequently affected.  In slight cases
there is stiffness and pain only when exercise is attempted.  At
other times the joint swells enormously, and there is a constant
though dull pain. The bone itself seems to grow out, often to a
monstrous size. This, however, is seldom more than a semi-cartilaginous deposit, and, indeed, the bony appearance is commonly
owing only to condensed coagulable lymph, or to the thickened
and hardened condition of the synovial membrane and capsular
ligaments. This affection of the knee is often confounded with
scrofulous or true'white swelling.' It is most common in the
colder regions, particularly in the vicinity of our lakes.
" When the disease locates itself in the hip joint, it is a variety
of'coxalgia,' and similarly confounded with the more formidable
scrofulous affection of the same part.
"Confined to the lumbar vertebra it often goes under the
name of'lumbago.' When the cervical vertebrae are its seat, it
occasions' stiff neck.'
"Rheumatic infammation of the joints often terminates in a
serous effusion, giving rise to true hydrops articuli."
If the rheumatism  be complicated with syphilis as is sometimes the case —
Phytolacca Decandria is a remedy of great value. It is also a
specific for this complaint, whether connected with syphilis or not,
when the pains are all of a neuralgic character; especially if the
stomach is affected with rheumatic or gouty symptoms. We have
used this article externally to the affected part, as well as giving
it1 internally.
"The external applictiou is best made by cloths wet with the
21                                         (rti.)



162                 LUMBAGO RHEUMATICA.
Tr., applied as warm as the patientcan bear it.  The applications
may be made at night, and discontinued during the day.
Prof. Neidhard thus speaks of Chronic Rheumatism, ic.:
"In nine out of ten cases Rhus will be found to deserve the
preference in rheumatic affections, as they are so common in our
climate. It will be particularly applicable in the most inveterate
chronic cases.  Characteristic  symptom~ are the following:
rigidity; paralytic weakness of the joints, with stinging pain along
the tendons and muscles; swelling and redness on or near the
joints. Rheumatism of hip-joint and wrist seem to be most effectually controlled by its action. The greatest rigidity and pain is
experienced on first moving the joints and waking up in the morning. After the joints have been moved for awhile the pain is
lessened.  I have numerous cases on record in corroberation of
the above experience —these cases would amount at least to
sixty. The first ten cases, consisting of three women and seven
men, had rigidity and pain as above described with the same conditions; the others had more or less the same symptoms with the
difference, that, in some cases, the joints of the upper and in
others those of the lower extremities were more affected.
"Many cases assumed the form of paralytic rheumatism; in a
few, that were cured, there was complete hemiplegia. The pricking, stinging sensation was seldom wanting."
"LUMBAGO RHEUMATICA."-" The seat of this disease is the
muscles of the lumbar vertebrae as far as the crista ilii; the pain is
rending, drawing, and moves from one place to another, coming on
periodically; the least motion excessively painful, on which account
the patient keeps his back very stiff; there is very little fever.
" The cases which fell under my notice in this disease I treated
chiefly by Nux.Vom., and a new remedy, the Lobelia Syphilitica or Oerulia, (as it has been also sometimes called.)  Nux is
indicated when the pain comes on periodically, with sudden jerking stitches, which extend to the shoulders, and also down to the
genital organs, producing stiffness and lameness of the lower extremities.  In the cases where I used Lobelia Cerulia, the characteristic symptoms were: shooting pain in the right side of the
back, and in the right sacro-iliac symphysis in attempting to rise;
the greatest pain is felt on turning in bed."



WHITE SWELLING.                     163
Chronic Rheumatism  of the extremities frequently depends
upon disease of the spine, where there is no curvature or pain to
attract the attention of the patient. An examination should be
made, in all cases, by pressing firmly along the spinal column, and
if any tenderness is found give Arnica, a dose every two days.
Apply a wet compress, covered with dry flannel, over night to the
tender portions.
The proper use of water is of great service in this affection.
The patients whole surface should be cleansed daily with pure water
at the proper temperature, and wet bandages, at night, around the
affected part will be serviceable.
The cold douche is to be used where the joint is stiffened, enlarged, but not painful, except from pressure.
The diet of the patient should be simple, unstimulating, and
rather spare - he should be restricted to less at all times than his
appetite craves. The affected joints should be regularly exercised,
care being taken not to subject them to any sudden or violent action, so as to give severe pain and excite inflammation.
CHAPTER XIII.
WHITE SWELLING- HYDROPS ARTICULI-AND ANCHYLOSIS.
SCROFULOUS or True White Swelling, a Suppurating Joint —Symptoms and Progress - RHEUMATIC White Swelling, or Dropsy of a Joint - ANCHYLOSIS, or Stiff
Joint - Treatment, mechanical or medicinal? -Extension- Exercise.
WHITE SWELLING.
THIS formidable and well-known disease is one of the opprobia
of the profession. In the country, indeed, the people seldom think
of calling in a physician with any hope of cure.
Cases known as " white swellings," are divided by some writers
into rheumatic and scrofulous, - the latter being such as occur in
scrofulous subjects, and all persons being liable to the former on
exposure to the exciting causes.  The propriety of such a dis



164                   WHITE SWELLING.
tinction, for the sake of popular designation, has been doubted;
and as chronic inflammation of the synovial membranes and capsular ligaments will be spoken of under the head of " Hydrops
Articuli," attention will be first called to the properScrofulous or true white swelling, which never occurs in any
but scrofulous persons. It is scrofula in a joint.. For a long time
after the disease has located itself there, the pain may be very
slight.  Gradually the patient's sufferings increase, and become
at last very intense, particularly at night. The central part of the
joint seems the point most affected. The swelling also is very slow
in its progress. Even then, there is no diseeloration of the skin,
or, rather, it appears whiter than natural, (whence the popular
name.) It becomes very tense, with a smooth, shining aspect, and
marked with varicose veins. The patient constantly experiences
a sensation of increased heat in the part. In this condition the
joint may remain for months, or even years, without any material
change.  Gradually, however,
The tumefaction increases, till the thickening of the soft parts
becomes so hard as to present the appearance of enlarged bone.
In very bad cases, involving the cartilages of the knee, (for as that
is the joint most commonly affected, we may as well study the disease as there manifested,) the tibia is thrown backward, the condyles of the femur projecting forward. The limb, both above and
below the knee, emaciates; and as a flexed position is easiest for
the sufferer, amehiylois takes place, with the. lisab permanently
bent. Finally,
Matter collects in the joint, either from  ulceration of the cartilage or boned or both, and sinuses form for its discharge.  Extensive caries may ensue, producing
Severe constitutional irritation, undr which the patient gradually sinks.
TREATMENT.-Where the disease has been produced, originally,
by a strain or bruise, as is often the case, and the acute inflammation still exists, suppuration not having come on, we have succeeded
in affecting resolution of the inflammation by the internal and external use ofArmica. If, however, the patient does not soon improve under the Arnwca, Rhus. should be alternated with it.
Calerew is useful at a later stage, after Arnica has subdued



WHITE SWELLING.                     165
the acute symptoms but some traces of the disease remain, or in
the first instance, the pain in the joint being pressing as if dislocated, shooting, acute pains coming on at intervals, the patient
weak and sickly.  More particularly useful when the disease is in
the knee. If, however, there is dull, heavy pain in the center of
the joint when at rest, changed to severe pain upon moving or
pressing the part, with occasional paroxysms of fever, or after
suppuration, the pus becomes yellow and ichorous, Iodine is a
valuable remedy.
Colocynth., for stiffness of the joints, with only dull aching pain,
the pains increased by mental excitement, especially anger.
Kali Hydriodicum, is a remedy of great value in this disease,
especially of the knee joint.  It is indicated by all the pains being
tearing and twitching, with twitching of muscles of the leg, the
pains worse at night or when at rest, palliated by motion.
Phosphoric Acid, for heaviness of the joint with great weakness,
pains worse when at rest, especially at night.
Hepar Sulphuris, for shooting pain in the joints with a bruised
feeling. The ulcers smell some like putrid cheese and bleed easily.
Useful when the disease is complicated with mercurial cachexia.
Rhodendron, is a remedy upon which great reliance may often
be placed in this disease. It is especially indicated by coldness of
the swollen knee, with severe pains extending to the leg, a drawing sensation in the p9pliteal space.  It seems to bear a particular
relation to the right knee. It should be used when the swelling
extends to the leg or thigh, pains appearing in stormy weather
and going off when the weather is fine, pain confined to a small
spot, most violent at night and during rest.
Mercurius, for white swelling in persons affected with syphilitic taint, night sweats, pains worse in damp weather, fungous
ulcer, especially where the bone is affected.
Silicea, also useful where the synovial membranes are affected;
or when emaciation has taken place, in alternation with Arsenic
and afterwards with Iodine.
Lachesis, is indicated by great emaciation with tearing and
contracting pains in the joint, great dread of exercise, deeply penetrating suppurations.  This may be alternated with Silicea and
Sulphur with advantage.



166                  HYDROPS ARTICULI.
The Cornus circinati has yielded excellent results in this disease.  So also the Phytolacca Decandria.
The Scrofularia exerts a marked beneficial influence in scrofulous white swellings.  It is one of the best remedies.  The
physician  heretofore referred to gave patients affected with
"white swelling," the infusion of Scrofularia freely several
times a day and washed the ulcer with the same, keeping in covered with a warm  poultice of leaves of the plant, when the
patients began to get worse under the effects of the drenching, he
discontinued it and gave no medicine, a rapid recovery in many
cases was the result.
The Stillingia Sylvatica may also be used with advantage.
Much advantage will be gained, during any stage of the treatment,
by washing it freely and cleansing all the ulcers thoroughly two
or three times a day, with cold or cool Castile soap-suds, by injecting the fluid freely into the sinuses, if any are formed. The
strength should vary in proportion to the sensibility of the ulcers.
The bandage should be used in all cases.  The application of
water to the general surface frequently, is of great importance
and should never be neglected. The diet of the patient should
consist mainly of milk, eggs and unleavened wheat bread. Meat,
especially fat meat, should not be allowed.
It was observed before, that these are almost always tedious,
as well as troublesome cases. It is important that we forewarn
the patient and his friends of the necessity of persevering in the
treatment a sufficient length of time. In some cases, a cure can
not be anticipated in less than half a year; and even a whole year
may be required, though, in others, half that time may be sufficient.
In the most favorable cases, a six weeks', instead of six months'
treatment will effect the object.
HYDROPS ARTICULI,
Is the result of rheumatic disease, that often passes under the popular name of "White Swelling," and should, if so called at all, be
distinguished as
Rheumatic White Swelling.  In this case the synovial membrane and capsular ligament are enormously distended, by serous
effusion. It renders the limb stiff, though the pain is slight, un



HYDROPS ARTICULI.                    167
less when aggravated by exercise. The dropsical effusion extends
along the tendons of the muscles. The whole limb even may be
distended with it.
The symptoms are frequently very obscure, as the patient
suffers, oftentimes little or no pain and in other respects is in tolerably good health.
Sulphur is, without doubt, a useful remedy to begin with, and
though there may be no very marked symptoms of any particular
remedy, after the use of Sulphur for a few weeks together with a
proper use of water, either the disease will yield entirely and the
cure be complete, or some symptoms will be developed indicating
the specific remedy.
The symptoms indicating the use of Sulphur are, however,
often presented. They are: unusual muscular weakness, the patient sweats easily, the pains are worse at night, the sensation of
fatigue is relieved by exercise, though the pain is aggravated,
trembling of the affected limb - it feels numb.
Silicea is generally useful in this disease. For enlargement
and lameness of the joints from pressing upon them, bruising or
straining, as by kneeling, dancing, &c., Silicea is particularly applicable. The patilla is pressed out by the increased secretion of
the synovial fluid, the whole joint being enlarged.
Iodine: Patient much emaciated; very nervous, weak and
trembling, twitching of the tendons occasionally, tearing sensations in the joint; night sweats.
Sabina: Rheumatic pains continue more or less severe after
the effusion has taken place, sense of paralysis after exertion, dull
drawing pains in the limbs.  Exercise in the open air relieves the
uneasiness.
Conium is suited to persons who have a lack of vital heat, and
lack physical or mental energy.
Digitalis, for a sense of painful tightness in the affected part,
great dejection of spirits, he is "weak and nervous," sweats too
easily, feels remarkably weak after meals.
Lycopodium, for persons who take cold easily, the affected
joint most painful during repose, glandular swellings, general dryness of the surface, ill humor, sad, anxious, dullness of ideas.
Arsenicum: pain worse at night, of a burning Character, great



168                     ANaCYLOSIS.
weakness, emaciation of the affected limb, dread of exercise, coEm.
tenance pale and appetite poor.
Antimonium: Great sensibility to cold, sense of weight in the
limb, contraction f the tendons,
Bryonia: the affected part sweats a great deal, pain of a toe,
sive character.
The affected part should be exposed for from half an hour to
an hour daily to the vapor of hot. water, followed immediately with
a cold douche, then rubbed off briskly and tightly bandaged. The
roller should commence at the toes and continue above the knee.
General bathing should be constantly enjoined. Passive motion
of the joint should be daily practiced, but over fatigue by walking
should be avoided, though gentle exercise by walking, when it gives
not too much pain, i advisable.
ANCHYLOSIS, OR STIFF JOINT.
This may be complete or incomplete. It is the result of disease
or injury to the joint.
In incomplete Anchylosis the ligaments, tendons and surround.
ing cellular tissue only are involved. The joint admits of slight
motion. In complete Anchylosis the extremities of the bones are
firmly united.
In TREATMENT, if there be any inflammation or soreness of the
joint, remove it.
If, after having removed the soreness, the joint admits of any
motion, hopes may be entertained from further treatment; but if,
on the contrary, it be stiff and immovable, any attempt to disturb
it by motion will do harm. It should be let alone.
If the joint admits of motion, machinery which will gradually
extend the limb, such as Dr. Chase's apparatus, (of Philadelphia)
will answer for this purpose. While the machinery, whatever it
be, is applied to make the extension, absolute rest on the part of
the patient should be enjoined, He must not be allowed to attempt
any use of the limb or any other exercise. He should be kept
perfectly free from all mental excitement or anxiety, and as much
retired from company as possible. As soon as the limb has become straight, or as straight as is thought practicable, all further
use of the extending force must be discontinued; but the limb



HIP DISEASE.                       169
should be kept in that position until free from all tenderness, if any
should have been induced by the treatment.
If any tenderness of the affected joint is present when we are
first called to the case, it must be removed by such remedies as
the history of the case or the symptoms present indicate. If it
arise from any injury, Arnica is the proper remedy. If from rheumatism, Rhus will probably be sufficient; if from syphilis, Mercurius; from mercury, Nit. ac. or Aurum.
During the time the extending force is being applied, the joint
should be exposed to hot vapor of water twice a day, if practicable,
then lubricated with the oil of the Rattle-snake (Crotalus Horridus).  At the same time a dose of the Crotalus should be given
every two weeks.
For any soreness of the joint that may be excited by the forcible extension, Arnica is the proper remedy.
CHAPTER XIV,
THE HIP DISEASE.
DESCRIPTION AND PROGREss - Diagnosis and Prognosis- Treatment in different
stages-Rest or Exercise? -Carved and Gummed Splints?  Direction for
making and applying Gum Shellac supports - Diet.
THIS disease, though mostly occurring in weak and scrofulous
children, may occur in persons of any age and constitutional
character.
The SYMPTOMS sometimes come on so gradually as scarcely to
excite attention. Months may elapse before assistance is called
for. The first thing complained of is very generally a slight pain
in the knee, no doubt from some implication of the nerves leading
to that part. On examination, it is found that the limb is slightly
disfigured: it may be increased in length, which occasions the
knee to be habitually bent. The elongation itself is usually referred to a partial protrusion of the head of the femur out of the
acetabulum.  May it not rather be apparently increased on ac22                                          (PART I.)



170                     HIP DISEASE.
count of a relaxation of the muscles, and an inclination of the
pelvis towards the affected side? At this period the pain is referred to the groin, or, perhaps to the posterior surface in the
region of the trochanter.. This pain will, in some cases, be very
severe from the commencement, and continue so until relieved by
suppuration, although many patients do not complain for a considerable time.
The pus does not make its appearance till the disease has
committed great ravages.  Sometimes the head of the femur is
entirely destroyed, a large abscess occupying its place, without
any tendency to approach the surface at any particular point. It
may finally open and discharge at different points about the hips;
more commonly it directs itself to the groin.
The ulceration almost invariably injures the joint, destroying
the cartilages, if not the articulating surfaces of the ilium and
femur.  Sometimes the matter may make its way out of the acetabulum without destroying or forcing out the head of the thigh
bone, in which case, though there is no dislocation, we may expect anchylosis.  More frequently the head is thrown out, and
dislocated backwards on the dorsum of the ilium, where it may
form a new joint, producing in effect a short deformed limb, though
there has been no actual destruction of bone. When the head of
the bone has been entirely destroyed, the constant contraction of
the muscles will draw the limb up several inches.  It is only in
rare instances that recovery occurs spontaneously, the ulcers healing up and the use of the limb being restored, without deformity.
Though a short leg is the frequent result of the disease, it
should be borne in mind that its first effect is, generally, as was
remarked, to lengthen the limb and turn inward the foot and
knee -a sign by which the mischief may be often detected in its
incipient stage.
The patient's constitution suffers severely during the progress
of the malady.  Chills and hectic set in, with occasional night
sweats - no doubt from the absorption of pus.
As to prognosis, Professor Gibson gives us the following encouragement: - " Some patients die dropsical before any important change has taken place in the joint - others perish from hectic
in a few months - a still greater number live for a much longer



HIP DISEASE.                      171
time, [!] —a few  have been known to survive nine or ten
years. [!!] * *  Upon the whole, there are few more difficult or
incurable complaints."!!!]
And Laurie remarks, that it is only.in the incipient period of
the disease that a favorable prognosis can be given. Such has
not been our experience.
The diagnosis requires notice.  When the pointing occurs in
the groin it has been mistaken for psoas abscess!  If the appearance of the matter is not sufficient, a critical examination should
enable the practitioner to determine the difference. In the hip
disease, the character of bone pus will be noticed, and some portions of carious bone, or phosphate of lime, will generally be observed in it. Probing will often bedecisive. Placing the thumb
upon the trochanter, and pressing it firmly into the acetabulum,
will often excite pain in a very early stage of the disease, before
its existence is suspected.
The errors of diagnosis in this disease, even among men who
stand high in the profession as surgeons, are most remarkable.
We might instance numerous cases which have fallen under our
notice within a few years past.  One case, that of a lady in Cincinnati, whose disease had been pronounced and treated for several
months as Psoas Abscess, after regular consultation with the Professor of Surgery in the Medical College of Ohio, is reported by
the late Dr. Morrow, in the Medical Reformer.  It was treated
by him for hip disease, and cured.  A son of Col. F., of Pickaway county, in this State, was brought to consult the same distinguished Professor, who agreed with the country physicians who
had been long treating the case as a rheumatic affection of the
knee, and decided that amputation of the thigh was the only
remedy.  On seeing the patient, Professor Morrow at once inquired of the father what had been done for the hip, and learned
that any disease there had never been suspected. A touch of the
finger upon the trochanter, pressing toward the acetabulum, produced excruciating pain, and more extended examination displayed
all the well marked symptoms of the Hip Disease-which was,
no doubt, the original cause of the trouble in the knee, and would
certainly have been little benefited by amputation.  We make
these statements for no invidious purpose, nor by any means as



172                     HIP DISEASE,
singular occurrences, but as warnings, seeing that men of such
standing and long experience, are liable to oversights so serious.
We have had two cases of club-foot produced by coxalgia, and
removed by curing the hip.
If the history of each case can be carefully traced back it will
generally be found that some mechanical violence has been done
to the capsular ligaments of the hip joint. A fall, or perhaps, a
strain by a false step or slip of the foot, the recollection of which
has passed entirely from  the mind of the patient, is the exciting cause. It is true that a depraved constitution is often the ulterior cause,
Arnica and Rhus, internally and externally, alternated once
in three or four hours will, therefore, generally arrest the progress
of the disease and prevent it passing into the more advanced
stages. If not, resort may be had to Mercurius, which is often a
specific in the early stages of this disease in scrofulous patients,
with pale bloated countenance, suffering little or no pain in the
hips, except a sense of stiffness and lameness.
Belladonna is more particularly needed when there is considerable pain and inflammation present.
Sulphur, is required for chronic and scrofulous cases, affected
with eruptive disease, scorbutic or hepatic affections, or caused by
the recession of eruptions; great exhaustion, profuse sweats and
great sensitiveness to the open air.
These means are sufficient to counteract the disease, and restore
health, if the suppurative process has not already advanced too
far; but if matter has formed, and not yet made its way to the
surface, make use of poultices and fomentations over the whole
hip, till there appears a tendency to point at some particular
place. At this place open a caustic issue, to facilitate the exit of
matter as soon as possible. So far from apprehending any evil
consequences from the freest escape of matter, we regard it as an
essential condition of any successful treatment. No one, certainly,
can point out any good result from the retention of a large amount
of pus in the system.  Its absorption, if we could insure it, might
occasion as much mischief to the constitution of the patient as its
presence is now doing to the part. But to bring about absorption
would be a very difficult matter, inasmuch as the absorbents, in



HIP DISEASE.                      173
common with the rest of the system, are by this time much
debilitated.
If, however, the matter seems to be rapidly approaching the
surface in a natural way, apply your emollients, and wait patiently
for a spontaneous opening. As soon as this occurs, or if there is,
when you are first called —
A free discharge, encourage it with poultices. Also, wash out
the abscess freely, once or twice a day, with injections of weak
Castile soap-suds, and then follow with an injection of Calendula
ofic., giving it also internally.  Although not mentioned by any
of our authors, we esteem it an important remedy in the suppurative stage, having used it with decided benefit in several cases.
Sometimes, owing to the great irritability of the patient, you may
not be able to use an injection oftener than once in two or three
days.  Repeat the operation, however, as often as the patient can
bear it. Should there be several
Fistulous openings, each is to be treated in the same manner;
and, if they are connected, introduce a ligature, and if practicable, bring them gradually together.  Should the patient not improve, or if caries is present, or if there are fistulous pipes, use
Silicea internally, and as an injection in the form  of solution.
Where there is much emaciation, it may be advantageously alternated with Arsenicum, Iodine, or Gale. phos.; China is needed in
all cases where copious discharges of pus are exhausting the vital
powers of the patient.
In some cases CaTc, Hepar s., Ac. phos., Phos. and Lach.,
may be advantageously employed.  (See Ulcers, Wounds, Caries,
and Necrosis.)
If after the use of the solution of Silic. for a fortnight, as directed above, there is no improvement. visible' in the character of
the pus, employ a solution of the sesqui-carbonate of potash, instead of it, as recommended in necrosis. This will soon destroy
and bring away all carious bone, and stimulate a healthy restorative action in the part.
Attention should be paid to the condition of the skin in all
diseases; but especially in this and similar ones where there is a
chronic formation of pus. It then not only has to throw off the



174                     HIP DISEASE.
ordinary transpirable matter, but a great deal of poisonous material taken up by the absorbents.
Judicious hydropathic treatment is an invaluable aid. Let
the diet be of the most nutritious but unstimulating kind -milk,
farinaceous food, soft boiled eggs. And, in very debilitated patients, the white of eggs beat till light, but not frothy; then
sweetened according to taste, and diluted largely with cold water,
and used as a common beverage.
Rest is an important adjuvant.  Let the affected part be
moved as little as possible. We are far, however, from sanctioning the routine recommendation, of keeping the patient confined
for several months to his bed. The depressing, and even irritating
effect of such restraint in a young and otherwise lively patient,
more than counterbalances all the advantages of inaction to the
affected part. On the contrary, we take the responsibility of advising, with proper precautions,
Exercise in the open air.  For this purpose, the patient must
be supplied with a crutch or crutches, the affected limb being so
secured as to allow as little mobility of the joint as possible. If
no dislocation has yet occurred, a suitable splint may answer the
purpose.  The "carved splint," to fit the patient from  chest to
foot, so highly prized by Dr. Physic, is still insisted on by many
surgeons (some writers taking particular care to require that it be
made and exactly fitted by a professed carver). But any wooden
splint, however neatly made and fitted, is too heavy and burdensome for a young patient, to say nothing of the fact, which professional authors so generally leave out of sight, to the great embarrassment of actual practitioners - that most families have not
an inexhaustible purse to draw upon. The expense of the required
"carved splint" would be enormous, if changed, as it would need
to be, with the progress of the disease, every month or two.
Happily, however, at least for all but the wealthiest, for whom
alone some medical men seem, in their works, to prescribe,
- A far better splint can be made with little trouble and comparatively no expense, one that is just as firm, though much
lighter than wood, and fitting exactly to the limb and body, as no
carved work ever can.  Get a piece of thick woolen cloth, (old



HIP DISEASE.                      175
will do as well as new,) and saturate it in a solution of gum shellac
(one pound to a pint of alcohol.) Expose it to the air, and when
the menstruum  is evaporated, your cloth will be almost as firm
and elastic as steel.  Two sheets, however, may be welded together, by covering again one side of each piece with the dissolved
gum, by means of a common paint brush, evaporating as before,
and then pressing them  together with a hot flat iron or tailor's
goose.  Three or four thicknesses of heavy woolen cloth thus prepared, will be as strong as any splint ever required for any surgical purpose whatever. Have your prepared material nearly of
the size required, and then heat it at the fire or by dipping in
scalding water until it is as soft and pliable as the original cloth.
In this state, or after it is cool enough not to burn, you can, with
two or three assistants, apply it to the parts, and fit it exactly by
pressing it down closely to the surface, where, in the course of
two or three minutes, it will stiffen. It will always retain the
shape thus given it. No heat of the body can ever be sufficient to
soften or weaken it. It should, however, be lined with canton
flannel, or some such material, to prevent its irritating the surface, such lining being fixed by a weaker solution of the same
article or common gum Arabic.
This shellac splint should extend from above the middle of the
thorax to the ankle, reaching half way round the limb, and above
nearly to the spine and sternum. It should be attached all the
way by rollers or bandages, applied moderately tight.  It will
bear being pressed on the surface much more tightly than any
other material less accurately fitting. Should the thigh or leg be
flexed, no force should be at first used to straighten it. The splint
must be adapted to the limb in its easiest position, and re-fitted as
often as the position of the limb changes.
With such a splint, so fixed, almost any desired amount of
proper exercise can be taken without risk of exciting the affected
joint.  Holes may be made in the splint to allow us to dress the
opening of the abscess or ulcer, so that the apparatus need not be
removed.  A gutta percha splint may be used instead of the shellac splint.
In adjusting the splint care must be taken not to apply too
much pressure about the hip while it is still sore or painful; but



176                        PSOAS ABSCESS.
when the disease has become more chronic and indolent, slight
pressure, equally applied, is decidedly beneficial.
When the head of the femur is protruding but not yet entirely
dislocated, judicious pressure upon tie trochanter may serve to
restore the bone to its natural location and the patient have the
use of the limb again.  But generally when there hag been any
degree of dislocation and much suppuration, no other result can
be anticipated than anchylosis or a locked joint. This is worse for
the patient than when the head of the bone is thrown entirely out
of the socket, without other injury, as it then forms an artificial
joint, allowing a certain use of the limb, though with shortening
and deformity.*
CHAPTER XV.
CHRONIC PSOITIS-PSOAS ABSCESS.
ORIGIN and early symptoms - Secondary symptoms and diagnosis -Matter to be
all let out - By puncture or caustic - Dressings and injections - General treatment essential, not mere "anti-phlogistics" -Necessary measures -Baths —
Preventive means.
THIs most formidable affection of its class (that is to say, of
phlegmonous disease not directly affecting vital organs,) especially
the chronic form, is another of the opprobria of ordinary practice
-  the terror of both patient and physician.
Lumbar abscess sometimes shows itself suddenly and  runs
quickly through its course.  Usually, however, it is stow and insidious in its progress.  It is even said occasionally to take years
in coming to maturity.
* The late Dr. Morrow, preceptor and partner of the authors,' spoken of in giving the diagnosis, was eminently successful in the treatment of this and other esteemed incurable diseases. The main features of his treatment were appropriate suri
gical aid, attention to the skin and secretions, and the use of a large:vegetable irritating plaster over the entire hip. The irritating plaster acted not simply as a
counter-irritant,but he contendeditproduced a constitutional influence by the medicines of which it was composed, being taken up by the absorbents as was proven
by their presence in the secretions.



CHRONIC PSOITIS.                  177
The suppuration generally commences in the sheath of the
psoas muscles, high up on the spine near their origin, and runs
down along their course over the pelvis, at various lower parts of
which it finally points, most commonly in the "groin " just below
Poupart's ligament, near the insertion of the psoas magnus into
the femur. Occasionally it opens into the abdomen, causing death
immediately, the rectum, or in the case of females, into the vagina.
The early symptoms are, a dull, heavy aching in the lumbar
region, occasionally extending down the outside of the thigh, and,
in some instances, to the foot, causing lameness of the limb, -
speedy fatigue, on taking exercise, and general locomotive dullness. When he lies down, the patient is disposed to flex the thighs
upon the abdomen, to take off all tension from  the affected
muscles.
A sudden CHANGE takes place after awhile, and very different
symptoms occur. Those just mentioned may have continued stationary, and the patient grown accustomed to them, or been gradually aggravated, the local pain becoming at last more throbbing
and intense. The appetite fails, the breath becomes foul and fetid,
chilly sensations are experienced, and, not unfrequently, night
sweats occur, with other accompaniments of hectic.
The swelling, which is caused by accumulation of matter in the
cellular tissue, usually appears in the region of Poupart's ligament,
may be at first mistaken for hernia. Sometimes the matter passes
down by the urinary bladder and makes its appearance in the perineum, or it may affect the bladder and open into it. The character of the swelling may be known by its fluctuating, particularly
when the patient lies down. If he continue the recumbent posture,
it will recede. When he stands up, it is much more tense and
firm. When he coughs, the tumor suddenly enlarges, as if blown
up with air. These peculiarities constitute the
Diagnosis from hernia; but the hectic fever is perhaps the
clearest criterion, that not being necessarily or often present in
the latter disease.
When the vertebra are affected, the result may be curvature of
the spine, or even loss of the locomotive function. Such cases may
be confounded with original spinal disease.
23                                   (PART I.)



178                     PsoAS ABSCESS.
The causes of Psoitis are sometimes mechanical violence, straining, lifting or carrying, a blow, a fall on the back or nates, pelvis,
or rheumatism.
In the early stage of the disease, while the pains are but slight,
rather dull and pressive, or even when quite severe, though we see
no symptomatic fever, or if any, it is rather of a low grade, the
patient stoops to relieve the tension of the psoas muscles and has
to be careful in moving lest it hurt him severely; give Bryonia.
But if the pains resemble the sensation produced by a bruise,
and there is rather a sense of soreness from motion, than constant
aching or pain of any kind, use Nux vomica.
Pulsatilla, is to be used for a similar group of symptoms, occurring in females.
Mercurius, is to be given when these pains are worse at
night. But if acute inflammation sets in, threatening the immediate formation of abscess, with high symptomatic fever, acute and
constant pain, with loss of appetite, give Aconite, and as soon as
the acute symptoms have abated, follow by Belladonna, or these
may be with advantage alternated, if the symptoms of both are
present to any considerable extent.
Colocynth is useful after the acute symptoms have somewhat
subsided, but there is still a stiffness and constricted feeling on
moving the limb of the affected side.
Mercurius should be used where, notwithstanding the use of
Aconite and Belladonna, we have failed to so far subdue the symptoms as to prevent the formation of abscess, and we have reason
to apprehend such a result.
lepar Sulphuris: To be used after abscess has formed, to
facilitate the pointing to the surface; to be followed by 2Mercurius
as soon as the matter has been discharged. This remedy should
be continued until the discharge assumes a healthy appearance
and is rapidly diminishing in quantity, unless the. symptoms should
sooner clearly indicate some other remedy.
As soon as a fluctuating tumor is discovered, if the patient is
not in too great danger from the absorption of pus, apply a poultice of equal parts of elm and flax seed pulverized, wet in warm
milk and water, until the pus has approached very near the surface, then puncture and let it be discharged.  But when there is



TREATMENT.                       179
great constitutional disturbance from absorption of pus and it still
lies deep, you may make an issue with caustic potash over the
point where it appears to be nearest the surface, or at the most depending point if you can choose, then apply the poultice until the
eschar sloughis off and the abscess opens. In puncturing, never
make the mistake of puncturing a hernial tumor for anabscess
and kill your patient, as did a physician of our acquaintance. Let
your artificial issue be large enough to allow the matter, as well as
your injections, to flow out freely. A small orifice may give trouble, by closing again too soon.
Should the pus lie deep, no local means will be safer, and tend
more to bring it to the surface, than the caustic issue. It may enable you to gain much valuable time. After applying the caustic,
the elm poultice should be constantly used. After having the abscess open, drain off all the pus,- whether you have punctured,
or let it open spontaneously, or aided the efforts of nature by
caustic, let the matter pass out freely.  Assist it by compression,
as far as you can, along the course of the muscles, and by a slippery elm poultice over the opening, the latter being frequently
changed, so that it may not become an impediment.
There is no danger from  the mere escape of imater, as the
books will lead you to apprehend. The sooner it is got rid of, the
better. The exhaustion of the system is in its production, not its
ejection.  Lest, however, when the quantity is excessive, the patient suffer from the shock of too great a change, by the sudden
relaxation of the parts that have been so long distended by the accumulated matter, you may at first restrain it a little. If, at any
time during the flow, he shows symptoms of fainting, stop it for a
while, and give him a little wine. Then replace the poultice, so
that the matter may flow more slowly. Be sure, however,
In dressing, not to let the air enter the wound. This constitutes the only danger, as it may produce excessive inflammation.
It is no reason, however, for only "having a small and oblique
opening with the lancet, to be occasionally opened and then carefully closed!  When covered with the slippery elm poultice, it
is "hermetically sealed " against the action of the air. As an additional precaution, however, compresses should be kept upon the
part, bearing, as much as possible, from above, downwards.



180                    PSOAS ABSCESS.
When the flow of matter has entirely ceased, you may let the
opening close. If the evidence of continued suppuration again
appear, re-open; give it exit; and then throw in an infusion of
Calendula.  Your best mode of injecting, in such a case, is by
means of a common catheter, pushed up as far as possible into the
opening.  If the opening be large enough, as those recommended
to be made with caustic, the liquids you throw in will soon return.
The catheter should be filled with the fluid to be injected, before
being introduced, so that no air may be forced up in advance of
it. Keep the external orifice open until the abscess heal up internally. Whenever the matter reappears after healing, open again
and proceed as before.
These or similar means are all the strictly local treatment required. But, though it is absolutely essential to drain off the pus
and make such applications as will aid the healing process, these
measures are, after all, the least portion of a radical cure. We
are told by an old school authority that " very few patients recover from this disease under any circumstances, and those that
escape remain puny and debilitated." This confession is not surprising, when we find that this same author says not one word
about constitutional treatment, after matter has once formed. By
proper attention and the administration of suitable remedies, you
may generally, we ought perhaps to say, almost always, succeed
in curing this much dreaded affection.
There is, perhaps, no chronic affection in which the beneficial
results of the proper application of water will be mote striking
than in this case. General daily ablution, wet compresses over
the affected part and a wet girdle around the loins, are not to be
neglected. Observing, always, to temper the water to the susceptibilities of the patient.
The preventive treatment against the formation of pus, mentioned in allopathic works, is admitted, even by those who recommend it, to have failed.  We, however, have remedies that are
specifically adapted to any stage of the disease that will arrest any
such case, if applied in time and with sufficient skill.
That such measures as "purging, bleeding and low diet,"
should have-altogether failed, is no reason for not having confidence
in a better and more rational plan. This antiphlogistic trio is all



TUMORS.                           181
the constitutional treatment mentioned by one very generally received authority.
During the suppurative stage, China may be advantageously
employed, when there is much exhaustion from excessive suppuration. Should the ulceration extend to the bones, Silicea or Phosphorus should be used.  Phos. is also useful and may be applied
to the surface of the abscess when the patient suffers from diarrhoea and exhausting sweats. Where the pus is large in quantity,
fetid and sanious, Staphysagria is an important remedy.  It is
also useful in the incipient stage of suppuration, when the pain is
of a beating character.
When the flow of pus is very profuse, healthy in appearance,
but there seems to be no disposition to heal,or diminution of the
discharges, the use of Calendula internally and the infusion applied to the abscess by injecting will soon bring about a favorable
change.
CHAPTER XVI.
TUMORS.
Definition and distinctions - Causes —ADIPOsE TUMORS - Nature? -Removal,
the knife preferable to cautery or ligature - FIBROUS TUMORS, structure, diagnosis and prognosis - Excision, or incision and dissecting out - Late or early?
- Precautions in and after operating - CELLTLAR TUMORS - Origin, progress
and termination, dangerous transformation-Early treatment, absorption or
excision? - Later means and methods - MALIGNANT TUMORS, and particularly
the Vascular — Description - Precautions - Compression, caustic Circumvallation.
A "TUMOR " may be defined a preternatural enlargement or
protuberance of the soft parts of the body, distinguished by its
permanence from an ordinary swelling. It is further characterized
by a structure, differing more or less in every case from that of the
part from which it arises.  Every enlargement that merits the
name of a tumor, arises from  some disease or unnatural action,
and is, therefore, a new formation.



182                       TUMORS.
Tumors that have the strongest resemblance to the natural
tissues, the merely fleshy or fatty tumors, contain a considerable
amount of lymph, and their bulk is indeed most generally made up
of that deposit.
A common induration, resulting from phlegmon, possesses a
peculiar structure, which, however, is not permanent; but, being
gradually absorbed, gives place to the natural conformation of the
parts. But in some instances, even of common inflammation,
neither resolution nor suppuration takes place. The inflammation
ceases, but the swelling remains; the "tumefaction" has become
a " tumor." After this the action going on in the part is neither
inflammatory nor healthy; it is a peculiar increased or perverted
development of the organism. The tumor is as permanent as any
other portion of the body; and in the regular progress of physiological action, it is absorbed only to be redeposited.
ADIPOSE TUMORS,
or fatty tumors, may be occasioned by a rupture of the vessels of
a part from any mechanical cause, or by a change in the nutrition
of the part brought on by previous inflammation.
Tumors, however, often appear spontaneously, that is, without
any obviously assignable cause. But it is by no means certain
that one or other of the above mentioned causes has not been in
operation.  The injury may not have been so violent, nor the inflammation so high, as to excite attention or be remembered.
It has even been supposed, by some, that all these fatty tumors
originated in living vesicles, thus assigning them a separate vitality, as a sort of hydatids. This idea of their nature, does not
invalidate that of their mechanical or pathological origin, just
given. This independent parasitic vitality, appears as the result
of the original vitality of the part perverted, but not destroyed.
These tumors, then,- possessing a new organism, if not " vital
principle," and each existing upon the body as a distinct member,
if not as an independent body or whole, - are not easily removed
by any constitutional means. The ordinary means for discussing
chronic inflammation, and promoting absorption, have little or no
effect upon them.
In the stage of tumefaction, however, or while the action in the



TUMORa.                       183
part still continues inflammatory, discussion of the incipient tumor
may almost always be accomplished.
If the tumor is painful or tender to pressure, give Arnica and
apply the Tr. with cloths wet in hot water, over its surface, using
as strong compression as the patient will bear.
Baryta, is reported as having removed the pain and arrested
the growth of a steatomatous tumor of the neck-also of the
axilla.
Bovista, has removed painless swellings on the lip, of many
years standing.
Causticum, has also removed sarcomatous tumors, causing
them to inflame, suppurate and then heal up.
Silicea, has cured lymphatic tumors of large size, on the thighs
and head, producing suppuration, followed by healthy granulation.
Dr. Geyrard, of Paris, reports a case of two steatomatous tumors cured by Thuja 15, once a day. The tumors disappeared in
about a month.
If, after a fair trial of the means pointed out, we fail, as we
may expect to do in many instances, and the tumor is so situated as
to be conveniently operated upon, the knife is generally the best
means we can resort to.
Tumors, can, however, in some cases, be removed by the ligature or caustic potash. The latter must be applied so as effectually
to destroy every portion of the organized mass, and cause it to
slough off. For the former, two needles must be drawn through
under the tumor at right angles and touching each other, carrying
Fxa. 2.



184                        TUMORS.
each a double ligature. The loops being cut, leave four ligatures,
or the " eight tailed ligature " under the tumor. The ends being
tied in four knots, it perfectly strangulates every part of the tumor.  [See Plate.]
The knife is far preferable to either of these means, when the
patient can be brought to submit to it, as it causes less pain, and
there is no danger, in this character of tumor, of a return, after it
has once been wholly. removed.
FIBROUS TUMORS.
These tumors, so called from their peculiar structure, appear,
when cut into, to be composed of a uniform yellow or whitish substance, sometimes divided into lobes by septa of condensed cellular
membrane.  Few  vessels penetrate them; and, in some cases,
none at all can be discovered. The substances of the fibrous tumor is always contained in a capsule of greater or less density, to
which it adheres very loosely, and which seems, in fact, to be the
surface from which the substance of the tumor is secreted.
This substance, - though the tumor very often has much the
appearance of the adipose tumor, -  is not found, when removed,
to melt by heat; nor indeed does it contain proper fatty or sebaceous matter. It is composed apparently, as the name imports, of
fibrinous matter.
The shape and surface are always irregular, but never feel
hard and firm like schirrus, but rather of the consistency of dough;,nor is it painful and slow of growth as that malignant formation.
However, if it acquire great size, it may become painful and irritating from its weight upon the surrounding parts; and may even
burst and form an open sore, after which an alteration may take
place in the character of the tumor itself.  In fact the principal
annoyance of this sort of tumor to the patient is from its bulk,
which also constitutes the principal danger from its mechanical
effects upon the surrounding parts, rather than any originally malignant character.
The removal of fibrous tumors is easy. They are almost always
so situated as to be accessible to the knife. It is simply necessary
to make an incision through the skin, and divide the capsule so
that the tumor can be removed with the fingers or forceps, its ad



TUMORS.                        185
hesion to the capsule being so slight as to offer little or no resistance. If there has been inflammation excited, it may be necessary
to dissect it out. There may also be adhesions to vessels so large
as to require them to be taken up and tied. Another precaution
to be observed in the cure of these vascular adhesions, if there be
also any appearance of present morbid action, is not to permit healing by the first intention, but keep it open and excite
healthy suppuration, and treat it in other respects as a case of
cancer.
But when the surgeon is consulted early, before any adhesions
have occurred, or any degeneration in the action of the part, and
the patient is willing, these tumors may be cut out without any
hesitation.
CELLULAR TUMORS.
These are formations of an evidently cellular structure. They
may, at first, be divided into laminae of cellular substance. After
a while the laminar structure becomes indistinct, and the layers
compacted together. There is always more or less albumen, sometimes fibrin also, in the cells; but the mass of their contents is
evidently oily or sebaceous matter.
This kind of tumor may have its original nisus in a small gland,
in which case it will appear to have a distinct capsule.  When it
forms in the subcutaneous substance, there is no proper capsule,
although the condensation and thickening of the surrounding
cellular tissue may bear a strong resemblance to a capsular
formation.
These tumors are smooth and compact, without the indurated
appearance of schirrus.  Nor have they any cartilaginous or membranous septa, like cancer and the fibrous tumor. They are never
painful unless they become inflamed, or from their weight and
pressure upon the surrounding parts affect the nerves. The cutaneous veins involved in the tumor sometimes become varicose,
and the skin over its whole surface may be destroyed. There is,
however, no tendency to fungous growths; nor much susceptibility
to suppuration or ulceration. When abrasion takes place it is more
apt to slough away.  In this way it is often, when small, spontaneously or accidentally cured.  But when the tumor is large, the
24                                         (PART I.)



186                        TVU.OR
slough is a long time in being thrown off, and there is, meanwhile,
a very offensive sore. This is accompanied also with great constitutional irritation and injury. It becomes, in fact, as dangerous
as true cancer. In its original character, however, this tumor has
nothing malignant about it: it is as free from danger, as it is easy
to manage. Even after inflammation and sloughing, it is much
more easily eradicated than any cancerous tumor.
In the TREATMENT of these cases, like the former, you may
sometimes succeed in promoting absorption by such means as were
before recommended.  If these means fail, or if the tumor is already very large, recourse had better be had to the knife, caustic or
ligature. If called to the case before any inflammation has occurred, and there appears to be no disease in the surrounding parts,
excision will be the best of all treatment,
But after sloughing has commenced, even if the knife be available at all, it should be relied upon alone.
If suppuration or sloughing should take place from the effects
of your remedies (Baryta, Bovista, Silicea, Caustieum,) before
mentioned, discontinue the remedy or lengthen the interval, and
let it go on until the cure is complete. If, however, the sloughing
come on spontaneously, or the patient becomes much prostrated
from the discharge of pus, give China.
Cleanse the abscess several times a day of all pus, by gentle washing with soap and water, injecting the same into any sinuses that
may exist.  Keep the tumor covered with an emollient poultice
and warm.  Give the patient nourishing diet and keep him very
quiet.
OTHER VARIETIES,
and other DIVISIONS of tumors, are presented in the books, but
the division into the three classes mentioned, comprehends all the
forms of non-malignant tumor, and appears as good - that is, as
practically useful as any.
"Encysted tumors " might be instanced. They are distinguished
as consisting of a sac, containing a thin fluid, which is not pus.
The definition evidently corresponds to the description of cellular
tumors above given. Strictly fatty encysted tumors are sometimes
called' steatomous;" those embracing honey-like matter, " meli



TUMORS.                        18
cerous;" and those having a pap-like fluid, different from either
of the others, " etheromatous."
What might seem the most important practical division, is into
those which are, and are not,
MALIGNANT TUMORS.
It should be remembered, however, that almost any tumor or
sore may become malignant. Thus, the fibrous tumor, above
spoken of, as well as the cellular, may become a tumor or sore as
"dangerous and difficult" to manage, by ordinary means, as any
schirrus or open cancer. Those forms known to be malignant, we
shall speak of as varieties of cancer, Among these,may be named
the tuberculated (a congeries of small, hard, rounded tumors), and
the medullary sarcoma, or fungus hoematodes. Under this head,
however, we may distingush the
Vascular Tumor.  (Telangiectasia.)
This is sometimes palled Aneurism by Anastomosis.  It is,' in
fact, a complete net work of vessels.  Some suppose it is caused
by arteries opening into the cellular interstices, giving rise to corresponding veins; others, that it is originally a particular structure,
formed by fibrous membrane, from the internal surface of which
prolongations pass off, crossing each other in various directions,
and accompanied by as many arteries and veins, to a "prodigious
subdivision." Certain it is, that the tumor, when fully developed,
seems to be wholly composed of vessels, a sort of placental formation.
When the vascular tumor forms just beneath the skin, or in
the integuments, it can be readily distinguished, by the external
appearance.  But when it occurs beneath the fasciaa, the external
appearance is no guide, and the diagnosis is very obscure for a
long time.  There will be some degree of tension and swelling,
with a sensation of throbbing and pain. It may be noticed, however, that the tumor will vary in size, according to the tension or
relaxation of the neighboring muscles, and according to the degree of excitement in the whole vascular system. Whenever we
discover a swelling to have these peculiarities, we should be on our
guard as to any



188                        TUMORS.
TREATMENT that may be adopted.  Wounds, or incisions, into
such tumors, are very troublesome, as it is almost impossible to
suppress the hemorrhage.  No attempt at an operation should be
made, unless the tumor be so situated that every portion of the
mass can be at once removed.  Their most common site is about
the eye, or upon the temporal muscle, or other parts of the head
and face.
In cases of children they may be removed by specific medication; but in adults the result is much more doubtful. Compression
immediately after birth, will facilitate the cure.
Carbo. veg., has succeeded in young children.
Nitric Acid, in persons farther advanced.
Sulphur, has also been successful.  It has been used with success in alternation with Phos.
Any, or all these remedies, may be used in their turn, for such
a period of time as may be deemed necessary to give each a fair
trial. Long intervals should intervene between the repetition of
doses. As there are generally no marked symptoms to guide us in
the selection of remedies in the early stages, we must select with
reference to the general condition of the patient.
If all specific remedies fail and the case is one threatening
danger, you can resort to
Obliteration of the vessels by exciting adhesive inflammation,
which may be accomplished by surrounding the part with an eschar,
made by caustic potash, when that is practicable, and then applying the plaster and compression. The vessels supplying the tumor will thus be destroyed, and active absorption at the same time
promoted.  At this circumvallation of the tumor is not always
practicable, the caustic may be applied to the surface of the tumor itself, if the proper care be taken, at the time, not to cauterize
so deeply as to rupture the vessels before inflammation is set up,
and afterwards to keep up sufficient compression.  This pressure
is important in all cases, in order that the vessels be not allowed
to continue their regular action and growth.



GANGLION.                         189
CHAPTER XVII.
GANGLION AND EXOSTOSIS
TUMOR on the TENDONS or LIGAMENTS - Character, causes, etc., -Ulceration and
Induration -Excision - Treatment, medical or surgical?- Tumors on BONES,
or EXOSTOSIS - Description and distinction from Hypertrophy of Bone - Progress- Treatment, general and local- Starvation and Gluttony - Operation.
THIS term GANGLION is used in surgeryto designate a peculiar
encysted tumor which forms in the fascia near the tendons and
joints, usually on the wrist, hand, and top of the foot. The fluid
it contains is like the white of eggs; or sometimes more like milk
or cream. It is generally found adherent to the tendons of the
muscles, or the ligaments of the joints.
The probable CAUSE is some mechanical injury, which occasions
a slight rupture in the sheath of the tendons, or the synovial membrane; in consequence of which the secretion of the bursae mucosve,
or the synovial fluid itself, escapes, and occasions the formation of
the membrane, sac or cyst, in which the fluid is retained, and continues to accumulate.  As the fluid accumulates, its new  membraneous investment constantly enlarges, producing, first, stiffness
in the adjacent joint, then emaciation of the muscles, contraction
of the tendons, and sooner or later, a total loss of the use of the
joint. Thus, on the back, or even front of the wrist, it may affect
several tendons at once, so as to destroy the power of extending
or flexing the fingers.
If the ganglion is allowed to follow its own course, an opening
is at last formed, from which a sanious fluid exudes, and a very
malignant ulcer is sometimes the consequence.
The Homeopathic treatment for wounds and injuries prevents
the development of ganglion. Ience its great superiority. It not
only removes present symptoms, but prevents evil results of the
injury upon the organism in future.
Arnica, Rhus, Silicea and Ruta, are the most important
remedies.
In all cases of ganglion arising from mechanical injury (and
nearly if not all cases are such), Arnica will prove valuable. We



190                       EXOSTOSIS.
have removed ganglion of years standing with it, when the tendons
were so involved as almost entirely to destroy the use of the hand,
and the tumor had become very painful. Give it internally once
a day, at first, and as the case improves, lengthen the interval.
At the same time apply the Tr. to the tumor, together with as
much compression as it will bear. Subject the tumor to a stream
of cold water from a height for several minutes each day —prohibit the use of the affected joint as far as practicable.
Rhus, after Arnica has been used for a few weeks, is often
advantageously alternated with it.
Ammonia Carb., is beneficial when it becomes very painful.
Phos. Acid, when it ulcerates and is painful; this should also
be applied to the ulcer.
If it becomes highly inflamed, Plumbum is useful.
Ruta, for ganglion from injury of carpal and tarsal joints, particularly for the painless swelling.
Silicea, is useful both when painless and when ulcerated.
EXOSTOSIS.
All tumors formed upon the bones in a healthy condition, are
included under this term. These tumors are of various forms and
densities, differing in their structural arrangement.  They may be
solid, dense and smooth as ivory, cellular and smooth on their external surface also, or rough and jagged, what is called " tuberculous."
Professor Gibson divides them into four classes:
1st. The cirumscribed, which is the most common kind,smooth, seldom painful, and rarely becoming very large.
2d. The lamellated, consisting of numerous plates laid over
each other, and often piled up in irregular masses.
3d. The tuberculated, consisting of knobs or irregular excrescences, either closely connected or insulated.
4th. The spinous, having slender processes terminating in
points or knobs.
These tumors are most frequently found upon the extremities,
the humerus and femur being often er affected than other bones.
Bone tumors grow from the periosteum, or from the external
surface of the bone, under cover of the periosteum. In some cases
the point of attachment is a small neck, the. main portion of the



EXOSTOSIS.                       91
tumor being bulbous.  These are apt to be broken off accidentally.
Others are attached by a more extensive surface.
When the surface of the tumor is rough or sharp pointed, it is
often a source of much inconvenience, by impeding the motions of
muscles, or pressing upon some important organ.  They have no
malignant character, being governed by the same laws as other
bony formations.
Bones sometimes become enlarged throughout their whole extent, and yet appear to be free from disease. This enlargement,
though perhaps produced by a similar state of the system, is not
properly " exostosis "-it is no tumor.
The causes are not well understood.  External injuries are
said to be the most frequent. Their progress is very slow and attended with but little pain or inconvenience. They can be distinguished by the peculiar hard bony feeling at points where bone
is not usually perceptible. If the tumor projects into a natural
cavity, as that of the skull, the diagnosis is difficult or impossible.
After having attained a certain size, it generally remains stationary, the surrounding parts becoming'accustomed to its presence and
accommodated to its size. No inconvenience then attends it. Occasionally, however, the pressure causes suppuration of the surrounding parts and becomes a source of much difficulty, if not danger.
The principal remedies are: Arnica, Asafetida, Dulcamara,
Belladonna, Calcarea, Aurum, Lycopodium, Mezereum, Phosphorus and Silicea.
Arnica, is to be used when the disease was caused by an
injury. Asafetida, is particularly applicable when it appears on
the legs or arms.  Belladonna, when it appears on the os
frontis.  Aurum, is used in cases caused by the use of mercury.
Calcarea, for exostosis on the spine. Dulcamara, when the affliction arose from suppressed itch.  Lycopodium, for scrofulous persons. Mezereum, particularly for the affection on the legs and
arms of scrofulous or syphilitic persons.  Phosphorus, is used for
painful bones, tendons on the head and clavicle. Silicea, is most
serviceable for this disease in infants.
All stimulating food and drinks should be avoided, and the accustomed quantity of food should be gradually diminished.  This
may be done, if carefully managed, without inducing debility.



192                         POLYPUS.
Most persons eat too much, at all times, and by thus over-taxing
the digestive and assimilating organs, the absorbent process is enfeebled; and hence we see sores, of various kinds, appear on the
surface to give outlet to noxious fluids, which should have been
taken up by the absorbents, and carried off through the natural
evacuations; or we have tumors appearing in the soft parts, or on
the bones. If then we can institute a course of regimen that will
correct this gormandizing habit, we do much toward removing these
tumors, by promoting the natural activity of absorption. We once
knew a young man in college, who made the experiment upon himself, of limiting and diminishing, from day to day, his allowance
of food, until he could live, and feel well, on less than one-fifth the
quantity he had formerly taken. His strength was not impaired
in the least, either physically or mentally; though he became very
much thinner, all the fat of his system seeming to have been
gradually absorbed without injury. Care should be exercised in
this matter, however, for if debility or nervous irritability is induced by the low diet or starvation, it will result in evil. If these
means fail, the tumor may be removed by an operation. The soft
parts over the tumor should be laid open and dissected sufficiently
to expose its face, and then it may be removed with a saw of the
proper dimensions, a trephine, or a chisel. The surface of the
bone from which the tumor is removed, should be made smooth by
the bone-forceps or file and the soft parts replaced, and adhesion
by the first intention promoted.
CHAPTER XVIII.
POLYPUS OF THE NOSE -POLYPUS OF THE WOMB.
POLYPI in general —NASAL POLYPUS - Cause - Various incipient symptomsProgress and results - "Cancerous polypi"- Treatment -General Remedies
and regimen - Relapse to be prevented - Mechanical surgery insufficient. 
UTERINE AND VAGINAL POLYPI- Slow Progress - Diagnosis - Application of the
ligature - Injections and topical applications - Examples of mistake - Treatment for prolapsus uteri.
POLYPI may be defined as fleshy excrescences, of a vegetative
or zoophytic, rather than animal character, varying in size, color



POLYPUS OF THE NOSE.                  193
and density, and occupying some of the cavities of the body,
generally growing on the introverted surface, lined with mucous
membrane.
As the nasal or uterine mucous surface is by far the most usual
habitat of these troublesome growths, all that need be said of
them will occur under the two heads of Polypus of the nose and
uterus.
POLYPUS OF THE NOSE.
This is a very common disease, particularly in climates that
are both damp and warm.  Wherever it occurs the state of the
weather has considerable influence over it. A polypus is a living
hygrometer.  Just before a storm and during wet weather, it is
much more swollen than at ordinary times, and when a change to
dry weather occurs, it perceptibly shrinks in size. Further than
this direct subjection to atmospheric vicissitudes, little is known of
its character and
- CAUSE. It has been supposed that it always originates in
some mechanical injury.  Another opinion is, that the predisposition to this disease is very generally hereditary.
The polypus often comes on as a mere swollen and thickened
state of the mucous membrane, independent of local causes, with
many of the symptoms of a common cold. This swelling frequently
appears to changeitsseat from one part to another, or even from one
nostril to the other. In other cases its distinct existence may be
detected when it is not larger than a pin's head, like a little fungous pimple, generally quite insensible. In other parts it becomes
dark-colored, but in the nose it is generally light-colored and
sometimes white, having a clear cartilaginous appearance, and
being much less vascular or liable to bleed.
The SYMPTOMS are at first those of catarrh, with unusual
sneezing, especially when the patient changes his position. As
the disease progresses, various unpleasant sensations are experienced, chiefly attributable to the mere mechanical obstruction.
A sense of fullness and dull pain in the head are seldom absent.
The eyes, one or both, are liable to become suffused with tears: the
ductus ad nasum  may even be quite closed up, causing "fistula
lacrymalis." The sense of smell is generally lost. That of hear25                                         (PART I.)



194                       POLYPUS.
ing, too, may be subsequently injured, in consequence of the polypus growing backward into the throat and pressing on the estachian tube. Even the teeth are sometimes crowded out, and the
voice assumes what is called the nasal sound from the air not
passing through the nose!
The actual sensation of fullnres is generally first felt at the
side of the nose, the parasite most commonly taking root in one
of the turbinated or spongy bones. After enlarging so as to fill
up the whole nasal cavity, it may project externally through the
nostrils, or backwards into the throat, occasioning difficulty of
swallowing and even of respiration. Sleep is thus often disturbed,
the patient having to lie with his mouth open. The disfigurement
of the face from swelling of the nose may be very great, independently of any secondary diseased action. The ossa nasi may be
separated for nearly an inch.
If the disease is allowed to continue it may occasion ulceration
of the bone; after which the patient rapidly sinks. The breath
becomes very foul, and hemorrhage from the part now occurs very
frequently, as well as from other parts of the body.  Hectic soon
follows, with coma and death.
Precise distinction is sometimes attempted between fungous
and cancerous polypi. But we are clearly of opinion that the
attempt must be ineffectual and often practically injurious. Any
polypus may, by neglect or improper treatment, assume a malignant character; and a tumor that is plainly cancerous from its
origin is improperly called a polypus* That cancers do result
from polypi is to be attributed more to bad management than any
natural tendency in the latter to such a transformation. Still, it
must be confessed, that a polypus may become, especially in
scrofulous individuals, quite as malignant and fatal as any "true
cancer."
In TREATING this affection, you have generally time to attempt
its removal by internal remedies. The principal remedies for
polypus of the nose are Phosphorus, Staphysagria, Calcarea,
Sepia, Silicia, and Sanguinaria.
Phosphorus is indicated in the early stage, when the patient
sneezes often, and begins to feel a fullness in the nostril, espe.
cially in the morning. Staphysagria should be used when, in



POLYPUS.                        195
addition to the foregoing, there is a suffused condition of the eyes.
Calcarea, at a later stage, when there is oppressive fullness and a
fetid smell constantly complained of, or where he has lost the
sense of smell, but the part emits a fetid odor.
Sepia, when, in addition to the foregoing symptoms, or any of
them, there is pain in the head as a constant symptom, especially
in damp weather.
Silicia is most useful in scrofulous ulceration of the polypus.
Sanguinaria. Coryza, profuse lachrymation, watery discharge
from the nose, redness of the nose, frequent sneezing, heat in the
nose.
We have frequently removed polypus of the nares, when not too
far advanced, by the simple application, with a camel's-hair pencil,
of this remedy finely pulverized.
Dr. Goullon reports a case of polypus of the nose, filling one
nostril and crowding upon the other so as to impede respiration
through it, cured by Calcarime carb. three doses in fourteen days,
when all traces of the polypus disappeared.
A case of nasal polypus, of thirty years standing, in a man of
sixty, cured with Teucrium, is reported in the Allg. Zty. Hom.,
vol. i., p. 69. The polypus extended into the posterior nares and
the antrum   both nostrils were closed and the sense of smell destroyed.  One drop of the 3d dilution was taken every evening,
and an inhalation from the mother Tr. every morning.  In two
months the polypus dwindled away to a small spot, sense of smell
returned, with free breathing through the nose.
If we should, however, meet with any case where all of those
remedies fail to make an impression, disorganization and sloughing of the tumor may be safely caused by an application of the
pure sesqui-carbonate of potash. When the remedies are operating properly, the polypus will turn black, and begin to slough off.
This degree of success will indicate the continuance of the same
remedy until the whole is removed. Where even the sesqui-carb.
is not sufficient to disorganize the tumor, aid it by mechanical
force.  Take hold of the polypus with sharp pointed forceps, and
crush it in various directions, even tearing away any parts that
can be detached. Be sure to disorganize the main part of it,
squeezing and twisting freely with the sharp teeth of the instru



196             POLYPUS OF THE UTERUS, ETC.
ment, in order that the subsequent applications may penetrate the
center.  There is but little sensibility to embarrass the operation;
and any hemorrhage that may be occasioned can be checked with
Phos.  After this "operation," reapply sesqui-carb. to the lacerated mass, in the shape of a strong wash, as often as once a day,
at least — occasionally applying a little of the dry powder, if it
do not give too much pain.
This plan will invariably succeed, the whole product of " perverted nutrition" passing away in the suppurative process. Continue the specific medicines according to the symptoms, with a
view to preventing a relapse and removing a disposition to return
of the disease.
Pungent articles should never be carelessly used as "errhines,"
i. e. snuffed up. The mere local irritation of them may, through
sympathy, excite severe sneezing and coughing, and their actual
inhalation may occasion inflammation of the lungs.
The diet may require to be restricted or regulated, watching
the effect of any change on the constitution. As in all cases, be
cautious of a too spare as well as too "full habit of body"avoid sins of omission as well as commission. The patient should
be neither starved nor stuffed.
The mere mechanical treatment of these affections does not
deserve to be called scientific. Little or no good is done by all this
violence.  The excrescence may be removed for a time, but is sure
to return again, if not to assume a worse form. There is an old
gentleman now in Cincinnati, who was operated on in Edinburgh
every year, for several years in succession, by the celebrated Liston, and subsequently by other surgeons, -once by Professor
Barton, in Philadelphia.  The polypus is now larger than ever,
completely filling both nostrils, separating the ossa nasi and
spreading the nose half across the face. It is not only a great
disfigurement and local inconvenience to the patient, particularly
in wet weather, but seriously affects his general health, though
there is still no appearance of malignancy or even ulceration.
POLYPUS OF THE UTERUS OR VAGINA.
This polypus is usually of a pear shape, and attached by its
smaller end within the cavity of the womb, or about its neck.  It



POLYPUS.                        197
is sometimes found adhering to the os tinca, at others just within
the cervix, or even to the fundus. It has often a small stalk or
pedicle, and the great mass of it projects into the vagina.
It may be very slow in its growth, and for a long time unnoticed, occasioning no inconvenience except as an obstacle on the
occasion of childbirth. It may give trouble in this way long before it is large enough to prevent conception. Dr. Hill examined
a case where he was fully satisfied the patient had given birth to
three children since the existence of the parasite. The difficulty
of parturition increased each time. The polypus grew out from
the body of the womb, and finally filled up the cavity and protruded into the vagina.
Polypus in the Vagina may be mistaken by the patient, and by
careless or very inexperienced practitioners, for inversion or prolapsus of the womb.' In such cases,
Your diagnosis will be aided by the history of the case. Of
course, there is no question of inversion if the patient has never
borne children.
An alleged case of "falling of the womb," however, which
does not soon right itself by suitable measures and regimen, must
be serious enough to demand an examination.  If, as is very possible, the supposed descent of the uterus turn out a polypus, the
latter will be distinguished from it by its greater hardness, and
readiness to bleed, by being dark instead of florid, and insensitive
instead of very sensitive to the touch.
Polypus of the womb is sometimes, but by no means necessarily,
connected, as will be pointed out hereafter, with a scirrhus condition or tendency in that organ.
The principal remedies are, Aurum, Belladonna, Thuja, Nux
Vomica, Sepia, Kreosote and Mercurius.  Cal. and Styphy. are
recommended to remove this tendency to the formation of Polypi.
Calearea, for hysterical women, the menses too early and too
profuse.
Aurum is to be used when the patient is tremulous, easily debilitated, is rather melancholy, desires to think and reflect a great
deal on her disease, but complains of being easily fatigued by
thinking; the mind gets tired. She suffers more or less from pains
in the abdomen resembling labor pains.



198                        POLYPUS.
Belladonna is indicated when she has no disposition to think
or reflect; she feels a fullness of the head, is forgetful and rather
hypochondrical, or has a kind of monomania about her disease, or,
it may perhaps, be some other subject; complains of habitual
dullness of ideas and occasional dizziness, is affected with leucorrhoea and colic pains, hemorrhoids.
Nux Vomica is useful when she has great fear of death, is
sure she will never recover, is peevish and fault-finding, or she is
inclined to "build castles in the air," wants to accomplish some
great thing, but fears to undertake it, because she will not live to
see it perfected.
Sepia is indicated by great sadness and weeping; she imagines
that she has consumption, though she has no symptoms of that
disease; she loathes life, is melancholy and peevish; is affected
with debilitating leucorrhoea attended by severe itching in the
vagina.
Mercurius for polypus with corrosive leucorrhoea, attended by
itching, while there is much sympathetic affection of the mammw.
If the patient has a scrofulous or cachetic constitution, give Mercurius, unless she is suffering from the effects of mercury; if so,
give Hepar sul., or Sul. acid.  Staphysagria is also useful in this
latter case.
The medicines should be given only at long intervals — say
from two to three weeks between doses.  Jahr says six or eight
weeks.
Though by perseverance you may be able to effect the cure,
you will often have much difficulty in inducing your patient to
wait patiently for the action of your remedies. If you cannot induce her to do so, or you are disappointed in the results, the polypus
still remaining unchanged or increasing, you may resort to surgical means for the removal of the tumor, and after that is effected,
return to the specific remedies to rid the system of the tendency
to a relapse.
The idea sometimes put forth by some of our homeopathic
brethren, that the interference of surgery for the removal of parasites is prejudicial to the specific action of remedies in removing
the morbid condition on which their growth depended, will not
stand the test of practical observation, while every day's experi.



POLYPUS.                            199
ence proves the contrary to be true —that morbid condition will
be much more easily corrected after the removal of the tumor, the
great obstacle to a speedy cure.
The removal of polypus of the womb is generally facilitated
by its pedunculated shape and position in the vagina. Having
ascertained, by very strict manual examination, or by the speculum, the exact state of the case, introduce your ligature, by means
of the polypus forceps, or double capula (Fig. No. 3,)* and draw
it tight enough round the pedicle to cut off the circulation.  In
from four to six days the strangulated parasite will slough off.
There may be some bleeding at this period: it can easily be
stopped with sanguinaria, arnica or calendula. If the body of the
polypus does not come away altogether, on the division of its attachment, remove it with the forceps.
It may, however, be difficult or impossible, to get at the neck
of the polypus, so as to apply your ligature, from its lying too far
up, or being too large to be passed; or from rigidity of the mouth
of the womb.
It may be necessary to speak of the errors in diagnosis to which
uterine polypi may give rise; even experienced men have committed very great blunders.  In "women's matters," the young
surgeon may be excused some hesitancy of judgment, since he is
not always readily permitted the necessary means of information.
A very respectable lady, about forty years of age, who once came
to consult Dr. Hill, had been mis-treated for several years by diff* The double canula, represented in Fig. 3, is made of two silver tubes, attached at their sides, with a ring on the lateral surface of each at one end. A ligature of silk cord, cat-gut, or a silver wire, is passed into each tube by its two ends,
leaving a loop at the extremity: while one end is fast to one of the rings, the other is
loose, and can be pushed forward, or drawn up, as you wish to enlarge or diminish
the size of the loop. The loop is passed over the polypus, or tumor, and then the
loose end of the ligature is drawn upon as tightly as is required, and fastened to
the other ring. The canula is allowed to remain attached until the tumor is
strangulated, or sloughs off. The ligature may be tightened, from time to time, if
necessary.



200                        POLYPUS.
erent physicians, on the supposition that the leucorrhea from which
she constantly suffered, depended for its cause and continuance
on prolapus uteri. At last she determined to try if there was not
a better practice. Her physician, however, too much accustomed
to seeing such failures to regard the ill success of such treatment
as she had been under, as any reason for suspecting false diagnosis,
and influenced, perhaps, a little too much by the fact of so many
doctors not differing, continued to treat the case as one of prolapsus.
This, of course, could not remove her local difficulties, though she
acknowledged to Dr. H. that her general health had been much
benefitted by the prescriptions. Her physician informed Dr. H.,
also, that the prolapsus was very deep, and the uterus so changed
in its form as well as place, that the os tincae could not be found!
Upon an examination he found simply a polypus, of the size of a
goose-egg, attached at about an inch within the neck of the uterus,
and reaching bodily into the vagina, where it would, by acting as
a pessary, havd effectually prevented any falling of the womb, had
there been any tendency that way; and where, by its pressure on
the delicate lining of the walls, it kept up the irritation and discharge, which latter it would have been worse than useless, had it
been possible, to stop without " removing the cause."  The whole
mystery of the obstinacy of the disease was explained at once;
and the long-sought remedy easily applied.
Another case was that of a young lady, of about twenty, who
had suffered much for two years previous from uterine hemorrhage, - so much indeed, that on several occasions her immediate
death from  exhaustion had been anticipated.  Her appearance
was such as indicated that the gradual exhaustion by hemorrhage
would ere long terminate in death. She was so emaciated that
osteology might have been studied upon her figure; and her face
was a bloodless white. Her physician spoke of the case as prolapsus, rendered difficult by debility from former hemorrhage, although he had made no examination.  The patient herself stated
that another physician, a man of years and of reputation for science
as well as experience, had examined and pronounced the cause of
her afflictions to be a "falling of the womb." On examination,
two polypi were discovered, one of the goose-egg size wholly in the
vagina, though springing from the cervix uteri, the other as large



CANCERS.                       201
as an ordinary hen's egg, extending some distance up into the
cavity of the womb.
What we wish to impress on the mind by relating these cases,
is the necessity, in all obstinate uterine difficulties, of a thorough
and critical examination, before venturing an opinion, much more
undertaking treatment.
CHAPTER XIX.
CANCER IN GENERAL.
THIS subject is one of very great importance and demands as
full an elucidation as is possible within the limits of this work. When
we bear in mind the intolerable sufferings of the unfortunate patient,
and the results of treatment, and the expressed opinions of distinguished men as to its curability; as true physicians, esteeming it
our highest privilege to alleviate and remove the suffering of our
fellow men, we may, with solicitude, ask if the beneficent Creator
has not given any means to stay the ravages of this terrible
destroyer.
Many seem to regard the terms cancerous and incurable as synonomous.  Said a distinguished allopathic authority to his class:
" Gentlemen, I never cured a cancer, and (consequently) I don't
believe any other man ever did! "  This class, measuring others'
knowledge by their own ignorance and others' abilities by their
own impotence, denounce as quacks and impostors those who profess to have succeeded. If they were cured, say they, in reference
to cases abandoned by themselves because cancerous, and returned
cured, they were not cancer; if they were not, they probably were,
and failure was the necessary consequence of so hopeless an undertaking.  They will rather disbelieve their own eyes, than take
another's word; rather impeach their own judgment, than authenticate another's skill; rather give up their own infallibility in all
other points, than doubt that they can fix the exact boundary be26                                        (PART I.)



202                        CANCERS.
tween the possible and impossible. They confess that they do not
always know what is cancer, but still insist that they do know that
cancer (if it were only known) never has been and never will be cured.
They are like the dog in the manger. And while their course may
do very well for the routinist, the follower of " authorities" too lazy
to think and investigate for himself, it is not that of the true physician or surgeon. If it could be proven that a case of cancer never
had been cured, that should be the most urgent reason for elaborating and trying new means and modes of treatment.
The name cancer has been applied by modern pathologists to
the morbid structures designated as scirrhus encephaloid and colloid, and is applicable to them in every period of' their development, before as well as after softening and ulceration. That these
formations should be thus grouped together is evident, since they
agree anatomically, chemically, physiologically and pathologically.
"Anatomically, for they are all composed of a containing and
contained part, forming a combination unlike any other in the
natural structures; chemically, since they are all distinguished
by the very great excess of albumen in their composition;
physiologically, for they all possess in themselves the power of
growth and of extension by continuity of tissue, that is, of assimilating to their proper substance the most heterogeneous material:
an inherent tendency to destruction and the power of local reproduction; pathologically, since they all tend to effect simultaneously
or consecutively various organs in the body, and produce that depraved state of the constitution known as the cancerous cachexia.
They are not entozootic, since they do not live without vascular
connexion with the parent organism, which is the case with entozoon. Yet the heterologous material of all carcinomatous formations is organizable, susceptible of vascular development, and hence
of undergoing all the changes of increase and decay consequent on
such susceptibility." M. Cruveilhier remarks,. that cancerous
products are living foreign bodies which possess vital powers of
their own, and, like the foetus in utero, assimilate materials derived
from the individual in whom they are developed, to their own peculiar substance.
Scirrhus is either infiltrated into the substance of organs, or is
developed in the form of a tumor.  A  scirrhus tumor is distin



CANCERS.                        203
guished by its extreme hardness, whence the common name stone
cancer, the resistance to treatment ordinarily sufficient for resolution and the very strong tendency to intractable ulceration. They
rarely become larger than a fair sized apple, and are usually
rounded or oval and flattened. At first the surface is smooth, but
soon becomes irregular and knotty to the touch; and the skin becomes wrinkled or puckered and of a leaden hue, occasionally dark
or purplish.  Sometimes there is an absence of pain, at other
times it is of a burning character, but generally it is at first merely
itching, crawling, or twinging, afterward lacinating and gnawing,
and very severe. Its growth is often slow, continuing in the condition above described, without any material change for several
years; sooner or later, however, the wrinkled skin about it seems
to become dry, and finally cracks open in several places; forming
deep grooves, from which is discharged a thin, fetid and excoriating
fluid.  These fissures deepen and widen in some instances slowly,
in others very rapidly, with extensive ulceration and sloughing.
The cavity thus formed constitutes one form of " open cancer,"
which, however, frequently fills up with an irregular fungous
growth.
The infiltrated form is most common in the uterus, female
mammae and the lower lip.  When it attacks the bones it gradually produces softening.
If a dissection be made of a scirrhus tumor, in its early stage,
it appears to consist mainly of pale, gray, cartilaginous or fibrous
bands, in appearance.  In some instances these form  spheroidal
cells, others a rectilinear disposition predominates, and in others
still there appears to be a fibro-cartilaginous nucleus, from which
they radiate to the surface of the tumors and sometimes extend to
the surrounding cellular tissue.  These radiating bands are intersected by others, not so distinct, thus forming a kind of fibrous
net-work, enclosing the softer parts of the mass, which are of a
bluish white color, and always presenting a glossy and peculiar
semi-transparent aspect. When, however, the tumor has approached
the ulcerating stage, its various parts become more blended together.  They are, however, still distinct cysts, including a pulpy
masS of dark greenish color, which has lost its transparency, and
is sometimes even black. There are frequently several of these



204                        CANCERS.
cysts of different colors. Sometimes they are very numerous, presenting a strong resemblance to hydatids.
These cysts in a tumor are regarded by some as the most positive, if not indispensable, evidence of the cancerous character. " I
am not prepared," says Professor Burns of Glasgow, "to prove
that cysts invariably exist in true cancer; but my examinations
enable me to say that they are rarely if ever absent."-Principles
of Surgery, page 339.
By forcibly pressing a slice of scirrhus tumor, a thin albuminous
fluid may be made to exude, which is called the scirrhus juice or
ichor, and which M. Cruveilhier affirms, forms the only distinction
visible to the naked eye, between some scirrhus and fibrous tumors
in the bones.
Encephaloid, so called from its resemblance to the brain, is also
infiltrated into the tissue of organs, or occurs as a distinct tumor
encysted or non-eneysted; found most frequently in the common
cellular membrane, the testicle, liver and stomach. Laurie describes the investing cyst as a smooth membrane, about half a line
thick, of a silvery white color, imperfectly transparent, and easily
removed from the mass.
The non-encysted variety is generally globular, but may be
flat, oval or irregular in form. Very rarely the surface of encephaloid tumors is perfectly smooth; usually, however, convoluted
like the brain, whence the name. They grow to a larger size than almost any other morbid growth. Professor Berard saw an encephaloid
tumor in the thigh of a female as large as the body of a man, and
Abernethy relates the case of a patient who had a tumor of this
class in each groin as large as the head of an adult. We have
seen them larger than the head of a man. In the diffused or infiltrated form, cancerous matter is deposited in the interstices of a
tissue, and if its growth is not arrested, gradually transforms that
tissue into its own substance.
Upon cutting into an encephaloid tumor we find a containing
part, consisting of firmer septa, which rarely intersect each other,
but describe curves circumscribing loculi of various shapes and
sizes, and dividing the mass into lobes and lobuli,- a contained
part, the cancerous matter, which gives the brain-like appearance
to the whole. It has the appearance of homogeneous matter of



CANCERS.                     205
an opaque milky color, usually dotted with pink-colored spots,
varying in their number, size and shape. Its consistency is that
of the healthy brain. This class of tumors is abundantly supplied
with blood-vessels; hence the great difference between this and
other species of cancers in the rapidity of their growth.
"There are two conditions under which the relation of the
encephaloid matter to its other contents is productive of appearances, which have led to the application of particular names to the
disease.  1. When interstitial hemorrhage leads to sanguineous
infiltration of the mass or irregular accumulations of blood, and
when, especially after ulceration of the integuments, a rapid
development of fungous growths take place from its substances,
the disease, in imitation of one of one of its earliest describers,
Hey, is termed
Fungus Hematodes, or as is called by some, Rose cancer. The
circumstances under which this name is applicable are, however,
merely fortuitous, and do not imply any fundamental distinction in the nature of the growth exhibiting them.  If (inasmuch
as the changes to which it refers materially affect the local and
general pathological influence of the morbid formation) this name
be retained for practical purposes, it should be strictly limited to
the disease when in the state described; as a general term for the
species, it is strongly objectionable; nor, strictly speaking, can
fungus  haematodes be considered a variety.  2. This term  has
also been applied in cases where an abundant vascular and erectile
rete forms a striking constituent of the growth (Dupuytren); but
this state is by some designated as hmmatode cancer."
Colloid, so called from the resemblance of the internal or contained part to glue, is developed as a distinct tumor, or in numerous
small masses scattered throughout the substance of an organ, or in
the infiltrated form. It attains considerable size, occurs most frequently in the stomach, and is the form of cancer most frequent
in osteo-sarcoma and spina ventosa.  A marked characteristic of
colloid growths, before ulceration, is, that they are equally transparent, firm and similar in appearance throughout the entire mass.
"The section of a colloid growth presents an appearance, which
once seen, can scarcely be forgotten. The surface is divided into
a vast number of alveoli regularly arranged, of an oval or rounded



206                        CANCERS.
shape, varying in size from that of a grain of sand to the largest
pea."
The septa composing the walls of these loculi possess distinctly
fibrous characters; their thickness is pretty uniform throughout;
occasionally, however, they are broader in some situations than in
others; in this case the thicker septa may generally be found to
give off productions forming the walls of secondary loculi, and
these again, others, constituting a tertiary order. The loculi sometimes form shut sacks, in other instances communicate with the
circumjacent cells. It is not very unusual to observe alveoli, of
which the walls seem to have cbllapsed and coalesced from the removal of the contained matter. In point of consistence a colloid
mass, of which the loculi are perfect, usually resembles firm cheese,
but may be much harder; the general color of the divided surface
is a greenish yellow. The latter is more especially the case with
the contained matter, which is, besides, semi-transparent, tenacious
and clammy, and resembles in respect of density, as in other
physical properties, soft jelly. It is not easily expressible from the
containing loculi, but may be picked out with the point of a
scalpel, or removed by maceration.
These tumors may continue for some time, even years, slowly,
almost imperceptibly increasing in size; giving the patient but
little trouble, except occasional lancinating pains; frequently,
however, their course is rapid. The character of the tumor and
nature of the tissue in which it is developed, will in part decide
the rapidity of its growth and its dimensions.  Encephaloid is
increased most rapidly, colloid next, and scirrhus least. Sooner or
later, however, the work of destruction commences.  Some part of
the carcinomatous tumor begins to soften.   The skin over it cracks
or ulcerates, and we have the cancerous ulcer or the open cancer.
The course of the disease is thence forward, usually very rapid.
The cancerous matter is then discharged in the form of an ichorous
liquid or in masses.
"The-appearance of the opening, or ulcer is, at first especially,
in a great manner accidental. Its edges are sometimes thin, irregular, level with the surrounding surface, or, it may be sunken,
undermined, and inverted; the latter condition amounting, in
some cases, to a kind of reflection of the skin on itself. But this



CANCERS.                         20T
aspect usually changes, and the edges become-elevated, and turned
upwards and outwards or everted; a state which is of sufficiently
constant occurrence to have been considered almost characteristic
of cancerous ulceration.  The surrounding skin acquires a bluish
red tint to a variable extent round the sore; and the excavated
surface of the latter presents an irregular series of elevations and
depressions, smeared with a thin watery matter, mixed with decomposed blood or pulpy detritus, or studded with black patches of
concrete hardened blood.  The surface of a scirrhus ulcer is, how.
ever, sometimes dry, and of reddish, grayish, or brownish color,
or in other instances, covered with a stratum of soft and putrid
fleshy substances, generally about one or one and a half line in
thickness and of the same colors as the surface of the sore; underneath this layer, hard scirrhus is discovered."
The discharge or ichorous liquid from these ulcers is thin, acrid,
and generally of a dirty green color, with a peculiar and characteristic fetor.  The color varies from blood or melanotic fluid being
mixed with it.
A marked characteristic of these ulcers is their disposition to.
hemorrhage.  By some, cancers in their primary stage are considered a purely local disease. The best authorities, however, now
generally concede that they have their origin in a cancerous diathesis, whether this is the result of hereditary transmission or an
acquired vitiated condition of the system. The fact that mechanical injuries are often the exciting causes is not sufficient to prove
the local theory.  What proportion of local injuries are followed
by the development of cancer? Will any degree of inflammation
induce cancer in a healthy constitution? It is a well-ascertained
fact, that age, sex, and civilized life act as predisposing causes.
Would this be so if the disease was the result of purely local
agencies?
The Diagnostic characteristics of cancerous ulcers have been
mentioned.
Hardened tumors, as well as simple indurations, not preceded
by acute or sensible inflammation, seldom  present the excessive,
hardness and lobulated surface of true scirrhus.  The tumors themselves, and the surrounding parts, retain much more of their natural
character.  They are not so isolated as the cancerous tumor, there



208                       CANCERS.
being generally a serous effusion into the cellular membrane around
them.
Tubercles are distinguishable from incipient cancers, in being
always more granular and in smaller masses, though frequently
causing much more visible swelling of the part in which they are
formed. The latter is a transformation and sometimes literally
condenses and diminishes the part.
There are also distinctly circumscribed and fibrous tumors that
may appear in various parts and be at first mistaken for cancerous;
but they are more regular and rounded in shape, and unaccompanied by pain. Should the over-excited fears of the physician lead
to their extirpation, no great harm will be done.
A softened encephaloid tumor has been mistaken for an abscess, and the introduction of the lancet been followed by immediate and dangerous hemorrhage, induration, and soon death. It
may, however, be distinguished by a sort of doughy elastic feeling,
with a moderate degree of softness in some of the parts, while
others will be hard and firm. Dupuytren says that pressure gives
rise in some portions of the growth to a sound like that of crumbling parchment. The history of the case, &c., will also aid. The subject of diagnosis will be further considered in treating of " Cancer,
locally considered."
The prognosis of cancer will be determined by the predominance of the cancerous diathesis, the exciting cause, the species
of cancer, its locality, the rapidity and stage of its development,
and the extent of the cachexia, or contamination of the general
system by the absorption of its secretions or excretions.
In the treatment of cancer, numerous modes and means have
been employed and with varying success.  For a time, one plan
or remedy has been  extolled, then with glory it has sunk
in oblivion to be again resurrected, glorified, and condemned.
(s not the Homeopathic law destined to be the clue that shall
guide us out of this labyrinth? the test that shall determine
the value of each remedy and furnish the sure criterion for its
employment?
The knife, ligature, cauteries, compression, and the application
of various remedies have been and are employed in the cure of
cancer.



CANCERS.                       209
The knife can be used successfully in the earlier stages, and
even the more advanced, provided the lymphatic glands are not
affected, and there is a distinctly circumscribed tumor which can
be removed entire.
The general rules contraindicating an operation are well laid
down by Walshe: "1. When such adhesions or local extensions
of the primary disease exist as would render it impossible to remove the mass completely by excision or by amputation of the limb.
2. When the disease is manifestly spreading or in a state of active
growth.  3. When the existence of internal carcinoma is even
probable. 4. When the cancerous cachexia is thoroughly established.  5. When the disease has existed for a number of years
in an almost stationary condition; gives rise to no serious derangement of health, and is rather an inconvenience than a malady."
While this excellent writer is so particular in warning us
against having a particle of diseased matter, that he advises to
remove a stratum of healthy tissue along with the morbid growth.
He has embraced (what we conceive) the great error in the use of
the knife; the idea that it is advantageous to heal the wound by
the first intention. We believe, except in case of amputation or
removal of the testicle, just the opposite, and would, on the contrary, advise that the surface be repeatedly washed with a solution
of the chloride of zinc, and poultices of elm be applied, and the
wound healed by granulation; such Homeopathic remedies being
given internally as seem to be indicated or are known to exercise
a powerful influence over this disease.
The ligature (see Chap. XVI.) has-been employed for the removal of cancerous tumors instead of the knife. It is certainly
preferable, where there is reason to fear obstinate hemorrhage.
Some also think that cancers are less likely to return when thus
extirpated.
Cauteries have been used and by some relied upon.  They
form the main reliance of Dr. Newton (who has been quite successful in the treatment of cancers), though he uses the knife as
we have recommended as an adjunct.  He holds to the theory
formerly promulgated by Dr. Adams, that this disease is dependent
on the generation of cancer animalculae, and that such applications
are to be applied as will kill these entozoa. His principal cauteries
27                                        (PART I.)



210                        CANCERS.
are oil of vitriol, sulphate of zinc, the lye from the ashes of red
oak bark evaporated to a convenient consistency, improperly called
extract of red oak bark; the chloride of zinc, and the sesqui-carbonate of potash. The chloride of zinc has been attended with
considerable success in the hands of M. Cancoin, A. Ure, and
Mr. Lawrence. Cases will be reported under the head of cancer of
the mamma and face.
Acid nitrate of mercury is claimed by M. Recamier to possess
a marked affinity for the diseased tissue, and to produce healthy
granulations, even on a cancerous basis. The chloride of gold is
also extolled by him. An interesting case will be reported under
the head of cancer of the uterus.  We were formerly in the
habit of relying upon the free use of the sesqui-carbonate of potash to complete the cure, after the greater part of the diseased
mass had been destroyed by a thorough application of the potassa
fusa or some other powerful cautery. The principle of successful escharotic treatment is, complete and rapid destruction of the
diseased mass, and the prevention of the absorption of the depraved fluids. When the battle commences there is no time to
parley with the enemy.  Other local applications have been relied upon for the cure of cancers, which seem to act by their specific influence.  The most prominent among these is
Arsenious Acid; this has formed the principal ingredient of
most of the cancer plasters that have attained much celebrityand although it has been alternately praised and condemned, the
testimony in its favor is such that we must ascribe to it much
value in the treatment of this disease, provided we can discover
some rule for its safe and appropriate employment. The objection to the use of this article and the reason why many of these
cancer plasters have fallen into disrepute, after having performed
repeated noted cures, is that the arsenic has been sometimes absorbed and produced its poisonous effect.
The yellow arsenic (Sulphide, Orpiment) seems to have been
more generally useful than the arsenious acid. It is the principal
remedy in one or two cancer recipes that have been very successful.  We have it, from what we believe reliable authority, that
this is the important remedy in the preparation of a celebrated
cancer Doctor, operating at the present time in New York city.



CANCERS.                       211
His preparation we are assured differs but little from that of a
friend of ours, in which this is the active agent, and with which
he has been almost universally successful.  He applied it in the
form of paste made with the white of eggs. A specimen of some
of his cures is shown in Fig. 4.
It is from a cast now in the pathological cabinet of the Homeopathic College at Cleveland, which was taken at the commencement of treatment.  A lady aged about 40 years had a tumor
which had continued to grow slowly for a number of years. An
operation for its removal was performed, and the wound healed by
the first intention. It soon after began to grow, and in several
months attained to the size represented by the drawing. The
Doctor gave arsenicum internally, and daily applied his paste to
the diseased mass, keeping it constantly covered with wet cloths.
The cancer sloughed off in large pieces and finally healed by granulation.  The lady recovered her health, and was afterwards
delivered of a healthy child, and continued well when last heard
from.



212                       CANCERS.
Compression has been successfully employed by M. Recamier:
"Of one hundred patients, sixteen appeared to be incurable, and
underwent only a palliative treatment; thirty were completely
cured by compression alone, and twenty-one derived considerable
benefit from it; fifteen were radically cured by extirpation alone,
or chiefly by extirpation and pressure combined, and six by compression and cauterization: in the twelve remaining cases the
disease resisted all the means employed."
The principle of its application is the same as when applied
for the cure of aneurism. It should be uniform over the entire
surface of the tumor; at first gentle, and gradually increased as
the diseased portion becomes habituated to its action. According
to M. Recamier, the conditions preventing a successful result are,
"Excessive magnitude of the morbid growth; the existence of
cavities in its interior; the conversion of the tissue of the diseased
organ itself into carcinoma; a state of softening, ulceration, or
fungous vegetation; the extension of the disease beyond the reach
of direct compression; obstinate local neuralgic pains and great
fullness of person."
Ligature of the principal artery leading to the cancer has been
attended in a number of cases with excellent effects. An interesting case is reported by Dr. Hosack. A lady, aged fifty-five years,
had a scirrhus of the parotid gland, which had continued to grow
for three or four years. It was then so large that she was unable
to open the mouth further than to admit the smallest-sized teaspoon, "and protruding from behind, through the space posterior
to the angle of the jaw occupied by the parotid, extended itself
over the masseter muscle, quite up to the zygoma, carrying before
it the lobe of the ear, and encroaching so much upon the external
meatus as to close it entirely." The doctor took up the common
carotid on the affected side. The tumor was sensibly diminished
in the course of a month, and finally so entirely removed that a
depression was formed, in form like that of the gland in the natural state.
So unsatisfactory have been the result of all proposed allopathic internal medication, that Dr. Walsh states as a fact the
following proposition: " Cancer has never been removed by medicinal agents alone." The cases reported in connection with can



CANCERS.                       213
cerous diseases of the different organs will prove, as far as Homeopathy is concerned, the falsity of this declaration.  As the
different remedies with their indications will be given when treating of "Cancer, locally considered," we shall here only give a
general classification of them, and mention the leading characteristics of a few of the more prominent, together with such general measures as we think important.
Scirrhus in the
OCCULT STAGE; Arnica, Conium, Bell., Carb., veg. and an.,
Aurum, Phos., Silic., Staph. and Sul.
For OPEN CANCER, Ars., Ars. sulphide, Con., Brom., Sil.,
Kreos., Carb., Phyto., Lach., Nit. and Mur. ac., Thuj. [Calen.,
Plantago maj., Cornus circin.]
For FUNGUS HIEMATODES, a form of encephaloid, sometimes
called Rose cancer; Bel., Phos., Thuj. Carb., Nit. ac., Staph.
Arsenicum album, which has been thought, from the days of
the ancients to the present time, by many, to be a specific for
cancer, appears to be especially valuable in the ulcerated stage.
It is our principal remedy in cancer of the nose, lips, face, tongue,
and uterus. It is particularly indicated where the vital powers
are enfeebled and the destructive tendency very rapid.  The ulcers consequently assuming, almost from the first, a malignant
appearance; the edges are irregular, everted and thin, or indurated,
and bleed easily; the discharge is a scanty sanies, or a copious
fetid ichor. The base. of the ulcer frequently has a lardaceous
appearance.  The pain is of a burning character and worse early
in the morning, or when the parts become cold-but then it is
tearing.
The Orpiment (Sulphide of arsenic), we think, will prove ultimately of even more value than the arsenious acid.
Belladonna is more particularly indicated when the tumor begins to inflame and become painful, or, having ulcerated, there is
discharge of bloody ichor, the ulcer burning when touched and at
night. It would seem to have considerable power in that form of
encephaloid denominated as fungus hematodes.
Carbo., veg. and animal, are indicated both in the occult and
ulcerative stages. Like Arsenic they are suited to cachectic individuals; but they are characterized by an almost entire want of



214                        CANCERS.
reactive power. The ulcers are, therefore, distinguished by their
torpidity instead of manifesting that disposition to extend into surrounding parts, as in the case of Arsenic. The base is dark and
putrid in appearance.
Conium; another remedy that has at different times attained
much celebrity in this disease, appears to be of but little use in
the stage of ulceration; its sphere of action being confined mostly
to that of the occult, except where the effect of. contusions. It is
specially indicated in cancer of glandular organs which have resulted from pressure or mechanical injury, both when the indurations are painless and inflamed. Noack and Trinks state, that the
principal influence of Conium is to fluidify and liquify animal matter, both normal and abnormal.
According to Dr. Boenninghausen, after its employment for
some time, it will lose its power of impressing the system, but on
giving an intermediate dose of some other remedy, such as Ars. or
Bell., it will again act favorably.
Thuja, from its power over morbid excresences, we would be
led to infer to be valuable in the treatment of those cancerous
growth, especially where  fungus increases very rapidly and
there is much hemorrhage. Clinical experience has verified it. -
See case under Cancer of the Eye.
Phosphorus, we might suppose, would be useful in cancers from
its isomorphous relation to Arsenic. Clinical experience has proven
it. It is suited to scirrhus formations which begin to inflame
and become painful, threatening ulceration and open cancer, with
a great disposition to bleed. This tendencyto hemorrhage always
exists where much fungus is formed, consequently we find it very
beneficial in fungus haematodes, one of the forms of encephaloid.
Its specific action upon the lower jaw, the most frequent seat of
osteo-sarcoma, would point to it in that disease.
Silicia is suitable for either stage; indurated, that itch a good
deal, and those badly ulcerating and abounding in proud flesh. It
is said to have been used successfully in fungus haematodes.
We prefer to repeat the remedies tolerably frequently, and
think it very important that they should be employed locally as
well as internally.  The most convenient way to do this when
they are ulcerated, is to have small pieces of patent lint, wet with



CANCERS.                         215
a dilution of the remedy and apply them piece by piece until every
part of the ulcer is covered. Over these wet cloths should be laid,
so that the affected part will be shielded from the irritating effects
of the atmosphere.  In treating of wounds and ulcers we urged
the importance of removing the pus as fast as it was formed; it is
even more indispensable in cancerous diseases. - See Ulcers.
The diet of cancerous patients should be nutritious, but unstimulating; milk, eggs and farinaceous food. They should use water
freely, internally and externally, and have plenty of pure air.
CHAPTER XX.
CANCER LOCALLY CONSIDERED
CANCERS of the Eye-Encephaloid and scirrhus-Case of Count Radetsky —
Of the Lip - Their origin in cracked lip - Prospects and Fatality - Early treatment -Of the Tongue - Description — Mercurial variety - Of the BreastFrequency   Origin and Progress- Cause by cross-lancing- Of the Rectum,
susceptible of treatment- Of the Penis — Description- Medical treatment more
convenient than amputation-Of the Testicle- Frequency - Excision necessary
and effectual.
CANCER OF THE EYE
Is either of the nature of scirrhus or encephaloid. The latter is
the most frequent and fatal form of the disease. It may be first
detected, according to some of the authorities, by a metallic appearance in the back part of the eye, which continues to advance
and enlarge.  The pupil is permanently dilated.  The progress
of the disease is slow while confined to the posterior chamber of
the eye; soon, however, the globe becomes enlarged, causing
excessive pain, and in a short time the cornea, or the sclerotic
coat at its junction with the cornea, bursts, and a fungous
growth sprouts up, the eyeball frequently becoming as large as a
hen's egg, completely filling up the orbit and projecting out beyond the lids.  The fungus in the eye is sometimes dark, sometimes of a light color. Profuse hemorrhage will occur from the



216                        CANCERS.
slightest touch, or even spontaneously from ulceration. In this
stage of the disease the patient rapidly sinks, and, if not cured,
dies of exhaustion or from the brain being directly involved in the
disease. The scirrhus form begins upon the external surface, involving the cornea, lens, humors and membranes in one mass of
disease. The size of the eye is not materially increased.
In most cases the surgeon will not be called before the eye is
irretrievably ruined; and any treatment may then be considered
successful which even saves the unaffected eye and the life of the
patient.
The eye may be removed by the knife, but so unsatisfactory
have been the results of extirpation, and so promising those of
Homeopathic practice, that it is entirely unwarrantable.
After the constitution has suffered much, and there is evidence
of the brain having been affected, the chances are against the recovery of the patient under the best treatment that can be
adopted.  When there is still any considerable amount of constitutional vigor, great hope may be held out, even if the local injury
is extensive.
When a cure is effected, the orbit will not always be completely filled up again. An artificial eye is then the only means
of avoiding great deformity.  In most instances, however, there
will be a sufficient amount of fleshy granulations to prevent the
ghastliness of mere "holes where eyes should be."
Laurocerasus has proved beneficial in lessening the pains in
cancer of the eyes.
Belladonna has been successful in malignant affections of the
eyeball, with violent pain in the afflicted part; bright red spot in
the posterior chamber, dilated and fixed pupil, indurated condition
of the eye, vision destroyed, iris blood-shot and dark colored.
Dr. Z. Stapf reports a case of fungus haematodes threatening
to destroy the whole eye, checked and circumscribed by Cale. carb.,
and finally cured by the successive employment of Lycop., Sep.
and Silic.
Phos. has proved successful in fungus haematodes in other
parts; we should think it valuable here.
Carb. an. or v. and Thuja, also promise to be powerful additions to our means of combating this dreadful disease.



CANCERS.                       217
These remedies effected a complete cure in the celebrated case
of the Count Radetsky, within the short space of two months.
This was pronounced by Dr. Flaser, an allopath, Professor of
Opthalmic Surgery in Pavia, fungus haematodes, and a case that
neither allopathy, homeopathy, hydropathy, or any other method
of treatment would be of any avail. This opinion was also concurred in by Dr. Jiger, allopath, Professor of Opthalmic Surgery
in the Joseph's Academy at Vienna, and staff-physician to the
Austrian emperor, who had sent him to Milan to consult with Dr.
Hartung, homeopath, having charge of the Count.
Both Dr. Flaser and Dr. Jager refused even to prescribe for the
case - so hopelessly incurable did they consider it.
One tumor was situated at the external canthus of the eye,
near the lachrymal gland, extending to the internal canthus. Another under the lower lid, a grayish-blue tumor, extending to the
nose.
The whole fungous excrescence was affected with lancinating,
burning, tearing and itching pains; it bled readily. The eye was
protruded from the socket and motionless. The disease extended
over a space of four inches.
After using various remedies without benefit, Dr. Hartung exhibited Carbo an., which arrested the progress of the disease. He
then determined to rely upon Thuja and this; giving first Thuja
30, three times daily.
After three days he applied, warm, to the eye every two hours,
an embrocation of six drops tr. Thuja to four oz. dist. water. The
external application of Thuja was continued for ten days.
Carbo an. 30, was then given evening and morning; and after
seven days the tumor was moistened with the 12th dilution of
Carbo. an.  The Thuja embrocations were continued.
The internal and external use of Thuja and Carbo an., alternately every eight days, completed the cure.
CANCER OF THE NARES,
Generally of the encephaloid species, is not of common occurrence, unless as the result of maltreated polypus.  Sometimes
tumors in the nostrils have their origin in the ethmoid bone.
Liston gives the following favorable! prognosis of these cases —
28                                    (PART I.)



218                        CANCERS.
"Such growths, when they present in the nostrils, are perfectly
irremedial and uncontrollable by any surgical proceeding. If such
tumors are ever interfered with, in order to give relief to the patient, by diminishing the obstacles to his breathing or swallowing,
there is a risk of considerable loss of blood, and a certainty of
very rapid reproduction."  Hartmann, on the contrary, says Arsenicum is a sovereign remedy.
A form of cancer that frequently locates on the side of the
nose, though it may occur on any part of the skin, and eventually
destroys this important feature, is Noli-me-tangere.
Quite a number of surgical writers have confounded this with
Lupus, using the term as synonomous.
The first appearance of this serious disease is very various
though essentially the same kind of ulcer is the result.
It most usually commences as a small tumor, of so little apparent importance, that it does not generally attract the patient's
attention until some abrasion of the surface occurs. This may be
months or even years after the tumor commenced, and it then
looks like a large red bullet.
There may, however, be only a slight inflammation of the surface, with little, if any, tumor or tumefaction. This results in a
dry "scaly scab" of a darkish color, which is rather easily detached, leaving a red and inflamed surface beneath. After this
scab has been several times removed and renewed, an ulcer takes
its place.
At other times it begins as a large and prominent wart, which,
from its exposed position, is easily bruised, and then becomes very
sore and inflamed.  If it be entirely removed from the surface, a
new one will soon sprout up and attain the original size, if not
probably grow a little larger.
Beside the small tumor or the scaly scab, and the warty excrescence, another form is the tubercle, a tumor of an oblong
shape, somewhat resembling a split bean. This form, however, is
not constant, there being often projections out into the adjacent
parts. The surface is sometimes smooth and shining, in others,
rough and indented. Occasionally it is white, in others, livid or
purple, when it is not inaptly called a "blood wart." If the
surface of this tubercle become abraded, a scab forms, and



ANCERS.                       219
ultimately an ulcer, precisely as in the case of the pimples first
mentioned.
The first form, or its resulting scab, is most frequently noticed
near the inner canthus of the eye, or the side of the nose -the
wart is more common upon the cheek —the tuberculous form occurs upon the body, most generally upon the back and shoulders.
After ceasing to be protected by a scab or crust, the ulcer generally increases ip size and depth very rapidly. Sometimes, however, it will become covered over with little projections, giving it the
appearance of a strawberry or mulberry (whence the name Moriform cancer), and may remain comparatively stationary. Hemorrhage is very frequent, especially where large fungous growths
sprout up, and there is usually a copious discharge.
It may be distinguished from Lupus by commencing as a single
tubercle or tumor, which, sooner or later, has lancinating pains;
by the scab coming off easily; by affecting the bones and deepseated parts; by attacking persons advanced in life; from being
aggravated by escharotics, and by affecting the glands. The reverse is true of Lupus.
CANCER OF THE LIP.
This very common affection often appears at first as a mere
fissure or "cracked-lip," which, when the weather is cold, is very
troublesome to the patient. It will commonly heal up in summer
and re-appear in winter, or on sudden changes of the weather. It
may thus continue for years, a mere periodical complaint, the patient having occasionally to wear a patch upon it to shield it from
the air. At last it fails to heal again and the lip gradually enlarges, a tumefaction rising all along the fissure.  It is at this
stage of the disease that the patient generally thinks it worth
while to apply for medical advice.
In other cases, however, the disease appears from the beginning in the form of a small tumor. It looks on the red lip like a
common squirrel shot, both in size and color; it will also roll under
the finger when pressed upon.
This little tumor is for a time devoid of pain; but if pressed
upon or handled it will easily become irritable.
As it increases in size, it becomes more and more firmly at



220                       CANCERS.
tached to the surrounding parts. In some cases it is immovable,
even from the beginning, being deeply imbedded in the muscles.
As it approaches the surface, it ulcerates, giving out a fungous
growth, which sometimes increases to a monstrous size, so as to
cover the whole mouth and chin.  The upper lip is seldom the
seat of the disease.
A third form under which it may make its appearance is that
of a "scaly scab," or squamous little ulcer —one of the forms
described under the head of NOLI-ME-TANGERE.
Any of these forms of lip disease will, if not arrested, extend
to other parts of the face, throat and neck, and prove certainly
fatal.  The glands about the mouth and throat become early
affected, and even the brain is not always long secure.
Arsenicum, as was before stated, is pronounced by Hartmann
the sovereign remedy for cancer of the nares.  It is our most important remedy in Noli-me-tangere and cancer of the lip, except
where the latter is the result of injury. It is indicated by tumors
in the nose, particularly if accompanied with a severe burning
pain and much hemorrhage, or if there is an ulceration high up in
the nares, discharging a fetid ichor. Also, cancer of the lower
lip, with lardeous base; disposed to spread much; very painful,
particularly when touched, or becoming cold; causing swelling of
the submaxillary glands.  And in the different forms of noli-metangere the ulcers of which it will be observed correspond to those
of arsenic; Sulphide of arsenic?
Antimonium er. is also useful in noli-me-tangere, particuarly
in the tuberculous kind.
Aurum for cancers of the nares and lip, occurring in scrofulous, syphilitic, or syphilitico-mercurial constitutions, and the form
of noli-me-tangere that begins as a small, dark, reddish-brown spot,
painful to the touch, especially if it commences on the nose, or if
it has ulcerated and has involved the nasal bones.
Clematis has proved curative in cancers of the lips, particularly
if they have a strong tendency to fungus growths, and occur in
persons laboring under the influence of mercury.
Conium- cancer of nose, lip and face, when the effect of
contusion-has cured a carcinomatous ulcer of the lower lip
caused by irritation from the pressure of a tobacco-pipe. It is



CANCERS.                        221
indicated for the scirrhus and the occult stage when the edges of
the ulcer are black, being corroded by the profuse discharge of
sanious ichor.  Dr. Stens states that he had employed it with the
happiest effect.
Calcarea; where cancer of the nares has originated from polypus or in those of the lip or face, commencing as a slight thickening
or scurf, finally proceeding to ulceration, with stinging, itching,
tearing pains, relieved by warmth, and aggravated by a draught
of cold air.
Nitric ac.; Hartmann exhibited, internally high and externally
low, for mulberry cancer of the face.  It is also useful where the
noli-me-tangere wart is first affected with lancinating pain, or
when ulcerated, there is a prolific growth of fungous, which stings,
and burns, and bleeds easily. According to the observation of
Professor Neidhard, this remedy is particularly beneficial in persons of a dark complexion, while the Muriatic acid, with which it
is very closely allied, is preferable in those of a light color. This
distinction should be borne in mind in prescribing these remedies.
Should the disease be complicated with syphilitico-mercurial poisoning, its employment will be the more important.
Phosphorus, Phytolacca, Bromine, Lachesis, Sepia, Silicia,
Thuja and Sulphur are valuable in some cases.
Dr. Attomyr reports the following case: "Alrysia Lyde, six
years old, lost the left half of the upper lip and the soft parts extending upwards to the zygoma, and sideways, a considerable portion round the angle of the mouth, by a cancerous ulcer. Arsenic
(6th dilution), repeated every eight days, brought about the healing
of the ulcer in six weeks. As a detergent application, the decoction of marsh-mallows was used outwardly."
Dr. Ganwerky stated at the Hom. Con. W. G., 1852, that he
had cured a case of cancer of the cheek with Conium, eighteen
years before, in a woman of sixty, who was then alive and well.
A case of fungus haematodes on the neck, just above the clavicle, was presented at the Clinique of the Cleveland Hom. College in the winter of 1853. The subject was a young lady. The
tumor the size of a goose-egg, dark, soft, and affected with lancinating and burning, gnawing pains; had existed for several months,
but grown rapidly of late, and become more painful. Prof. L.



222                       CANCERS.
Dodge treated the case with Plantago maj., locally and internally, effecting a speedy and permanent cure.
Sepia cured the following case: Tubercle on the lip of a man
of about thirty years, increasing to the size of a bean, having
sometimes a cartilaginous appearance, sometimes bleeding, and resembling a scirrhus very much, with a broad base."
Dr. Ganwerky mentions a case of fungus hbematodes upon a
man, bleeding profusely every day, in which Phos. 30 did no
good, but Phos. 200 effected a most rapid cure. -Horn. Con. N.
G. 1850.
Phosphorus 30 effected the following brilliant cure of a case
of Fungus Hematodes -Syrp: "Conical swelling of the size of
a fist on the thigh, between the trochanter and the spinous process of the ilium; it is somewhat movable near the root, hard,
elastic; was painless before and cool, but is now warmer and painful. The tip has burst open like an abscess; venous blood is continually oozing out, at times coming out in one stream, at times in
drops.  A similar, but smaller swelling on the left limb, one dose
effected a complete cure, being permitted to act a long time. A
second fungus hoematodes on the little finger yielded to the same
drug.- Ruckert's Ther.
Dr. Boenninghausen reports a case of fungus haematodes of the
cheek, cured with a single dose of Staphysagria, 200th dilution.Horn. Con. N. G. 1850.
Dr. Hunt reports the case of a cancer involving the whole
lower lip, scirrhus, ulcerating, with a good deal of fungus and
burning pain. It had progressed so far and so rapidly under the
internal use of Arsenicum 5, and the constant application of lint,
kept wet with a weak solution of the same remedy, that a cure was
almost certain. During the absence, however, of the Doctor from
the city, the patient was taken sick —sent for his former family
physician (allopath) —lip became aggravated, and he was pursuaded to consent to an operation.
Hartmann removed with Antimonium er. 3, one dose every
day, and the local application of a little butter of antimony, a
horny excrescence under the lower lip: "the horn fell off every
eighth day, after which it grew again; after falling off, the surface of the stump, which kept increasing, looked like raw flesh,;



CANCERS.                       223
the fleshy papillae looked like the papilla on the tongue; a viscid
humor oozed out of every single papilla. If the scurf to which
the thickening of the humor gave rise, remained more than eight
days, the humor oozed out between the scurf and the horn which
now developed itself in breadth. The horn was painless, except
when knocked against, in which case it bled.
With Ranunculus bulb. 6, m. and n., first being applied externally, he cured, in a few weeks, similar excrescence on the forehead.
"The patient complained frequently of a burning itching in the
excrescence; the scurf formed more rapidly than in the former.
After falling off, the stump resembled a deep, eating ulcer with
sharp edges."
Mr. Laurence states that he had effected two permanent cures
of cancerous ulceration of the face, superficial, though of long
standing, by the application of chloride of zinc.
CANCER OF THE TONGUE.
This organ is not unfrequently attacked with a species of
eating ulcer, which, although it resembles it, cannot properly be
called a cancer. True cancer, however, may attack this as well
as other parts of the body.
A peculiar species of cancer of the tongue is the mercurial;
and this is not the least difficult and tedious to manage. It is more
apt than all others to reappear when seemingly cured. In some
cases the simple ulcer that existed before, seems to become cancerous under the mercurial influence. The whole tongue may become very much enlarged, having small tumors at different points;
sometimes of a hard and semi-cartilaginous feel, at others of a
spongy structure. But generally there are deep fissures or cracks
of an irregular form upon one or both sides of the tongue, rarely
in the center. The edges of these fissures are always hard, having a bluish or purplish appearance, and their surface covered with
a tough yellowish, or thick gray looking pus.
At other times we have a hard rough tumor with a broad base
of a warty appearance, situated about the middle of the tongue or
towards the tip, becoming after a time a ragged ill-conditioned
sore of a fungous character. It then bleeds very easily and occa



224                       CANCERS.
sions a sharp lancinating pain, extending to the throat and to the
base of the skull.
This latter form of the disease, if not arrested in the early
stage, is very liable to prove fatal, owing to excessive irritability
and hemorrhage.
Ulcers on the tongue frequently assume a malignant appearance from being irritated by the projection or sharp point of a
tooth. A removal of the tooth is then indispensable to a cure.
Cancers of the tongue are removed by excision and ligature;
the last is now generally preferred as being less liable to be followed by hemorrhage. Bransby Cooper says, "although the hopes
held forth by an operation in this complaint are but slight, it
offers the only chance of saving the life of the patient." He further states as the result of his experience, "I have on four occasions extirpated the diseased portions of cancerous tongue by ligature applied so as to completely include the affected parts, which
were of course ultimately removed by sloughing. None of these
cases were, however, successful; the lympathic glands under the
jaw sooner or later became involved in the disease, and in no case
did the patient survive more than two years after the operation."
Specific medication promises a much more favorable result.
Arsenicum, Hartmann says, is a sovereign remedy for this
disease. It is indicated by corrosion and cracks in the edges of
the tongue, with burning pain and fetid discharge. (See also
General Treatment, art. Arsen.)
It may be sometimes advantageously alternated with Muriatic
acid, which has the following pathogenetic symptoms-tongue
feels. heavy and elongated, with great dryness in the mouth and
fauces; tongue becomes sore and bluish-red, burning vesicle on the
tip of the tongue; deep ulcer on the tongue, with black base and
inverted edges.
Conium; for scirrhous or ulcerated conditions of the tongue
that have been caused by irritation of a tooth.
Lachesis promises to be exceedingly valuable, as would appear
from  the following case: Dr. Laomis of Syracuse, reported in
Symp., Cod., art. Lahc., "was called Dec. 5th, 1846, to see a
young lady, aged nineteen, who had been ten days in this country, Three days previous to my visit she was attacked with se



CANCERS.                       225
vere pain, of a burning nature, in the right side and near the
point of the tongue.  Salivation and sloughing soon followed.
The disease extended along the side of the tongue for sixteen
lines.  The surface became black, accompanied with pricking
pains, as from needles, in the whole body of the tongue. Under
Lachesis 400, every four hours, the patient improved for thirtysix hours, when a severe aggravation was experienced, which was
checked by Samb. n. 12, one dose, when the case went on without
a repetition of Lachesis, until the tongue was entirely restored.
Mercurius sol., one-twelfth of a grain, cured, in sixteen days, a
case with the following symptoms: "On the edge of the tongue
there is an ulcer of the size of a bean; along the adjoining parts
of the tongue, in the substance thereof, there are several hard nodosities, and a deepening resembling an incision. The base of the
ulcer looks gray, reddish, uneven, secreting a fetid matter; the
edges are hard, elevated, of a blue appearance; burning in the
ulcer."- Ruck. Ther.
CANCER OF THE BREAST.
Carcinomatous affections of the female mamma are perhaps
more common than of any other portions of the glandular system,
or of the body. Women who have nursed a great many children,
and such as have arrived at the age when the catamenia cease,
without having had children, are the most liable to suffer from this
disease, though it may occur at any age. It has occasionally been
developed in girls as young as sixteen. Cancer of the breast is
generally of the scirrhus species, sometimes of the encephaloid, and
occasionally of the colloid.
The first appearance of cancer is usually as a small tumor near
the nipple, which at first appears to be loose under the skin, and
nearly insensible.
This tumor may be stationary for years, while, at other times,
it grows rapidly. In those cases which are considered most malignant, it may acquire a very considerable bulk in a very short
period.  Commonly, after having grown to a moderate size, the
tumor becomes shriveled or contracted. The nipples are thrown
inward, and buried beneath the surface. The skin becomes of a
dark leaden hue, and is closely adherent to the tumor. The whole
29                                   (PART I.)



226                       CANCERS.
breast assumes an irregular shape, and feels as if it were filled
with knotty, hardened tumors, of an irregular form. The pain
becomes lancinating, frequently extending into the axilla, and even
through the chest.  As the disease advances, other lymphatic
glands, besides those of the axilla, become involved, particularly
those of the neck.
Eventually, the skin over the tumor yields; a thin sanious
matter is thrown out through the ulcer that is then established.
This assumes, at first, the form of a fissure or crack, and becomes
partially filled with fungous growth.
In some cases, the patient sinks, from the cancer affecting vital
organs, particularly the lungs, even before the stage of ulceration.
In others, life. may be protracted ten, twenty, and even thirty
years, before the slow but steady progress of the disease cuts it
short.
A simple mammary abscess may become cancerous by ill-timed
and improper lancing, especially where the incision is made ACROSS
the course of the lactiferous ducts, so as to divide a considerable
number of them. Out of some fifteen or twenty cases of mammary
cancer, into the history of which we have inquired, there were only
two that had not been thus operated on, and did not have the evidence of the bad surgery in the cross-cut scar!
According to Sir A. Cooper, scirrhus of the breast is from two
to three years in growth, and from six months to two years in
destroying life after reaching its acme. Velpeau estimates the
mean duration of encephaloid, at from six to twelve months. The
exciting cause of many of these cases is some contusion or mechanical injury.
Hartmann says of these cases, " a cure is impossible in every
case where the knife has been used." "No scirrhus or cancer has
ever been cured by an operation, and where such a cure is said to
have been effected, the operator mistook a simple glandular swelling for a scirrhus induration." Were such men as Sir A. Cooper,
Dr. Warren, M. Velpeau and Dupuytren, always unable to distinguish scirrhus from simple glandular induration? Even when
they dissected it after ablation?
M. Velpeau saw patients in perfect health two, four, six, and
in one case, ten years after excision of well-marked encephaloid,



CANCERS.                     227
that worst form of cancer. While we think that the most of these
cases can be cured without ablation, we know from our own personal experience and observation, that it will be generally successful if performed in the manner before directed and before the
axillary glands are affected. The great error has been in healing
by the first intention and not by suppuration. In relying upon the
knife as a cure, and not as an adjunct.
The removal of the morbid mass can not be relied upon to
eradicate the cancerous diathesis, although it will sometimes produce such an alterative influence upon the constitution that no
manifestation of the disease will be perceived during life.
The remedies appropriate to a removal of this constitutional
disease ought, in all cases, to be given internally and applied externally to the wound until after a healthy cicatrix has formed.
Injuries of the mamma if treated homeopathically are not
likely to be followed by scirrhus formations, even in persons of the
cancerous diathesis. It does not leave indurations, the germ of
future disease. Where these are present and are the result of recent
injury, Arnica montana will usually be sufficient for their removal. It is also indicated for the painful lumps in-the breast of
girls, traceable to no particular cause, rendered more distressing
by the open air.
Conium is, however, more appropriate in old indurations.  It
is our most valuable remedy in all cases arising from a contusion
of the gland.  In the occult stage with occasional shooting or
darting pains, or when every little cold inflames the scirrhus gland
and excites severe stinging and burning pains, so aggravated at
night as to arouse the patient from sleep, as well as in the open
cancer.  Further indications are, oppressed breathing and an
aching pain in the sternum. Dr. Boenninghausen recommends to
give a dose of Ars. or Bel. as an intermediate remedy, to renew
the susceptible of the system to the action of the Conium.
Pulsatilla; if hard tumors appear in the breast of young girls,
resembling in form and density true scirrhus, and are insensible.
But if sore or painful, with drawing pains, getting worse in the
open air or at night, or if they become inflamed and red, give
Chamomile.
If inflamed, with stinging, burning pains, increased on the least



228                       CANCERS.
movement or contact, and a flush around the part, Belladonna;
which is also aplicable for similar symptoms in older persons.
Arsenic, where there is burning and tearing pains in the tumors, lessened by motion, but aggravated by rest and warmth, and
so tender to pressure that she can not lay on the affected side.
In the open stage, when the ulcers have the Arsenical character.
Clematis is particularly indicated when the indurations are
only painful when pressed upon, or where the cancer is open, with
burning, throbbing in the ulcer and stinging in the edges on
contact.
Kreosotum, when the breast is rough, scurfy and bluish, frequently discharging a good deal of thick, dark blood.
Carbo. veg., when the scirrhus indurations of the mammae are
accompanied with burning pain, low spirits, and constant complaining, or great itching of the back.
Lachesis, for those cancers that have an extraordinary disposition to bleed. The bottom of the ulcer is bluish, with dark streaks
of coagulated blood over it. Dr. Petrasch says, he knows no
remedy so efficacious against the pains in cancerous ulcers as
Lachesis.
Hepar has cured a scirrhus ulcer on the mamma, with a burning, stinging in the edges, the pus having the smell of old cheese.
The empirical use of the Yellow Arsenic (Sulphide) we have
mentioned before. We would suggest a trial of it in very bad
cases.
Bromine promises to be a valuable addition to our means of
combating this fearful opponent. ( See case of Dr Ganwerky.)
Phosphorus is all powerful in inflammations of the mammae, has
proved invaluable in fungus hkematodes, and has isomorphous relations with Arsenic, whose efficacy has been proven. It may be
sometimes advantageously employed.
The indications for Phytolacca decandria may be learned from
the following article by Dr. Neidhard:
"Cancer of the mamma connected with rheumatic affections.
- The effects of Phytolacca decandria in the following case was
so striking, and the symptoms so well correspond with those obtained by experiments on the healthy that I can not help adducing
my testimony to its power, in order that it may be employed by



CANCERS.                       229
others in similar affections. This is the more important as the
remedy possesses an ancient reputation for the cure of cancer, among
the people of this country.  Miss S  -  had for three years a pain
in the left mamma, where, on examination, an indurated tumor was
discovered, having all the characteristics of true cancer. She
describes the pain as darting through, and even before the tumor
appeared, she had, for a long time, a similar pain; the pain comes
and disappears like griping, sympathetically affecting the wrist and
the shoulder of the right side, she limps about from a pain in
the hip also, on the same side —it is worse at night, is constantly
shifting from one place to another, without producing any swelling
or alteration of the part which it attacks. The nearest she can
describe the pain is, that it is of a jerking kind, also highly characteristic of the pains produced by Phyto. dec.
" Of the numerous medicines prescribed, Jayne's Expectorant
gave the only transient relief; the same was the case with the
homoeop. Sulphur and Pulsat.  From  the Phytolacca a more
permanent benefit was experienced than from any other medicine.
In a case of cancer of the left mamma (an old lady), Conium
always relieved the induration and produced a softening of it; it
also relieved the violent sticking pain.
"Next to Conium, Carbo. an. and veg., deserve our consideration, if the above symptoms are present, especially if conjoined
with extraordinary itching in the back. These two remedies were
also given in the above case.
"In a case of an old lady, Miss G-, Phos. and Carbo. vey.,
given at intervals, retarded, for ten years, the progress of the disease.  The symptoms were the following:
"Burning in the cancerous tumor of the mamma, which also extends down the side; the sanies which is discharged smells badly,
headache over the eyes every morning; tongue full of blisters.
The pain in breast is worse in damp weather, and shoots through
to the shoulder; there is also burning between the shoulders and
over the eyes, the arm is lame, the patient is very weak and
feverish.  I do not know on which side the tumor was situated, as
I forgot to mark it down on the record."
A young lady had a lump of considerable size in one of the
mammae; this and the other breast wasted. She had taken Iodine



230                        CANCERS.
from the allopathic practitioners in large quantities.  The nipple
of the affected side was retracted; the tumor was very sensitive to
the touch and painful.  She had a few doses of Conium and the
cure was completed in about three months with the Iodide of Arsenic. ( B. J. JE., vol. vii., p. 514.)
Dr. Ganwerky reported to the Horn. Con., N. G., 1852, that
he was treating a case of cancer of the breast, accompanied by
swelling of the axillary glands and burning, lancinating pains in
the scirrhus parts, which was first exceedingly improved by Bromine, and had advanced so far toward a cure under the subsequent
alternate use of Brom. and Con., that he had no doubt of a favorable result.
Dr. Burritt stated to one of the authors that he was congnizant
of a case, where a lady was given up to die with cancer of the
mamma.  Upon recommendation she began to use freely, as a
drink, a decoction of the Cornus cireinnati, and to keep the diseased breast covered with cloths wet with the same; she entirely recovered.
CANCER OF THE RECTUM
Is usually situated from two to four inches above the anus, where
it is a primary affection. It generally progresses upwards rather
than downwards, is of the scirrhus or colloid species, and is either
in the form of a tumor or a thickening, by a deposition of cancerous matter, of a part or the whole of the circumference of the rectum, terminating abruptly both al)ove and below. The course of
the disease is in other respects similar to that in other parts,
ulceration, fungus, &c.
The first symptoms of cancer of the rectum are the same as
those present in stricture of this part.  Constipation, the taperlike feces, pain in the sacral region, constipation alternating with
diarrhea, tnd finally ulceration.
In this disease hemorrhage is frequent, especially when in examination the finger or other instrument is brought in contact with
the diseased part. Touch also excites stinging and burning pains.
The reverse is true of permanent stricture. The character of the
discharge is different, being bloody and ichorous, while that from
ulceration of simple strictures is similar to ordinary pus from mu



CANCERS.                       231
cous surfaces. Examination with the speculum ani will also show
a difference in the appearance.
Cancer of the rectunW is spoken of as necessarily incurable, because not accessible to the knife, but with specific medication this
conclusion does not inevitably follow. It is, however, a very dangerous disease, and the cure rendered exceedingly difficult by the
feces constantly irritating the part. Should the disease not be
too far advanced, and the cancerous cachexia too deeply seated, we
consider it curable.
None of the Homeopathic works, or any journals that we have
been able to procure, ever mention this disease. We would not
infer, therefore, that cases had been successfully treated by specific remedies.
Dr. Bauer, of Cincinnati, was called to a case pronounced cancer of the rectum by the late Dr. Shotwell (professor of anatomy
in the Ohio Medical College), and cured it with internal remedies.
He relied principally upon Arsenicum and Carb. veg.
Dr. Hunt was called to prescribe for a case in the last stages,
and succeeded far in relieving the sufferings of the patient and
staying the progress of the disease. That he thinks treatment at
an earlier stage would. have been successful.
Arsen., Brom., Carb. veg., Con., Kreos., Lack., Phos., Thuja,
will be found of service.  (See Cancer in General.)
CANCER OF THE PENIS
Is mostly of the scirrhous kind and generally effects the prepuce or
glans.  The prepuce and the glans are the parts most commonly
affected. A small tumor, usually resembling a wart, first appears.
Its base is generally broader than its surface, and as it is deepseated it looks much more like a continuation of the substance of
the glans, than any outgrowth.  By this circumstance it can be
distinguished from a venereal tumor, the latter having an evidently
diseased character, and only a small neck, the base always smaller
than the apex. The reverse, in all respects, is the case with the
scirrhous or cancerous glans, presenting itself only as an irregular
tumor, and growing slowly. It finally ulcerates, and throws out
fungous growths as in other cases; and the matter discharged becomes fetid and bloody. As the disease progresses, it involves all



232                       CANCERS.
the surrounding parts. It may extend along the body of the penis up into the abdomen, or still farther down towards the rectum,
destroying especially all the inguinal and adjacent glandular
structure.
ii other cases, cancer of the glans penis assumes more of a
chronic character, the glans enlarging very greatly, becoming
hardened, and discharging by fistulous openings into the urethra,
at the base of the glans, and then out through the meatus urinarius, -the cavity of which becomes very much enlarged, having
hardened callous edges, very painful on pressure.
The TREATMENT in these cases should be as for cancer in other
parts.  We have never seen but two cases. In one of these the
glans penis was three or four times as large as the original size,
hard, almost of callous firmness. The meatus urinarius was permanently dilated to three times its usual caliber, lined with a cartilaginous wall, an inch and a half in its length, discharging a
profuse ichor, pain, burning and lancinating. The cure was completed with sulphate of zinc.
CANCER OF THE. TESTICLE.
The cancerous testicle appears externally considerably enlarged,
rough and heavy, like a lump of lead. As the disease progresses,
the Spermatic Cord and Inguinal Glands become affected, though
it may exist for a long time before there will be much suffering.
The first symptom is a constant lancinating pain, extending along
the cord and through the loins down into the thighs. This tumor
does not usually attain a very large size, though in some instances
it is an enormous burden and deformity.  The scrotum  becomes
inflamed, and sometimes ulcerated, throwing out the peculiar cancerous fungus which easily bleeds. The distinguishing features of
the case are the hard, rough feel and the dull leaden weight.
In this case, ablation had better be performed at onee, as experience has clearly shown that it is almost invariably successful.
[For the Operation of Castration, see Part II.] If, however, the
disease has been communicated to the contiguous membranes, or to
the cord, the case will have to be treated in the same manner as
cancer elsewhere.
In one case operated upon by the late Dr. Morrow, that of Mr.



CANCERS.                       233
K -, of Lockland, in Hamilton county, the diseased mass that was
removed was found the day after the operation to weigh five pounds
and three-quarters. In this case, the cord was involved in the
disease, so that to complete the operation, a dissection had to be
made through the external up to the internal abdominal ring. This
was the largest scirrhous testis we ever saw. The parts healed
kindly after the operation, and the cure was effectual.
CARCINOMA UTERI.
This is not of as frequent occurrence as is generally supposed.
Many of the cases usually called such being nothing more than
bad cases of ulceration. The patient sometimes will not complain
of much pain until it has proceeded to ulceration. Generally, however, there are occasional darting and twinging pains in the uterus
itself, coming on and going off suddenly. The patient complains
much of bearing down. There is a sense of weight in the lower
part of the abdomen.  The pains become very severe, especially
at night.  There is over the pubic bones and in the small of the
back a violent burning and stitching-boring. This extends to the
thighs and makes walking difficult, and even sitting painful.
On examination, the neck of the womb will be found hard and
rough, and not unfrequently much enlarged. The os tincae may
be entirely closed, or considerably dilated, its lips having become
a hard, jagged ring. There is, frequently, large fungous growths.
Soon an ulcer forms, which is usually so irregular that it can easily
be detected by the touch, which discharges freely a peculiarly
offensive sanious ichor. When the disease is far advanced, dangerous hemorrhage is frequent, and patients experience great
constitutional irritation and emaciation. It is indispensable to an
accurate and thorough knowledge of any of these cases to make
an examination with the vaginal speculum, as the severity of the
symptoms do not, in all cases, bear a strict relation to the extent
of the organic lesion.
The remedies should beemployed locally through the speculum
as well as internally, and this is so much the more important, as
the disease is malignant; and he who depends alone upon the
internal treatment of bad cases, will have the registry of his suc30                                        (PART I.)



234                        CANCERS.
cess upon the tomb-stone. From our experience we should expect
more favorable results from exclusive local, than exclusive internal
treatment. But from both combined, success where either singly
would fail.
The symptoms resulting from induration and ulceration, and
the incipient forms of this disease, and their respective boundaries
being so difficult to define, we have spoken of the remedies applicable to each.
For induration of the womb without ulceration use, Carbo.
animalis, Aurum, Belladonna, China, Sepia, Staphysagria, Rhus
tox., Iodine, Phosphorus and Sabina.  For the ulcerated condition or true cancerous state, Graphites, Kreosote, Carbo. an., Arsenicum Aurum and Lachesis.  For phagedenic ulceration, Nitric
acid, Thuja, Arsen., Bell., China, Cocculus, Bryonia, Mercurius,
Sepia, and Platina. Consult, also, the remedies and their indications under other forms of cancer.
The symptoms requiring Belladonna are, excessive nervousness, pressing pains in the back, sanguinous ichorous discharge,
with a sense of fullness in the pelvis.
Platina is to be used for stinging pains in the ulcerated state,
with hemorrhage of thick, dark, venous blood, and has cured indurations of the uterus with spasm and stinging.
If the patient is costive, occasionally, in alternation with other
remedies, give Nux vomica, especially if there are frequent, periodical, long-continuing, acrid and bloody discharges, accompanied
with itching and burning.
China should be used when the patient is much debilitated by
profuse hemorrhage.
Arsefzicum is indicated by burning sensations, phagedenic or
corroding ulcer, internal and underneath the pubic bones, worse
at night, towards midnight insupportable anguish in the chest,
restlessness, burning thirst, induration of corroding ulcer on the
neck of the uterus, and an acrid discharge per vaginum.
Aurum, for desponding, melancholy persons, with simple or
malignant chronic induration of the womb, particularly if scrofulous or mercurialized.
Cocculus should be given for the spasmodic pains behind the
symphysis, with a serous discharge.



CANCERS.                       235
Bryonia is used for a state of great nervous irritability, pain
in forehead and eyes.
Kreosotum is useful in advanced stages, where there are stitching pains in the womb, with burning and swelling of the labia,
hard tubercles on the os uteri, with eating, ulcerative pains,
where the menses appears a week or more before the proper time
and continues for several days too long, with dark, bloody, lumpy
and ichorous discharge, with pungent smarting and itching pains,
aggravated during the night.  Menses intermittent coming, and in
three or four days going off, and then reappearing; pains bearing
down; the patient in constant low spirits.
Iodine is to be used for induration of the neck and part of the
body, or when the neck is destroyed, the patient being much emaciated, occasionally affected with faintings and spasms.
Thuja, for the above symptoms in addition to a cauliflower
excresence on the neck, with ulceration and stinging, burning
pains, and manifesting the hemorrhagic disposition of fungus
haematodes.
Graphites, for painful lymphatic swellings in the vagina, the
neck of the womb being hard and swollen, with fungoid tubercles
that bleed easily and are very painful to the touch; the patient
complains of a sense of weight in the abdomen and lancinating
pains in the uterus, running down the thighs, darting like electricity. Frequent chills, livid, anxious countenance, and frequent
pulse, menses delayed, at which time the sufferings of the patient
are aggravated.
Scale, for a putrescent state of the uterus.
Sabina, for labor-like pains, the ostincae being open.
Carbo. veg., for excessive burning pains, deep in the pelvis, paroxysmal in their character, with regular intermission between the
paroxysms; occasional cerebral congestions.
Conium is a very valuable remedy in uterine cancer, especially when the lymphatic glands are diseased. The symptoms indicating Conium are, cramping, pinching pains in the uterus, a sense
of tightness in the lower portion of the abdomen, with lancinating
pains, itching of the external and  internal organs, bearing
down pains; catamenia premature and small in quantity, pains in



236                       CANCERS.
the breasts before the appearance of the catamenia, burning and
excoriating leucorrhea.
Dr. Neidhard thus remarks of genuine carcinoma uteri: " Having carefully sifted the homeopathic literature without finding any
c'ases on record of carcinoma uteri, I must presume that no cure
of a fully developed case has taken place uuder homeopathie
treatment, else, if such had been the case, we should have heard
of it in the homeopathic journals. I have no doubt, however, that
at its commencement it can sometimes be arrested and the painful
symptoms always mitigated by Kreosote, which has been of great
service to me in more than one important case. Next to this come
Conium, Phos., Sulph., Ars., Carbo., an. and veg., Phytol. dec.
and Orobanche, which must be selected according to the predominating symptoms and the history of the case."
Dr. Kallenbach mentions a case of carcinoma uteri, where all
the symptoms of cancer of the uterus had given place to those of
cancer of the stomach, but where, nevertheless, on post-mortem
examination, no disease of the stomach was found, Kreosote had
produced this apparent removal of the symptoms. In his case, as
well as those relieved by myself with Kreosote, the pain was always diminished in the uterus, and the fetid, brownish, watery discharge removed. In Kallenbach's case the uterus could not be
reached by touching.
The Chloride of aold (aqua regia 1 oz., pure chloride of gold
6 grs.) appears to have produced extraordinary effects in the hands
of M. Recamier.  " A woman affected with fungating cancer of
the cervix uteri, which had already destroyed almost the entire of
that portion of the organ, underwent seven or eight applications
of' this caustic; the local and general symptoms yielded completely; the ulceration ceased; the body of the organ, which had
been engorged, losf its unnatural size; lancinating pain and hemorrhages were no longer complained of."  He afterwards, however, preferred the chloride of platina.



CARBUNCLES AND BOILS COMPARED.               237
CHAPTER XXI.
ANTHRAX, OSTEO-SARCOMA.
ANTHRAX, a malignant boil?- Boil, "a miniature carbuncle!"  Early symptoms
and progress-Persons and parts liable - Prognosis not discouraging -Size and
character - "Equivocal"-Treatment.
OSTEO-SARCOMA, bony or bone cancer- Symptoms-Old school prognosis and
prescriptions
CARBUNCLE OR ANTHRAX.
ANTHRAX is an unhealthy inflammation of a circumscribed
portion of the cellular tissue and integument, attended with more
or less mortification and sloughing.
Illustratively, it might be said that a carbuncle is a malignant
boil, that is,-still more popularly interpreted,-" the worst kind
of a boil," one that "won't get well."  Such expressions, however, must be regarded as but popular, as rather indicating analogies, than stating facts of identity or direct connection.  Such a
" definition" will not stand the test.  You cannot safely reverse
it, and make the two things compared define each other.  Yet
this is what one surgical writer, in high repute, has actually ventured on-  "Boils," says Mr. Druitt, "are miniature carbuncles!"
This is the reductio ad absurdum of such comparisons.
Carbuncle and boil differ as health and disease, life and death,
positive and negative. In the one, nature is doing her best for
us; in the other, her worst.  A  common boil is plainly, if anything is that ever occurs in the organism, a successful effort of the
" vis medicatrix;" a carbuncle is something worse than an unsuccessful effort of such a power- to characterize it, you must refer
it to a vis necatrix. It scarcely differs less in its symptoms than
its termination; for 
Anthrax commences as a livid red swelling, exacting attention
by its burning, smarting pain, which continues, worse and worse,
to an insupportable degree.  Its distinction from  a common
healthy phlegmon becomes more and more marked as it pro



238               ANTHRAX OR CARBUNCLE.
gresses; and it is only in rare instances that it does not show its
true character from the beginning. As an abscess, it has no particular source, or central " core," and, as an ulcer, it may be said
to commence " fistulous."  As soon as the more ordinary symptoms of local inflammation have subsided,-or without their having gone through their regular stages, vesication commences; and
when it bursts, instead of a truncated cone with one opening or
crater, as in the boil, there is a flat top with several sinuses.
From their orifices, instead of healthy consistent pus, an acrid
fluid exudes, resembling thin gruel, and excoriating all parts with
which it comes in contact. The parts where they originate seem
to be in a state bordering on mortification.
Anthrax always implies an unhealthy and debilitated, if not an
exhausted condition of the system. It rarely occurs in any but
aged persons, and those, too, whose constitutions have suffered
other ravages than those of time. Hard study, anxiety of mind,
trouble, and consequent depression of spirits, intemperance, etc.,
are enumerated among predisposing or remote causes.
Severe constitutional symptoms generally attend.  The digestive function is always more or less deranged, and nausea very
commonly complained of. Under great suffering and attending
fever, loss of sleep and consequent prostration of strength, the
patient rapidly sinks.
It is generally located on some part of the back. The next
common seat is the head, where it is still more dangerous, though
not " almost surely fatal," as some of the books would have it.
The prognosis, indeed, need not be so alarming as it is generally made. (Most patients would probably get over it at last,
even without treatment.) Still it is always a most distressing and
occasionally a fatal affection.
No time should be lost, and no means spared to mitigate
suffering, even if we could not arrest the process of " local death"
and prevent its becoming general.  We can generally have the
satisfaction of effecting both these objects, and by the same
means.  The extraordinary pain is a " natural call," an alarm of
the whole endangered organism, a true "indication of cure."
The boil theory or metaphor must not lead you to limit the
idea of carbuncle to the ordinary dimensions of healthy phleg



CARBUNCLE.                       239
mon.  You need not look out for some less familiar or more
learned name, when this species of malignant tumor presents
itself of an enormous size, which it often attains with a mushroom
rapidity of growth.  Dr. Hill saw one on an old lady's back, as
large as her head, having swelled out to that extent in the course
of two weeks.
Indeed, like many of the fungi, these sudden developments
seem  to thrive on death, to flourish on decayed or decaying vitality. They are true parasites, exhausting the trunk they spring
from, killing that they may live, -for they really have a sort of
independent vitality. They evidently absorb from the soft parts
around them, which wither away, the muscles especially becoming
wasted and enfeebled. Emollient applications that would soothe
ordinary irritation and inflammation, really seem to nourish these
tumors, and stimulate them to more rapid development.
In fact, though we have, for the sake of description, compared
these growths to fungi and parasitic plants, we regard them as a
result of perverted nutrition, giving rise, by a sort of " equivocal
generation," if you please, to a new center of animal vitality,as a congeries of entozoa feeding on the flesh, - as " organized
stomachs," absorbing and digesting, like the sponges, the matter
they come in contact with.
TREATMENT.-Arnica is to be used in the early stage of th6
disease when there is a sense of bruisedness in the part, with
some redness and rather dull pain; and this should be followed
by nux vomica as soon as the symptoms have abated, especially if
thepatient is in low spirits, and there is torpidity of the liver
with rather sallow countenance. This may often be followed by
Silicea, advantageously, of which one dose has cured carbuncle,
with hard swelling, of a viscid consistence, having a badly-colored,
dark, purple-red appearance, secreting an acrid, corrosive, fetid,
yellowish-green ichor, corroding the cellular tissue and the muscles; faintness, loss of appetite, restless nights; suppression of
the pulse, livid countenance. Arsenicum is indicated when turning purple, the pain is burning (sometimes as if a live coal was on
the part) and severe, the patient is in great anguish, and gangrene
is threatened; or it is the result of contagion, or has cavities
from which lice creep forth.



240                ANTHRAX OR CARBUNCLE.
Dr. S. M. Gate, of Augusta, Me., has furnished us with a report of an interesting case of malignant carbuncle, treated with
Arsenicum successfully.  It was of the most malignant character;
in fact, pronounced by allopathic physicians to be fungus hematodes.  The patient was a man aged sixty; locality of the carbuncle, on the back of the neck, size of a tea saucer, oblong in
shape, and elevated some three inches; gangrenous in the center,
outer parts hard, bluish, and irregular. Treated by the saturated
alcoholic solution of arsenic applied to the ulcerated surface by a
brush wet in water, and five or six drops of the solution put on
the brush, and two drops of the solution given internally, three
times a day.  The symptoms abated immediately, and in six days
the sore appeared healthy and healed up rapidly. The Ars. was
only used twice a day after the sixth day. No medicinal symptoms were noticed.
Mrs. L-, of Cincinnati, aged fifty, treated by one of the
authors for a large carbuncle on the back of her neck.  The
symptoms were those of general prostration of strength, low, feeble pulse, pain in the carbuncle, " burning," as if covered with
live coals of fire.  Arsenicum, first trituration (decimal), was applied to the surface of the affected part, and the internal use of
the 4th.  Immediate abatement of the symptoms and rapid recovery to health was the result.  Also Mr. R., of Cincinnati, age
about fifty-five, treated in the same manner, for a carbuncle of
extraordinary size and malignancy.  He was very much debilitated, from a recent attack of fever while at the south, from
whence he had lately returned. The effect of this remedy was
equally speedy and successful. All these cases were treated from
four to six years ago, and still remain well.  We sometimes have
to treat old cases that have been badly, i. e., allopathically
treated, and still remain sore and painful. For such, prescribe
the remedy according to the symptoms present, as in a recent case.
Lachesis will be useful when the ulcers are deep and the surrounding surface is livid with dark fluid oozing out of the orifices.
For great nervous prostration, give Hyosciamus.  A remedy
not generally known and not yet "proven," but is. doubtless worthy of attention in this disease, is the Pyrola rotundifolia (canker
letucae).  We have used it successfully in several mild, and one



ANTHRAX OR CARBUNCLE.                   241
very malignant case of carbuncle.  The manner of using the
plant was to lay the green leaves over the ulcerated surface, and
change them as often as they became dry. The good effect would
soon be experienced by the pain ceasing, and in a few hours the
swelling would begin to subside, the discharge to diminish and
become more healthy; in a few days the ulcers would heal, and
the patients regain their health.
We formerly used it entirely locally, because we first saw the
good effects of its use in that manner, but would now use it internally as well as externally.  It is doubtless a specific for this disease in some of its forms, if not in all. But if the carbuncle
does not yield promptly to carefully-selected remedies, proceed at
once to a full and free application of
Caustic potash. Let it not only thoroughly saturate the surface, but pass through the sinuses into the cavities within, until
no part of the mass is untouched.
There need not be any fear of increasing the patient's sufferings; on the contrary, after a little smarting for a few moments
succeeding the first touches, he becomes perfectly easy.  The
caustic is here the only effectual anodyne. We have seen a patient who had not been able to sleep for a week before, so pleasantly relieved, that in thirty to forty minutes after the application was begun, she sank into a sound sleep; and afterwards went
through a rapid convalescence without a momenit's further suffering.
After the application of caustic potash, emollient poultices
should be used, changing them  frequently and washing off the
eschar at every dressing.
The parts destroyed will soon become putrid and slough off.
To correct thefetor that attends the gangrene, a dilute wash
of pyroligneous acid may sometimes be advantageously employed.
After the sloughing of the eschar produced by the caustic, give
such specific remedies as are indicated by the symptoms, dressing
the sore with wet compresses.
As soon as the diseased portions have sloughed off, a simple
dressing is all-sufficient. The Momordica Salve will probably suit.
Under it, the parts will readily heal up, provided the patient's
strength be supported. To secure this indispensable condition
31                                          (PART I.)



242                     OSTEO-SARCOMA.
The diet should be as nourishing as possible, as soon as the
patient's appetite admits of it. A lost appetite should be encouraged and welcomed back, like any other prodigal, but not forced
or anticipated,
OSTEO-SARCOMA, OR BONE CANCER.
In this disease the bone is enlarged, and its structure altered,
from a deposite of flesh-like matter mingling with its substance.
The changes thus produced seem to be the result of inflammation,
often excited by some mechanical injury, or some long-continued
local irritation.
The word has been also applied to tumors in any part that
seem to be of a blended osseous and fleshy consistency.
The bone enlarges as the disease progresses, and the internal
structure is changed from the proper cancelli or hard reticulated
tissue to a brownish fleshy mass. As this morbid formation increases, the parieties of the bone are extended and often become
very thin, in some places giving way entirely, fungus then filling
up the crevice. In other cases (which do not therefore exactly
correspond to the definition) the cancelli are only enlarged and
their cavities filled with pus. Whenever the swelling opens on
the surface, large quantities of pus of a peculiar character are in
most cases discharged.  "This disease," remarks Mr. Liston,
" occurs most frequently in the lower jaw;"-a fact attributed
mainly to caries of the teeth, though other exposures of that
bone, as to sudden changes of temperature in drinking, may help
to account for its greater liability.  In other respects, weak and
cachectic constitutions are the most liable.
The SYMPTOMS at the beginning are acute pain in the affected
part, with slight constitutional disturbance.
The part soon begins to swell, becoming hard and elastic, and
the pain is more dull.  At a still later period, acute lancinating
pain returns.  Severe constitutional symptoms now set in, the
tumor becomes fluctuating, and in consequence of loose pieces of
bone floating in it, crepitus can be felt on handling. Eventually
the integuments burst, and large fungous growths sprout out with
a profuse bloody discharge. The patient at this stage is much



OSTEO-SARCOMA.                    243
prostrated, and if not soon relieved by amputation, or the proper
medication, can not long survive.
In speaking of the
TREATMENT,
Druitt remarks, page 228-9:-" It is often impossible to distinguish between these two classes" (malignant and non-malignant
cases). " The same measures that will cure the curable affections
will check the incurable ones." The measures referred to "are
repeated leeching, mild mercurial alteratives, sarsaparilla with
small doses of iodine and potassium, and change of air and othe'r
general tonics." "If these means fail, the only recourse is amputation or extirpation."  "But the extirpation of the truly malignant growths should be very early and very complete, partial extirpation being unmeaning and utterly useless cruelty."
Prof. Gibson observes, that "before an osteo-sarcomatous tumor has attained a large size, it may possibly be removed by local
and constitutional remedies, without the aid of an operation.
Leeches applied to the part itself or its vicinity will be found useful.
Blisters also, often repeated and kept open by Savine Cerate, and
pressure applied to the part, will prove still more beneficial. As
a constitutional remedy, Sir Astley Cooper has extolled the exhibition of the oxymuriate of mercury (corrosive sublimate), combined with the compound decoction of sarsaparilla." " When these
remedies fail," continues Prof. Gibson, "the operation will becGme
necessary."
Mr. Liston, after telling what should be done to remove the
tumor by medication, if that were possible, concludes thus:-" I
must say that I am unacquainted with any remedies capable of
performing the above indications. The knife only is to be depended;
upon."  Again he says, "all operations on malignant tumors, in
their advanced stages, are unwarrantable."
Hastings, in his " Practice of Surgery," after quoting Gibson's
language, adds, respecting amputation, "but unfortunately this
does not always prove successful, for the disease has reappeared
on the stump after the operation." We might continue these quotations, from Old School authority, to a great extent, but we deem
it unnecessary, for there is so much unanimity among them on the
treatment of this disease, that it would be sheer tautology (though



244                     OSTEO-SARCOMA.
they do not all exactly copy each other's words). We have given
from  English, Scotch, and American standard modern authors,
the substance of all that is recommended for this malignant disease 
and you can clearly see that it amounts to this:  That if leeches,
blisters, mercury, sarsaparilla and low diet, will not cure - nothing
will!  The operation, by amputation or extirpation, is indispensable; but even this, according to the same authority, is often of
doubtful utility.
This must be admitted on all hands to be a malignant and
difficult disease to manage; but bad as it is, the results of our practice present a very different face to the picture.
We may be called to treat cases so far advanced, -where the
constitutional powers are much prostrated, or when some vital organs or large vessels are implicated to such an extent, - that the
patient will not live long enough to give the remedies a chance to
act. In such a case, we, as well as others, must fail. But if called
at the stage of the disease, when the surgeon is generally consulted,
the chance of success will be very fair, and a failure should be a
rare occurrence.
In TREATMENT, if the disease be in a limb, and far advanced,
involving the whole surface of the bone, it may be necessary to
amputate, but even in many such cases we may save the limb as
well as the patient. In the early stage of acute inflammation, before pus has formed, use such remedies as are recommended for
ostitis (see chap. xi.), with the hope of arresting the inflammatory
action and preventing ulceration. But if called too late for this,
or for arresting the inflammation, pus having formed, the limb
continuing to swell, apply an issue with caustic potash over the
most prominent portion of the tumor, so as to cause an opening
into the center of the diseased mass as soon as possible. If it be
in the jaw, extract some of the teeth nearest the point of the disease, and through the bottoms of the alveoli, make an orifice to
the disease, if it has not already extended to the roots of the teeth,
as it does very early. Having thus made an exit for the pus, or
if it has opened to the surface spontaneously, wash out the whole
cavity freely with strong soap suds, and proceed to treat it the
same as for any other cancer with similar symptoms.
Amputation should not be delayed too long.  If the disease



SCALD  HEAD.                         245
does not yield, and the patient is sinking, operate; if possible,
having a healthy joint between the diseased portion and the point
of amputation.
CHAPTER XXII.
SCALD HEAD   MAXILLARY ABSCESS -SALIVARY AND LACHRYMAL
FISTULAS.
TINEA CAPITIS -Description - Contagiousness - Ulceration and scabbing - Originates and spreads only among children - Cause? - Plenty of soap the first
measure of treatment- Other measures - Bathing and other alteratives.
MAXILLARY ABSCESS - Cause and consequences - Symptoms - Preventive and
early treatment - Mechanical and medicinal - Later measures.
FISTULA PAROTIDEA- Cause and progress - Remedial measures, mechanical and
medicinal.
FISTULA LACHRYMALIS - Strict and popular definitions -- Medicinal treatment in
mild cases —Probing often operation enough- A radical cure to be attempted
in all cases.
TINEA CAPITIS, OR SCALD HEAD.
THIS is a disease of the scalp, peculiar to children and young
persons. It varies a good deal in its character. Sometimes it appears as a scabby eruption, covering small portions or the whole
of the scalp. In some cases a great amount of matter is discharged
from the affected parts, in others but little. This discharge may
be either thick and purulent, or, as is more frequently the case, a
thin and sanious fluid. This matter is often contagious in character, and so irritating, that when it gets about the ears or neck
it occasions ulceration.  These secondary sores, however, heal
spontaneously, showing that the contagious disease belongs exclusively to the scalp, and will not continue long in any other part
of the integument.  Its diffusion over the scalp, and propagation
from  child to child show, clearly, that among children it is as
contagious as the itch.  Whatever the cause, we never knew an
instance of a grown-up person catching the disease, though adults
often have it, having retained it from their childhood.



246                      SCALD HEAD.
There is often a great thickening of the scalp at particular
points. At the apex and lower portions of the occiput, in particular, you will often discover callous spots. There will also, in some
cases, be considerable ulceration. Large and deep cavities will be
formed in different points, with raised edges and all the other
characteristics of the  indolent ulcer."
In some cases the suppuration or ulceration will be but slight,
but the whole scalp will be covered with dry scabs (ptyriasis),
which appear at first view, like the thin branny scales of dandruff;
but when they are combed off, they are seen to be a complete
crust, leaving the scalp beneath of a fiery redness, as if recently
scalded, and itching and burning from the exposure.  It is particularly in this form of the disease that the hair falls off, leaving
large spots nearly bare, the scalp presenting there an inflamed
and shining appearance.
At other times the morbid secretion will be so abundant and
the eruption so extensive (impetigo), as to form scabs over the
whole head, covering it like a shell. And this happens, too, in
spite of all exertions to prevent it by the strictest cleanliness, especially if the hair has not before fallen off to a very considerable
extent.
The CAUSE of this disease is not well known, further than that,
when developed, it becomes contagious. It may be communicated
by using the same comb or towel, or by sleeping with one already
affected.  It is commonly supposed to be most prevalent among
poor and ill-fed persons, or such as are living in low, damp and
filthy places; but it is not by any means confined to this class.
We have seen as many cases in cities among the children of the
better-provided classes as among their little fellow citizens in rags.
It may occur at any age from birth to puberty; but it seldom or
never originates in an individual after puberty. Persons who have
had it throughout their childhood, may continue to be affected with
it up to the meridian of life, if it do not previously end in consumption, -as it not unfrequently does, being often connected
with a general cachetic condition of the system, which predisposes
to pulmonary affections.
It is believed to be owing, in very young children, to a neglect
of properly washing them at birth. It is said, also, to have been



SCALD HEAD.                       247
produced indirectly from scalds and burns, by the action of the
irritating secretions on other parts of the head. In some instances
there has appeared reason to attribute it to syphilitic virus in the
mother.
TREATMENT.
First and foremost let there be no want of soap and water.
Cleanliness is a principle of treatment that applies to all cases.
In anything like a bad case, let your soap-suds be a lather, and
not only wash the whole head, but shave off all the hair. Have the
whole scalp bare and smooth, if possible.
Where there is scabbiness with soreness, it will be first necessary to remove the irritation. This can be best done by washing the
head twice a day with strong soap-suds -and putting on between
times, as a cap, a warm slippery elm poultice, as much of the hair
as possible being first removed with scissors. This will soon prepare the parts for the razor. After the shaving, continue the soapsuds night and morning.
The remedies which have been mostly used in this disease are -
Rhus tox., Arsenicum, Baryta  carb., IHepar Sulphuris,
Staphysagria, Nitric ac., Dulcamara, Oleander, Psoricum, Gale.
carb., Magnes. carb., Natr. mur., Graphites and Phytolacca.
Rhus tox. is used for the more obstinate cases, where there is
much fetid discharge, the hair falls off, with great itching, especially at night, the pus accumulates and forms a thick crust, and
there is great trouble in getting rid of lice which accumulate with
astonishing rapidity.  It may be used with success not unfrequently in the milder forms of the disease.
Arsenieum, when the pus is of an ichorous character, corroding
other parts with which it comes in contact, forming itching, burning ulcers. After allaying these symptoms and producing an improvement with Arsenicum, if the amendment does not continue,
thus tox. should be given and the cure will generally be soon completed.  Dulcamara, for scrofulous children where the glands of
the neck are affected, the child is pale and the eruption is of a
mild form.  Oleander is indicated in the mild form of this disease
where there is a scaly eruption, or where the pimples are like itch
vesicles, with great itching and smarting on being scratched,



248                     SCALD HEAD.
especially in scrofulous persons. Hepar sulplhuris is most beneficial where the eruption, in mild cases, extends to the neck and
face, and affects the eyes; the patient has frequent sweats when
asleep.  We have known some very bad cases cured by the use of
an infusion of the Scrofularia Marilandica applied as a wash to
the head night and morning, and a small portion of the same taken
internally every night.
The Cornus circinati is also a valuable remedy, and will often
alone be effectual in removing the most obstinate cases.  We apply it locally and internally as in the former case, always observing, in either case, to discontinue the remedy as soon as amendment is very evident, or if there is a marked aggravation of the
symptoms, which will sometimes occur. In the latter event the
cure is certain.
We have cured some very obstinate cases where the discharge
was abundant and ichorous, with Phytolacca d. The tincture was
also applied externally, after the washing, before recommended.
Dr. Ganwerky reports an obstinate and ill-looking case of
tinea, accompanied with urticaria, which had resisted, for a long
time, both allopathic and homeopathic treatment, cured with a
single dose of Psoricum.
The following report of cases was furnished us by Prof. C.
Neidhard, of Philadelphia:
"An aggravated case of tinea was treated by me in the beginning of my homeopathic career. The case in question was a
young French lady residing in Philadelphia, who had always consulted Andral, of Paris; Sir Astley Cooper, of London; and the
most distinguished physicians of New Orleans, as well as this city,
without benefit. The disease might be called an impetigo, large
scabs covering the whole head and constantly discharging.  The
terrible allopathic treatment she underwent, it might be instructive
to detail, did time and space permit. I will only mention one
remedy employed; it was the horrible pitch skull-cap, by which
the whole scab was removed, but of course only for a short time.
She was entirely cured under homeopathic treatment, after a long
aggravation. Unfortunately very few special indications for the
application of remedies can be given by which others may profit.
We are too glad to cure our cases, without asking how it was



SCALD HEAD.                       249
effected. I only know that Psorine was the chief remedy in this
case. Experience has taught me, that if a remedy acts beneficially
in tinea, it will always bring out more of the eruption; if it remains
indifferent, it does not suit the case. Judging according to this
dogma, Psorine undoubtedly had the best effect.  I find noted
down in my record, the following as the action of Psorine:
"'Already, after the fourth powder, the discharge commences
to run, spreads behind the ears and becomes very fetid; there also
appear pimples in the face, it now itches more through the day,
and not, as formerly, at night.' Next to Psorine, no remedy had
a better effect than Baryta carb.
"A  second memorable case was a species of tinea, of a
squamous nature, on the head, with a peculiar and highly characteristic great redness of the base of the tetter.  Magnes. carb.,
half trit., produced the usual aggravation in such cases in bringing
out the tetter to an enormous extent, not only over the whole head,
but also over the neck and shoulders. By means of this very aggravation, however, a complete cure was effected. These two cases,
as well as my subsequent observation of the water treatment at
Graefenburg, have taught me a lesson which I have not forgotten.
I am convinced now, that no important and inveterate case of
chronic cutaneous disease can ever be radically cured without an
apparent aggravation of all the cutaneous symptoms, and this aggravation may not only occur once, but several times, before a
complete cure is effected; but, of course, at each renewal in a
milder degree.  This is, undoubtedly, the cause why so few cutaneous eruptions are radically cured under allopathic treatment.
Calc. carb; this wonderful remedy is employed in diseases
of the most diversified character. The cases of tinea to which it
is best applicable, are those called by pathologists, Pityriasis,
Herpes furfuracious, or dandruff, appearing on the hairy scalp, and
are usually very obstinate. In very many cases of this kind, particularly in persons of light complexion, inclined to obesity, I have
employed it with eminent success. In order to perform a complete
cure, it must, however, be persevered in for a long time, high and
low dilutions must be given in alternation. Nearest allied to this
remedy in dandruff is Nat. mur. I am unable to furnish any special indications for one or the other remedy; all I know, that these
32                                         (PART I.)



250                   MAXILLARY ABSCESS.
two cure oftener cases of this kind. With the internal use of Nat.
mur, I sometimes combine the external application of salt water.
" My indication for using Graphites in tinea capitis, is the seat
of the disease behind the ears, with painfulness on the least
touch.
" Oleander I have used in several cases with great benefit,
where the scabs looked very yellow and where the disease was aggravated in winter; hot weather and perspiration also aggravate
it; the itching is then intolerable."
As cleanliness of the diseased part is an important consideration in this disease, so also is cleanliness of the whole surface of
the patient no less important. The restoration of the healthy
function of the skin, that all-important eliminating organ of the
system, which in all such cases is in an unhealthy condition, is a
matter never to be overlooked. Regular baths should be strictly
enjoined.
MAXILLARY ABSCESS, OR ULCERATION OF THE ANTRUM.
The ANTRUM HIGHMORIANUM is subject to a disease which is
always very distressing, and when of long standing difficult to
cure. It rarely occurs in young or very old persons, being generally confined to those of middle age. It may exist for months
and years without the sufferer being aware of its nature.  For a
long time it may pass for mere "tooth-ache;" indeed its most
common
- CAUSE is the irritation of the lining membrane of the cavity
by decayed teeth. The ulcers on the roots of the teeth not unfrequently penetrate into the antrum, thus communicating their
irritation or disease to the mucus membrane, and that to the periosteum and bone. Irritation also from  any other cause, as from
a common cold, originally affecting the schneiderian membrane,
may proceed to inflammation and thence to ulceration; the discharge from which, finding no sufficient outlet into the nose, becomes an additional cause of irritation, until the bone also ulcerates,
when the fetor becomes almost as great an annoyance to the patient as the pain. It is offensive to everybody about him, particularly at night.
The chief SYMPTOM in the early stage is a severe pain in the



MAXILLARY ABSCESS.                    251
face, just beneath the prominence of the malar bone, which is constant and unremitting. The neighboring teeth not unfrequently
become secondarily affected, and are extracted without any relief.
In other cases, though the teeth may have been the original cause,
their roots not entering the antrum itself, or not making a sufficient orifice in it for the matter to flow out, nothing is gained by
extracting them, and the patient and surgeon may be still in the
dark as to the nature of the affection. If, however, any considerable quantity of matter flow out, there will, of course, be no more
doubt. A considerable discharge' of offensive matter through the
nose, from the sinus overflowing, is in connection with the seat of
the pain, another diagnostic symptom. In some instances the face
gradually swells, and becomes very much disfigured.  The walls
of the antrum may be visibly distended by the accumulating pus.
They have been in this way destroyed, opening into the cheek or
into the orbit. In connection with the diseased antrum, the inflammation may extend to the frontal sinuses, and purulent collections be formed there also. In all cases of long standing, the
chief complaint of the patient is, the fetid effluvium or discharge
through the nostrils.
If called to a case of this kind early enough, your OBJECT will
be, if possible, to allay the inflammation. This may often be
effected, and suppuration with all its inconvenient consequences
prevented, by a timely use of specific remedies.
If the disease is the result of a sudden cold, whether connected,
with diseased teeth or not, setting in with chilliness and followed
by fever, Aconite is the proper remedy, especially if pain in the
head is severe, the patient restless, and there is severe drawing or
pressing pain behind the malar bone.
Belladonna will be found most serviceable in the acute stage
when there is redness of the face and eyes, throbbing pain in the
head and affected side of the face, with swelling and a deep flush
of the cheek.
When the pains are rending, or tearing and burning, Arsen.
will be found most useful, especially in the later stage, when suppuration is about to take place, the patient feels weak and faint,
from the severity of the pain.
This disease runs its course through the acute stage in a short



252                   PAROTID FISTULA.
time, and if resolution is not effected in five or six days, an abscess
will most likely form, pus collect in the antrum, and the disease
sooner or later extend to the bones.
If pus has formed, let no time be lost in using means to let it off.
While it remains it is a source of great mischief, and more or less
dangerous. Extract the second or third molar tooth -it may be
necessary to take out both. Should the alveolus not communicate
with the antrum, with a sufficiently large opening, you may also
have to
-drill a hole about the size of an ordinary goose-quill.  It
requires at least that space to let out the pus freely and allow free
access for washing out the cavity.  The operation may be performed with any common drill, causing little or no pain unless the
bone is inflamed.
Inject warm water to remove all pus, once a day at least, and
also throw in a low dilution of the specific remedy you are administering.
To prevent the orifice from closing by the growing of the gums
or the bone over it, keep in a tent or canula, removing it several
times a day to let off the pus. If the pus is thick and yellow,
with little or no pain, Lycopodium will be a useful remedy.
If it is thin and ichorous, the parts sensitive to the touch, especially if the bone is diseased, Assafetida should be used.
Carbo. veg. is the proper remedy for slow, indolent ulceration,
the parts being nearly insensible, the pus fetid and dark colored.
PAROTID OR SALIVARY FISTULA.
Wounds of the face, which sever the parotid or stenonian
duct, often cause much difficulty. As the healing process goes
on, the duct is closed, and the secretion of the parotid gland is
prevented from escaping into the mouth.
It accumulates and forms a tumor at or near the original
wound, which inflames and sooner or later ulcerates, opening upon
the outside of the face.
This fistulous opening, out of which pus as well as the saliva
secreted by the gland is constantly passing, continues to be sore
and painful, and iS a source of great annoyance to the patient,
both on account of the discharge and the disfigurement of his face.



FISTULA LACHRYMALIS.                  253
The proper TREATMENT consists in allaying the irritation and
inflammation, and opening a passage for the saliva into the mouth,
so that the fistula may be allowed to heal.
Calendula, given internally and applied to the sore by cloth
wet in the infusion laid over it, will, in a short time, allay the irritation and bring about a healthy condition.
When the parts become healthy, make an opening with a small
trochar, or a diamond-pointed steel probe, from the inside of the
buccinator muscle, at or near the original point of opening for the
duct.  In making the orifice, pass the trochar into the open end
of the duct at the fistulous opening: or it is better to let it enter
the parotid duct a line or two back of the opening, if practicable.
Insert a silver or gold tube from the mouth into the duct, so as to
guide the saliva into the mouth. The tube should be long enough
to pass for an inch into the duct, so that it will not be liable to
come out into the mouth.
The Fistula may then be readily healed, generally requiring
only simple dressings. But if it does not heal kindly, resort to the
use of Calendula as before directed.  If this does not effect the
healing, the edges may be scarified and brought together. The
Canula should be left in the duct until all the parts are sound and
healthy, and then removed.
The continual flow of saliva will then prevent any danger of a
closure of the duct.
FISTULA LACHRYMALIS.
Any obstruction in the ductus ad nasum causing regurgitation
of the lubricating fluid upon the eye, or rather its constant accumulation and consequent overflow in the shape of tears, is called
by this name, although it only strictly applies to the case where
there is not only distension of the lachrymal sac, appearing as a
tumor at the inner corner of the eye, but where that swelling has
occasioned inflammation and ulceration, with an opening for the
tears on theface, instead of into the nose.
In ordinary cases, the stoppage in the duct occasions but slight
inconvenience from suffusion of the eye-ball and obscuration of
vision.



OPHTHALMIA.                         255
It may take several months to cure a case, or it may be cured
in a few weeks or days. (For the operation, inserting style, &c.,
see Part II.)
CHAPTER XXIII.
OPHTHALMIA, -SPECIFIC VARIETIES.
Oculists and surgeons —" Ophthalmia," its species and principles of division —
Common Ophthalmia, or simple conjunctivitis,-Catarrhal, Purulent, Gonorrheal
and Scrofulous Ophthalmia, described and compared - TREATMENT of each in order - Important and effectual general measures - Difference in the Chronic Stage
or Form - O. Purulenta -different measures in infants and adults - O. Scrofularia - Peculiar and effectual measures in O. Gonorrhealis, a curable disease -
Importance in all forms of constitutional remedies.
THE eye may be considered as next to the brain itself, the
most elevated part of the whole animal organism. It is the agency
by which the individual holds most direct communication with the
universe.  Its structure is the most delicate and diversified of any
organ in the body. This complexity of mechanism and variety of
constituent tissues, together with its almost constant use or abuse,
expose it to a proportionate number of accidents and diseases.
To treat in detail of every morbid derangement of the organs
of vision, would require a separate volume, and merely to give a
catalogue of them would be useless parade.
Every surgeon, however-that is, every " general practitioner"
of medicine, as he is called in England -ought to be competent
not only to treat all acute disease of this important organ, together
with its simpler and more common forms of chronic derangement,
but to distinguish these, with readiness and accuracy, from the
rarer and more complex malformations or disorganizations, which
may justify him in referring the case to professed eye-doctors.
Although then you may not propose to become professional oculists or exclusively " operative" surgeons, you are still bound to



256                      OPHTHALMIA.
study and discriminate many of the diseases fully treated of only
in works devoted to this one organ.
OPHTHALMIA is the generic term for all inflammatory diseases
of the eye. This word, like pneumonia, was in general use before
the modern device was adopted, of indicating inflammation of a
part by its technical name with the artificial termination -itis. It
seems quite unnecessary to change such general and generally understood designations, although specific distinctions are well marked
in a single word, by such terms as conjunctivitis, sclerotitis, corneitis, iritis and even retinitis.
Inflammation of the eye, however, has other diversities, and
requires other classifications, depending on a more important principle than even the anatomical distinction of the part or tissue
affected.
As far as nosology or nomenclature is of any importance, these
distinct principles of classification should be borne in mind.  They
are independent of and often cross each other. Thus every case
of " ophthalmia " must in respect of location, imply one or more of
the species just mentioned: but, having regard to its cause or
character, it may be either acute or chronic; either simple inflammation or scrofulous, or rheumatic, &c.; either idiopathic or symptomatic, epidemic or endemic.
SIMPLE CONJUNCTIVITIS or inflammation of the mucous membrane, covering the front of the eye-ball and lining the eye-lids, is,
as might be expected from  the exposure of the part, by far the
most frequent form of "ophthalmia," and that which is generally
understood by the word, when no other special form or variety is
mentioned.  Several varieties of conjunctivitis are, however, of
sufficient importance to require distinction.
COMMON OPHTHALMIA,
Or simple inflammation of the membrana conjunctiva, may be
brought on by the introduction of foreign substances between the
lids and ball, or other modes of external injury, -too strong an
impression of light, exposure to cold, &c., &c. In short, the surface of the eye is peculiarly liable to all the causes and predisposing causes of ordinary inflammation.
The first symptom of the irritation tending to inflammation is



OPHTHALMIA.                      257
an uneasy sensation in the part, a sensation of itching or scratching, whether there be any foreign substance actually causing it
or not; and not unfrequently the patient will call on some one to
look into his eye and remove the supposed offending cause. The
next stage is probably more or less intolerance of light.
The eye-ball soon seems to be swollen, with a diffused redness
of the whole visible surface, and a sensation of increased heat.
There is also an increased secretion of tears, which not unfrequently become hot and scalding to the cheeks, on which they fall,
from being produced too fast to be all admitted into the puncta
lachrymalia.
As the disease continues to advance, the pain appears to become more deeply-seated, darting and burning, sometimes it extends to the forenead. Symptoms of general fever may always be
detected and are often violent and obvious enough. Costiveness
and more or less derangement of the stomach are rarely absent.
In some cases the conjunctiva becomes thickened, presenting a
kind of fungous appearance; or there is more or less extravasated
fluid of some kind between it and the sclerotic coat, and in rare
instances even in front of the cornea. The disease may even
spread in the suppurative stage to the extent of separating the cornea from its attachments. This, however, is very rare.
In healthy individuals the inflammation usually terminates in
resolution. It may, however, assume a chronic and obstinate character; but it by no means necessarily follows that it is then so
" very difficult to manage," as some distinguished authorities would
have us believe
Although exposure to cold was mentioned as one of the ordinary causes of this form of the disease, some peculiarities are presented when it appears epidemic, as
CATAtRHAL OPHTHALMIA.
This would appear from the books to be much more frequent
in Europe, than among ourselves. It is there a very common accompaniment of influenza.
One of the SYMPTOMS in which this differs from the common
form, is at the beginning a dryness of the eye instead of an unusual secretion of tears. In a short time, however, the pain di33                                        (PART I.)



258                    OPHTHALMIA.
minishes, while a copious flow of tears sets in, which soon changes
to a mucous discharge, and then becomes acrid and excoriating.
The patient is constantly feverish.
In some cases the whole visible surface of the eye is covered
with pustules containing a yellowish secretion.  This pustular
suppuration is one of the circumstances that distinguishes it from
PURULENT OPHTHALMIA. (Egyptian Ophthalmia).
This is considered a very serious disease. One eye is often
destroyed by it, occasionally both.
It may attack individuals of all ages.
We have seen it, however, much more frequently in children
than in adults. It usually makes its appearance a few days after
birth. The cause of this singular fact has been much disputed.
Some have attributed it exclusively to gonorrhea, or at least leucorrhea in the mother! We have had cases, however, where the
former was certainly not the cause, and when we had every reason
to believe that the latter could not have been. We are much more
inclined to attribute it to the fault of the nurse than of the mother.
It is more reasonable to regard it as produced by the peculiar but
healthy secretions with which the child is always covered at birth;
and from which it is not always properly cleansed in the first instance.
The eyes are at first slightly reddened and swollen. This is
soon followed by discharges of thin matter rather adhesive in its
character, —the lids being frequently glued  together by it.
When it is very copious, it becomes of a yellowish and sometimes
greenish color and very acrid.
The disease extends not only over the'whole front of the eyeball, but throughout the conjunctiva membrane lining the lids,
which then becomes much thickened and assumes a fungoid appearance. The distended fold of the membrane may project downward'and cover the cornea. The cornea itself, more frequently
than in simple ophthalmia, becomes involved and sloughs off, destroying the eye.
There is always great constitutional irritation attending the
early stage of the disease, but it generally subsides in a few



OPHTHALMIA.                       259
days, after which the affection becomes chronic and continues apparently local.
GONORRHEAL OPHTHALMIA
- is generally regarded as produced by a want of attention to
cleanliness in patients having the urethral form of the affection,
and allowing some of the matter to getinto the eye. This matter.
is said to have the same reproductive action on any other mucous
surface as in the original location. But we are told from high
authority, that " there is reason to believe also that the disease is
sometimes produced (in the eye) by sympathy or in the way of
metastasis, in consequence of suppressed gonorrhea;" * that is,
be it observed, in consequence of the cure of the disease according
to the routine course of treatment! "Oh, medicine! how many
crimes are committed," how many maladies engendered "in thy
name!"
The symptoms are much the same in character as those of the
last-mentioned form, called especially "purulent ophthalmia," but
the disease is much more violent as well as " virulent." Hence an
additional reason for believing that purulent ophthalmia, as it effects
new-born children, can not be of gonorrheal origin. When this
specific inflammation attacks the eyes of adults -whose systems
from their being at the time affected with it elsewhere, may also
be supposed in some measure hardened or accustomed to the virus
— it often destroys one eye, if not both. How then should the
susceptible surface of children's eyes, which can not yet bear the
light itself, get off without still worse results than those of " ophthalmia purulenta? "
Of this gonorrhea of the eye, we are told by the author just
quoted, that " it unfortunately admits of no relief." A probable
reason for that opinion on his part, and of a more hopeful one on
ours, will be given when we come to speak of treatment.,
SCROFULOUS OPHTHALMIA
-may be generally distinguished by the constitutional affections and appearance of the patient, as well as by the fact of the
* Gibson's Institutes of Surgery, vol. ii, page 810.



260                     OPHTHALMIA.
eye-disease being peculiarly obstinate under ordinary modes of
treatment.
The most peculiar of the local symptoms are irritability and
intolerance of light, with little or no pain, however, when the eye
is protected from this and other sources of irritation. Occasionally there are some pustules or ulcerated spots upon it, which may
continue for a long time without any material change.
We shall take up the
TREATMENT
-of the different forms of the disease in the order in which I
have mentioned the symptoms. First, then, for
SIMPLE CONJUNCTIVITIS.
In the early stage of conjunctivitis, during the itching or
scratching sensation, as from a foreign substance in the eye, or
when following this there are great intolerance to light, redness
and swelling, injected and inflamed condition of the superficial vessels of the eye, profuse flow of tears, heat, the tears are scalding,
the pain darting and burning, with fever, Aconite should be administered internally and applied, in dilution, to the surface of the
eye. Cloths wet in warm, or rather hot water, with Aconite, should
be laid over the eyes, and the light excluded. The heat of the application should be proportioned to the inflammation; highest in
the more acute stage, and diminished as the inflammation subsides.
Should there remain, after the acute symptoms have been subdued by Aconite, redness of the lids, with a bruised pain when
touched, or difficulty of moving the eyes, with photophobia, especially towards evening or by candle light, Hepar sul. should be used.
When the eyes become worse at night, when warm in bed, or worse
after slight fatigue, the itching and scratching pains returning,
redness of the sclerotica remaining, with morbid sensibility to light,
Mercurius is the proper remedy. Belladonna will be serviceable
when there is erysipelatous inflammation of the eyes in the early
stage, or later, when in other forms there remains bright redness
of the sclerotic coat, the pupils dilated, headache, dizziness and
giddiness, pressive pains around the eyes, or pains which penetrate
deeply.



OPHTHALMIA.                       261
In epidemic or CATARRHAL OPHTHALMIA the same tissue is involved as in the common form of this disease.  In fact there is
but little difference between the two affections, except that the
former is generally connected with more or less inflammation
of the mucous membranes of the air passages, and always, in the
early stage, attended with general catarrhalfever.
Aconite is the proper remedy for the early symptoms, which
do not differ from those of common conjunctivitis, except that these
are more violent. The eye is at first dry, but afterwards, the flow
of tears is abundant.  The Aconite should be used until the fever
is subdued.
In the later stage, when there are pustules on the sclerotica,
with a free discharge of mucous tears, Euphrasia will be appropriate.
Calendula is very valuable in this case, when there is profuse
suppuration from the surface of the ball or lids, or both. We use it
as a local application as well as internally.
If the eruption on the ball or lids is rather vesicular than pustular, Mercurius should be administered.
Patients suffering from this disease are always more or less feverish, with chills alternating with fever, the skin dry, the feet and
legs cold, and the head hot. Under these circumstances, warm or
hot baths, followed by the "wet-sheet pack," will be of great service.
PURULENT OPHTHALMIA.
The incipient stage of this complaint is characterized by many
of the symptoms of Aconite, especially in adults; and if administered early, it will either remove the disease entirely or so modify
it as to render it amenable to Euphrasia or Calcarea.
The Aconite should be given while there is fever during the
high inflammatory action, after the acute febrile sypmtoms have
subsided, or, as in case of infants, if no fever should be present.
Chamomilla is the proper remedy, especially for children, or
when the pains are very severe, the patient is in great anguish,
and there is an abundant flow of adhesive mucous and tears. When
the pains are excessive and burning, as if coals of fire were in the
eyes, the patient in great anguish, great constitutional irritation,



262                      OPHTHALMIA.
Arsenicum  should be administered. When the disease becomes
chronic, the constitutional symptoms having subsided, but the purulent discharge continues, the lids swollen and ulcerated, the pain
pressing or smarting, Causticum will be found especially applicable. A solution of the remedy should be applied daily to the eyes.
If any pustules remain on the ball after the subsiding of the acute
stage, Sepia will be found most serviceable.
Argentum  nitricum  is highly spoken of by Dr. Dudgeon, in
this form of ophthalmia. He reports one very obstinate case cured
in a week by Argent met., six given every night.
For Gonorrheal Ophthalmia, it will be found best to use the
remedies that would be most efficacious for gonorrhea located in
the urethra.
Pulsatilla is directed by some of the books. Thuja, Cannabis,
and Argentum  nitricum will be found very efficacious.  If the
patient is suffering under syphilitic taint, Mer. cor. or Cinnabaris,
may be used with advantage.
The introduction of a solution of the Sesqui-carbonate of potash
by means of a syringe, into the urethra, repeatedly, at such
strength as to produce a discharge resembling gonorrhea, was,
several years ago, suggested to the authors by Dr. I. W. Prowell,
of Lexington, Ky.
It was found that as soon as the " artificial gonorrhea " was
produced in the urethra the eye symptoms began to subside, and
the proper remedies for gonorrhea in its original character would
relieve the eyes, while the artificial disease would also subside in a
few days.
We have also used dilute Tr. Sang. can. to produce the discharge from the urethra with success.
In the earlier stage of SCROFULOUS OPHTHALMIA, while there is
great intolerance of light, pressure and itching, in the eyes, a feeling as if a foreign body or sand were in them, Sulphur will be
beneficial.
If, however, there is high fever, with severe pain in the eyes
and head, Aconite is preferable. Or, where the pains are stinging, the lids are partially or wholly paralyzed, coryza, alternate
chilliness and fever, Bell. is more suitable.
But should the weakness of the eyes continue, with excessive



OPHTHALMIA.                      263
sensibility, little or no pain in a dark room, but the pain severe,
smarting and burning, when exposed to light, with excessive lachrymation or preternatural dryness and a rough feeling, Capsicum
is the most effectual remedy. It should be used both locally and
internally. We have employed this remedy at various dilutions, successfully in many cases of this kind. Dr. Dudgeon speaks highly
of Argentum nit. in this disease.  We have used it with excellent
effect in several cases.  Dr. D -    contends that the cures performed by its local application, as recommended by allopathic
authors, are purely homeopathic.
In the treatment of scrofulous ophthalmia, the condition of the
general system of the patient must always be taken into account,
and the medicines directed with reference to that, as well as for
the local symptoms. The Scrofulous cachexia will have to be corrected, to a greater or less extent, in many cases before the eye
symptoms will yield.
Dr. Boeker reports nine cases of scrofulous ophthalmia, with
pustulation of the lids and ulceration of the cornea, cured in from
six to ten days respectively, by Mercurius corrosivus, in solution of
half a grain to five scruples of distilled water; two drops given
three or four times a day.  In some cases he made it twice as
strong, and in one case used it locally as well as internally with
good effect.
From what we have seen of the action of this article in similar
very bad cases, we are disposed to consider it one of the best remedieswhen there is great intolerance to light, pustules on the eye or
on the margin of the lids, the lids are swollen and red, and the patient is afflicted with eruptions or glandular swellings.
If the patient has been previously treated with large doses of
Mercury, lEuphrasia should be first employed, and followed, if
necessary, by the Mer. cor.
Arsenicum and Conium in alternation have been successfully
used in this disease.
Professor Jas. J. Kitchen, of Philadelphia, in a communication
to one of the authors, thus speaks of scrofulous ophthalmia:
"Regarding Scrofulous Ophthalmia, there are two remedies,
which I have found of great value, and all-sufficient in the cases
which have fallen under my notice since practising homeopathy.



264                      OPHTHALMIA
They are Arsenicum and Conium. In acute cases I give the 3d
potence every four hours, in alternation; chronic cases, the 6th;
Ars. in the morning and Conium at night.  I have succeeded in
every case which I have yet treated."
We will conclude this article with indications for remedies, and
report of cases furnished us by Dr. C. Neidhard.
"The following symptoms induce me to use Sulphur in preference to any other remedy: Inflammation of conjunctiva and sclerotica, the inflammation sometimes more or less advanced, but always more of a chronic kind, with predominating scrofulous diathesis,
sometimes scabs around the eyelids, but particularly a sensation like
sand in the eyes and intolerable itching; the two last symptoms must
always be present, if a beneficial effect is to be derived from Sulph.
" Next to Sulph. in importance and perhaps even superior to
it are, Aeon. and Bellad. These two remedies are, perhaps, more
frequently used in inflammation of the eyes than any others. With
me the chief indication for Aeon. is intense pain; if it does nothing
more, it removes that. The following case exhibits a very fair
representation of the symptoms which would lead us to select
Bellad.
" Miss M    —, aged twelve, of fair complexion, almost from her
birth had been subject to enlargement of the glands of the neck,
which suppurated several times whilst under aleopathic treatment,
so that they became gradually indurated. She had also frequently
suffered from erysipelas of the face, and labored under enlargement of the thyroid gland.  All these affections had subsided to a
considerable extent during homeopathic treatment of one year. In
the spring of 1841, she was attacked with an inflammation of the left
eye. The tunica sclerotica of the left eye of a bright red color, with
extreme intolerance of light, stinging pains in the eye and head,
particularly at night, paralysis of upper eyelid, profuse flow of
tears, chills and fever, and bitter taste in the mouth, thirst and
want of appetite, coryza on the same side as the affected eye. The
symptoms being very striking for Ballad., I accordingly mixed five
drops of the tincture in a wineglassfull of water, of which she took
a teaspoonful every two hours; at the same time ten drops of the
tincture were mixed in a teacupfull of water, with wvhich the eye was
frequently bathed. In the space of four days, I had the satisfac



OPHTHALMIA.                      265
tion of seeing the inflammation completely removed. The ulcer
on the cornea was afterwards cured by repeated doses of Silic.
and Hepar sul., in alternation.
"Next in importance, in my estimation, to Ac. and Bell., is
Conium.  The following case will illustrate its action: it occurred
in a child aged eight, several months after an unsuccessful vaccination.  The inflammation commenced in the left eye and soon involved also the right; intolerance of light and irritability of the
eye excessive; she can not bear the least touch on the head; shooting pains penetrating the eyes upwards into the head.  Tinct.
Acon. six drops in half a tumbler of water, every hour a spoonful,
soon removed the pains. The intolerance of light, excessive nervous irritability, however, continued. Small doses of Conium, Sil.,
Sulpph., which were most specific in this case, did not prevent the
cornea of both eyes from becoming opaque, so that the sight was
entirely obliterated. Notwithstanding this apparent unsuccessful
issue of the case, the homeopathic treatment was not abandoned
by the family, and I was convinced that the homeopathic law
would enable me to find a proper homeopathic remedy. As Con.
mac., even in small doses, seemed always to exert the best influence,
I now gave the strong tincture, four drops in water, three times a
day, which dose was gradually increased to eight; at the same
time, the eyes were directed to be bathed every two hours with the
tincture, mixed with a little water; in four days from the commencement of this treatment, the nebula began to disappear, and
the sight was perfectly restored in two weeks.
" I have subsequently used this remedy in several cases with
equal beneficial success, sometimes in large, at others, in small
doses. It seems to be particularly applicable in inflammation of a
bluish-red color, great sensibility of the eye, paralysis of the upper
eyelids, and where the patient is of a nervous temperament, with
dark complexion, to which, I may add excessive photophobia and
specks on the cornea.
" Next in importance in scrofulous ophthalmia, I must mention
an important group: Gale. carb., Hepar. and Graph.
"  The following case was almost cured byCalc. carb. Mrs. B,
from Boston, had been under the care of various physicians without receiving any benefit. The symptoms denoting a kind of
34                                   (PART i.)



266                     OPUTHALMIA.
scrofulous ophthalmia, were the following: Sensation of sand in the
eyes; an ulcer is visible in both eyes, which obscures the sight like
a veil or mist over the eyes; the pupils are dilated, the eyes are in
tears in the morning, with weakness, and are always worse in summer; pain in the left shoulder to the back on sitting much or being fatigued; costiveness, nervous temperament; the eyes feel best
in twilight. She also had glandular swellings in her neck in childhood, and dry scabs on the head.. After the exhibition of Calc.,
there appeared a thin, scaly eruption on various parts of the body,
with more itching on the right than on the left side. Cale. c., 1st,
produced, at first, a violent aggravation, but, afterwards, a great
improvement took place in her disease. The lady left the city before the cure was completed.
"The following case will characterize the Graphites variety:
A little boy, five years of age, had first a cough, which is followed
by inflammation of the eye; scabs all around the eyelids, eyes
closed in the morning with dry scabs over them and also on the
cheek, photophobia, left nostril is obstructed, looks red and tumid
at the opening, there is no appetite, and he is very much emaciated.  The improvement after Graphites, 3d, was every way
satisfactory; it removed the whole disease in a few days.
" Several similar cases might be here detailed. My experience
with Graph. is abundantly corroborated by homeopathic writers.
Observations like the following occur frequently throughout homeopathic literature; they point out clearly the cases where Graph.
would be indicated.
" Graph., says Dr. Knorres, I have found useful in a scrofulous ophthalmia, with ulceration of the cornea and great intolerance of the light. Hartlaub says, Graph. opens the gummed up,
photophobic eyes of scrofulous children, where there is at the same
time an eruption of the face.
"With regard to Hepar. Sulph., Dr. Schroen gives the following indications, to which I have nothing to add:'In inflammation
of the eyes, accompanied by burning pains at the edges of the lids,
which are red at the internal surface, photophobia and lachrymation, enormous mucous secretion from the meibomean glands, in
consequenc'e, agglutinations of the lids; pustules on the sclerotica
and even on the cornea, where some small vessels converge to its



OPHTHALMIA.                       267
periphery. I have frequently employed, with success, Hep. sul. c.,
though I could not discontinue its use until a considerable lapse
of time, for the same symptoms would again return.  When the
photophobia was excessive, it was necessary to interpose Bellad.
" Quite lately, in a case of nebula of the cornea, with ulceration and violent inflammation of the sclerotica, with photophobia
after small-pox, Graph., next to Silicea, contributed more towards
its cure than any other remedy.  The subject was a young girl,
undoubtedly of scrofulous habit.
"A  remedy, allied to Graph., and also used in cases of a
scrofulous nature, is Kali. carb. Both Graph. and Kali. have the
eyes gummed up in the morning, but Kali. has not merely scabs
on the lids like Graph., but also violent itching in the eyes, with
swelling of the lachrymal duct and flow of tears."
CHAPTER XXIV.
OPHTHALMIA  STRUCTURAL VARIETIES.
Local and structural distinctions - Conjunctivitis and 0. TARSI- 0. SCLEROTICA 
0. CORNEE, distinctions and reference -0. IRIDIS, peculiar symptoms and
causes  PROCIDENTIA IRIDIS.
THE distinctions in inflammatory disease of the eye, of which
we have been speaking, are founded on the character of the diseased action, or that of the patient's constitution. Another principle of division requires consideration. The ordinary cases of
inflammation of the eye,- and those, therefore, which are commonly included under the term "ophthalmia," -are such as involve primarily and principally, if not exclusively, the external
surface.  They are, therefore, more technically described as varieties of conjunctivitis.
Other varieties have now to be noticed, distinguished by the
particular part, or rather the peculiar tissue of the eye concerned.
These structural distinctions and designations sometimes coincide



268                     OPHTHALMIA.
with the specific one founded on the character of the disease. Thus,
inflammation of the fibrous structures of the eye is like that of
such structures elsewhere, rheumatic; while iritis and retinitis may
be symptomatic of syphilis.
As a sort of local variety of conjunctivitis, we will first take
up what is called
OPHTHALMIA TARSI,
-or, more modernly, ophthalmitis tarsalis. This consists in a
form of simple inflammation confined to the eyelids, and perhaps
originally to the Meibomian Glands. The secretions of these
glands, being altered by the disease, become irritating, sometimes
very acrid.  The itching of the eye thus caused, — which is a
diagnostic symptom and the principal complaint of the patient, -
has occasioned the clumsy name of "PSOROPHTHALMIA."
This perverted secretion of the Meibomian glands is not only
acrimonious, but often of a glue-like adhesiveness, sealing up the
eye when long closed, as in sleep, and causing considerable trouble
to separate the lids again. The force necessary to effect this keeps
up the irritation, and increases the chance of the disease running
into the chronic form.  The eye-lashes then not unfrequently drop
off, leaving the edges of the lids smooth, glossy and red; which,
with their baldness, occasions a great disfigurement of the countenance.
The intolerable ITCHING of the eyes, as before remarked, is the
first complaint of the patient. He is obliged to be constantly rubbing them, which only aggravates the irritation. The inflammation sometimes extends to the ball of the eye. That of the lids
very generally proceeds to suppuration; and occasionally there is
ulceration of the tarsal cartilages.
Closure of the lachrymal duct sometimes occurs, giving rise to
what used to be called Epiphora (or mechanical weeping), one
form of obstruction which was mentioned under the head of " FISTULA LACHRYMALIS."
THE TREATMENT
-for the acute form of this affection should be that directed for
"simple ophthalmia."



OPHTHALMIA.                       269
As a large portion of these cases are scrofulous, it will be necessary to bear in mind that condition in making our prescriptions.
In the early stage, while there is simply the itching and redness with more or less inflammation of the surface of the lid, Rhus
tox. will generally be sufficient.  But in the more advanced stage,
Sulphur should be the first remedy.  If it does not yield to this,
and there is an acrid secretion with pimples on the margins, or
sties on the lids, Pulsatilla will be applicable; or else profuse suppuration, Mereurius; or if the. pus is adhesive and the edges itch,
Hepar sul.
If there are ulcers on the lids use Causticum.  For granulations on the inner surface of the lids, Capsicum or Argentum nit.
will be the best remedies; or if there is a gluey puss discharged,
Hepar should be used.
The local application of the remedy indicated at the same time
it is used internally, will greatly facilitate the cure. We have
cured a case with Hepar sulphuris, Pet. first, applied to the diseased surface with a brush, in a week, which had resisted the
efforts of several physicians, with various homeopathic remedies,
for a whole year. We have produced similar results by the local
application of other remedies in this disease, giving the same internally.
It is worth some trouble to prevent "gluing-up " the eyelids
during sleep. For this purpose let the edges of the lids be sufficiently lubricated before going to bed, with some animal oil — lard
oil may answer the purpose well enough, and is much better than
olive oil, which seems to unite with the secretion and become
gluey.
SCLEROTICA OPHTHALMIA.
Inflammation of the second coat of the eye-ball is sometimes
popularly and conveniently distinguished as
— Rheumatic Ophthalmia, not only from the character of the
pain and course of the disease, but from the fact that it occurs in
persons affected with, or liable to other forms of rheumatism.
In the commencement of the disease, the PAIN is usually in the
temple, extending downwards towards the eyebrow of the affected
side. When the pain becomes seated within the ball, it is



270                      OPHTHALMIA.
constant, but much more severe  of an evening  or late at
night.
There is, at first, no appearance of disease on the eye. There
is no peculiar discharge or irritability, nor any intolerance of light.
Soon, however, the surface of the eye-ball seems to redden. The
distended blood-vessels are seen, on closer inspection, to run in
parallel lines beneath the conjunctiva, terminating at the margin
of the cornea: they are so numerous as to have the effect of a continuous red surface. The hue, however, is not bright as in conjunctivitis, but rather of a peculiar dark dusky dingy shade.
The inflammation may become so severe as to extend and involve other coats of the eye.
The most important part of the
TREATMENT,
If fever is present, with full, hard, and frequent pulse and thirst,
Aconite will be useful, and in the commencement of the attack,
may arrest it entirely. But, generally, it will have progressed so
far before the surgeon is consulted, that this remedy will not be
applicable.. If there are present deep, shooting pains in the head
and through the orbit, pains aggravated by moving, pain in the
temple and eyebrow, pupils dilated, or sparks before the eyes, Belladonna is appropriate. It will frequently be sufficient to complete the cure.  Spigelia is important in this disease.  It should
be given when the pains are pressive or shooting, deep-seated in
the orbits, a feeling as if the balls are too large, pains violent.
Colocynth will relieve when the pains are burning and extend
deep in the head, with spasmodic pains in the side of the head and
nose, and great restlessness.
Phytolaccais useful when the pains are of a neuralgic character, pressing pain in the upper parts of both eyes; the left eye is
the seat of the disease.
We once knew a case of violent inflammation of the inner membranes of the eye, and finally amaurosis, produced by the application, in domestic practice, of a roasted poke-root to the back of
the neck for headache.
We have used Calendula in several cases with admirable suc



OPHTHALMIA.                       271
cess.  It is particularly serviceable when the inflammation has
arisen from any mechanical injury, or from over-straining the eye
as by looking at the sun in an eclipse.
CORNEITIS.
Acute inflammation of the Cornea is unimportant as a distinct
species. What is sometimes so called, being strictly speaking, but
a variety of conjunctival inflammation, over and about the cornea,
in which that part of the eye may become involved and destroyed,
as already mentioned. It occurs chiefly in young persons of a
scrofulous constitution, about the age of puberty. Its TREATMENT
requires no peculiar directions.
IRITIS, OR IRIDITIS.
Inflammation of the IRIS is accompanied with great sensibility
of the eye, and intolerance of light, &c.
The pain is lancinating, extending from  the eyebrow to the
orbit, and darting in different directions through the ball.
There is no redness or change in the outer coat of the eye,
though vessels of the second sometimes become affected and enlarged as in sclerotitis proper.
On the anterior surface of the iris, red vessels may be discovered; and its swelling, more or less in different parts, causes the
pupil to appear contracted and irregular in shape.
Inflammation of this delicate organ rarely proceeds to ulceration, or even suppuration1 but adhesions are not unfrequent or unimportant terminations.  A deposit of lymph may be thrown out
on the surface or rim of the iris, and by obstructing its freedom of
action, interfere seriously with vision. Sometimes it is produced
in so large a quantity as to fill the anterior chamber of the eye,
occasioning immediate obstruction of sight.
The CAUSES of iritis are some of them common to other varieties of ophthalmia. The books enumerate wounds, bruises, sudden
exposure to cold, or a strong light, and last, not least important of
predisposing causes, those inseparables -those Siamese twins, 
" syphilis and mercury "- We beg pardon: we ought, of course,
to have said, " the abuse of mercury! "



272                      OPHTHALMIA.
Scrofula, gout and rheumatism, are also mentioned as producing distinct varieties of iritis.
THE TREATMENT
-of iritis is very important, as it is not only a peculiarly acute
and painful variety of inflammation, but runs its course very rapidly, and unless arrested or modified, by prompt and effectual
measures, will probably occasion irreparable mischief.
The remedies directed for inflammation of other parts of the
eye (especially of the sclerotica) are applicable to this affliction.
Aconite may be used, but in the more advanced stage, with
pain in the head, Belladonna is preferable.
Mercurius cor. is useful when the sight is obstructed by exudations of lymph.
In the chronic stage of iritis, if the pupil is closed, relief is
sometimes procured by the application of Belladonna extract
around the lid; dilatation is produced and the sight restored.
Stramonium will answer the same purpose, or a solution of the
latter may be put into the eye, while the Bell. is smeared on the
outside.  We have used the two for dilating the pupil preparatory
to operations for cataract, and believe they do better than either
alone.
Clematis erecta is regarded as a useful remedy in iritis. It is
employed when the pain is of a smarting character and the veins
are in an injected state.
Ranunculus bulbosus is valuable when, in the early stage, the
pupils are fixed, neither dilate nor contract, a sense of pressure in
the eyes - pain is burning.
PROCIDENTIA IRIDIS.
This is the name now most generally given to the case, where
there is an external protrusion of the iris through a wound or ulcer in the cornea and its coverings.
The pain attending this accident is very severe, and the intolerance of light peculiar. The least impression of light on the exposed iris is excruciating.
The pupil always assumes an unusual shape —generally oval.



AMAUROSIS.                         273
The form, however, depends on the site and size of the opening in
the cornea.
Adhesion is apt to take place between the iris and the parts
through which it passes, if it is allowed to remain but a short time
exposed; and the protruded part becomes hardened and often ulcerated.  Air and light seem  sufficient irritants to this delicate
part to excite inflammation.
If called soon after the accident has occurred, endeavor to return the iris. This can sometimes be easily effected; and when it
is done, as it always should be, immediately, there will be no further difficulty.  Even if some time has elapsed, this replacement
should be attempted.  We give this direction on the supposition
of a wound.  When ulceration of the cornea is the cause, the iris
cannot be retained. If the protrusion has been allowed to remain
until ulceration or adhesion has occurred, it is too late for mechanical restoration. All the treatment is then to cure the ulcer as
soon as possible.
Calendula, internally and externally, will, in nearly all cases,
effect a speedy healing of this.
CHAPTER XXV.
AMAUROSIS AND OPACITIES OF THE CORNEA -STAPHYLOMA AND
ULCERS OF THE CORNEA.
AMAUROSIS or Nervous Blindness - Symptoms and Diagnosis - Causes - TREATMENT.
CATARACT, and other opacities, with illustrations.
OPACITIES OF THE CORNEA —Nebula, Albugo and Leucoma defined and treated -
Means for generally removing nebula without inflammation or division of vessels.
ULCERS OF THE CORNEA, - Described and treated.
" STAPHYLOMA " - Restricted to a variety of opacity, with protrusion of the Cornea - Puncturing the eye- Means for avoiding that operation.
AMAUROSIS.
THE eye may appear sound and perfect so far as we can trace
its complex and delicate mechanism; it may reflect the general
35                                       (PART I.)



274                       AMAUROSIS.
healthfulness of the body, and seem to us still the mirror of the
soul, varying its expression with every shade of thought or feeling,
yet all the while be virtually dead -be no better than a glass eye,
in respect to the great.functions to which all its others are secondary. This loss of sight in a seemingly sound organ is distinguished
as "nervous blindness."  AMAUROSIS, the technical name, may,
indeed, be defined paralysis of the optic nerve.
The early stages of this disease are apt to be neglected. The
first SYMPTOM is a sensation of cloudiness, as if vision were obscured by smoke; or it seems to the patient as if threads were
drawn across the eye. Sometimes he sees or imagines he sees blue
and yellow specks; at others, brilliant spectra intermingled with
darker spots. These obstructions or perversions of sight continue
to increase, until the patient gradually loses the sense altogether.
Not unfrequently, however, he is unconscious of his loss. It may
be months after the subsidence of these anomalous appearances in
one eye, before the person discovers that he is blind, although the
probability is, that in all such cases the blindness was complete the
moment he ceased to see the spectra alluded to.
The disease generally progresses with very little pain, sometimes none at all. The patient suffers more from anxiety of mind.
In the early stages there is commonly, however, a determination
of blood to the head.
The pupil is, in most cases, slightly dilated, and does not regularly enlarge and contract like the sound eye with varying degrees of light. The DIAGNOSIS is, however, often difficult. It will
sometimes take several trials to find out which is the affected eye.
We have found it necessary to blind the sound eye in order to ascertain the sensibility or lack of it in the other, as a completely
blind eye will sometimes contract, on the approach of a strong
light, from sympathy with its fellow.
The most obvious of assignable CAUSES is any excessive application of the sight, - reading, writing, fine needle-work, &c. Gazing at the sun to watch an eclipse, or at an exhibition of the Drummond light, has been known to produce it. These occasional causes,
however, presuppose more general ones.  The predisposing cause
may be organic diseases of the brain or nerve.  The patient is frequently ascertained to have been long afflicted with headache, cos



AMAUROSIS.                      275
tiveness, dry skin, &c. Syphilis and mercurialism may be also
distinguished among remote causes. Congenital amaurosis may be
set down as incurable.
TREATMENT.
The first thing, as common sense would dictate, is to prohibit
much exercise of the eye. Reading, needle-work at night, and all
straining of the sight, must be forbidden, as well as any particular
use or abuse that may seem to have produced or to be aggravating
the evil.
Belladonna is an important remedy in amaurosis, especially
when the power of vision is nearly or quite extinct, with a sense
of pressure in the eyes, occasional throbbing pain in the head,
double vision, or the objects appear wholly or partially reversed.
Blurs appear before the eyes like a fog or mist, red spots and
flashes flit before the vision, a halo appears to surround the
candle, the pupil permanently dilated. It is better suited to persons
of full plethoric habits, often affected with congestions of the
head.
Nux vomica is indicated by contracted pupil, spasmodic motion of the eyes, intolerance to light, intermittent vision, black
spots before the eyes, stupefying headache, vertigo and vibrations
of light, melancholy mood; particularly useful in cases caused by
hard study or fine needle-work.
China is indicated by dilated pupil, insensibility to light or
slightly contracted pupil, with the appearance of a white cloud before the eyes, and when the obscuration comes on suddenly; best
for persons debilitated by loss of fluids and irritable.
Phosphorus, when the pupils are natural and objects seem to
be enveloped in smoke, with black spots appearing before the vision when in a dark room, with luminous vibrations in the light of
a candle, the candle appears to be surrounded by a green halo.
The patient is gloomy; particularly useful in amaurosis of old
persons and onanists.
Ruta graveolens. is suitable for contracted pupils with spasmodic action of the lids, involuntary movement of and a sense of
weight and pressure in the balls, and motes before the eyes, a red
halo around the candle. The patient is peevish and irresolute.



276                       AMAUROSIS.
Stramonium, when the eyes are staring and glistening, the pupils are dilated, with a sense of weight and tension in the eyes,
and specks floating before them, black colors appear grey, there
is a red halo around the candle, vertigo and headache.  It is best
for paralytic cases, and those caused by suppressed menses, hysteria, epilepsy or catalepsy.
China - two doses, at an interval of two weeks - cured a case
of incipient amaurosis in a man of fifty years, brought on by excesses and intoxication. The pupils were dilated and scarcely
movable, letters appear blurred, back ground of the eye looks
smoky.
Nux vom., 12th, one dose, cured a lady of incipient amaurosis.
Her sight frequently vanished; black spots like flies before her
eyes, mist, constant lachrymation; cannot bear light, feels pressure in them; exerting them produces pain.
Phosphorus, 30, one dose, cured a boy of nine years-was
hardly able to see a letter in daylight; all objects are obscured.
Ruta, pure tincture, one drop, cured, in eight days, a man of
twenty-nine years. He was unable to read, a mist appeared to be
before his eyes.
Sulphur, tr., one drop, cured incipient amaurosis in a woman
of forty-five years. Had violent tearing in the forehead, feathery
filaments before the eyes. (Ruckert, p. 64-5.)
The report of the following cases is furnished by Dr. C. Neidhard.
The following is the history of a remarkable case of amaurosis attended by me in 1851.  Miss M, aged twenty-three,
seamstress, had a white swelling when ten or eleven years old,
which was cured, as the saying is, by some external application.
A celebrated surgeon of this city, now deceased, gave a great deal
of medicine, but only once some medicine as an external application for the amaurosis. For the last four years she has been
nearly blind, and for the last three months she was at Willis' Eye
Hospital, from whence she was discharged in a greatly aggravated
state.  The present symptoms, as I noted them  down, were the
following: -Black specks before the eyes (since homeopathic
treatment also white specks), all the time sparks before the eyes,
worse in the fore part of the day, better in the evening; the right



278                       CATARACT.
vertigo and sick headache, I have exhibited Cicuta virosa in alternation with Sulph., which was sufficient to cure the disease.
In Saturnine amaurosis in a gentleman engaged in the manufacture of white lead, Plumbum metall. 3, effected a complete cure.
Symptoms: like vapor before the eyes, severe costiveness three
days or more; no evacuation, appetite good, tongue yellow-coated;
evening worse.
" I will also mention in this place that in all swellings and excrescences of the eyelids known in ophthalmic works under the
name of Hordeolum, Milleum, Verrum, Condyloma,. no remedy
has been found superior to Thuja; this was also the principal
remedy used in a scirrhous tumor of the eyes in the case of the
Austrian Marshal Radetsky."
CATARACT.
This is, perhaps, the most interesting cause of blindness next
to that last treated of. While,
FIo. 6. 
FIG. 6    however, amaurosis is properly..........,...:  described as " nervous blindbe only a functional disease;;,'~:~ —~-~-~~ —         these are necessarily organic.
In the former, the proper organ of vision is effected, in the latter some of its media are alone
concerned. Hence the obstruction of vision may, in some of these
FIG..            cases, admit of a merely mechanical remedy.  This being
especially the case in regard to
t          K       ^the various forms of cataract,
that subject will be fully treated
of in Part II.
The general distinction between this affection and opaci-..... -ties of the cornea, is, that the
opacity is here behind the pupil, either in the crystaline lens itself,



CATARACT.                      279
or its covering. Hence by the removal or absorption of these
parts, vision may be restored.           FIG. 8.
three principal forms of cata- 
ract is presented in the fore-.
going cuts: Fig. 6, represent- 
ing  the  hard  LENTICULAR;
Fig. 7, the soft LENTICULAR                          c __
CATARACT, and Fig. 8, the pos- 
terior CAPSULAR.
Though this disease is generally looked upon as incurable by
any course of medication, and the knife or needle is the only remedy supposed to be efficacious in removing the difficulty, experience
in the use of homeopathic remedies has, in numerous instances,
proven that it not only may but often is cured; especially in the
early stages and sometimes even after the lapse of much time, and
the disease has become "confirmed."  We may yet hope to accomplish much more.
On this subject, Dr. H. V. Mallon, in the British Journal of
Homeopathy, writes as follows:
"No medicine or internal treatment has as yet been of any
avail in confirmed and ripe cataracts; this was left for better days
in medical science, and homeopathy has given us means of cure,
which were totally unknown before. I do not mean to say, be it
well understood, that homeopathy will entirely supersede surgery,
or that we are not to trust this latter means or ever employ it -no;
but I wish to draw attention to these three remarks only-that
first; In many cases homeopathy will cure, completely cure,'real
cataracts,' even old and ripe ones; second —in many more it will
prevent the progress of the cataract on the other eye, when as yet
only one is affected; third- that if it does not always succeed in
curing, it will always prepare the whole constitution for the surgical operation, prevent inflammatory accidents after it, and secure
its success.
"This part of medical treatment has been, to this day, too
much neglected, because, to our eyes, this more or less exorganic
body seemed not fit for medical treatment, and because we have
been accustomed to hear that surgical operation only is of any use.



280                       CATARACT.
We have left aside the internal treatment which will often be
crowned with far more success than is generally expected. Not the
least process in the human body, morbid or natural, can take
place without the whole constitution taking part in it. We can
not expect that an organ of the body, be it ever so small, can become affected quite independently of the organism, but that it becomes affected in consequence of morbid process existing, though
not seen, in the organism itself. I am as far from admitting such
confirmed notioAs as I would be right to admit that the very same
organ has no common tie with the rest of the body, and is not one
constituent part of it by its nerves, its vessels and all its textures.
"If, therefore, one part of the body is diseased, we must not
direct our treatment to it solely, and use what is called a local
treatment alone. We must act on the whole constitution in the
same way as we would direct our attention to the whole tree when
it bears decayed fruit. In this case, and for this very simple reason, it is not only advisable, but necessary, to have an internal,
general treatment, and this way of attending to disease will prevent many a failure, and the harm which might ensue from a local
treatment. In a case of cataract, therefore, the whole constitution must be acted upon as in all similar diseases. Our Materia
Medica has many a remedy against such a state. My intention is
not to discuss here the comparative value of each of these, but to
make a few remarks on the treatment in general. The remedies
reckoned the most important, are Sulph, Silic., Cann., Phos., Calc.
and Con.  The antipsorics, of course, must form the basis of the
treatment, as the whole constitution must undergo a change from
the action of the remedy, which must extend to the primary cause
of the disease. This cause is what has been called psora. If the
psora has been acquired by the patient and the cataract has developed itself after the disappearance, more or less sudden, of the
itch, even many years afterwards, the treatment will not only be
easy, but sure.
" I have remarked in the few cases which came under my notice, that under the influence of antipsorics, and particularly of
Sulph., an eruption was produced, with the intensity of which, the
symptoms of the cataract gradually amended. This speaks for the
use of antipsorics at once. If there are no accidents which would



CATARACT.                      281
prevent this mode of treatment, the antipsorics, and at the head
of them Sulph., must, therefore, be resorted to, in one or two
doses, at intervals of a day, and not repeated till their action is
over.  Sometimes there are accidental symptoms, which, though
not very prominent, will require to be removed by an apsoric before the antipsoric can have any action at all on the constitution;
and this is true in other cases, as well as the one under our present
notice.
"Should the psora not have been acquired but inherited, the
treatment will be longer and more uncertain, particularly if the
cataract is already advanced; it is then habitually connected with
a bad state of the general health, a long chronic affection, which
is to be considered, not as the cause of the cataract, but as its accompaniment only; and the symptoms of the general health keeping pace with them.
"Here the treatment must, at first, be directed to the general
health; as long as this is no better, not only will the cataract not
be amended, but will make progress, and its cure will be rendered
impossible. In regulating the general health of the patient, the
cataract will be benefited and its progress retarded. When the
health is restored to its normal state, then the eye should alone be
attended to, and then only will the disease yield to the treatment.
It is not to be understood by that, that no remedial treatment
must be used; on the contrary, it will always prepare the constitution, as we have already mentioned.
"According to these views, Sulph. is the first remedy to be
given; one or two globules of a high potency.  Should no improvement follow, another antipsoric to be given in the same way.
I do not mention any one in particular, because there is a great
danger in prescribing a remedy from  a few isolated symptoms.
The remedy must be chosen according to the symptoms of the case,
and with the greatest care and exactitude, for it is not the size of
the dose nor its repetition, nor a succession of remedies, which
will be of use in cataract any more than in other chronic cases; it
is the right choice of the remedy, of which one single globule will
then do much more than many doses of ill-chosen remedies. It is
not possible to say that in this or that species of cataract, this or
36                                        (PART i.)



282                       CATARACT.
that remedy will cure. The tout ensemble of the symptoms must
always decide us in the choice of the remedy, and in all cases, no
second remedy is to be given before the first has exhausted its action."
The selection of the proper remedy is sometimes a very difficult matter, owing to the fact that the patient appears to be in
good health, or at least he does not complain of any pain or unpleasant sensation in the eye; the simple fact of blindness being
the only difficulty. Where, however, there are any symptoms of
deranged functions in other parts of the system, or any hereditary
dyscrasia taint, or any evidence of suppressed eruptions, the state
of the systems must be prescribed for rather than any particular
symptoms.  When a remedy is selected, its effects should be very
closely watched, and if beneficial results are noticed, great care
should be exercised not to interfere with its action, by a repetition
of the same remedy or the administration of any other, before the
first has spent its whole force.
In a case of cataract of ten years' standing, a single dose of
Sulphur 30, produced a slow but steady improvement in the general health and in the sight for two months, and then the improvement ceased for some ten days, when a repetition of the remedy
produced no effect.  A dose of Aurum, given two weeks after,
produced a decided improvement, and the patient was, two months
from the time of the exhibition of the Aurum, nearly well and
constantly improving in health and sight.
The selection may be made from  the following remedies, as
near as possible, in accordance with the totality of the symptoms:
Sulphur, Aurum, C7onium, Phosphorus, Causticum, Silicea, Hyoscyamus, Euphrasia, Nitric acid, Opium, Pulsatilla, Electro-galvanism and Phytolacca decandria.
We have produced decidedly beneficial effects by the use of
Phytolacca decandria in the early stages of cataract. One case
was entirely cured in two weeks by drop doses of the third dilution of the tr. daily, and the tincture diluted with water in the
proportion of twenty to one, applied to the surface of the eye.
Several other cases have been greatly benefited and the progress
of the disease apparently arrested in one eye, where the other had
for some time been blind.



OPACITIES OF THE CORNEA.                 283
Phosphorus is said to have cured cases of cataract when the
lens was of a green color, sometimes called GLAUCOMA.
Conium is particularly indicated when the opacity arises from
a wound or blow upon the eye, or where the blindness is but partial and the patient complains of dazzling light, with black spots
or colored bands before the eyes, objects appear red; the ball of
the eye looks yellow or pale red.
OPACITIES OF THE CORNEA.
NEBULA, ALBUGO, LEUCOMA.
NEBULA, or "cloudiness," is the result of acute ophthalmia of
the conjunctiva, leaving a preternatural deposit which has become
permanent, and even organized, between that membrane and the
cornea.  It may be attended also with an enlargement of the vessels of the conjunctiva where it covers the cornea.
This species of blindness is not complete. It is of course external to the cornea itself, and comparatively superficial. The
opacity may cover the whole of the cornea, yet the patient can distinguish objects as through a vail; and his iris and pupil may be
seen through it. At other times the nebula is only scattered, or
in distinct specks, each of which is furnished with separate vessels.
These vessels continue to support (or prevent the absorption of)
the deposit, which occasions the difficulty to vision.
ALBUGO in some respects resembles nebula, chiefly differing
from it in being deeper seated. It is also referable to some preternatural deposit of lymph between the laminae of the cornea itself, to which it gives a pearly white appearance.
LEUCOMA differs from the two other varieties of opacity in being more dense, and of a chalky white color, although with a shining aspect. It is a transformation of the substance of the cornea
itself and an adhesion to the mucous covering. It may result from
a small pox pustule or a wound in the part.
TREATMENT OF NEBULA, &C.
The remarks that were made when speaking upon the subject
of cataract, are applicable here.



284                ULCERS OF THE CORNEA.
For specks on the cornea use, both internally and locally, some
of the following remedies: Belladonna, Sulphur, Hepar, Chelidonium, Conium, Nit. acid and Arsenicum.
For opacities use Sulphur, Cannabis, Nit. acid, Capsicum and
Phytolacca.  With the two latter remedies used locally and internally, we have relieved very obstinate cases, after the other
remedies of the books had failed.  Dr. Dudgeon reports a case
(British Journal of Homeopathy, Vol. II, page 320) of opacity of
the cornea (Pannus), cured by introducing into the eye, matter
taken from the eye of a child affected with purulent ophthalmia.
There was great photophobia, the cornea highly vascular, dull and
irregular, with granulations, conjunctiva and sclerotica very vascular, upper lids covered with a mass of fleshy granulations. The
inoculation with the matter produced great inflammation and suppuration, but finally terminated in a complete cure.
ULCERS OF THE CORNEA.
These not unfrequently result from the same causes as in other
parts of the body, and are more serious, as always endangering vision. They occur not only as the consequences of mechanical injury, or of some variety of ophthalmia, but also of some strong or
peculiarly irritating substances thrown into the eye.
The whole cornea may be in an ulcerated condition, or the
ulcer may be very small, appearing on it but as a speck. The
latter is not always the less dangerous form, as the ulceration is
often "burrowing;" and may work its way deep in between the
layers of the cornea until it spreads all over the anterior chamber
of the eye.
The edges of the corneal ulcer are generally elevated and
rough; and its surface is commonly covered with a brownish pus,
similar to that of indolent ulcers in other parts.
Extreme pain frequently exists, not only in the ball but the
lids,- attributable, mainly, to the irritation of the rough and projecting edges of the ulcer.
The principle remedies directed by the authorities for this
affection, are Belladonna, Arsenicum, Calcarea, Euphrasia, Hepar, Lachesis, Mercurius and Sulphur.  Of these, Calcarea and
Euphrasia have been the most serviceable.



STAPHYLOMA.                      285
C(austicum, though not mentioned in the books as a remedy for
ulcers on the cornea, should be placed at the head of the list. Few
remedies will compare favorably with it when properly used. It
should be applied locally as well as given internally. The local
solution should be strong enough to produce slight smarting. The
sesqui-carbonate of potash is the best for this purpose; let it be applied either in solution or in form of a powder, with a camel's hair
pencil, fixing the ball with a speculum while the application is being made, keeping the eye covered with a poultice of ulmus during
the interval. Wash the eye well with warm milk and water at
each dressing.  As soon as the ulcers assume a healthy appearance, discontinue the caustic applications, but continue the milk
and water.
We have had no difficulty in speedily removing the ulcers from
the cornea by this course of treatment. If active inflammation
should arise, as sometimes occurs, discontinue other remedies and
use Aconite until the inflammation subsides.
If there is any eruption on the surface of the body or about
the face, you should use Sulphur for a while before using the
Causticum.
STAPHYLOMA
is the name given to a disease of the substance of the cornea,
resulting in thickening and opacity of its layers, and a considerable
protrusion of the anterior surface. This last circumstance gives
name to the affection.  "Staphyloma" means swelling out like a
grape. There may be staphyloma of the sclerotic coat also; but
that is less frequent and less important.  "Staphyloma Iridis"
was spoken of under the more descriptive appellation of " Prolapsus or Procidentia of the Iris." Confining the term to cases in
which the cornea is involved, -
" Complete Staphyloma" implies that the whole of the cornea
has become opaque.
"Incomplete Staphyloma " is when the cornea is still in some
degree transparent, or at least translucent, and vision to a proportionate degree is yet possible.
In advanced stages of the disease, the before enlarged cornea
is sometimes absorbed, when both the anterior and posterior chan



286                    HYDROPHTHALMIA.
bers of the eye seem  to be filled with matter more or less
opaque.
The internal and local use of Arnica has been successful in the
removal of this disease in the earlier stage. The authors treated
one bad case with Calendula, and in three months all deformity disappeared, and the sight, though not perfect, was so far restored as
that he could see to read and write.
In the advanced stage of the disease a restoration of the power
of vision is hopeless, as the tissues are too much disorganized. Subdue the inflammation by such means as are directed for ophthalmia.
A case of opacity of the cornea, of three years' standing, resulting from violent inflammation brought on by drinking freely
of ice water when quite warm. First, under allopathic treatment,
one eye entirely disorganized, could not see objects out of the
other.  Dr. Hunt applied electro-galvanism.  The patient was
finally so entirely cured that he was able to resume his tradethat of a carpenter.
CHAPTER XXVI.
AFFECTIONS OF THE EYE, CONTINUED.
HYDROPHTHALMIA - General and partial - Symptoms and progress - Treatment
for avoiding paracentesis oculi - That operation a dernier resort, and then but
a palliative. - PTERYGIUM - Description and varieties. - ENCANTHIS - Distinction from pterygium - Inconvenience and frequent malignancy - Excision not
"the only remedy - Two cases in proof.- HORDEOLUM.
DROPSY OF THE EYE.
UNCOMPLICATED HYDROPHTHALMIA is a disease of rare occurrence, even in those constitutionally predisposed to serous accumulations in other parts.
The SYMPTOMS are a gradual enlargement of the globe of the
eye, without, at first, much pain or injury to the sense of vision.



AFFECTIONS OF THE EYE.                  287
As, however, the accumulation increases, the membranes become
very tense, and the eye-ball is visiblyprotuberant from the socket.
The pain then becomes excessive, and sometimes extends to other
parts, giving rise, among other complaints, to violent cephalalgia.
At this stage, also, the sight is considerably affected. The aqueous
humor becomes turbid and opaque.  The iris looks as if deeper
seated in the eye than natural; and, whenever the eye-ball is
moved, appears to be floating and tremulous. Finally, if the morbid fluid is not absorbed or evacuated, irritation and active inflammation set in, and terminate in suppuration, to the destruction
of the eye.
Partial serous effusions sometimes occur between the separate
coats, -as between the sclerotic and the choroid, or the choroid
and the retina, -but these cases are still less frequent than the
accumulation within the chambers.  The vitreous humor is sometimes absorbed, we are informed, in consequence of the pressure
from effusion between the choroid and sclerotic coats.
TREATMENT.
Like many other chronic affections, there are so few subjective
symptoms that we have to prescribe more from general than local
indications.
In the early stage of this complaint, while there is yet some
pain and inflammatory symptoms remaining, Arnica will prove serviceable; especially if there is soreness and a bruised feeling on
moving the eye - the pupil contracted.
Arsenicum is useful when there are burning pains, beating in
the head, heat about the eyes, fullness of the face, great weakness
and loss of appetite, a sense of prostration.
If it is connected with scrofula or any eruptive disease, Sulphur
should be given first and then followed, if necessary, by Ars. or
Am.
Iodine will be found serviceable when there is much emaciation, with glandular swellings or a tendency to dropsy in other
parts, great nervous irritability.
Should the ACCUMULATION go on notwithstanding these measures, or should it have been too great, at first, making immediate
relief indispensable, the surgeon may be obliged to



288                AFFECTIONS OF THE EYE.
- PUNCTURE THE EYE. This operation can be performed with
a common lancet, if a couching-needle is not at hand. The point
may be introduced into the anterior chamber through the cornea;
or —where it is less likely to do permanent injury — behind the
junction of the cornea with the sclerotic coat, into the posterior
chamber, as is usually directed in operating for cataract.
This tapping of the eye should be regarded as a mere palliative; requiring the same means afterward to obviate reaccumulation, which if used in time, or to a sufficient extent, would have
prevented the necessity for resorting to it. It is not a triumph of
surgery, but a confession of its inefficiency; and unlike amputation, and some other of its " handy work," it is not final, removing
for ever the evidence against itself.
PTERYGIUM.
This is a name given to a very common disease, or rather accidental formation, which is not generally of sufficient importance
to be accounted morbid. It may, in fact, be nothing but hypertrophy and extension of the Plica Semilunaris. It is a mere membranous reflection of a portion of the conjunctiva, appearing as a
triangular patch at the inner canthus, and spreading from the caruncula lachrymalis towards the cornea.
In its early stages, it is light-colored, containing few blood vessels. As it is thus but a slight disfigurement, and no inconvenience,
it excites but little attention. When inflamed it reddens, and its
vessels are then very distinct.
It may extend, however, so as to cover more or less of the cornea.  Its growth is more rapid when irritated or inflamed.  It
rarely spreads all over the cornea, commonly ceasing to advance
after covering a small segment of it.  We have seen several cases
where the growth had commenced from each corner of the eye,
and gone on to meet the opposite one in the center.
That proceeding from the external canthus is still less serious
than the other, and sometimes distinguished as "pinguicula," from
its more frequently fatty appearance. Two varieties are mentioned
by the writers, the merely membranous and the fleshy.  The variety called PANNUS, is sometimes cancerous.



AFFECTIONS OF THE EYE.                 289
Pterygium is an abnormal or adventitious growth, and if not
inflamed, can not properly be looked upon as a disease.
TREATMENT.
If it is inflamed, use such means for removing the inflammation
as are directed for ophthalmia.
It sometimes grows suddenly from the surface, having been
inflamed by some injury.  In such a case, Arnica or Calendula
will most likely subdue the inflammation, and with the subsidence
of that, the pterygium disappears. So favorable a result need
not, however, be expected very often.
If, then, there be present no inflammation and the growth has
not been removed in whole, or nearly so, by the treatment, the best
plan is to operate - cut it of. The operation is simple and safe.
[For the mode of operating, see Part II.]
ENCANTHIS.
This affection of the eye is nearly related to that last described.
It is, however, of a more decidedly morbid character, and not unfrequently malignant. Even the "encanthis benigna," so called,
is a source of great inconvenience. It arises from the same parts
as the pterygium; but while that appears as a mere superfluous
fold of the mucous membrane, perhaps a little thickened, forming
as it were an additional over-coat to a part of the eye,
ENCANTHIS is a substantial enlargement or out-growth of the
caruncula lachrymalis, and plica semilunaris. It is soft and of a
livid hue. As it enlarges it becomes smooth on its surface, which
is seen to be numerously supplied with varicose vessels.
Three consequences of this excresence may be distinguished:
first, by its size and position it prevents complete closure of the
eye, and otherwise impedes the free play of the lids; next, both
by compression and displacement of the puncta lachrymalia, it
keeps the eye constantly suffused with tears; and, lastly, by these
and other modes of irritation, it excites and keeps up a troublesome
OPHTHALMIA.  Other parts may be so involved as gradually to
destroy the whole eye-ball.
The MALIGNANT, or, as it used to be called, " inveterate ENCANTHIS," may become very large, and perhaps hardened, with lan37                                         (PART I.)



290               AFFECTIONS OF THE EYE.
cinating pains, proneness to bleed, and other usual cancerous
characteristics.
"The only remedy for this disease," according to prevalent
authorities, is excision of the caruncula lachrymalis and valvula
semilunaris; and we are informed, that even this "frequently
fails."
How far we are from being disposed to adopt this view, may
be judged from our usual protests against these " necessarily incurable " judgments.  There is nothing in the nature of the
affection in question, or of the parts affected, to render all the resources of the healing art unavailing. We can not determine what
proportion of cases ought to be cured in a disease of such rare occurrence; but this much we can say, - that the only four cases that
ever fell under our notice were cured
TREATMENT.
In the early stage, Pulsatilla will be quite sure to remove it.
If, however, a high degree of inflammation has arisen before remedies are resorted to, Aconite should be used until the acute symptoms have subsided, after which, Causticum, applied locally and
used internally, will generally complete the cure. Ar^enicum may,
in some cases, be preferable; especially in pale and sickly-looking persons.  If the patient be scrofulous, give Sulphur, and follow by Causticum Ar Arsenicum, if necessary. If pus has formed,
give Hepar for a day or two, and then puncture; dress with a
poultice after puncturing, and wash out the cavity with a weak solution of Causticum.  Staphysagria is recommended as a useful
remedy after Aconite.
Thuja is worthy of much confidence in this disease, especially
in the early stage before the tumor has become much enlarged or
indurated. If it assume a malignant form and does not yield to
remedies apparently indicated by the symptoms in a short time,
but continues to increase, the better plan is to extirpate the tumor by Caustic as soon as possible.
A case of this kind was treated by one of the authors, several
years since-an aged gentleman, Mr. D. W-, of Erie
county, in this State. The case and the cure were well known,
as the disease had been pronounced cancer by all who saw it. The



AFFECTIONS OF THE EYE.                  291
tumor, excresence, or whatever it is to be called, was distinctly
"encanthis " in respect of its location and origination.  It had
grown, however, as large as a butternut, - discharged a sanious
and corrosive fluid, and was overspread with a net-work of varicose
vessels, which poured out their contents on the slightest touch.
The course adopted was the following. The eye was first protected by a slippery elm poultice, wet with vinegar, and the pencil of potassa fusa was freely applied to the cancerous growth, and
kept there for several minutes, so as at once to disorganize nearly
the whole of it.  It was dressed with the simple slippery elm,
which was directed to be renewed every three or four hours (a
very necessary precaution in all such cases, in order to absorb all
the matter as quickly as it is discharged). The sore was further
washed in a strong solution of the sesqui-carb., which article, in
the powdered state, was also sprinkled occasionally on the face of
the slippery elm poultice. After the sloughing of the first eschar,
whatever portions of the diseased mass remained were retouched
with the caustic, until the whole face of the sore assumed a healthy
aspect. It was then regularly dressed as before stated. In the
course of a few weeks it all healed up soundly. Eight years have
since passed without any recurrence of the disease.
HORDEOLUM,
-which means a "little barley-corn," is the name given to,
what is called in the vernacular a sty, and may be briefly defined
as a small inflamed tumor on the eyelid. It appears to be simply
a modification, from the confined situation, of what would elsewhere become a boil.
The STY, or boil on the eyelid, increases but slowly in size,
and although it finally suppurates, shows little or no tendency to
spontaneous opening.
It may remain a long time stationary as a little yellow-topped
pimple.  If not interfered with it may be eventually absorbed, or
changed into a hard indolent tumor, sometimes called grando or
chalazion.
Pulsatilla will remove this disease almost invariably in the
early stage, before there is much inflammation and fever, but if
not used thus early, Aconite should be used until the fever sub



292                 AFFECTIONS OF THE MOUTH.
sides. Puls. may then be resorted to, or if it becomes chronic
and hard, and but slightly painful, except when pressed upon,
Staphysagria will be beneficial.
If it is quite painful, burning and smarting, Puls. having failed,
Arsen. will be appropriate.  When inflamed it should be kept
moist and warm by the proper dressings.
CHAPTER XXVII.
AFFECTIONS OF THE MOUTH AND THROAT.
AFiFCTIONS OF THE TEETH.- Necessity for studying-Serious disease caused by
" bad teeth "- Cases - Crowded Teeth - Caries -TOOTHACHE, neuralgic, rheumatic and from decay - Palliatives and radical cure for the latter - Cleanliness.
EXTRACTION OF TEETH. - Forceps - the dentist's kit unnecessary - The new molar
forceps, with two other pair, all-sufficient - directions for using - hemmorhage
-superfine elm flour.
EPULIS, or tumor of the gums —neglected beginning and destructive progress —
early and later medical treatment -operation. -RANULA, and other tumors or
obstructions- incision or abscision.
TONSILLITIS, &C. - Acute inflammation. - CHRONIC ENLARGEMENT - excisionits danger?
CHOKING - symptoms and effects of the accident - pushing down or pulling up the
obstructing substance? - Various means and methods.
AFFECTIONS OF THE TEETH.
WE shall not, at this time, attempt to go into this too much
neglected subject, with the minuteness of detail that properly belongs to Dental Surgery. As, however, professed Dentists are not
always to be found, except in cities and towns of considerable size,
it is absolutely necessary for the general practitioner of medicine
to understand and practice more or less of dentistry. So far as
the mechanical part of the business is concerned, with the exception of simple tooth-drawing, we shall leave you to obtain your
knowledge from  the excellent works on Dental Surgery, which
have been published within a few years past.  But the physiology



AFFECTIONS OF THE MOUTH.                293
and pathology of the teeth have a much greater claim on your attention. As surgeons, and even as physicians, you are bound to
study these subjects. The advantages of a good set of teeth, and
of a good use of them, in mastication, are little appreciated, and
still less are all the disadvantages of diseased or decayed teeth.
It must be understood, then, that the local pain and inconvenience of bad teeth are not alone the matters worthy of consideration in this connection; but that, in a great variety of serious
affections, the future health, nay, the very life of the patient, may
depend entirely on the removal of the decayed teeth. So long as
this prolific source of general and local disease remains in the
mouth, all your efforts at a removal of other affections will often
prove abortive.
Numerous diseases affecting the general system may be traced
directly to diseased teeth or gums as their exciting and sustaining
CAUSE. Neuralgia, ulceration of the tonsils, tumors or ulcers on
the tongue, often becoming malignant, violent and continued headache, with glandular swellings in the throat, proceeding in some
cases to ulceration, not unfrequently arise entirely from this
source.  Serious and intractable disease of the stomach, with
general disorder from imperfect digestion, is a still more frequent
and less suspected result.
We have been not unfrequently called to patients, during the
last five years, who were laboring under chronic diseases of various
forms, for which they had been treated by Allopathists, Eclectics
and Homeopathists, in turn, for years, but without receiving any
material benefit - the ill success owing entirely, we have no doubt,
to the failure to recognize and remove the dental cause. On examining the mouths of such patients, we have found, in some instances, not more than one or two diseased teeth, but in others,
five or six, and perhaps a dozen or more old rotten snags or roots
of teeth, which had long since become insensible and ceased to
attract attention. Around them was collected a gluey substance,
which, if brought in close proximity to the olfactories, would impart the most horridly sickening and putrescent smell imaginable.
The gums all around were swollen, inflamed, and more or less ulcerated. Yet of this condition the patients did not complain, nor
had any of their medical attendants inquired about it.  Our first



294              AFFECTIONS OF THE MOUTH.
prescription in these cases was "a dentist " —utterly refusing to
make any other until all the diseased teeth and fangs were removed, and the mouth and gums cleansed.
In numerous cases, where the patient and friends had abandoned all hope of recovery, this dental operation, and cleansing
of the mouth-the removal of this "Augean Stable " in the highway to the stomach - has been followed by a rapid restoration of
general health, without the aid of any other means than perhaps
bathing and gentle tonics. We might mention numerous cases.
One young lady of Cincinnati had been for two or three years
declining —had been sent from home to consult an eminent stethoscopist and medical professor in relation to her case. He, in
connection with his colleagues in the college, after several months'
unsuccessful efforts for her relief, pronounced her case one of incurable disease of the heart. She was sent home, with a written
request from her medical adviser, that her case be brought before
the faculty of another old and celebrated medical college. Their
decision in the case confirmed the former diagnosis. Some weeks
after this last consultation, one of the authors was requested by
the parents of the patient to examine and give an opinion as to
the probable result - they had no doubt of the correctness of the
diagnosis which had been given. In the course of his inquiries,
he naturally, in searching for the cause of her bad symptoms,
looked into her mouth, when he found, what had been suspected,
a number of diseased teeth and decaying fangs, in the condition
before described. The services of a dentist were prescribed, and
proved most effectual. After removing all the decayed teeth and
fragments, the gums soon healed, and, with a little treatment, all
symptoms of heart disease disappeared, and her health became
good.
A gentleman of Cincinnati had been afflicted for a long time
with neuralgia and dyspepsia, with numerous other derangements
-so that he had been, for months, unable to attend to business,
and suffered much, at all times, from severe pains in different parts
of his body and head.  Though he had many decayed teeth, as
they did not ache, he had never suspected that they were doing
any harm.  His physicians had never intimated anything about
injury from his teeth; and when we informed him that they were



AFFECTIONS OF THE MOUTH.                 295
the cause of all his sufferings, he could not be made to believe it,
until we scraped off a portion of the matter from one of them, and
induced him to smell and taste it, when the terrible nausea and
vomiting produced by so small a portion, soon satisfied him. His
cure was easily effected by a removal of the foul source of disease.
How any physician, especially a homeopathist, can expect to
get the proper effect, or any at all, from minute portions of medicine, while such an amount of filth and poison is in the patient's
mouth, coming in contact and intermingling with it, we are at a
loss to conjecture. The very effluvia from the mouth is enough,
in numerous cases, to sicken a well person, and taint the air of the
room to an extent far more obnoxious to the effects of homeopathic
remedies than any quantity of "perfumery," camphor or musk,
that we often meet with.  What wonder, then, that old cases of
"dyspepsia," "general debility," 5c.,'c., resist all medication.
To proceed with the different dental diseases, we will first
mention
- CROWDED TEETH.  The irritation of the gums, caused by
the teeth crowding too closely together, will often produce inflammation and ulceration, and if the latter be around the posterior
teeth, it not unfrequently produces dangerous inflammation of the
tonsils and pharynx.  Crowded front teeth will also cause ulceration of the gums, and even the bone itself may not escape. TREATMENT is simple.  Extract a tooth from the crowded space —remove the cause, and nature will generally repair the injury. If
not, treat the ulcer as in other cases.
CARIOUS TEETH is the term used to denote decay of the body
of the teeth, while ULCERATED TEETH is applied to the disease of
the fangs or roots. In the case of superficial caries, if the tooth
has never, or but seldom ached, and is not now tender, the decayed
portion may be removed by the proper dental operations, and the
tooth filled and saved. But if it is painful and sore, or tender to
the touch, by all means extract; for, even if it be cleaned and
filled, it will most likely still ache; and if so, it is more than probable that there is disease at the roots, which will do more or less
injury to the general health, besides constantly annoying the patient by the local pain, and endangering the jaw



296              AFFECTIONS OF THE MOUTH.
TOOTHACHE. - Odontalgia.
The numerous remedies for the common forms of toothache,
with their characteristic symptoms, will be found in perusing the
homeopathic works.  It is therefore unnecessary for us to treat
of these forms of odontalgia, mostly affecting decaying teeth.
The rheumatic form, however, which not only affects the decayed but sound teeth, as well as the jaws, face, head and eyes,
is ably treated of in the following excellent article furnished us,
among others, by Dr. C. Neidhard, in reply to our inquiries as to
the results of his experience.
" Odontalgia and Cephalalgia Rheumatica."
" The symptoms are of the most diversified character; it either
affects one or two teeth, or the whole side of the face; sometimes
it springs from one side to the other.  In severe cases the pain
extends to the eyes and ears, often accompanied by swelling of
the gums and cheeks.  The pain is of a gnawing, aching kind, in
some instances an abscess is formed. The cephalic rheumatism
generally attacks only one side of the head, shooting along the
temporal and occipital muscles, and not unfrequently coryza is
present. I have reason to suppose that this affection is confined
to this continent, for I find no description of such a toothache as
prevailing to any extent in other countries, in the literature of
homeopathy; it has the characteristic symptoms of being ameliorated by heat and perspiration and aggravated by cold, particularly draughts of air.
" The remedy on which I principally rely in this complaint, is
Calc. carb., from the second to the thirtieth dilution. Rheumatic
toothaches and headaches, which had lasted for six months, and
even for years, were relieved in a few days, although allopathic,
and in some cases homeopathic treatment, had been resorted to in
vain. In order to illustrate its action more fully, I will detail
some of the cases wherein I have found it useful.
" Case 1. For ten days, pain in the malar bone under the eye,
the pain is throbbing and worse at night, dark-red, swelling of the
gums; the pain shoots also from  the lower jaw to the right ear;
amelioration from heat and perspiration.
" Case 2. Rheumatic pain on the top of head, forehead and arm



AFFECTIONS OF THE MOUTH.                297
joints, brought on and increased by draughts of cold air -better
in warmth; also pain in bones of face -worse at night.
" Case 3. Miss C. Aching pain in bones of right lower
jaw and teeth towards the center; worse in draught of air, with
swelling of bones and gums.
"Case 4. Mr. J. N. Dull heavy pain as if in the bones of
the right side of the face, moving about from one side to the other
in the lower jaw, zygomatic process of temporal bone, cheek bone,
and top of head. The patient had suffered excessively for months,
and had been attended by a well-known professor of this city distinguished for his enmity to homeopathy. This one had prescribed
Lupuline, a new hobby, with zinc pills, but with only transient relief. The all-powerful blue pill was then resorted to with like
effect, with several more remedies. The pain was extremely violent, without intermission day or night, aggravated by the least
draught of air. After receiving the first dose of Calc. carb., he
slept for the first time for many nights.  Cale. carb., 30, six and
and three, given at longer and shorter intervals, entirely cured
him: when after the lapse of some months it returned again, it
was removed by the same remedy.
"Case 5. Martha J. Similar pain to the last, aggravated by draughts of air, with bluish swelling of gums.
" Case 6. Mrs. B -. This case presented swelling of parotid glands with sharp, shooting, drawing, and sometimes beating
pain in zygomatic process of temporal bone, sore to touch, aggravated at night, preventing sleep, relieved only by applications of
heat; draught of air causes a return of it, gums red and swollen;
pain extends to ear and head.
" Case 7. In this case the pain came on periodically from ten
in the morning to five in the afternoon; it principally affected the
bones around the eyes, first one side and then the other; there was
also indigestion, hot bread producing pain in the stomach. The
conditions, under which the pain was increased or diminished, were
the same as in the other cases.
" Case 8. Miss C. In addition to a pain over the eyes
similar to the last mentioned, there was sickness at the stomach,
acid eructations and vomitings, with pain in region of the liver,
and sallow complexion.
38                                          (PART I.)



298              AFFECTIONS OF THE MOUTH.
" Case 9. Henrietta H -. Pain in teeth of left lower jaw,
shooting to eyes, ears and head, during the whole summer; aggravated by draughts of air and from  eating, gums and cheeks
swollen; yellowness of sclerotic coat of the eye.
" Many cases of a similar kind might be here detailed, for they
are of almost daily occurrence, but the enumeration of the above
will be sufficient to give a general idea of them. In all of them
a permanent cure was established in a very few days, even in cases
where the disease had lasted for months. I am acquainted with
no remedy where the characteristic symptoms are better known,
and where a successful issue can be relied on with so much certainty. Upon critically examining and analyzing these cases, we
are compelled to acknowledge, that the exact seat of the disease,
as well as the nature of the pain, was less essential to the choice
of the remedy, in these cases, than the conditions under which aggravation took place, namely, the draught of air; and the application of external heat for its amelioration, as highly characteristic. I also consider the sensation of pain as if it were in the bone
or periosteumwith the swelling of the gums; the pains themselves,
as well as their seat, were of the most diversified character; thus
we have throbbing, rheumatic aching, dull heavy, sharp shooting,
and drawing pains, and the pains also affected various parts of the
face, the neighborhood of the eyes, top of the head, lower jaw,
zygomatic process of temporal bone, malar bone, etc. The exact
nature of the pain seems to me on this account of less importance
than the conditions; there is hardly one in five patients who is
able to describe the exact nature of the pain from which he suffers.
He will, however, have no difficulty in explaining the conditions
under which his pain is aggravated or ameliorated."
If a decayed tooth aches, your course is plain — take it out.
No well-informed surgeon will ever advise the retention of extensivelydecayed teeth, however free from pain they may be; or however confident he may be of having a certain remedy for toothache.
Nor should country practitioners ever be without the means at
hand for their only safe and radical cure, - EXTRACTION. The
necessary description of instruments and instructions for this important part of surgery, we will give in this connection, instead
of reserving it for the Operative Part.



AFFECTIONS OF THE MOUTH.                 299
Before doing this, however, we would enjoin upon the physician to direct all his patients, whose teeth or gums are unsound or
unhealthy, to keep them perfectly clean. Direct them  to wash
the teeth thoroughly with Castile soap and cold water, inside and
out, every morning and after each meal. Apply the water with a
soft tooth brush, rubbing the teeth and gums briskly. All bits of
meat or other food should be removed from between the teeth, by
a tooth-pick, immediately after each meal.
EXTRACTION OF TEETH.
The only proper INSTRUMENTS for this often indispensable operation are forceps.  Formerly, the turnkey was in use, by nearly
all, for the back teeth; but as dentistry became generally recognized as a distinct profession, this cruel and clumsy agent was laid
aside and intelligent force substituted for mechanical.  Dentists
have many differently constructed forceps for the different teeth, -
at least six or eight pairs. There may be four for the molars, -
a special pair for the upper, and another for the lower, on each
side, and perhaps even separate ones for the-last molars; different
ones for the upper and lower incisors; one pair each for the cuspids and bi-cuspids, and several for taking out fangs, - amounting,
for a full set, to ten or fourteen pairs of forceps. This formidable
array of instruments may do very well for the dentist, though
even his efficiency will depend much more on his skill than his
tools, but is altogether out of the question with the country practitioner, who must have his tools at hand, being liable to be called
on to use them when miles from his office. Dr. Hill seeing and
feeling this inconvenience when practicing in the country several
years ago (and having before experienced, in his own person,
enough of the bruising and mangling of the turnkey), he invented
FIG. 9.
the simple MOLAR FORCEPS (Fig. No. 9). These are a perfect



300             AFFECTIONS OF THE MOUTH.
substitute for all the four, five or six pairs, kept for the same purpose by the dentists.  With these any molar tooth on either side
of either jaw, as well as the bi-cuspids, or any other tooth that is
out of the reach of the straight incisor forceps, can be readily exFio. 10.
tracted. With these and the common INCISOR FORCEPS (Fig. No. 10),
any tooth can be drawn with as much ease, and as little pain to
the patient, as with any of the dentist's kit. For the extraction
of parts of teeth and fangs, small sharp POINTED CURVED FORCEPS
FIG. 11.
are used (Fig. No. 11).  With these three pairs, nearly every
tooth or portion of tooth may be extracted.
Before EXTRACTING A TOOTH separate the gums completely from
its surface down to the bone, inside and out, as well as between it
and the adjoining ones. Then seize the tooth with the forceps,
pressing the blades firmly down to the alveolus, and by steady
force in the most direct line of the fangs, draw it out. The incisor
forceps can be applied to the cuspids in most cases, as well as to
the incisors. For the extraction of fangs after detaching the gums,
using the fang forceps (Fig. No. 11), press the sharp points as far
down at each side of the "snag" as possible, seize and rotate it a
little, when it will generally come out easily.
Troublesome hemorrhage sometimes, though rarely, follows the
extraction of teeth.  We have had some very severe cases.  The
application of common salt to the bleeding surface will usually arrest the flow: even cold water will be sufficient.  The surface
should be washed out with Arnicated water immediately after the



AFFECTIONS OF THE MOUTH.                  301
tooth is extracted, and if the ruptured vessels are not preternaturally large, it will arrest or prevent hemorrhage. The saturated
alcoholic solution of Phosphorus arrests hemorrhage from small
vessels immediately.  Dilute tincture of the Hamamelis Virginica (witch hazel), applied to the bleeding gums, arrests hemorrhage "almost instantaneously." But some cases will resist these
means, and the blood pours out profusely. We have been able to
arrest the hemorrhage, even in the worst cases, by filling the alveoli with superfine powder of the Ulmus fulva. (For this purpose
it is necessary to have that which is made of the pure bark, having
not a particle of woody fiber in it.) This forms a coagulum with
the blood that completely clogs the mouths of the bleeding vessels,
and adheres to the surface with such tenacity as not to be washed
off by the flow of blood, or soaked loose by the saliva.
TUBERCLE OF THE GMS - EPULIS.
This disease occasionally assumes a malignant form, - and extends rapidly from its original seat to the adjacent parts.  If not
arrested early it will be very likely to prove fatal.
However trifling tumors upon the gums may at first appear, to
those unacquainted with their occasional malignant termination,
the well-informed surgeon will always urge the propriety of early
attention to them.
EPULIS generally appears on the gums of the incisor teeth,
above or below. While the teeth are perfectly sound, and before
any appearance of the tumor, they will sometimes be loosened and
protruded beyond their fellows. Commonly, however, a small seedlike tumor is seen on the gums, partly between the teeth. This
may remain, for several months, nearly stationary, growing so
slowly and being so free from pain and irritation as to attract no
notice. Finally it looses its hardness, grows more rapidly, becomes
very soft, and bleeds on the slightest touch — on its surface
becoming accidentally abraded, fungus spreads out with prolific
growth.
From this time it continues to involve the gums, displacing the
teeth, and affecting the glands and other soft parts of the mouth
in rapid succession, until the patient is destroyed by the irritation
and hemorrhage.



302              AFFECTIONS OF THE MOUTH.
To TREAT this successfully, the proper measures should be
adopted early. After it has extended to the lymphatics and the
cellular portions of the ethmoid bones, the tongue and palate, success is quite doubtful.
The remedies most useful in this disease, are Thuja, Silicea,
Phos., Lach., Carbo. veg. and Arsenicum.
In the early stage of the disease, while there is but little soreness of the gums or tumor, though it may bleed easily, Thuja will
be quite sure to prove effectual. The tincture should be applied
locally. Even in the later stage it has been successful.
Silicea is useful also in the earlier stages, after the gums have
become sore and bleed.
Arsenicum, Phos., Lach. and Carbo. veg., are appropriate in
the later stage, when it may be looked upon as cancerous in its
character. It is then to be treated as a soft or fungoid cancer.
RANULA.
This disease consists of a small tumor situated under the tongue,
caused by some obstruction to one or more of the Whartonian or
Rivinian ducts. The fluid secreted by the sub-maxillary or sublingual glands accumulates at the point of obstruction, forming a
tumor which becomes inflamed and painful, and if not opened will
ulcerate and prove quite troublesome.
Thuja or Cal. carb. will generally be sufficient to remove the
inflammation and discuss the tumor. If, however, notwithstanding
these the swelling continues, cut through the surface of the tumor
with the points of sharp scissors, and take out a small portion of
its substance. Then wash out the cavity with a solution of Calcarea carb., using the remedy internally once a day for a few days,
and if the tumor does not subside, use also Thuja.
CHRONIC ENLARGEMENT
of the tonsils frequently occurs after repeated acute attacks,
especially in scrofulous persons. This is a source of much inconvenience, if not danger.
The patient is liable to frequent inflammation of the parts —
the voice is changed and rendered hoarse -deglutition is obstructed, and respiration often rendered difficult and noisy, espe



AFFECTIONS OF THE MOUTH.                   303
cially during sleep. Much deafness is occasionally caused by the
enlarged gland obstructing the Eustachian  tubes.  And, it is
said, suffocation has occurred from viscid mucus collecting between
them.
Bell. is most used for the acute inflammatory condition; iepar
sul. for the suppurative; Calcarea for the chronic suppurative
stage in scrofulous persons; Sulphur in scrofulous persons affected
with eruptions; Ignatia for delicate females; Lachesis, when the
throat is much inflamed, with a dark putrescent appearance, Bell.
having failed to relieve. These may be alternated.
This disease is not unfrequently very obstinate, and it requires
a long time to produce any considerable impression upon it. We
have employed, with excellent success, the Arum Triphyllum and
the Phytolacca, and in a few cases, the Stillingia.*
The Arum  is indicated more particularly when there is pain,
burning or titillation in the throat, with a sense of contraction in
the fauces; the throat looks red, there is considerable secretion of
saliva and red tongue.  The Phytolacca, when the soft palate is
swollen, the uvula elongated, throat dry and sore, white or yellow
mucus about the fauces, especially in the morning.t
Dr. Hartung, in reporting the case of Count Radetsky, drops
the remark that he had often cured swollen and indurated tonsils
with Thuja occ. and Petroleum, alternately. Dr. Boenninghausen
cured a case of hypertrophy of the tonsils with Staphysagria, which
had resisted several other remedies.
The following is from the pen of Prof. C. Neidhard:
"Belladonna is to be exhibited when the swelling of the tonsils is less the predominating, than the extreme scarlet redness and
inflammation of them and the surrounding palate and throat; when
the glands on the outside of the neck, particularly those on the
back of the neck, are also swollen and painful; there is a stiffness
on moving the head and neck.
* The Stillingia Sylvatica seems to exert a very beneficial influence on this disease. From our knowledge of its pathogenesis by observing the effect of large
doses given for syphilis, we were induced to try it in chronic tonsilitis, and we
think it bids fair to be a valuable remedy for this disease, especially in scrofulous
patients.
t The Arum Triphyllum was used in place of Arumn  aculatum, as the latter
was not at hand.



304              AFFECTIONS OF THE MOUTH.
"In similar conditions, but more of a chronic kind, Calc. c.
and Lachesis are indicated. Cale. c., particularly, when the symptoms are aggravated by a draught of air, and Lachesis, when the
rigidity of the muscles of the neck is very great.
" In cases characterized by swelling, ulceration of the tonsils
and fetid smell from the mouth, with yellow and mucous coating
of the tongue,  Ierc. Sol. H., in the 2d or 3d trit., will seldom
be prescribed in vain.
"If the patient complains of a sticking pain in the throat, I
have often given, with benefit, Acid nitric, generally in the 6th,
but also sometimes in a lower dilution.
" If the enlargement of the tonsils and the ulceration was more
on the left side, Lycop., 3 to 30, was more to be depended upon
than the other remedies.
"But in those very dangerous cases, where the throat is entirely closed by an immense swelling of the tonsils, and where the
patient is unable to swallow even a drop of water, gargling the
throat with the original tincture of Bellad., mixed in a little water,
will perhaps have the most salutary effect.
" In several cases of this kind which fell under my notice, the
patients were able to swallow some thin gruel in the space of two
hours, after using the Bellad. in this form.
" My indication for Amm. mur. is a collection of thick, viscid
phlegm in the throat, which can not be detached without difficulty.
" If the symptoms of tonsilitis are accompanied by a choking
sensation or a feeling of a ball in the throat, I generally prescribe
Ignat. amar., and these symptoms at least will always disappear.
" In some cases, where the throat was inflamed, accompanied by
a soreness and dryness and swelling of the right tonsil, Sang. can.
has been very useful to me; in similar cases of a more chronic
nature, Phos. of Lime may be given.
" Some physicians, even the eminent and successful practitioner,
Dr. Gouillou, of Weimar, have counseled the removal of part of the
tonsils by the knife, as less dangerous and more sensible, than
large homeopathic doses of Iodine.
"I am compelled, judging from my own experience, utterly to
condemn this practice, having seen, in several cases, symptoms of
consumption immediately arise after the excision of these enlarged



AFFECTIONS OF THE MOUTH,                 305'tonsils. Some of them met with an early death as soon as these
outposts of the disease were gone.  On the other hand, I am
well aware that in prescribing Iodine in too large and often repeated doses, we may, it is true, cure the enlarged tonsils, but tubercles will gradually develop themselves in the lungs. The same
experience applies to goiter, which may also be cured by large
doses of Iodine, but if cured too quickly, will often be followed by
a very serious cough.
" If the chronic enlargement of the tonsils was accompanied
by induration and swelling of the external glands of the neck,
Conium has, in many cases, removed them.  In ordinary cases,
particularly in children of stout habit or robust persons generally,
Cale. c. and Silicea, alternating higher and lower dilutions, will be
found sufficient. The Bromide of potash, also, here deserves to be
mentioned in the case of persons of light complexion.
"Profiting by Negrier's observations on Juglans Regia in
different scrofulous affections, I have of late made use of it in
many cases of enlarged tonsils as well as glandular swellings of
the neck, and with the most decided success; such cases were particularly benefited in which the glands had a tendency to suppurate, and also where the scrofulous constitution of the patient was
fully developed."
FOREIGN BODIES IN THE (ESOPHAGUS (CHOKING).
A substance lodged in the oesophagus generally stops at the
narrowest or most confined place, which is opposite or just above
the cricoid cartilage. It is not, however, likely to remain there
long, as by the efforts of the patient or others, it is generally
pushed further down, and remains at some point above the stomach. It is, however, sometimes raised a little, and sticks fast in
the pharynx, opposite the larynx.
The substance may produce so much irritation as to cause
spasm of the glottis and immediate suffocation. But more generally nothing more than irritation, with difficult or impossible deglutition occurs, until a sufficient time has elapsed for inflammation
to be induced. The inflammation will soon advance to suppuration
or ulceration, and prove very destructive and dangerous to life.
Or, if the substance be very large, it may peril life by the direct
39                                     (PART  )



306              AFFECTIONS OF THE MOUTH.
pressure upon the glottis or trachea. It often happens that a foreign body lodged for a time, at last slips down into the stomach
spontaneously, leaving for awhile a tumor behind it, at the point
of lodgment.
The TREATMENT for this case is to extract the article, if possible; or if it be a substance, the presence of which in the stomach
would do no harm, being digestible or soluble, to push it down.
First, seat the patient, throw the head far back and open the mouth
widely; then pass the finger into the pharynx, regardless of the
gagging or efforts of the patient to vomit, and as quickly as possible search at every point for the substance. If felt, endeavor to
take it away with the fingers, by attaching it to the nail. But if
you fail in this, immediately introduce curved forceps (such as
every one should have in a pocket case), along side of the finger,
using the finger as a guide. If the object can be seen, of course
the forceps alone are sufficient.
If, however, the substance has passed below the pharynx, and
be proper for the stomach, push it down. If it is not, and the
patient can still swallow, tickle the fauces with a feather and give
mustard. But if he can not swallow, put the oil or extract of
Lobelia into the mouth, and let him hold it for a few minutes.
This will excite vomiting. It may be pushed down with a Probang, - a piece of whalebone, with the end rounded and covered
with silk to make it smooth. But if this passes by the substance
without moving it up or down, attach firmly to the end of the
whalebone a piece of very fine sponge, perfectly dry, having its
surface lubricated with oil or soap, which will make it still smoother.
It must not be so large as to produce suffocation by pressing on the
trachea. Pass this down to the substance and press gently upon
it. If it moves the substance before it, continue until it enters the
stomach, and then carefully withdraw the probang. But if the
instrument, with the sponge attached, passes by the article, push
it on a few inches further, and let it remain for several minutes.
It may even be passed down into the stomach, where, by absorbing
fluid, it will become swollen so as to fill up the oesophagus, and
when withdrawn, bring up the substance before it. Another plan
is-to fix threads to the whalebone, with a great number of loops
hanging from its end, and along its surface: pass it down beyond



AFFECTIONS OF THE MOUTH.               307
the obstruction, and the substance becoming entangled in the loops
may be brought up with it.
If it be some substance which would not be digested or dissolved, and too large to pass through the pylorus and be discharged
from the bowels, every effort must be made to bring it up. The
oesophagus forceps (made for the purpose) must be used, if emetics
fail. Or a tube connected with an air-pump, or a common stomach-pump, may be passed down on to the obstructing substance, -
when by exhausting the atmosphere above, it would attach to the
end of the tube and be withdrawn with it. If the substance fill
the passage completely, the oesophagus forceps could not be passed
down by, so as to grasp it; and in the attempt to do so, there
would be danger of pushing it into the stomach. Hence the resort to the pump is the best plan. One case is named, where a
fishhook with a line attached, was fast low down in the oesophagus.
A hole was drilled through a bullet, and that let down the throat
over the line, when coming in contact with the hook, the latter
was disengaged by its weight, and the point then turning up against
the leaden ball was prevented from catching hold again, as both
were drawn out together.
If the obstruction is in the cervical portion of the oesophagus,
and can not be otherwise extracted, it may possibly be removed
by the operation of (ESOPHAGOTOMY.



308                       BRONCHOCELE.
CHAPTER XXVIII.
BRONCHOCELE AND MAMMARY ABSCESS, —"SWELLED NECK" AND
"SWELLED OR BROKEN BREAST."
GOITER or hypertrophy of the THYROID GLAND - where epidemic - persons liable
- Relation to scrofula - Progress and Results - Iodine not to be depended onRADICAL CURE.
INFLAMMATION of the MAMMARY GLAND-Cause, symptoms, and serious consequences- Various stages with appropriate local treatment- Constitutional
treatment - Lancing to be generally deferred- Special precautions in puncturing- consequences of their common neglect - contingencies and measures after
opening.
BRONCHOCELE OR GOITER.
THIS disease consists in a preternaturally enlarged thyroid
gland.  It prevails very extensively in  Switzerland and other
mountainous parts of Europe.  It is found in the United States,
everywhere, but more frequently in low districts and near the
great lakes, where the atmosphere is moist and the soil rich. Individuals of all ages and of both sexes are subject to this disease,
but females are by far the most frequently affected with it. It
rarely occurs in children before the tenth year, nor is it likely to
commence in very old persons.  Persons of light fair skin, of relaxed constitutions, light hair, large light eyes and precocious intellects, in short, of the scrofulous habit, are most likely to have
goiter.  The memory of the child is often very vigorous, and the
whole mind in point of development several years ahead of its age.
But when goiter appears, a sudden change frequently comes over
the mind.  Oftefi in bad cases, as the disease progresses, the
countenance becomes more pallid, and changes from the brilliant
intellectual appearance to a dull unmeaning aspect; the eyes lose
their luster and assume a vacant look. Intellectual development
seems to be nearly arrested.  If it become very large, respiration
is more or less obstructed and difficult; the voice changes, and
articulation is indistinct.
The intermarriage of persons affected with goiter, is likely to
result in the production of the disease in their offspring. Usually



BRONCHOCELE.                      309
the goiter diminishes in cold dry weather, but on the return of
warm moist weather it enlarges. In some countries it affects horses,
cattle, dogs and sheep.
It begins by a small tumor on one or both sides of the trachea.
It may occupy both lobes and the isthmus of the gland, so as to
have the appearance of a uniform tumor, or be only on one side,
or on both, the isthmus remaining unaffected, dividing the two
lobes by a deep fissure. It sometimes extends back on both sides
so uniformly as not to have the appearance of a distinct tumor.
It is usually slow in its progress. In most cases, it is soft and insensible, and may be handled with impunity; in others, it is closely
bound down by the muscles, and feels firm and hard.  If it becomes inflamed, it is extremely painful, and presents very troublesome symptoms, which are often quite difficult to subdue.
In this country, severe or dangerous cases are very rare. The
principal difficulty attending them, in a very large proportion of
cases, is the deformity. The striking effects upon the mental constitution, before referred to, are, among us, still more rare. Various modes of treatment have been recommended and pursued by
allopaths, all of which have had their strong advocates, and most
of which have been abandoned, either as useless or too dangerous.
IODINE seems, from numerous authorities, to stand higher than any
other remedy. It is mostly used in allopathic practice internally, in
the form of Iodide of Potassium, and of Iron. It is also applied
externally, in the form of an ointment, with lard, or some other
convenient vehicle, rubbed on once or twice a day, over the tumor.
It is also dissolved in alcohol, and applied as a wash. Extract of
Cicuta is highly recommended by Prof. Gibson, while he has by
no means the same confidence in Iodine that is expressed by others.
Of this favorite article he thus speaks:-" The reports of Coindet in favor of this medicine " (Iodine)" were soon fully confirmed
by many other continental surgeons; and its reputation rose
speedily to the highest pitch; strange as it may seem, however,
its decline has been almost as rapid as its rise, being now considered in the estimation of many practitioners, nearly inert, and
by others pronounced a most virulent poison. But, from all the
statements made on the subject, we have, I think, fairly a right to
infer that it is a medicine of great power, calculated, in some cases,



310                      BRONCHOCELE.
to produce a very strong impression on goitrous and other tumors, as
many well attested cases decidedly show; and that, on the other hand,
it is followed occasionally with tremendous symptoms and even death.
Again, it is equally certain that, upon other patients, not the
slightest impression has been made by its use, either upon the tumor or upon the constitutions of the individuals who have taken it,
sometimes for months together, and in the largest doses. My own
experience in its use is very limited, but, judging from this, and
from the reports made to me concerning it by my colleagues, in
the Philadelphia Hospital, I should feel inclined to doubt its efficacy. Still it is possible we may have been deceived, either by
the bad quality of the medicine or by other circumstances. Lastly,
it may be stated that Dr. Coindet himself has abandoned the internal use of the remedy, and merely employs it in the form of inunction, from which he states that he has derived very beneficial
results."
From the foregoing it will be noticed that Iodine, while it has
been successful in some cases, has in others done injury. From
the results of the homeopathic use of this drug in minute doses,
we are assured that it not only has great power, but it is homeopathic, that is, specific to some forms of this disease. Dr. Hugh
Cameron, in an able article read before the British Homeopathic
Society, remarks, " I shall now in a few words relate the leading
features of three cases, which I have selected out of many, because
they prove that Iodine, administered in infinitesimal doses, will act
beneficially in bronchocele when it has been employed in large
doses (allopathic) without success; and that this remedy, allopathically prescribed, sometimes increased the disease it was given to
cure.
"The first case, a woman aged forty, had the disease from
childhood; swelling extended from the sternum to the chin - hard
and covered with a net-work of varicose veins. It impeded respiration as well as the circulation, so that she had great fullness of
the head, cough, dysnaea, &c.; had been treated with Mercury,
Hyd., Potass., also Tincture Iodine, internally, until it produced
giddiness, fainting, palpitation, tremor, pain, and increased fullness
and tension in the tumor. For some years she left off all treatment; all the symptoms had greatly increased, when Iodine 30



BRONCHOCELE.                      311
was given and repeated every two days for a week, after which it
was repeated at longer intervals for six months, when all symptoms
except the swelling disappeared.
"The other two cases were similar, the treatment the same,
and with similar success. In the last, however, a young lady, the
tumor entirely disappeared."
We have used Iodine and Spongia, alternately, with good
effect.
Dr. Goullon reports a case of extreme rapid growth and swelling of the thoroid gland -a man aged sixty-two -produced by
taking large doses of Kali. iod. for scrofula. Another of a young
girl, four grains of Kali iod. produced rapid diminution in a
swollen thyroid gland.
Besides Iodine and Spongia, or where they fail and the tumor
assumes a diseased condition, becomes painful, with a swollen and
varicose condition of the veins covering its surface, Carbo. veg. or
Lycopodium should be given.  If, however, there are any symptoms of acute inflammation, with redness, increased swelling, with
headache and a difficulty of swallowing, use Belladonna, repeating
the dose every ten or twelve hours, or oftener, as the symptoms
require. If there should arise considerable fever, Aconite is
more appropriate.  When, however, the fever is of a milder form
and there is no redness or sudden increase of swelling, or if suppuration is threatened, Mercurius will be beneficial.  It should be
repeated as often as every four or five hours until the abscess
points (if pus has already formed), or the inflammation subsides.
Hepar or Silicea will aid in forwarding the suppurative action.
For the discussion of the enlarged gland, where inflammation has
never been present, or after its disappearance, besides Iodine and
Spongia, Conium has been effectual in some cases.
Podophyllum, though it has not been much used by homeopathists, we think will be found equally efficient, in fact far superior, to any of the foregoing remedies. Many years ago, before
Homeopathy was known in this country to any considerable extent,
Dr. Kilborne, of Columbus, Ohio, was in the habit of prescribing
very small portions of this remedy for goitres, and gained quite a
notoriety for curing cases which had been treated unsuccessfully
with large doses of Iodine and other remedies for a long time.



312                   MAMMARY ABSCESS.
Since becoming homeopathists, we have been using it, and are free
to say, that no medicament has acted so promptly and efficiently
in our hands as this.  We give the 3d or 4th dilution of the tincture, or the same trituration of Podophyllin, internally, and apply a dilution of one to fifty of the tincture in alcohol to the tumor.  In some cases, however, we have found drop doses of the
mother tincture, taken internally, to succeed, when the dilutions
failed.
The following remedies may be consulted with advantage:Staphysagria, Natrum  muriaticum, Causticum, Am. carb., and
Thuja.
MAMMARY ABSCESS.
Although this disease is most commonly met with in lying-in
females, it is not exclusively confined to this class of persons. It
occurs occasionally among others, and even males are sometimes
affected with troublesome mammary swellings.  In the case of
males, however, this affection rarely, if ever, requires any treatment.  It will gradually subside of itself.  When abscess forms
immediately after delivery, it is usually the result of some mechanical injury, received at that time, or of a sudden cold. It rarely
occurs, however, before the lapse of from four to six weeks after
parturition.
The first SYMPTOMS are generally slight swelling in some part
of the gland, with throbbing pain, which is soon succeeded by a
severe chill, and followed by more or less general fever.
In some cases the chill and fever will appear before the patient
has noticed any affection of the breast. There will be in this case
much restlessness and irritability, and, if strict examination be
made, a small hard tumor will be found, most generally far back
towards the base of the gland, which is extremely tender to the
touch, though it has not previously occasioned any sensation of
pain.
If the inflammation and tumefaction begin on the top of the
gland or near the nipple, it will be the first symptom to attract
notice.  Soon after the occurrence of the chill, the breast enlarges
in all directions, and becomes highly inflamed and extremely painful, and so tender as not to bear the slightest touch. The secre



MAMMARY ABSCESS.                          313
tion of milk may be entirely suppressed, but generally it continues,
though very much altered in its appearance, becoming often injurious and sickening to the child.
Suppuration, if not prevented, will usually take place in about
ten days, rarely sooner; but sometimes, if it be allowed to take its
course, several weeks elapse before pus is formed, during which
time the patient's sufferings are indescribably great.
The matter when formed is not always in one cavity, but may
be in distinct cysts. These abscesses are sometimes of the character of sinuous ulcers, having several openings with long pipes
winding tortuously into the substance of the breast, from which
fungous sometimes sprouts out, and in large masses. This kind
of ulcer in the breast rarely heals spontaneously. If not arrested,
it will sooner or later prove fatal, the constitution of the patient
being undermined by the pain, irritation and discharge. Hectic
sets in and she soon sinks.
The TREATMENT of these cases, though they are rarely of a
malignant or dangerous character, is nevertheless very important,
particularly on account of the extreme suffering of the patient.
If called early, before the chill, or soon after, examine the
breast critically to ascertain the exact condition of the swelling.
If it be still confined to a small compass, we ought by no means
to allow it to extend so as to involve other parts in the inflammation. Give Bryonia, and repeat the dose every four or six hours,
using a low dilution of the same as a wash to the affected part,
keeping it constantly wet.*
This remedy will often suffice for cases even where the indura* The extreme tenderness and sensibility of an inflamed breast will be allayed and
the sufferings of the patient greatly palliated (an important consideration in so
distressing a complaint) in a short time, by having a dish of water, as warm as can
be borne, placed below and near the breast, and with a sponge constantly applying the heated fluid to the gland byletting a stream flow gently over it, taking care
to keep up the temperature by adding more hot water. The process should be
continued for from half an hour to two or three hours if the pain and tenderness
are not allayed sooner; it may be repeated at any time, when the extremely painful symptoms return. Whatever medicine is being used at the time, may be put
into the water at a low dilution. It will be found that all the remedies indicated
in this affection will act more efficiently if applied to the affected part at the same
time that they are used internally.
40                                                (PART I.)



814                  MAMMARY ABSCESS.
tion is extensive, before any redness appears on the surface, but
after the breast swells and the surface becomes red with burning
pain, use Belladonna in the same manner.
If the inflammation has arisen from any recent injury, Arnica,
or if from  an old one, Conium will be appropriate.  But if the
disease does not soon yield to these remedies, chills will set in, and
the patient will be affected with symptoms not unlike a severe paroxysm of ague.  If these should occur during the treatment or
before its commencement, and the fever be severe, give Aconite
and Belladonna alternately, or Aconite internally and apply Belladonna to the breast.  When the fever subsides, continue the
Belladonna as long as improvement goes on, but lengthen the intervals of its administration.  If, however, some degree of active
inflammation should remain after one or two days, the breasts being much indurated, give Bryonia in alternation with Belladonna,
at intervals of six or eight hours.
Should the induration continue after the active inflammation
has subsided, give Mercurius solubilis; to be repeated in one day
and afterwards, at longer intervals.
We have employed Phosphorus almost to the exclusion of other
remedies, not only to facilitate the suppurative process, as recomniended by Croserio, but to prevent the formation of pus, with more
satisfactory results than any other remedy.
Should these remedies have been employed too late to prevent
suppuration, and abscess goes on to form, the next object will be
to palliate the symptoms and "bring it to a point," with as little
pain to the patient and as soon as possible.
Hepar sulphuris, if given early after the symptoms of suppuration have set in, will often so far arrest the suppurative process
as to allow but a small part to become involved and very little pus
will be formed; besides, it greatly lessens the pain during the
process of suppuration and facilitates the "pointing" of the abscess.  We may not be consulted until all attempts at preventing
abscess are fruitless -it may have already formed. Don't puncture too soon. It is better here to let the abscess alone, and allow
it to open spontaneously, if practicable. Wet compress or an elm
poultice should be applied. Flaxseed poultice is very good, as it
does not adhere so closely. The elm or flaxseed, wet with scald



MAMMARY ABSCESS.                     315
ing milk, and applied quite warm, aids the suppuration. When
the matter has collected in considerable quantities, it may be very
slow in coming to the surface, and, if its escape is very long delayed, it may do much harm by producing hectic, and, if the lungs
are weak, it may seriously affect those organs. If the patient be
feeble, scrofulous, or inclined to pulmonary disease, we ought not
to wait very long for the matter to make its way to the surface.
It is much better, however, in all cases that will admit of delay,
to allow it to come so near the surface that nothing but the skin
will intervene -and then open.  But in the cases just particularized this might not occur until fatal injury had been inflicted on
the lungs.  Examine and ascertain as nearly as possible the seat
of the pus, and the point where it approaches nearest the surface.
Puncture with an abscess lancet at the most depending point at
which the pus can be conveniently reached.  In puncturing, be
careful in all cases to make the incision parallel with the course
of the lactiferous ducts. Have the edge of the lancet look towards
the point of the nipple. By this means we will avoid severing
many, or perhaps any, of the ducts.  It will be recollected that
the breast or mammary gland is made up of an immense number
of little glands, each having a separate duct or tube leading from
it, from which the milk secreted by the glandulae is conducted towards the nipple, from which it escapes by a number of larger
ducts.  As these little tubes approach the nipple, they run in
similar directions, all converging to the same point, the smaller
ones uniting —thus lessening their number and increasing their
size as they advance. Now, if the lancet be introduced parallel
with the tubes, though some may be split, none need be entirely severed, so as to destroy their functions; but if, on the contrary, the
lancet be plunged in across the ducts - that is, with the flat side
towards the nipple, forty or fifty, or even more, may be cut through,
and the cicatrix close them up completely. Thus, the outlet from
several hundreds of the still smaller ducts beyond are entirely and
forever closed. These glands remaining sound, will secrete milk,
as usual, at the next period of pregnancy. There being no way
for the milk to escape, it will accumulate along the ducts, between
the glands and the obstruction, causing inflammation, abscess, and
very generally ulceration.



316                  MAMMARY ABSCESS.
This is the history of thousands of cases operated upon by
physicians- or we ought to say quacks —whether they are graduates or not-who are too ignorant of anatomy, or too careless in
their operations to be trusted with a cutting instrument. Let any
one enquire into the history, and examine the scars of those unfortunate patients who have been afflicted so strangely with repeated
abscess and ulceration of the breast, and he will soon become convinced of the truth of our remarks. This kind of surgical disease
is moreover particularly liable to take on a malignant character.
[See under CANCER, page 226.]
After the escape of the pus, dress the part with the elm poultice as long as there is much discharge, and when it diminishes,
with simple cerate. It generally heals kindly. But if it become
indolent and heal slowly, give Phosphorus, keeping it covered with
the cloths or a poultice. It is also very valuable in the ulcerative
stage, the ulcers being partly fistulous with fungous growths,
the patient being affected with sweats, loss of appetite and much
debility, the lungs appearing implicated.
On the disappearance of these hectic symptoms, if the ulcer
does not assume a healthy appearance, or if there are sinuous
ulcers in the absence of these constitutional symptoms, give Silicea.  If it inclines to bleed easily when touched, and assumes a
dark color with a fetid odor, give Lachesis.  Carbo animalis
may be used with advantage should Lachesis have failed to entirely
remove these symptoms. The breast should be sustained by a suspensory bandage so as to prevent the pain that would arise from
its dependent position.
In some instances, where it has beeen lanced too early, the
wound gapes open widely, and the substance of the gland turns
out like a rose, as large as a coffee-cup. These cases are sometimes called " cancer," and often really become malignant, if long
neglected. In one of the worst cases of the kind we ever saw, the
leaves of the Pyrolia rotundifolia (canker-lettuce) were applied in
a green state, laid over the sore and changed once in two hours,
effecting a perfect cure in the course of two weeks. We have used
this article with like success in several similar cases, though none
so bad.  It deserves to be "proven."



MAMMARY ABSCESS.                     317
Acid nit. was extremely useful in the case of a female whose
two breasts had been removed on account of scirrhus.
Silicea 30; abscess, in the case of a young girl, resulting from
violent phlegmon, which came on without any ostensible cause.
Symptoms: pale, livid, emaciated, no appetite, hectic fever and
short breath, continual general dry cough. The affected breast was
hard and tumid, but pale. Towards the axilla the breast exhibits
an opening with callous fistula extending as far as the sternum, the
lower half of which is painful and swollen, paralytic pains in the
right arm.
Phos. 30; abscess during lactation.
Symptoms: Breast swollen and inflamed; several openings
with callous edges suppurating, some parts of the breast remaining hard; suspicious cough, generally dry and frequently accompanied with expectoration of blood, oppressed breathing, circumscribed redness of the cheeks, no appetite, chilliness in the evening,
with subsequent heat, especially in the palms of the hands; viscid
night sweats.
Phos. 30; abscess in a lying-in female.
Symptoms: Gnawing burning in the thoracic cavity, with
short oppressed breathing and dry cough; hectic fever, with coliquative sweats and diarrhea. Breast swollen, hard, dark red, with
burning pain and stinging when touched but slightly. Seven ulcers,
partly fistulous, partly ulcerated, partly covered with proud flesh,
discharging fetid badly-colored copious pus.
Phos. cured a very painful breast, as hard as a stone in many
places, but suppurating in others.
Phos. has frequently been curative in inflammation of the
mammee or long suppurations, which continually inflame.  (Ruckert, p. 309-10.)



818                 HERNIA OR RUPTURE.
CHAPTER XXIX.
HERNIA OR RUPTURE.
DBFINITIONS and distinctions -Inguinal and Femoral Hernia, with illustrationsIrreducible Hernia -the sac and its neck  Omental and Intestinal HerniaStrangulation, cause and symptoms -mortification and seeming relief- Directions for the Taxis - Original means for effecting reduction - Treatment.
BY the term HERNIA is commonly understood a protrusion of
some portion of the intestines or omentum, or both, from the cavity
of the abdomen, in the form of a tumor found to be suspended in
a peculiar sac (which is a fold of the peritoneam carried on before
the bowel and still enclosing it). The word RUPTURE, which is the
popular synonym for hernia, more strictly expresses the break or
breach, or widening of the opening, in the abdominal parietes,
through which the viscus or viscera make their escape.
In some cases, as where the accident is caused by a wound dividing the peritoneum, or where the caecum protrudes from behind
that membrane, there will be no hernial sac; and other viscera
than the intestines, as the bladder, ovaries, uterus, &c., may constitute the tumor.  These rarer cases are still called "hernia."
Indeed the most general definition of the word is the protrusion
of any viscus from any of the natural cavities. This more extended
meaning of the word is always indicated by the name of the particular case. Thus, "hernia ventriculi" is a variety of ventral
hernia, in which the stomach, instead of any lower portion of the
alimentary tract, is protruded; "hernia vesicalis" involves the
urinary bladder; and "hernia cerebri" means a swelling out of
the brain and investing membrane at any point where the cranium
is deficient, or has been removed. The greater liability of the
bowels to this accident than any other parts, arises as well from
the great amount and variety of pressure to which they are subject, as the comparative weakness of the parts that cover them in
front. The weakest parts are those at which the accident most
frequently occurs; and anything that occasions general or local
muscular debility, becomes a
- predisposing CAUSE: such as dropsy, pregnancy, abscesses,



HERNIA OR RUPTURE.                   319
wounds, &c.  The exciting cause is any sufficient pressure on the
viscera, such as straining in evacuating the bowels or bladder, or
in lifting heavy weights, or some other violent bodily exertion (especially during debility from sickness).
The parts most LIABLE to be protruded are, after the omentum,
either some of the small intestines, or some part of the arch of the
colon. The PLACE where the tumor manifests itself is, in ordinary
cases, near the navel or the groin, running down, in the latter instance, either in front of the thigh or into the scrotum or labia.
(See Figures 12 and 13.)
Fia. 12.
The particular POINTS of protrusion give name to the most frequent cases; and the distinctions are sometimes vitally important.
When the rupture is at the navel, the case is sometimes called
"Exomphalos," more commonly and correctly "Umbilical Hernia."  When at any other point of the abdomen than those we
shall now go on more particularly to explain, it is simply "Ventral Hernia." Byfar the most common points concerned, and most
important to be borne in mind, are the Abdominal Rings with
their intervening Canal (for the passage of the spermatic cord),
constituting INGUINAL HERNIA (see Figure 12), of which several
varieties are to be distinguished; and the Crural Ring and Saphenic or Lymphatic Hole, with the intervening Femoral Sheath
under or behind Poupart's Ligament, giving rise to FEMORAL HERNIA. The amount of protrusion at this part is usually small, and



820                   HERNIA  OR  RUPTURE.
the diagnosis from bubo and other affections of the groin is not
always easy. It is more common in women than men.
In INGUINAL HERNIA, the intestine, after passing through the
internal Abdominal Ring, may be arrested in the canal, and form
a tumor there above Poupart's Ligament: this is "Incomplete Inguinal Hernia." " Complete Inguinal Hernia " is when the protruded part traverses the abdominal canal and emerges at the External
FIG. 13.*
Ring, following the same course that the testicle did in its passage
from the abdomen into the scrotum.  When the bowels runs on
with, or rather, within the cord far enough down, it becomes
"Scrotal Hernia " (Fig. 13). When a protrusion through the same
points occurs in females, the tumor appears in the labia pudendi.
This complete Inguinal Hernia is sometimes called the " Oblique,"
in contradistinction to the case in which the bowel forces its way
through the space between Poupart's and Gimbernat's Ligaments,
leaving the External Ring and the Spermatic Cord on the outside
of it.  This is the "Direct or Ventro-Inguinal Hernia."  This
* This cut represents inguinal hernia when it has not only become complete,
but advanced so far as to occupy and distend the tunica vaginalis, then constituting
it a case of "scrotal hernia."  This, as well as the former illustration, represents
the protrusions of a medium size and as they appear in a sitting posture. It will
be noticed that the tumor on the thigh (Fig. 12) is much smaller than the pouch.of
Fig. 13. Its position is also above that of the other, though the other commences
much higher up in the body. The dotted lines on the tumors indicate the direction
of the incisions in operating for strangulation.



HERNIA OR RUPTURE.                      321
protrusion is not often very large, and may extend on towards the
scrotum, but is unconnected with the Spermatic Cord or tunica
vaginalis.
These distinctions of origin or location are not the only or most
important ones to be noticed. Every Hernia is either Reducible
or Irreducible, that is, susceptible or not of being put back into
its place. The distinction is not the merely relative one depending
on the means used for actual reduction. All serious cases would
thus be, for awhile, relatively " irreducible; " and when they are neglected, or efficient means are not resorted to in time to prevent such
a result, they become absolutely and permanently irreducible. This
is what is technically meant by the distinction. It is caused by adhesions of the sac and contents, or by an enlargement of the tumor
from fatty deposit or other growth.
For the sake of beginners, we will observe that this subject of
reducibility is not, as it might seem to them, the most important
practical question, and is not to be confounded with the subject
of strangulated hernia.  In simply irreducible hernia, the functions of the part go on the same as if they were in their proper
place. It is said to be strangulated when (from swelling of the
neck of the sac, spasm of the muscular parts around it, distension
by flatus or faeces, or from any similar cause) the sanguineous circulation through the part or passage of its proper contents is obstructed,-rendering the death of the part and almost necessarily
also that of the patient inevitable, if the case is not speedily relieved. Strangulation occurs most frequently in cases of longstanding rupture; but is by no means to be regarded as a mere
variety of "irreducible hernia." It is, of course, irreducible for
the time and under the circumstances, and may have been permanently so before the distension or constriction; but many a fatal
case of strangulation has been such as admitted of easy, reduction, had the patient or the practitioner resorted in time to proper
means.
The neck of the SAC, of which mention was just made in describing strangulated hernia,-the narrowest part where it immediately protrudes from  the abdomen,- necessarily contains a
larger amount of the peritoneal membrane crowded and puckered
up than the lower expanded part; and becomes thickened and
41                                      (PART I.)



322                 HERNIA OR RUPTURE.
condensed by pressure. Sometimes there are two necks, the sac
having enlarged or descended further and drawn out more of the
peritoneum, after one part had permanently grown into a neck at
the fissure. In Complete or oblique Inguinal Hernia, there are
always of necessity two necks, one at the Internal, the other at the
External Ring. The body of the sac increases in size by distension and growth, as well as further drawing out from the abdomen.
Adhesive inflammation, or adhesion without inflammation, soon forms
with the surrounding parts, so that when the protruded intestines are
replaced, the peritoneal protrusion or sac is very rarely returned
with them.
It is well for the practitioner to DISTINGUISH between a protrusion of the omentum only, and one of intestine, or of both.  The
hernial tumor containing OMENTUM only (epiplocele), is insensible
and inelastic, feeling to the touch like dough.  When formed
of INTESTINE (enterocele), it is harder as well as elastic, and gives
pain on being pressed. If both are included in the sac (enteroepiplocele), you will find one part of it springy and sensitive, while
another has the peculiar doughy insensibility.
The protrusion at either of the points mentioned is liable to
become "strangulated," i. e. to have the orifice through which it
has passed contracted upon it, so as to prevent its return and obstruct its circulation and other natural functions. This is a condition, which, if not relieved, must soon occasion death. Any
cause of inflammation or spasmodic irritation, supervening on the
simple hernia, may bring about this alarming complication.
The symptoms of STRANGULATED HERNIA are first an irritable
condition of the parts, with a hectic flush over their surface, and
pain at the point of protrusion and constriction. When inflammation
is not itself the cause, it soon follows on strangulation. The pulse
becomes hard and quick, and other symptoms of the sympathetic
fever set in. There is costiveness, of course, when the alimentary
canal is itself obstructed. This symptom occurs also when it is
only omental hernia. There may be ineffectual attempts at a discharge per anum. Above the constricted part, the peristaltic
movement is inverted. Vomiting early occurs, and continues till
the contents not only of the stomach and duodenum, but of all
the intestines above the hernia are brought up, the ejections being



HERNIA OR RUPTURE.                   323
more or less faecal.  These various symptoms continue more or
less severe until
- MORTIFICATION begins, when the patient becomes easy and
thinks he is getting well. The abdomen sinks; and if examination is made over the protruded parts, crepitus may be felt. The
vomiting gives place to gulping and ominous hiccough. The apparently flattering changes soon betray themselves by sinking,
clammy sweats, rigors, &c.  The hernia subsides spontaneously,
or is easily reduced by the finger. This sometimes precedes any
obviously alarming change, and is immediately followed by a satisfactory stool.
When this EASY OR NATURAL REDUCTION takes place suddenly
in a case of some hours' standing, we may be pretty sure that our
patient will die. And here let us warn the young surgeon never
to be so inconsiderate as to fall into the error that physicians as
well as patients have often done,- mistaking pain for danger, and
the ease arising from insensibility, for a ground of hope. The
feelings of the patient on his final release from suffering, are well
calculated to deceive. What of life is left, when death is begun,
often seems all the freer and fuller.  The old maxim, "while there
is life there is hope," would be truer if it ran, "while there is
pain, there is hope."
Still, in rare instances, which are among the wonders of nature, strangulated hernia has been spontaneously recovered from,
without either reduction being affected or adhesion taking place;
- that is, if it can be called recovery for the protruded parts to
slough off and leave an artificial anus.
When called to a RECENT CASE of hernia, if inflammation has
not yet taken place, we should endeavor by all means, whether
there be irritation or not, to "reduce," i. e. to replace, the protruded parts within their natural cavity.
In order to REDUCE with more facility, place the patient on the
sound side in a horizontal posture, elevating the hips, however,
and flexing the thigh of the affected side upon the abdomen while
we draw it down toward the other. By these means we draw
off the incumbent mass of intestines, and relax the muscles and integument over the points of protrusion. Although the limb is
somewhat in the wav, it is better to maintain this position until



324                  HERNIA OR RUPTURE.
the desired object is attained.  Then, for what is technically
called
- THE TAXIS.  Commence pressing up to and within the point
of protrusion as much of the tumor as possible with one fore-finger,
while the other hand supports and gently elevates the whole of
the sac. Retain all that is brought up with the first finger, and
reach down as far as possible with the middle finger; bringing up
and securing with it as before.  The fore-finger may then be again
brought into requisition, and perhaps the ring-finger also. Continue the operation until all the parts are carefully returned in the
inverse order of their emergence, pressing gently all the time
with the other hand, so as not to contract the bulk of the sac, and
avoid irritating it by too much handling.
We will notice one most efficient MEANS of REDUCTION which
appears to have been strangely overlooked; though to us, at least,
it has long seemed the most obvious and natural of any that can
be devised. We have often easily succeeded in cases where there
was considerable irritation, and sometimes even a degree of inflammation, by placing the patient in the position before described,
and applying a large cup to the abdomen, covering the umbilical
region. In one instance the patient had been in terrible pain for
several hours, and there was strong evidence of strangulation
when Dr. Hill arrived. After regulating the patient's position,
and ascertaining the critical state of the case,-it being complete
inguinal hernia, with a large tumor too sensitive to allow of the
necessary manipulation,-the Dr. looked about for some means
of getting the advantage of traction from within, as a substitute
for pressure from without. The only thing in the room that seemed
available, was a half gallon pewter measure. But the spout or lip
was in the way. He recollected, however, that fire could remedy
this obstacle; and seizing the vessel, ran into the kitchen and
melted off the projection. Inserting and firing a sufficient amount
of cotton, he clapped it on, and instantly had at least a quart of
intestines in it, —a considerable proportion of the abdominal contents, — among them, no doubt, part of those that had constituted
the hernia, for that was gone. Instantaneous reduction without
external manual assistance, was the happy result.
The internal traction by CUPPING has many advantages over



HERNIA OR RUPTURE.                    325
pushing in by manual taxis, when the latter is not easily affected
without much handling.  A moment's reflection will satisfy any
one that the sudden withdrawal of so large an amount of intestinal mass, must be accompanied with a powerful tendency to
what may be called "spontaneous reduction," in comparison with
any other artificial means. The force thus brought to bear is precisely in the best possible direction, and is applied to the parts directly concerned, and no others.  The difference between this
pulling, and the usual pushing in of the knot of intestines, is like
the difference between "pulling out" a common bow-knot by the
end left for the purpose, and literally untying it by pushing back
the loop.
While we are giving our experience, we will relate another
original mode of reduction; at which, however, Dr. H. was only
an astonished spectator. Occurring while he was quite young,
and under peculiar circumstances, it made a strong impression
upon his mind, to which, perhaps, he is indirectly indebted for the
idea of his own plan. Few things indeed could be more calculated to make a boy think,- and to think of becoming a doctor!
An old gentleman living near his father's farm had been subject
for a great part of his life to rupture. On several recent occasions it had become strangulated, requiring the aid of a physician.
Dr. H.'s father, though not a medical man, was generally called
in to assist whenever the old gentleman's " bu'st would come down
again." On the occasion in question, a doctor had been sent for
as usual, but had not arrived, and things were in a worse condition than ever before.  Great was the alarm,- and not without
reason.  Much time had already been lost, during which the patient had been laboring under all the usual violent effects of strangulation.  He was now visibly sinking. All the means which the
friends and neighbors had ever known or heard of had been already tried without avail. Nothing now was looked for but immediate dissolution. At this juncture, the other persons present
were probably as much astonished as Dr H. to see his father, who
was a tall, powerful man, seize the patient by the feet, draw them
over his shoulders, and spring up from the floor with the sick man
hanging at his back,-back to back and head downward. In this
style he made several sudden jumps, settling down again very



326                 HERNIA OR RUPTURE.
firmly, and, of course, heavily on his heels. During this jolting
and traction by inverted gravity, the strangulation was overcome,
the tumor entirely disappearing; and the patient was laid upon
his bed again, cured by this Brobdignagian operation. The cupping plan is certainly an improvement on the backing, -as far as
convenience is concerned, but not probably any more effective than
that would prove. In case of spasmodic strangulation, the fright
of the patient might aid the cure.
Unfortunately, however, we will often not be called in, until it
is too late for immediate reduction, dangerous inflammation if not
consequent adhesions having occurred in the parts.
Any considerable amount of INFLAMMATION contra-indicates
other means for immediate reduction, but does not by any means
authorize an operation. Under the Homeopathic practice the necessity for the knife is often dispensed with.
THE OPERATION for strangulated hernia is sometimes successful
and occasionally indispensable, but it should be the last resort.
Still there is danger in delay; when once determined on, it is to
be promptly put in execution. Let all other available means have
been attempted before recourse to so dangerous and uncertain
a measure; but when it must be done - do it, without waiting for
the assembling of half a dozen other surgeons, and by delaying
lose all chance of success.
Having failed in effecting a reduction by "taxis," inflammation not having already set in, if the tumor is not very sensitive
and there is no considerable redness over and around it; the
hernia has come on spontaneously from a relaxed condition of the
parts, or if it be an old hernia and the strangulation is of a spasmodic character, not depending on any mechanical violence or
strain, and there is little or no symptomatic fever, give Nux. vom.
This should be repeated in two hours if the symptoms do not
abate, or if they have been ameliorated, but improvement has
ceased. If, however, the patient is not evidently better in an
hour and a half, or two hours, after the second dose, you should
choose another remedy.
Should there still be no active inflammation, there being redness of the face with hardness and fullness of the abdomen, vomiting of fecal matter or putrid eructations, Opium should be given,



HERNIA OR RUPTURE.                   327
and may be repeated more frequently than the former remedy.
Some recommend a repetition as often as every fifteen minutes.
After repeating this remedy three or four times, let the patient
rest without any medicine for one, two, or three hours, unless he
gets worse.  If improvement ceases and is not continued by a
repetition of the remedy after the suspension, or if he is not benefited in the first instance, and active inflammation is not present
(whether there be fever or not), and if there is pinching pain in
the abdomen with a sense of weight and pressure, with burning sensations, the nausea continuing with burning and thirst, give Alumina, and repeat the dose in half an hour, if no amelioration takes
place sooner; then wait an hour before repeating or changing the
remedy, unless symptoms of inflammation arise.  When even an
amelioration of the symptoms occurs, attempts may be made at a
reduction of the hernia, not however by the usual "taxis," as all
handling serves to keep up the spasmodic action. But the cup may be
applied to the abdomen, even if too much tenderness exists in the
sac to admit of the "taxis."
The patient during the whole course of treatment should be
kept as much as possible on the back, inclined to the sound side,
with the hips and shoulders elevated, and the thighs flexed upon
the abdomen, so as to keep the abdominal muscles relaxed, and
favor a spontaneous return of the protruded parts, as soon as the
spasm is relieved. Should the hernia have been caused by some
recent external injury or strain, or if in an old hernia, the strangulation had been caused by a similar accident, Arnica should be
used, taken internally and applied locally. CALENDULA, however,
is important in the early stage of incarcerated hernia arising from
violence.
If active and violent inflammation should arise during the treatment or before, either from an injury or from the long continuance
of the spasm, with excessive burning pain in the abdomen, nausea,
bilious vomiting, abdomen sensitive to the touch, pulse full, hard
and frequent, with thirst, give Aconite, and in severe cases repeat
the dose in one hour, unless amelioration occurs sooner. Should
not the patient improve in three or four hours and cold perspiration appear, the pulse becoming irregular and feeble, the vomiting
being acrid, use Sulphur, one dose, and wait two or three hours



328                      HERNIA  OR  RUPTURE.
unless the symptoms change so as to demand some other remedy.
If symptoms of gangrene appear in the tumor, its surface being moist and purple, give Lachesis; or if the surface is dry, the
thirst intense and burning, with great prostration of strength, the
pulse becoming small and feeble, Arsenicurm.
While it is generally true that we ought to take into account
the known pathology of the case in making our selection, it is
equally true that a remedy which will remove certain symptoms
produced by unknown causes, may with great propriety be prescribed for similar symptoms, though produced by a known cause,
and that, too, a secondary one and quite different from the former.
So in the case under consideration, if there are present vomiting,
cold perspiration and coldness of the extremities, a cadaverous
countenance, great anguish, fear of death and despair, the prominent symptoms of Veratrum in cholera, and such as will usually
yield to this remedy, we should most assuredly administer it, and
may expect favorable results from its action in hernia, though the
cause may have been a mechanical injury instead of an epidemic.*
* "A few words in regard to strangulated hernia in so far that as an organic
cause it gives rise to colicky pains and the relations which our remedy bears to such
pains:
"One would suppose that it would be the thing whether the strangulation was
congenital, old, recent, or occurred in a rupture produced by external violence, as
the cause which produces the pains is always the same. If this were the case, all
strangulated hernia must yield to the same curative method that had conquered a
few cases.
" Nux must then prove curative in all cases, as it has proved of such essential
service in some. Still I much doubt if it deserves the name of a specific in those
cases; at least, oft-repeated experience must confirm its power. I believe that Nux
is to be applied with most certainty when the rupture is of recent occurrence and
suddenly becomes strangulated, and which could have been cured by Nux if the
strangulation had not supervened. In a case of this kind, we should attempt the
reduction of the hernial protrusion, by means of the taxis; if it is reduced, the
pains soon mitigate and all of the symptoms dependent upon it disappear.
"' Should, however, we not be able to reduce soon by this method, which is
most frequently the case as the constriction of the muscular fibers of the intestines
and abdominal ring is increased by the irritation produced by the taxis, and thereby
a more powerful resistance is induced, we should, under such circumstances,
without useless attempts at reduction, administer Nux vom. in the smallest dose.
I do not say without reason, in the smallest dose; for where the sensibility of the
patient is so much exalted, we should endeavor to avoid every possible exacerbation from the remedy, in order not to bring the life of the patient in still greater



HERNIA  OR  RUPTURE.                          329
Though some of the authors depreciate all local applications in
this disease, and probably so far as relates to their effect in mere
spasmodic strangulation, aside from inflammation, they are useless
danger by producing spasmodic complaints.  Observations coincide with mine in
these cases, that soon after the administration of the remedy the pain ceased, the
intestine replaced itself, even if before, this had been impossible with the taxis.
"W —, aged thirty-six years, a stocking weaver, whose frame had been
much reduced by care and disease, endeavored to refresh himself by short sleep in
the afternoon, for the remaining toils of the day, and despite his miserable nourishment, he always gained sufficient strength, although not without exertion to
enable him to pursue his labors. A long time since, I had happily cured him of a
chronic hepatic affection, and from that time the man enjoyed at least tolerable
health. In the summer I was called to him at night, and on entering his chamber,
I found him in bed wringing his hands and exhibiting the following picture of
disease:
" Early in the morning the patient had felt as well as usual, had a natural stool
as generally, had eaten enough at noon and then taken his usual siesta, from which,
however, he was awakened by a griping, stinging pain in the right inguinal region,
which, after his arising, continued to increase hourly, and towards evening obliged
him to lie down. Notwithstanding, he still hoped that nature would afford.him relief, until finally the pains extended over the whole abdomen, which was painfully
tense and distended; eructations of wind, vomiting of a greenish, bitter fluid supervened, and he was troubled with restlessness, which he could not overcome. At
the same time, he complained much of thirst; the pulse was small, quick, contracted; burning heat over the whole body, with cool, clammy sweats in the face
and on the extremities. By external examination of the abdomen, I found in the
right inguinal region an elastic swelling, which gave him much pain by pressing
upon it, and gave me the idea that hernia existed, although the patient assured
me that he had never had a rupture. By more careful examination, it was evident
that a hernia which had just arisen existed.
" As twelve hours had elapsed since its first appearance, and the taxis proving
of no service, I did not longer delay the application of the proper remedy. On
personal experience I could not depend, whether homeopathic remedies were applicable in-such cases; I could not upon the experience of other homeopathists. I
indeed would not at an earlier period have believed that such a small dose could
have proved beneficial in such a case, as according to allopathic rules very large
doses of the most violent drastics are frequently given without effect. They had
already administered a few enemata of chamomile tea without effect, as it had
scarcely been possible to give them to the patient. I laid everything aside, gave
bread water as drink, and administered Nux 24, and waited for its effect. After
a quarter of an hour had elapsed eructations and vomiting had ceased, the belly
appeared less tense, and the rupture was not so painful to the touch. In about two
hours the incarceration was not only overcome, but the rupture had disappeared
without ever recurring, as far as I have had opportunity of observing in the individual sense."  (Hartmann's Remedies, p. 150.)
42                                                  (PART I.)



330                      HERNIA  OR  RUPTURE.
or even injurious; yet we have in our own experience the most
conclusive evidence, that when the part becomes inflamed, the frequent application of cloths wet in water, as hot as can be endured
by the patient (the degree of heat usually being in proportion to
the intensity of the inflammation - higher as the inflammation increases), will be a most powerful auxiliary to other homeopathic
remedies, in restoring a healthy action in the parts. Should the
inflammation  extend  over the  abdomen, the hot cloths should
be equally extensive.*
* "The Homeopathic Materia Medica possesses already a considerable number
of remedies by which the symptoms of incarcerated hernia can be more or less simulated, but olzy a few of these have been employed up to the present time. In my
own practice, I found the greatest assistance from the following:
" Nux vomica, Acidum Sulphuricum, Lycopodium, Belladonna,, and finally I must
mention one or more remedies, which, although it does not appear in the series of
symptoms that it is capable of producing, those which accompany the formation
and incarceration of a hernia can yet not be dispensed with as an appropriate, intermediate or auxiliary remedy in certain forms of incarcerated ruptures, on account of the unlimited influence which it exercises upon the vascular, and chiefly
upon the capillary system, and accordingly not only compromises among its symptoms the type of inflammatory fever, but also the type of acute local inflammations;
farther, on account of its effects upon the mind which manifest themselves particularly in the form of inconsolable anguish, forebodings of death and great disposition to be frightened -states of mind which we not unfrequently meet with in
persons affected with incarcerated hernia; I allude to Aconitum napellus.
" The method I have hitherto adopted in the treatment of incarcerated ruptures
is as follows:
" Having convinced myself of the existence of an incarceration, I first place the
patient in a comfortable reclining posture, the chest and the pelvis somewhat raised
in order that the abdominal muscles may be relaxed as much as possible; the lower
extremities being at the same time moderately drawn up. The patient having continued in this position for a few minutes, I proceed to the selection of the remedies.
"In reference to the concomitant symptoms, we meet with three forms of incarcerated hernia, which presents materially different marks of distinction.
First Form  of Incarceration.
"The rupture has just occurred for the first time, or one that had formerly existed has reappeared, and has suddenly become incarcerated, in which case the
rupture is always small, the symptoms appear suddenly and with greater intensity;
they consist in a pinching or squeezing and pressive sensation in the region of the
rupture; violent dragging pain with periodical tearing, and a sort of spasmodic
constriction in the abdomen; nausea, inclination to vomit, and actual vomiting of
an acid mucus; obstruction, with frequent inclination for stool; most of these



HERNIA  OR  RUPTURE.                           331
Two cases are reported in the N. A. Horn. Journal (1851, p.
403), of strangulated hernia cured, one by Nux and Veratrum 3d,
given every half hour; the protrusion disappeared without taxis.
symptoms are increased by the slightest pressure on the rupture, as also by movement.
" Nux vomica corresponds with symptoms of this form of incarceration.  I accordingly give ten to fifteen globules of one of the higher potencies every half hour,
or every hour. Frequently a remission of the symptoms takes place after the first
dose or two; if, at the same time a sensation of movement takes place in the rupture, or if gurgling noise be heard, then a remission of the incarcerating muscular
contraction and a speedy replacement without any external treatment may be expected. Should this not be the case, but, on the contrary, the sufferings return
again with unabated vigor; or if an oppressive soreness or pain, as if from a wound
and a violent burning, prevail in the region of the rupture, and the superincumbent
teguments become very sensitive to the slightest touch, or if the heat in the affected
parts increase, and thus betokens an increased determination of blood towards these
parts; or should the incarceration have been preceded by a fright or some other
mental affection, and the patient be in a state of general irritation or excitement,
then I usually give one drop of Aconitum of the third to the sixth dilution, and an
hour afterwards, Nux vomica at a lower dilution than in the first instance, and in a
liquid form in preference (Nux vom. two drops x-xv, Aq., destill. oz. ij), a teaspoonful every half hour to an hour.
Second Form of Incarceration.
"The rupture becomes suddenly incarcerated and is generally small; tearing,
dragging pain, both in the rupture itself and' in the whole abdomen, predominates;
the patient sometimes experiences fugitive stitches in the region of the rupture;
the pains undergo periodical remissions- disappearing almost entirely for a time,
and then returning with increased violence: the patient feels much exhausted during the remissions; he complains of a general sensation of cold, the abdomen is
much distended by flatus; often a continued desire to vomit; the patient eventually
vomits an acid-tasting fluid, and, notwithstanding a very urgent inclination for
stool, no evacuation takes place.
"In this form of incarceration likewise, Nux vomica is an excellent medicine,
but Lycopodium vies with it in efficacy. I generally administer both these medicines alternately, at intervals of one to two hours. If, however, these symptoms
appear in a crural rupture, if they take place in a woman, or has the incarceration
in the latter case taken place during or immediately after the appearance of the
menses, and if, moreover, the individual is of a mild, yielding disposition, Lycopodium is to be preferred. I give this medicine in the middle attenuations (10-15)
either in globules or in the liquid form (Tinct. Lycopodium, drops x -v. Aq. destill. oz. j), a teaspoonful every half hour, or every hour. If throbbing, burning,
and other symptoms indicating Aconitum becomes predominant, administer the
latter as an intermediate remedy.



332                     HERNIA  OR  RUPTURE.
The other, Aconite and Veratrum.  There were present stercoraceous vomiting, great prostration, &c.
Time is a matter of vital importance  in this case; therefore,
when we have made use of the remedies heretofore directed or any
Third Form of Incarceration.
"The third form of incarcerated hernia (which occurs chiefly in aged persons,
and in ruptures of long standing, that have for the most part been kept back by
appropriate bandages, or have been continually protruding, and have attained a
large size), is that in which the incarceration comes on insidiously and imperceptibly, and betrays itself at first only by a distressing, pinching, and constrictive sensation of the region of the rupture, by uneasiness and fullness in the abdomen, and
by periodical sickness and constipation. The rupture is not very painful to the
touch, the incarcerated part is also not so tense and hard as in the two preceding
forms, but feels more doughy. This incarceration may often exist for days, without any perceptible increase in the concomitant symptoms; gradually, however,
twitchings and pinchings, combined with periodical transitory tearing pains, supervene in the abdomen and groin; the sickness then becomes more lasting, a sweetish, saline, or bitter fluid is sometimes eructated, and is not unfrequently followed
by vomiting, of a watery fluid, and subsequently of ingesta.
" In this form also two medicines concur; and the one is again Nux vomica,
which competes with Acidium sulphuricum for the rank of priority. If the patient
is of a sanguine-choleric temperament, which, however, is but seldom the case,
Nux vomica, at a low dilution, must be given first; and should the removal of the
incarceration not be effected within twelve hours, Acidium sulphuricum must be administered. If the incarceration takes place on the left side, and the patient is of
a melancholic-phlegmatic temperament, Acid. sulphuricum should be employed from
the beginning. I have hitherto been in the habit of prescribing in the disorder in
question, a drop of the tenth dilution of this medicine to be taken every hour. By
means of the foregoing treatment of incarcerated hernia, I say it with heartfelt joy,
I have always more readily and more frequently succeeded in attaining the desired
result than was the case in my former practice, when I treated my patients in accordance with the principles of the old school.
" If my assistance was sought sufficiently early, it formed a rare exception to
the rule when an incarceration of the first and second form was not removed within
eight hours, and that of the third form within twenty-four hours. Still more rarely
did it happen that homeopathy can not yet renounce the operation as the last resource in the treatment of incarcerated hernia. Whether this will ever be possible,
I shall not investigate here; we may, however, presume with every appearance of
certainty, that those cases in which the operation is now deemed indispensable,
will become more and more scarce, the more closely that the re-provings of medicines
yet unknown or untried, will be discovered to approach in similarity individual
forms of this disease.
"If the homeopathic medicines do not remove the incarceration within a given
space, to be determined by each individual case, but if on the contrary, symptoms
of a more troublesome and dangerous character make their appearance; if not only



HERNIA  OR  RUPTURE.                        333
that may be indicated by the symptoms (bearing in mind that if
they do not act promptly, they will not probably be serviceable at
all), and the case still remains obstinate, the danger every moment
increasing, we must resort to the operation or some efficient means
for producing muscular relaxation, so that the hernia can be reduced without the knife. We prefer to try the latter first. For
this purpose we have used, with success, Lobelia inflata in doses
sufficient to produce aperfect flaccidity of the muscular system. It
may be used in the form of the saturated tincture, the etherial oil
or liquid extract. Begin the former in half drachm doses, the two
latter in one or two drop doses. It should be given in repeated
small doses, the minimum dose at first, a little more at the end of
a quarter of an hour, double that amount in ten or twelve minutes,
and so on, increasing the quantity and diminishing the intervals,
until you have brought his system  completely -under the relaxing
influence of the medicine; meanwhile use warm  enemas of the
same. If we need to bring about still greater relaxation, this may
be effected by enemas of tobacco, though it is necessary to be cautious in the use of this "poisonous weed," as very little will occasion dangerous symptoms in some patients, while others can take
it with impunity and advantage. In injecting, use a large syringe
with a long pipe, and have the patient retain what is thrown up as
long as he possibly can. The relaxing enemas should be repeated
once an hour, if not oftener.
When you have brought about complete muscular relaxation,
have the patient turned in the proper position (if he is not kept
the rupture itself, but also the abdomen and the epigastric region become very sensible to the slightest touch; if the existing pains and the tension of the abdomen
becomes more intensely violent; if nausea, the inclination to vomit and the vomiting itself increase and the patient vomits more liquid than he has taken, even during the prevalence of excessive thirst; should traces of bile or of other intestinal contents be discovered in the matter ejected; if high fever, with a hard, full pulse supervene and the patient becomes more and more restless, it is to be presumed that
the medicines administered (although no others can be found that correspond better with the form of the disease under treatment) are either not strictly homeopathic to the case or they have been employed in an improper dose, or finally, that
the medicine appropriate to this individual case is as yet unproved, and therefore
unknown. Under such circumstances I never hesitate for a moment to propose an
operation and, if the patient consents, to perform it as soon as possible." (M.
Traub, Allg. Horn. Zeit., No. 12, 31st.)



334                     HERNIA OR RUPTURE.
in it all the time) and endeavor to effect reduction- as often as
you can do so without causing pain. So long, however, as there
is much tenderness, attempts at the taxis have little chance of
doing good, and may do much harm.
But the application of the large cup to the abdomen, is unattended with any risk of increasing the inflammation. The intestines themselves, it should be remembered, may be quite free from
inflammation, though the integuments over the sac are tender to
the touch. There is great danger of the peritoneum becoming inflamed, but this is not likely to be more in the natural than in the
abnormal situation of that delicate membrane.
The relaxing measure should be kept up, even though the patient appear much prostrated. They may, however, be carried to
an unsafe degree, and your judgment must be exercised in the
case according to the symptoms. There is no danger, however,
with the articles recommended (except the Tobacco) of any such
permanent prostration as follows from the use of tartarized antimony.
The enormous doses of Lobelia formerly used by the Thomsonians, bringing on the " alarming symptoms " without any danger to
the life of the patient, prove that we need be in no great fear of killing our patients, though we may have a medicinal disease to treat
afterwards. But even the danger and the after disease from'the
use of the Lobelia, are by no means to be so much dreaded as the
danger and death of the patient so often following the use of the
knife, even in the most skillful hands.
We were consulted in a case in February, 1855, in Cleveland,
then under the care of two homeopathic physicians: an Irishman,
with strangulated hernia (Scrotal).  The tumor was exceedingly large, the patient in extreme agony - all attempts to reduce
it by taxis had failed, and it was evident that unless relief was afforded soon he must die. Instead of the operation, we advised Tobacco injections, which produced such a state of relaxation as to enable the attending physician to return the protrusion by taxis. Should
twelve hours elapse without any favorable change, recourse should
be had to the operation. Bear in mind, that with this extreme
measure the chances are three to one against the patient.  Give
him the benefit of it, however, when it is his only chance, or you



'336                 HERNIA OR RUPTURE.
IN RECENT CASES OF RUPTURE in young and healthy persons, a
simple truss alone will sometimes excite adhesive inflammation, and
prevent the necessity for its further use, —the parieties of the abdominal canal or femoral sheath effectually coalescing. But to insure any probability of this desirable result, or for safety against
a relapse,
- THE TRUSS should be made to extend from the point of first
emergence out of the abdominal cavity, to the point of external
protrusion beneath the integument,- from the Internal to the External Abdominal Ring,-so as to compress the whole Canal or
Sheath through which the viscera have passed.
This measure alone cannot be relied on unless applied soon
after the accident that caused the original rupture. The patient,
moreover, must be kept quiet for several days after the first application of the truss; and whenever it is removed, he should assume the horizontal position, and not be allowed to move until it
is securely fixed on again.
In ADULTS, the truss rarely succeeds in effecting the radical
cure, even under the most favorable circumstances.
The numerous cases to be met with in every civilized community, sufficiently attest the truth of this last remark. One medical
statician has even estimated that one-eight of the human family is
in the ruptured condition! He must, certainly, have lived among
a weak-bellied race. Still, however extravagant may be this estimate, far too many are everywhere suffering or living in fear of
death from this common accident; and this, too, where every drug
store or apothecary shop is well supplied with trusses of every
imaginable form and character, not a few of which claim to be
all-sufficient for a complete cure.
We believe it is pretty generally admitted by the most eminent
allopathic surgeons of the present day, that the only plan that
furnishes any reliable probability of a radical cure, is an operation
with the knife. But this operation is not even one of the " kill
or cure" resources.  It may kill; and when it does not, may
leave the evil operated for as bad as before, or worse. The risk
is without anything like an equivalent chance of benefit. Hence,
indeed, but few persons are tempted to try in such a lottery of
life.  The clumsy mechanical resources of the truss has to be still



HERNIA OR RUPTURE.                    337
resorted to, without any hope of ever dispensing with such an artificial safeguard.
We have carefully examined all the published reports and have
not been able to find the record of any case of Inguinal or femoral
hernia, which had existed for years, in an adult, cured by internal
remedies; nor even of umbilical (of years' standing in an adult),
except the one of Dr. Hunt's. Hernia in children, and recent cases
in adults, have been cured. Incarcerated hernia has been relieved,
— the inflammation subdued and the reduction of the tumor effected, or rendered feasible by the internal remedies. But there
the record ceases, there the case is left.  The truss, with great
caution, is the patient's only safeguard. He is doomed to undergo
the inconvenience and suffer the fear that necessarily attaches to
such a condition, during his whole life; or submit to the dangerous and uncertain expedient of an operation for radical cure,
as recommended and practiced by allopathic surgeons. Such is
the condition in which this case is left both by allopathic and
homeopathic authorities.
To any one acquainted with the anatomy of the parts concerned in this accident, it is obvious that any mode of treatment,
be that medical, mechanical, or surgical, which will effectually
close the sheath, canal or opening through which the protrusion
takes place, will be effectual; and without such a safeguard, such an
adhesion of the parieties of the canal or orifice to each other,
or to their contained parts, so as to effectually prevent future distension, and bar the re-entrance of the intestine, no safety exists
or assurance can be given against the return of the accident, at
any future period.
It is well known that inflammation excited in these parts, tends
to produce adhesions, and if the parieties of the canal or orifice
can be kept in contact, and in that situation a moderate degree of
inflammation excited, adhesions will take place, effectually closing
it. This simple, safe, and efficacious plan for obviationg a dangerous surgical operation, and yet curing Hernia more effectually,
was hit upon by that eminently practical surgeon, the late muchlamented Prof. T. V. Morrow.
The necessary inflammation was induced by simply using an
43                                    (PART I.)



338                      HERNIA  OR RUPTURE.
irritating plaster.* From observing the effects of that application
in a variety of other cases, Dr. Morrow came to the conclusion
that it was just the thing wanted, to insure the requisite adhesion
of any parts of the abdominal parietes involved in hernia. He
had long been dissatisfied with the ordinary means resorted to for
that purpose. Since his first report of a case so treated and permanently  cured  [See Medical Reformer, Vol. VI., No. 1, for
July, 1846], the plan has been extensively adopted with the most
satisfactory success. No failure, so far as we have been able to
ascertain, has occurred in a single instance.t
* The plaster he used was made by adding to I quart of Tar (to which 4
ounces of Rosin had been added, and boiled to evaporate the water from the tar),
2i ounces each, of finely pulverized Sanguinaria,Phytolacca,Podophyllum and Arum
triphyllum, mixed and stirred together when not quite scalding hot.
t THE PLASTER made use of should be large enough to cover the whole canal
or sheath,- say from two to two and a half inches wide and from three to three
and a half in length,- and the PAD of the truss should be nearly as large as the
plaster.
The PART to which the application is to be made should first be smoohtly
shaved; the plaster laid on carefully, the pad over it, and a truss brought to press
with considerable force, as much as the patient can bear.
The COMPRESSION, however, will have to be gradually lessened as the parts become tender. When the truss is taken off for this purpose, or to re-spread the
plaster (which should be done every day), the patient must be made to keep perfectly still in a horizontal posture, with the thigh flexed on the abdomen. After a
while the truss will become too painful to be borne; when a large compress must be
substituted, and carefully kept in place by bandages round the body. The patient
had then better keep to his bed on his back. When obliged to move at all, he should
be directed to apply his hand to the compress, as a further security against accident.
The purulent discharge excited by the plaster, so frequently renewed, will
be considerable. If the pain and irritation should at any time be so great as to
deprive the patient of sleep, or extend downward along the spermatic cord to the testicle, remove the irritating applications for a while and substitute an elm poultice.
The suppurating process should be kept up for from three to four weeks. Probably a
shorter time would in most cases suffice; but it is better to err on the safe side.
Better let the patient suffer a week too long than run any risk by giving up this
essential part of the treatment a single day too soon.
The surface may be allowed to heal as soon as the plaster is removed. Dress it
first with an emollient poultice, and then with simple cerate.
The TRUSS should be reapplied, as soon as it can be borne again, and kept on
for eight or ten weeks longer. All applications may then as a general rule, be



HERNIA  OR RUPTURE.                          339
UMBILICAL  AND  VENTRAL  HERNIA.
Both these consist in a protrusion of the intestines or omentum
through the parieties of the abdomen.  When the navel is the
point of protrusion, it is umbilical hernia, to which  infants are
most subject a short time after birth, from their straining the abdomen in crying, while the bandage around the body securing the
umbilical dressings is too loose. It sometimes occurs in parturient
females, the muscles giving way during their powerful contractions
upon the gravid uterus. It may be produced in any individual by
any force applied to the abdomen sufficient to rupture the muscles.
Hernia may occur at any other point along the Linea Alba, or, indeed, at any other part of the abdomen, though it would not be
called umbilical, but ventral. "Ventral Hernia," then, means an
abdominal protrusion at any other point than the Umbilicus, Abdominal Ring, or Femoral Sheath. True Umbilical Hernia is very
rare in any others than infants.
The proper TREATMENT is the same in principle, whether for
an infant or an adult, and whether the accident occurs at one point
or another above Poupart's Ligament.
First, for the REDUCTION of it, place the patient upon his back,
discontinued. The pressure, however, should be gradually lessened, before being
entirely taken off, and the part frequently bathed in cold water. This CURE will
be complete and effectual.
In addition to the means originally devised by Dr. Morrow, we have had reason
to believe that advantage resulted in some cases from a few drops of the oil of eggs,
rubbed on the parts, once or twice a day, after the removal of the irritating plaster.
(This oil is obtained by simple pressure, from the heated yolks.) This article which
seems to have the effect of promoting adhesion is one of the principal agents relied
on in a patent for the cure of Hernia.
The other means relied on in this tolerably successful secret treatment, are a
pad, truss and plaster. The plaster is an extract obtained by boiling equal parts
of the barks of Hemlock, White oak, common break (Pteris aquilina, -probably
the rock-break, Pteris atropurpurea), and green osier (Cornus circinata). This is
removed once in three or four days, and the surface lubricated with oil of eggs.
As the cure progresses, the round leather pad is diminished in size.
One precaution is necessary. It is absolutely essential to success, that NO PROTRUSION takes place during the period of treatment. The danger is greatest when
the sore is most irritable; and if the patient is not then warned against much
straining or motion, all treatment may easily prove a failure. Present restraint
is the indispensable condition on which future freedom of action may be insured.



340                HERNIA OR RUPTURE.
with the thighs flexed upon the abdomen and the shoulders a little
elevated.
In this position, the protruded portion will generally return
spontaneously. If not, it can be easily pushed back by applying
the fingers to the tumor. The taxis accomplished, apply a TRUSS,
under which a pad should be placed, made as follows: Take a circular piece of the thick spongy portion of sole leather, of the proper
size to cover the opening and extend from one and a half to two
inches all round it. Have the pad regularly concave, the center
of the depression being about half an inch below the plane of the
circumference. Place the patient in the position above described,
and bring the parieties of the hole in the muscles in contact, so as
completely to close the orifice, by pressing from the sides, while
the muscles are in this relaxed condition. The edges being thus
kept in contact, apply, directly over the point of protrusion, a
layer of raw cotton or soft lint, wet with Calendula. This application should be just large and thick enough to fill the excavated
surface in the leather, without causing any pressure. Apply the
leather pad over it, and secure it by a bandage passed round the
body, sufficiently tight to compress the muscles, and keep in contact the parieties of the hole. It is better to fasten the pad to the
bandage before it is applied. This should be kept on six or eight
days without being removed, unless it produce too much irritation.
It should be wet once or twice a day with the medicine, by applying it above and allowing it to soak through the cotton.
In INFANTS, a sufficient amount of adhesive inflammation will
generally take place in three or four days to unite the parts;
though this dressing should be continued for ten or twelve days,
diminishing the strength and pressure gradually. A bandage tight
enough to support the muscles, and to prevent distension of the
abdomen, should be worn for several months, and the part washed
daily with Calendula. In an ADULT, it may be necessary to wear
the first dressing for a month or more.
When it becomes necessary to remove the dressings during the
treatment, great care should be taken that no protrusion then occur. The patient should be placed in the same position as when
the first applications were made, and the parietes of the abdomen
should be firmly held by an assistant, so that no motion will be



HYDROCELE.                        341
allowed at the point of protrusion, and the muscles will not be put
upon the stretch. The dressings should never be removed when
the intestines are full. Great care should be taken to prevent costiveness. If the patient be in poor health aside from this, the
proper attentions should be bestowed upon his general system.
CHAPTER XXX.
HYDROCELE, -MEDICAL AND MECHANICAL TREATMENT.
HYDROCELE - causes and varieties - diagnosis - dropsy of the cord   " congenital hydrocele" — Repressive Treatment - Gum-Elastic Bag, &c. - a RADICAL
CURE without the operation-Directions for OPERATING and after-treatmentmeans for avoiding re-accumulation of fluid -Hydatids -Treatment of Dropsy
of the Cord - of congenital hydrocele - hydrocele with anasarca - hernia and
other complications.
HYDROCELE,
-OR DROPSY OF THE TESTICLE, is quite a common disease.
There is sometimes an cedematous condition of the scrotum, with
serous effusion throughout its cellular tissue, which may be mistaken for true hydrocele, - as also, on a superficial examination,
may scirrhus or any other cause of swelling in the part.
" Hydrocele " is limited to a collection of serum  in the tunica
vaginalis, a serous membrane enclosing the testicle. It is but an
abnormal quantity of the fluid naturally secreted to protect and
allow free motion to the part. The immediate cause of the disease
then, may be either increased secretion or diminished absorption.
It may affect persons of all ages, and even exist at birth.
The swelling begins at the lower portion of the scrotum, or
rather the accumulation naturally sinks and first shows itself there;
gradually becoming diffused and extending up towards the abdominal ring. The tumor is finally pyriform in shape, and elastic to
the touch, - or it may be described as feeling like a bladder distended with water. It gives no pain on pressure, unless the testi



342                       HYDROCELE.
cle itself is pressed upon. The skin of the scrotum retains its
usual wrinkled state, even though the part may attain an immense
magnitude, the serous bag within sometimes containing a pint of
fluid. Thefluid itself is usually crystalline or colorless, occasionally
yellowish.
It rarely happens that both sides of the scrotum are effected
with this disease at the same time; more on the left than right
side.
The diagnosis of this disease is sometimes difficult. In order
to come to a satisfactory conclusion, you should examine into the
history of the case. Recollect that hydrocele proper begins in the
form of a tumor at the bottom of the scrotum, and gradually ascends; while anasarca of the scrotum is more diffused, pits on
pressure and is generally attended with anasarca of other parts or
ascites. SCIRRHUS of the testicle presents a uniform enlargement,
is also accompanied with pain, and quite heavy, feeling to the patient and the examiner like a ball of lead. In hydrocele, moreover,
when recent, before the membrane thickens, the whole mass of the
tumor below the substance of the testicle is transparent or translucent, -as may be ascertained by placing it, when the room is
darkened, between your eye and a lighted candle. It may be distinguished from scrotal HERNIA, by observing that in the latter
case the tumor commences above instead of below, and if the patient coughs, the swelling will be enlarged, and a distinct impulse
imparted to the finger pressing on it.
The CAUSE of the effusion must be inflammation of the serous
membrane itself, but that may be occasioned by disease of the testicle, by direct external influences, or by metastasis from other
textures of the same order. Most generally the cause can not be
ascertained.
When there is enlargement of the testicle in connection with
the serous accumulation, the case is called " HYDROSARCOCELE."
HYDATIDS may occupy the tunica vaginalis, and present the
appearance of hydrocele, and be mistaken for it.  The two diseases not unfrequently coexist, hydatids occupying a part of the
cyst, while fluids accumulate in another part. These parasitical
growths may adhere either to the serous membrane, the epididymis, or the substance of the testicle. This state of things can only



HYDROCELE.                      343
be ascertained by the protruding of the cysts in question out of the
wound.
HYDROCELE OF THE SPERMATIC CORD occasionally occurs, sometimes alone, sometimes in connection with effusion in the tunica
vaginalis. It occasions an oval tumor near the abdominal ring,
or it may be even in the canal above the ring, having so strong a
resemblance to INGUINAL HERNIA, as to be easily mistaken for it.
It is, however, free from pain, and translucent, and does not go
down and disappear, on placing the patient in a recumbent position, as will be the case in hernia, unless it is strangulated, when
the nature of the case will be but too evident from other symptoms.
Dropsy of the cord is also to be distinguished from VARICOCELE, as
will be noticed under that head.
CONGENITAL HYDROCELE has some peculiarities; and cases of
the same kind, which occasionally occur in after life, are incorrectly
called by the same name.  The original connection between the
tunica vaginalis and the peritoneum, of which it was a part, continues, and the fluids that collect in the cavity of the abdomen descend and accumulate, generally producing dropsy or "hydrocele"
of the tunica vaginalis as well as of the cord. This may be distinguished from  common hydrocele by placing the patient on
his back and raising his hips, when the swelling will entirely recede, but instantly reappear when the erect position is assumed.
The other symptoms of hydrocele, as transparency, &c., have to
be also considered, as the affection may be mistaken for HERNIA,
with which it may also co-exist (the same cause occasioning liability to both).
TREATMENT.
If the cause is known, that will often aid us much in the selection of the appropriate remedy. When the disease is the result
of an injury, Arnica should be used.
This remedy is also applicable when the swelling is of a bluishred color, large, or when it involves the penis. It is also applicable in congenital cases.
Conium is successful when it arises from a mechanical injury
and there is swelling and pain in the testicle.



344                      HYDROCELE.
Rhododendron; especially when the hydrocele effects the left
side. Four doses, one every eight days, cured a hydrocele in a
boy of eighteen months.
Graphites; in persons subject to erysipelatous affections, eruptions, with constipation; and for dropsical affections of the scrotum
and prepuce as well as for hydrocele.
Puls.; in recent cases, or in young children, or when the swelling is of a bluish-white color, when the patient has the Pulsatilla
temperament, or when it is the result of metastasis. It may be
sometimes followed by JDigitalis with advantage.
Digitalis- the scrotum looks like a bladder filled with water.
Sulphur is sometimes useful when there is a psoric diathesis.
Besides the foregoing remedies, the following may be consulted:
Mer., China, Aurum, Lye., Nux v. and Silicea.  The latter especially for scrofulous patients.
Psoricum  30, two doses, one every eight days, removed an
accumulation of water in the tunica vaginalis testis; the sequel of
repressed inflammation from the pressure of a truss.
Dr. Sterns related a case of hydrocele cured with Silic. alone.
(Ger. Cong., 1852.)
Dr. Francis Black reports a case of hydrocele of the right side
in a man, produced by an injury, which had been twice tapped,
the water drawn off and tincture Iodine injected, without effecting
a cure.  The hydrocele reappeared several months after and became very large, causing by its size and weight great discomfort.
The cord was also swollen, appearing like hernia descending to the
scrotum.  It was cured in four weeks by  Graphites 12 and
Silicea.
Another case- a child three months old, cured in three weeks
with Graph. 12.
PRESSURE on the scrotum, as well as suspension of it, will
greatly stimulate absorption. Some convenient means of making
equable pressure on this part was long wanting. This is supplied
by an India-rubber bag. The bag should be so small as to require
considerable distension to get it on. We have found it convenient
to have it previously distended to the requisite size by two or three
coils of watch spring, which can be drawn out when it is on. An
improvement is an elastic open ring at the mouth, which may be



HYDROCELE.                      345
conveniently pulled out at any time when it is required to wet
the surface with any medicament.
We have succeeded by this new means in avoiding the operation
and effecting a RADICAL CURE in several severe cases. In slighter
forms of the disease, we have often found it suffice.
In some cases of long standing, where the quantity of fluid is
large and the tunica vaginalis thickened and insensible, external
and constitutional means will not be sufficient. We must then
resort to the long-established
OPERATION,
for the purpose of removing the fluid, and preventing its reaccumulation by such means as will substitute adhesive for effusive inflammation between the folds of the tunica vaginalis.
As this operation is a very simple affair, we give directions how
to perform it in this connection. Taking hold of the scrotum from
behind, and stretching it tense, make an incision through the integument with a scalpel or bistoury (at any point not too elevated
or too near the septum or raphe, between the two sides). Through
this cut, introduce the trochar inclosed in a canula, and push them
on into the sac in such a direction so as to avoid the testicle.
FIG. 14.
This can be held up out of the way by the left hand, though the
contraction of the cord on handling the part (which may be made
44                                        (PART I.)



346                      HYDROCELE.
more effectual by previously applying cold water to the scrotum)
will generally draw it out of danger. Withdraw the trochar, and
push the canula further on into the sac, and fix it there until all
the morbid accumulation has drained off, taking care to allow none
of it to pass into the cellular tissue of the scrotum (where it would
cause inflammation and perhaps sloughing).
If a trochar is not at hand, all the parts may be cut through
with the bistoury, and a catheter or any tube about the size of a
goose quill will answer for the canula.
After having drawn off the fluid by means of a canula, inject
through it Arnica tincture, diluted four to one with water. This
is to be left there until it produces considerable smarting or pain;
then drawn off and the canula be removed.  Take care never
to take away the canula until the injection is all withdrawn, or the
membranes may contract upon and retain it, producing more mischief than the natural secretion that has been removed. After the
removal of the fluid and canula,- insert a TENT (or strip of linen)
far enough in to remain, and keep up the inflammation; and prevent the external orifice from closing. Remove it from day to day
and apply another, until a sufficient amount of adhesion has occurred.
If too high a grade of inflammation should be excited, the tent
must be laid aside, and the means to subside it be employed. One
of the best local means in such a case is to let the patient sit over
the vapor of hot water, after which emollient poultices can be applied until the inflammation has subsided.
This operation for hydrocele is generally effectual. In some
chronic cases, however, it may be necessary to employ something
more powerful; a solution of the Sesqui-carbonate of potash will be
good.
Great care is to be taken in performing this operation, not to
injure the testicle, nor allow the lancet or trochar to pass through
the opposite fold of the tunica vaginalis, so as to make an opening
into the cellular tissue on the outside, and cause a diffused inflammation there.
If, after drawing off all the fluid, the tumor does not entirely subside, it is presumptive evidence that it is partly caused by HYDATIDS.
If the latter protrude, the nature of the case is sufficiently plain.



DISEASE OF THE TESTES.                     347
If they do not present themselves thus spontaneously, and there is
reason to suspect their existence (which cannot be known with absolute certainty beforehand), make a large opening and squeeze
upon the tumors, when more or less of them will be pushed out,
enclosed in their proper membranes or cysts.  They may be all
dissected away with the knife by laying open the scrotum sufficiently, or clipped off with scissors. This operation is very painful, but generally effectual. Clipping off a considerable portion
and letting out their contents may be sufficient. The smaller ones
or parts that remain will most likely be obliterated in the progress
of the cure, especially if tents are used.
CHAPTER XXXI.
DISEASES OF THE TESTIS, CONTINUED.
HEMATOCELE -Distinction of symptoms and treatment from Hydrocele.
VARICOCELE - Symptoms and progress - compression, &c.
SARCOCELE -early means or final castration.
FUNGUS TESTIS, Soft Testicle or "Hernia humoralis "-its connection with gonorrhea, and treatment accordingly.
ORCHITIS proper - various causes, symptoms and consequences- treatment.
IRRITABLE TESTES - obscurity and complexity - treatment.
CHRONIC ENLARGEMENT, and other diseases of the testes -causes and dangersearly treatment, or the radical cure.
HAEMATOCELE.
THIS is the name given to a swelling of the scrotum, resulting
from a collection of blood instead of water in the tunica vaginalis.
The extravasation, however, may be in the tunica albuginea (within the vaginalis), or simply an effusion into the cellular membrane
of the scrotum.
It may RESULT from blows or other injuries of the scrotum or
spermatic cord. A frequent cause is the wounding of some large
vessel in operating for hydrocele.
The DIAGNOSIS of haematocele from  hydrocele depends on its



348                DISEASES OF THE TESTES
greater solidity and weight, and being neither transparent nor
fluctuating. The history also will frequently determine the nature
of the case. The external parts are often thick and black, as in
venous infiltration. This may at first occasion suspicion of gangrene; but the color is the only point of resemblance, and the
general system is not at all affected.
The TREATMENT should first be directed to arrest any inflammation that may be present by the use of the proper specifics and
the external application of warm vapor or water —cold water as
used by some, is rather dangerous; as it lessens vitality too much
and may hasten gangrene, when there is any tendency to it.
If from contusions or any other mechanical injury, Arnica,
internally and also as a local application.
Other cases require Puls. or Zinc, or Nux. v., Rhus., and Sulph.
If these means fail, the scrotum may be laid open, the coagula
evacuated, and the wound allowed to heal by granulation. If after
this operation there should be trouble from fresh hemorrhage, the
bleeding vessel must be found and tied.
Many persons have been very unjustifiably castrated for this
disease, the only benefit resulting from the loss of the sound testicle being the removal of the blood, which might have been done
as just directed.
VARICOCELE.
The disease so called from analogy to the other names of surgical diseases of the parts, is simply a varicose condition of the
veins of the spermatic cord.  As might be expected from the
length and unsupported position of these veins, they are more
liable to this relaxed and diseased condition than any others. The
left cord is more liable to this state than the right, perhaps from
obstruction to the return of its blood at the sigmoid flexure of the
colon, as well as from its greater length. The distended part of
the cord assumes a cone-shape, with its apex upwards, generally
extending from the testicle as a basis up to the abdominal ring.
The veins can be separately felt, rolling under the fingers like
twisted cords.
There is a constant uneasy sensation in the part, neuralgic



DISEASES OF THE TESTES.                  349
pains not unfrequently extending down into the testicle, —which
is often diminished in size, from the proper amount of nutritive
fluid being prevented from reaching it.
The swelling sometimes increases so much as to be inconvenient
from its mere bulk, especially if the individual attempts to ride on
horseback.
In the TREATMENT of this disease, great care should be taken
that the testicle be kept suspended, so as not to pull upon the
cord in the least. When the difficulty has arisen from a mechanical injury, Arnica is the remedy. If the vessels are at any time
unusually swollen and painful, benefit may be derived from a dose
or two of Aconite with the wet compress; Laurie recommends in
most cases to commence with Pulsatilla and follow with Lachesis,
particularly when the vessels present an extremely livid appearance.  When severe burning pains are present in the tumor, Arsenicum or (arb. v. should be exhibited — Nux. v. if constipation
be present and neither Pulsatilla nor Lachesis is indicated -this
may frequently be followed with advantage by Sulphur.
These means frequently succeed in affecting so much relief that
the patient suffers no sensible inconvenience. In two instances, one
of them a student of medicine, we succeeded in effecting a cure,
and by nearly the same means as for the radical cure of hernia. If
these fail, resort may be had to the NEEDLES. These are inserted
behind the veins so as to cause them, with the help of pressure
from a ligature, to close by adhesive inflammation. Great care,
however, must be taken that neither the Vas Deferens nor the
Spermatic Artery or Nerve be wounded by the needle, or compressed by the ligature,-as any obstruction to the flow of blood
through the artery, or the seminal secretion through the duct,
would be fatal to the testicle.
SARCOCELE.
This, as the word implies, is a fleshy or flesh-like tumor of the
testicle. The most common form is a simple enlargement of the
testicle, depending upon chronic orchitis.  The tumor is then
smooth and almost painless, its weight being the  principal
source of inconvenience. This termination of inflammation in the



350               DISEASES OF THE TESTES.
part is most common in persons of a scrofulous diathesis, but occurs
in others.
Sometimes there is an accumulation of fluid in the tunica vaginalis, at the same time constituting hydro-sarcocele.
Occasionally the tumor is attended with shooting pains, extending to the loins and back, enlarges and becomes knotty and
irregular; and if not checked, ulcerates, forming a (phagedenic)
ulcer with indurated edges, which discharges a very offensive
matter; sometimes, however, from the ulcerated surface painful,
hemorrhagic fungus shoots out. When not too far advanced to terminate in resolution, we may generally succeed with one or more
of the following remedies-Agar.,Aur., Clem., Graph., Lye., Rhod.,
Sul.; but if not, the simplest and safest treatment is castration
at once, before a malignant character shall have been fully developed and other parts become affected.
THE SOFT SWELLING OF THE TESTICLE, SWELLED TESTICLE, SOFT
TESTICLE, OR FUNGUS TESTIS,
- is not an unfrequent affection, which is still called by a sort
of double misnomerHERNIA HUMORALIS."
This species or result of orchitis is most commonly the consequence of gonorrhea, or rather of its " cure," making its appearance about the time the gonorrheal discharge ceases, or is suppressed. Sometimes it sets in suddenly while the gonorrhea is at
its height, a metastasis seeming to occur to one of the testes or
both. It may shift again from one to the other.
The only symptom for awhile is the swelling of the testicle,
which, however, soon becomes painful. The hardness eventually
comes on, which is at first confined to the epididymis; and the pain
extends from this part along the course of the cord to the lions.
Symptomatic fever generally occurs with nausea and vomiting.
If the disease continues for a long time, a permanent enlargement of the testicle is the consequence; but it frequently subsides
in a few days or weeks, at most, leaving no permanent injury. If
it occurs during the height of the gonorrheal discharge, it will
generally subside on the gonorrhea being re-established.



DISEASES OF THE TESTES.                 351
If there is much fever and inflammation use first a dose or two
of Aconite, and then the specific remedy, which is generally Mercurius or Pulsatilla, or Aurum, Clematis, and Nitr. ac.  Puls.
seems to be especially adapted to those cases arising from the suppression of gonorrhea (or when there is a painful drawing and
stretching along the spermatic cord to the inflamed testicle, both
feeling bruised when touched.) Mere., to a swelling of the testes remaining after gonorrhea. (Hartmann prefers 2d or 3d Trit. Mere.
Sol).
In all cases preserve as far as possible the horizontal position
and use the suspensory bandage - and when much pain and inflammation, the vapor or fomentations of warm water.
Mere. Sol., 5 doses, removed a swelling of the testes remaining
after gonorrhea.  Symptoms -" Testes hard and swollen, the size
of a hen's egg, violent drawing pains coming on with a jerk,
reaching from the testes to the abdomen and down to the foot;
Scrotum, especially the right side, red and shining, tingling in the
right testis. Violent chilliness alternating with heat, vertigo and
feeling of the whole body as if bruised, tearing pains in the head,
especially the right side. Pulse somewhat feverish."
In a case of swelled testicle from the suppression of gonorrhea,
which did not yield to the specific remedies alone, the application
of cold wet compress over the lumbar region speedily caused a return of the gonorrheal discharge and consequent removal of the
swelling.
ORCHITIS,
Or inflammation of the testicle, may arise from other causes
than that last considered, and most frequently does,- such as cold,
Erysipelas, wounds inflicted during the operation for hydrocele,
bruises, and other external injuries. In these cases the symptoms
will not at first be so violent as in the case of suppression or metastasis of gonorrhea.
SYMPTOMS.- The pain or irritation will at first appear to be
near the bladder, and in the spermatic cord. Very soon the epididymis will swell; and then there will be a general enlargement
and thickening, with a painful sensation of the whole testicle, the
part feeling exactly as though it were enclosed in a firm compress.



352               DISEASES OF THE TESTES.
The patient suffers severely from continuous and tearing, stinging
pains, which occasionally shoot into the abdomen and groin, and
even the hips and loins, and down along the inside of the thighs.
The patient suffers great constitutional IRRITATION. The pulse
is hard, full, and quick. The tongue is always furred; skin dry
and hot; bowels constipated. If suppuration takes place, there
are rigors; and if the process is not soon arrested, the tunica
albuginea ulcerates, and the matter is thrown out by fistulous
openings, and in most instances fungous growths will appear.
An occasional CONSEQUENCE of this inflammation is absorption
of more or less of the substance of the testicle itself, so that it
dwindles away to one-quarter or one-eight its usual size.
Arnica externally and internally is the specific remedy, when
the disease has arisen from mechanical causes; preceded by a
few doses of Aconite, if the fever and inflammation should be
acute. Next to which we would place Calendula offic., both of
which should be given internally, and the diluted tincture applied
externally.  Conium sometimes removes the effects of contusions
of glandular organs.
Erysipelatous orchitis generally yields to Arsenicum; rheumatic to Bry., Bel., Rhus. Tox., or Puls., Spongia, Staphy or
Carbo. v.
Carbo., Puls., Staph, especially the latter, are excellent for
an aching pain and drawing burning stitches in the testis and
spermatic cord.
Clematis; when a swollen and indurated testicle is painful and
sensitive, and there is a drawing along the spermatic cord, sometimes accompanied with a crampy, bruised feeling when touched,
and drawing and stretching in the lumbar region, thigh, and
scrotum.
Spongia, when the pain in the swollen testicle is a crampy, contusive, choking pain, with dull stitches striking suddenly through
the part and reaching into the swollen spermatic cord.
Orchitis, when the testicle swells up to the size of a child's
head, particularly under the allopathic use of mercury, and nothing but an operation is relied on, frequently yields either to China,
Aurum, or Sulphur, Spongia, Iodium, positive electricity, or Rho



DISEASES OF THE TESTES.                353
dodendron, Chrysanthemum and Mezereum, Mere. Sol. 2d and 3d,
are excellent remedies for chronic indurations of the testes.
The vapor or fomentations of hot water and the suspensorium
should'be used as recommended in the preceding article, and the
horizontal position preserved.
Immersing the patient in a warm bath is sometimes of great
advantage.
When the acute symptoms have subsided, the disease is apt to
become chronic, just as in the case arising from gonorrhea.
If, however, we are called too late to prevent ULCERATION,
the safest way is at once to castrate - that is, to perform the operation of castration on the affected side. The reason for this is,
that the ulceration is not only liable from the peculiar structure
and position of the part to become chronic and destructive, but
malignant, endangering the life of the patient, —or (what some
would regard still more seriously), the other testicle.
IRRITABLE TESTES.
After orchitis, when the parts have assumed their natural size
and all other visible traces of inflammation have disappeared, a
state of irritation continues which is often very inconvenient, and
sufficiently important to be treated of as a separate disease. This
sequel does not follow proper homeopathic treatment. It may not
make its appearance for months after the inflammatory disease
has disappeared, and the individual appears to have become, in
every respect, healthy.  In every case we have met with, the
symptoms of spermatorrhea were present, though this is a circumstance which appears to have been overlooked by surgical
writers.
The SYMPTOMS are extreme pain in the testicle after coition,
tenderness of the whole testicle to the touch, with pain on the
slightest motion, extending to the loins and back, and sometimes
to the urethra. There is seldom any enlargement of the testes;
they may even be dwindled in size. The fixed PAIN is generally
located at some particular point, and otherwise of a neuralgic
character. The patient is apt to lie on the side opposite to that
which is affected.
45                                        (PART I.)



354                     FISTULA  IN  ANO.
Nausea and vomiting are often among the concomitant symptoms; and the patient's MIND very soon becomes dejected.
The disease may CONTINUE for a long time, even for several
years, perhaps only troubling the patient occasionally, while at
other times he is comparatively free from it.
When the testicles have the sensation of being bruised, Arm.,
Digit., Argent., Rhod., Coccul., Nat. carb., Acid oxalic. The last
five when both testicles are affected; Cocculus, especially when the
pain is very severe; when it particularly affects the right testicle,
Dig.; the left, Argen.  When the pain is of an aching character,
increased by contact and affecting both testicles, Nit. ac., Thuj.,
Phos., Scill., Canna., Sulph.  Caust., if felt especially at noon;
Bism., if the pain is confined to the right testicle, Staph., if in
the left.
The testicles should be constantly supported by suspensorium.
It is also important to keep them warm.
CHAPTER XXXII.
FISTULA IN ANO.
Interest taken in this disease? - Definitions and distinctions - Liability of anus to
fistula - Causes -Abscesses and treatment -General measures in confirmed fistulas- "The operation" exclusively relied on - Its results - Reasons for preferring the ligature to the knife- Directions for applying- and for incomplete
cases - Time for cure -Danger in pulmonary complications!
THIS is a disease as common as it is distressing, and in the
treatment of which we shall depart very widely from all established
authority. We shall therefore endeavor to be quite explicit, and
may perhaps appear too minute and particular.  This blame we
willingly bear- nay, court. The only danger is from the opposite
fault.
The author of a recent monograph on this subject, thinks it
necessary to inquire why such an affection as that in question, and



FISTULA IN ANO.                     355
one so naturally concealed by the sufferer, should be a subject of
such general interest, even to non-professional persons.
For every disease, however, there is necessarily a class of persons more deeply interested than even medical men —the sufferers and their friends.  This interest is of course more manifest in
respect to chronic disease than acute, especially when it is one of
great but gradual fatality, and of rare and uncertain cure. It is
well, perhaps that the non-professional public are not quite so indifferent about medical matters, as some professional dignitaries
would seem desirous of having them.  The people generally will
find out bye-and-bye, that it is not only their "right," but their
duty to look into what their physicians and surgeons are doing with
them, as well as what their lawyers and politicians are doing for
them, in matters of less consequence, and what their priests and
preachers would have them do in matters of still greater moment.
A more intelligent public and more inquisitive patients, are what
the profession greatly needs, to make it more industrious in the
acquisition of knowledge, and more cautious in reducing it to
practice.
"The interest taken in fistula, both by the profession and by
the public, can be accounted for," concludes the author alluded
to,* "only on the well-ascertained fact, that the disease does not
admit of remedy, except from an operation, which was formerly
one of great suffering, and even of considerable danger." This
curious passage implies not only the absolute necessity, but the
present safety and matter-of-course success of the operation! There
are in almost every neighborhood cases which imply something
very different from this, and which explain the public interest in
the subject by something more than the mere " fact " of an operation.  The real fact is, that the disease is not only uncured without the operation, but often operated on in vain, and not unfrequently rendered worse than before —or, rather, converted into a
new and more distressingsurgical disease.
The term "FISTULA" is applied to all ulcers that have a long
passage and narrow opening, through which the products of ulceration or the contents of natural cavities find exit. It is this latter
circumstance, or their opening into some cavity of the body, that
* Professor Syme, of Edinburgh.



356                   FISTULA  IN ANO.
more  strictly distinguishes  "fistulas"  from  other "sinuous
ulcers."
Of fistulas generally, it may be observed that they are ulcers
of an obstinate character, having no tendency to heal, their sinuses
being fortified by callous growths, though almost always exuding
a sanious matter, or suppurating unhealthily.
The neighborhood of the anus is particularly liable to fistula,
not only from functional derangement of the rectum, but from
laxity of the cellular tissue, causing any abscess or ulcer that forms
there to become diffuse, and the mobility of the sphincter preventing the healing process.
"FISTULA IN ANO" is, therefore, understood to imply the result of any abscess about the rectum, which has opened either just
within or without the anus, or both on the external surface and into
the bowel. The last condition is necessary to constitute
" Complete Fistula,"    an open communication from the outside of the body into the rectum; one end of the ulcer connecting
with the cutaneous surface, the other with the mucous.
The "Incomplete or blind Fistula" may connect by its open
end either with the skin or the gut, being thus either a "blind
external " or "blind internal fistula."
The SINUS, or fistulous pipe, is very rarely simple or straight.
It is commonly not only tortuous in its course (agreeably to the
popular usage of the kindred terms, " sinuous and sinuousity"),
but branched. Several sinuses may thus exist where there appears
only one, or several distinct openings be internally connected, or
spring from the same source. This source or origin of the sinus,
is always
- An ABSCESS, walled up with hard cartilaginous matter, which
is generally continued along the whole course of the sinus or sinuses. The lining of the pipe appears itself a semi-cartilaginous
formation, but is to be regarded as a proper mucous membrane,
which has the property of continuously secreting the thin yellowish pus, characteristic of fistula.
Notwithstanding this induration, fistulas are always extremely
tender to the touch, so that it is difficult to probe them, until their
morbid irritability has been allayed.
If neglected, the local irritation and inconvenience will not long



FISTULA IN ANO.                     357
be the worst symptom. Irritation of the lungs is so frequent an
accompaniment of this disease, and fatal consumption so often the
termination of badly-managed cases, that fistula in ano has ever
been looked upon by some as a sort of alternative or safety-valve
for phthisis pulmonalis!
The most probable CAUSE of the frequency of fistula in this
part was before alluded to. Besides the peculiar anatomical structure of the part, and the liability to derangement of its physiological function, external injuries and foreign substances lodged in
the rectum have been known to be the remote causes.  Habitual
costiveness, or, rather, inattention to the calls of nature for evacuation, may no doubt give rise to fistula, as it does to stricture of
the rectum - the mucous membrane "giving way" to pressure in
the former case, instead of being hardened to it as in the latter.
Ever so little foecal matter would thus be the commencement of an
abscess, which might become a fistula, though the crevice in the
rectum should heal, and no fresh irritation occur from that source.
Constipation, however, and "torpidity of the liver," are by no
means necessary conditions to the formation or continuance of fistula. Erysipelatous inflammation about the anus is still more
likely than phlegmonous to degenerate into this kind of ulceration.
Long neglected piles may easily become fistulous.
If we have to treat a case in the incipient stage — which, by
the way, will rarely happen, the necessity of early attention being
so little known, we can generally arrest the inflammation and prevent the suppuration, by the administration of Bel., Bry., Phos.,
or the 2d or 3d trit. of Hepar or Cale. phos. and hot sitz baths
frequently repeated.  Calc. phos. has caused abscesses in the
healthy, near the anus, terminating in fistula. Dr. A. Bauer, of
Cincinnati, stated to one of the authors, that in proving it upon
himself, first an abscess, then a fistulous pipe, was the result which
took considerable time to heal up; also that several others, who
were engaged in the proving, had symptoms of anal abscess, but
did not push it to the same extent that he did. These results
would point to it as the remedy for the different stages of this disease. We have never employed it except in the suppurative stage,
not having been called thus early to a case, since our attention has



358                   FISTULA IN ANO.
been directed to it, —when an abscess has formed near the anus,
but no fistulous pipes are yet clearly developed -bring it to a
head as soon as possible by the frequent administration of Cale.
phos., and such other means as are recommended for abscesses
(see p. 53-57). And as soon as there is evident fluctuation near
a convenient part of the surface, puncture.  Have an orifice large
enough for all the pus that has formed to pass out readily.
Never delay puncturing, for the skin to become attenuated
after there is evident fluctuation or permit the pus to be pent up
until the skin becomes of a livid appearance.  Many bad cases
of fistula in ano, some with half a dozen fistulous pipes as well as
long bills (surgical), are thus manufactured.
As soon as the pus is evacuated, heal up the abscess as soon
as possible; never "leave the approximation and union of the
sides of the cavity to nature," or permit the orifice to heal before
the abscess fills up. This is easily prevented by the use of a tent.
Keep the patient at rest.  Give a dose of the 2d or 3d trit.
of Cale. phos., once or twice a day, washing out the abscess daily
with a solution of the same or Aqua calendula, shield it from the
action of the atmosphere, and if the success is such as we have had
in a number, the abscess will rapidly heal and the formation of
fistula be prevented.
Where the suppuration is at all abundant, the Aqua calendula
should be used as an injection into the abscess and drop doses of
the tincture alternated with Calc. phos. But we will not often be
called on with a view, or in time, to prevent fistula - seldom, indeed, in any of its earlier stages.
When an abscess near the rectum is left to open itself spontaneously, it will often be by several orifices, the discharge appearing to come from different points in the surrounding cellular tissue.
Some of these openings soon close up, while others, if not prevented
by proper measures, will continue to discharge a more and more
unhealthy pus, and become indurated and regularly "fistulous."
In such a case, give the Cale. phos. before recommended and wash
out the opened abscess, and all the sinuses that can be discovered,
with Aqua calen., several times a day, applying a wet compress in
the intervals. The " T. bandage" will retain the wet compress in its



FISTULA IN ANO.                     359
place. If, however, the parts are not perfectly soft or free from
callus, the bandage should not be applied so tightly as to produce
any sensible pressure.
This, with the internal treatment and rest on the patient's part,
will often suffice to cause a very threatening abscess to heal up, instead of becoming a confirmed fistula. But if the case has been
longer neglected, and become
- the TRUE FISTULA, with hardened pipes, pouring out sanies
instead of healthy pus, something more will be necessary.
This is the condition in which established " authorities," and
all routine practitioners "subject" thereto, consign their patients
to the tender mercies of the knife.
"For the operation," we shall not refer you, as usual, to the
Operative Part of the Course; because we would never sanction a
measure so often worse than useless, when we can effect the object in view by other means, so much less objectionable, safer,
and more certain of success.  "The operation," by the way, is
simple, and its object rational enough, were there no other means
of attaining it, and were it oftener secured by that measure. The
fistula is connected with the rectum, the sphincter being cut through
and kept from uniting again until the ulcer heals up to it from the
bottom —that is, sometimes kept open forever after!-the patient losing all control of this important organ, and being subjected
for life to an annoyance far more disgusting and distressing than
any fistula, and more deprecated by many than death itself.
/ This " laying open," as it is familiarly called, and of which the
books speak as if it were a mere trifle - as to the mere operator
it no doubt is - this " operation for fistula in ano," is the sum and
substance, the beginning and the end, of "regular treatment."
The success of this " sole reliance "   to say nothing of its occasionally fatal, and frequently worse than fatal consequences just
alluded to -may be judged of by the fact that a large majority of the worst cases we are called to treat, are those which
have been operated upon. When not killed or cured, they are, of
course, invariably injured by being "laid open." This is in private practice.  Could the remote as well as immediate results of
hospital "operations" be "laid open," what a "cutting up" business would it not be? Could grave-yards speak (or did their reg



360                    FISTULA  IN ANO.
isters record, as they should, the causes of mortality), we verily
believe we should find that one-half, if not a far larger proportion,
of all who are affected with this variety of fistula, ultimately die,
either from the effects of the uncured disease, or of the " surgical
cure."
Yet one of our surgical authorities * tells us briefly, that the
"treatment of fistula in ano is simple, and if the disease be merely
local, usually quite effectual! " He is even so well satisfied of this,
that he advises us to allow abscesses about the anus to become fistulous! because, forsooth, their cure is then so very "simple and
effectual!"
This favorite operation will be found described in every surgical work.  Reference can be made to any of them if it is desired
to have recourse to so easy and mechanical an expedient. Of all
our American writers at least, Gibson alone raises a dissenting voice
against the otherwise unanimous opinion; but in doing so, he substitutes no satisfactory course of treatment.
"An opinion very generally prevails," observes Prof. Gibson
(Surgery, vol. ii. p. 161), "that every fistula in ano requires an
operation.  There can not be a greater mistake.  So far from it,
that almost every case, where the patient is tolerably healthy,
might, I am inclined to think, be healed, if attended to in the commencement, and judiciously managed.  Nothing will contribute
more to this end than absolute rest, simple dressings, moderate
diet, and mild laxatives. I have known a fistula protracted'and
kept open for months, while the patient walked about, and healed
in a week by perfect quietude and the horizontal position."
If this be so -if means so simple can lead to a cure in favorable cases, why should not measures a little less "simple," or more
powerful, be directed in still more advanced stages; and how mischievous must be the effect of the "generally prevalent opinion,"
that nothing can be done to prevent or supersede the necessity of
"the operation."
If something more specific were used than the Philadelphia
professor's "simple dressings," no doubt, with his other stringent
conditions (if any patient could be induced to submit to them) of
"absolute rest," or "perfect quietude," and the "horizontal posi* Miller, Practice of Surgery, p. 289.



FISTULA  IN  ANO.                         361
tion," many cases might be successfully treated, even without recourse to the ligature. That measure, however, is generally indispensable in most all confirmed cases. It does not exact such an
absolute prostration of the patient, and may be said, with the
proper adjuncts, to insure success.
The LIGATURE is less objectionable than the knife, not only inasmuch as it is less alarming, and, when properly applied, less painful
to the patient, and on account of the subsequent treatment being simpler, less confining; but its comparative slowness is itself an advantage. It gradually substitutes a healthy for an unhealthy action of
the parts, by removing the cause of the latter; and thus not only obviates the liability to relapse, but the greater danger of other diseases occurring  on  the too sudden drying up of an accustomed
drain. This danger is so considerable that it is, in some contingencies, held as a sufficient reason for not curing fistula, and in
others, for only venturing on it with the precaution of setting up
artificial issues in other parts! With the ligature, moreover, there
is no danger of fatal hemorrhage from the hemorrhoidal vessels, or
even temporary loss of control over the sphincter, as the division
made by the cord usually heals behind it as it goes, if allowed to
do so.  Another danger obviated is that of inflammation from an
extensive wound, in a delicate part and an enfeebled patient.*
* To show what a hobby of operative surgery this unfortunate disease has been
made, and how authority sustains (by repeating) itself, we will subjoin a few quotations. To begin with a popular book of Reference: -
Gardner's recently corrected edition of the well-known Hooper's Medical Dictionary, lays it down, without any qualification, that "the cure is by a surgical
operation.'
Another American work is quite as positive: " The only effectual treatment is
the division of the sinus and the sphincter ani muscle." -(Hastings' Surgery,
p. 278-Philadelphia, 1850-a compend from Druitt, Gibson, &c.)
" The grand remedy," according to Druitt, in his careful digest of established
English practice, p. 253, " is the division of the sphincter ani, so as to prevent the
contraction of that muscle for a time [how often, forever! ] and cause [how often?]
the fistula to heal from the bottom."
Would it not seem that medical surgery had taken a disgust at the part concerned
and given it over to dissection? One only of our American writers is a little more
hesitating or discriminating than the rest. His language (as quoted in the text) is
quite a rebuke to the orthodox dictum; but unfortunately it is unaccompanied with
any sufficient or satisfactory directions for a better practice than that fostered by
the prevalent "mistake."
46                                                 (PART I.)



862                        FISTULA  IN  ANO.
Dismissing, therefore, all thought of the operation, in the
TREATMENT OF CONFIRMED FISTULA,
The first thing is to ascertain as precisely as possible the magnitude, direction and number of sinuses.
The probing, however, for this purpose may have to be delayed
in consequence of the irritable condition of the parts. In such a
case give Assafetida when the parts are very irritable and the
discharge thin and discolored. But if the patient is much prostrated, the matter ichorous, and  the pains are  somewhat of a
Our German brethren are much more discriminating in their judgments, as well
as comprehensive and profound in their inquiries.  It may be instructive to show
to what an extent these mental and geographical differences affect men's opinions.
We have consulted the second edition of an elaborate work of established authority
in Germany, though of recent date. It consists of three volumes, with a folio accompaniment of splendid plates, all devoted exclusively to Akiurgy (that is, knifesurgery), or that part of Operative Surgery usually requiring bloody operations.
Yet in treating this particular affection, for which our authorities resort to the knife
alone, the author restricts its use to so few and exceptional cases, that it is equivalent to a proscription of it altogether. A critical history of treatment, modern as
well as ancient, the whole biography, so to speak, and bibliography of the disease,
is given with truly German minuteness and accuracy.  The most recent eminent
surgeons of England and France are quoted, in corroboration, or for the purpose of
justifying a dissent from their conclusions.
Of the four methods of cure - by Ligature, Excision, and Cauterization- the
author considers the first two the only ones not antiquated. Liston, and other of
our Operative Surgeons, dismiss the subject of ligature as out of date, because formerly associated with the actual cautery.
After fully discussing the question between the ligature and the knife, our author gives the former a decided preference: "Verdient die Ligatur im Allgemeinen
den Vorzug. - Sie ist mit Ausnahme der S. 261 genannten Fmlle ueberall angezeigt."
These excepted cases, in which he allows that incision may be admissible, are
either so very exceptional as to be out of the question (as, for instance, the possible
complication of stone in the bladder, which would certainly indicate the use of the
knife in a different direction), or such as really afford additional reason for the ligature with our accompanying means (they being those we should use for " malignant
or suspicious" disease, if unconnected with fistula).  The only plausible objection
to the ligature, is confined to the single circumstance of the outer orifice being so
far from the anus, that it would be too long in working its way through -a difficulty which we have not experienced, or, which rather resolves itself, in a medical
view of the operation, into a positive advantage.  In these apparent exceptions,
moreover, our author premises all the time that the fistulas in question are not old
or "hard cases"-" Noch nicht alten Fistela -nicht starker Callositet der Fis



FISTULA  IN  ANO.                            363
burning character, benefit will be derived from the use of Arsenicum.  If, however, with this irritable condition of the fistula, the
lungs seem  to be affected, give Phosphorus  (perhaps, even here,
Calc. phos., would be preferable). When it is attended with an Erysipelatous inflammation, Belladonna will be beneficial. But if
the orifice is surrounded with small pimples and there is a tendency to the development of proud flesh, Sulphur should be employed. At the same time make use of hot sitz baths and vapor or
fomentations two or three times a day, together with emollient
poultices. Keep the patient perfectly quiet. The rectum must
be kept free from fecal matter. To insure this, if necessary, use
Enemas twice a day.
After a short time the patient will be able to bear the operation of probing, though it may even then be quite painful.  Having thus ascertained the state of the case,
if the fistula be already " complete," and large and direct
enough for the purpose, arm a common silver probe with a ligature.
For this purpose, the best material is saddlers' silk, doubled. Pass
tel " —that is, that they are not bad cases at all, but such as he had before admitted might be cured, by proper medical treatment, without even tying, much less
cutting.
Lest we be suspected by those to whom this information will be so strange, in
their confidence in partial authority, and as this valuable work has not yet been
translated into English, we will give, not all he says favoring our views, but just
one paragraph, in which he lays down formally the cases for the knife.
1ST METHOD-Incision-indicated in still recent cases (bei noch nicht alten Fisteln), particularly if there
be many branches, or the outer orifice be far from the anus, because the ligature
would then take too long in working its way through, - where it is desirable to lay
open the bowel for the very purpose of exciting stronger and more continuous inflammation - in complication with malignant or suspicious disease of the neighboring parts, which the ligature might render worse, or with foreign bodies, stone
in the bladder, for example:
- contra-indicated in fistulas, the inner opening of which is more than an inch
and a half [1~ zoll] above the anus,- where there are many or large hemorrhoidal
tumors, - when the fistula has become much hardened with callus,- [bei starker
Callositaet der fistel] or when there is great irritability of the rectum, risk (or
rather apprehension - besorgniss) of a secondary affection or habitual diarrhea." —
[ARIURGIE VON ERNST BLASIUS, M. et C. D., Prof. der Chir. an der Koenig. Universitaet zu Halle - III Band, 261 P - Halle, 1841.]



364                    FISTULA IN ANO.
the threaded probe from the external to the internal orifice. When
it is through, turn the outer end a little upwards, that the other
may be seized by the finger in the rectum, and the string brought
down.  By separating the nates, the end of the-probe and the
ligature may be seen; or the rectum may be dilated, and the operation facilitated by the Speculum Ani.
The two ends of the ligature are to be tied as firmly as the
patient can comfortably bear, and afterwards drawn a little tighter
every day.  This tightening is commonly effected by rolling on
or twisting with a piece of wood. A better plan is, before tying,
to let the ends of the string pass through a large vial-cork, and
FIa. 15.      over a little wooden roller, fitted to radial
grooves cut on the end of the cork.  These
notches will hold the stick, after turning or
twisting, like the fall of a windlass.  The
surface is thus less irritated, the pressure of
the cork being more equable than any "toggle " fixed there.
7v/^^ -If there are several sinuses, they should
all, or the principal ones at least, be treated
in the same manner.
While the ligature is on, the parts should
be fomented every day, and every sinus thoroughly injected two
or three times a day with a dilution of the internal remedy, a
strip of patent lint, or a narrow silk ribbon should also be pressed
little by little into the pipe behind the ligature, until it is completely filled. This should first be wet in the solution used
as an injection, and be permitted to remain from one dressing to
another.  The degree of pressure it should exert upon the sides
of the pipe, is to be determined by the extent of the callus, slight
when this is slight, more powerful when it is greater.
As soon as the ligature has cut its way completely through,
foment and poultice, continuing to completely fill whatever fissure
may remain with the lint or ribbon tents. Every part will then
rapidly heal, the tents causing no impediment to the process, but
rather seeming to stimulate to a more healthy and rapid granulation.  When the restoration is nearly complete, and but little
matter is discharged, the parts feeling soft and natural, the poul



FISTULA IN ANO.                    365
tice and fomentations may be dispensed with, and some other
simple dressing substituted.
There is no danger from this course to the sphincter muscle;
the healing process, as was before remarked, following up the ligature, and being generally nearly complete before it comes away.
It is sometimes even necessary to prevent this, and keep the fissure open until all callus has been removed; after which it can
always be readily healed up.
Should there be other sinuses branching from or leading into
the main one, they must not be closed until all callosity at their extremity or along their course has disappeared, and the parts seem
natural to the touch and without soreness.  Enlarge all such
branches by lint or ribbon tents, until all appearance of callosity has gone, when the parts may be allowed gradually to heal.
We formerly used the Sesqui-Carbonate of Potash in connection with the tents to destroy the callus, but are now satisfied that
the simple pressure of the tents upon the sides of the pipe with
the internal homeopathic medication is preferable.  We should
not, however, hesitate to employ the preparation of Potash in
very old and obstinate callus until it began to dissolve.
If the case be a "blind internal fistula," ascertain the point
where it approaches nearest the external surface. Open with a
pointed probe, and having it thus " complete," proceed as before
directed.
If it be a " blind external fistula," it need not always be made
"complete."  By the appropriate medication and the persevering
use of the lint or ribbon tents, it may very often be cured without the operation even of the ligature. If, however, it be a very
bad ease, and remain obstinate or get worse, insert the armed or
threaded probe clear through the bottom of the sinus, into the
rectum; bring the ligature out; and proceed as before directed
for " complete fistula."  Whenever, on passing the finger into the
gut, a hard lump can be discovered at the upper extremity of the
sinus, do not delay, but perforate the rectum, and introduce the
ligature at once. This laying open of the source of the original
sinus is the safer way, inasmuch as the secondary branches, as
well as this callus reservoir, can thus be reached, and easily over



366                    FISTULA IN ANO.
come by the process before described, if care is taken to keep open
a large orifice by means of the tents.
Recollect that the Elm Poultice (kept on by a " T " bandage)
should be used over the affected parts during the whole of the
treatment; — the peculiarity of this cure consisting in the callosity
being dissolved and carried off by the suppurative process, the
fistulous ulcer being made to heal by healthy granulation, and
leaving no trace of the morbid formations.
An ordinary case of fistula in ano can be cured in from three
to eight weeks, a bad case, especially if the lungs or general health
are much affected, will require several months, a much speedier
cure would not be desirable in all cases, even were it possible.
The remedies that are recommended by homeopathic authors
as having yielded the best results in confirmed fistula, are Cale.,
Caust., Puls., Phos., Silic,, and Sulph., particularly the first and
last two above named, though they have given no special indications for their employment. As before stated, judging from the
provings of Calc. Phos., by Dr. Bauer and others, and our limited
use of this article, we think it will prove the remedy in this disease, even in the advanced stages, particularly if Cale. or Phos.
should be indicated and not yield favorable results:
Gale. and Phos. are more particularly adapted to those cases
when there seems to be an implication of the lungs.  Cale. for
fistula when the surrounding parts are red, somewhat swollen and
hardened.
Phos., where there is much disposition to bleed, edges callus,
the pus offensive and badly colored, and much constitutional disturbance, sometimes the fever of the hectic character- Caust.,
when attended with painful hemorrhoids. Silic. when the orifice
of the fistula is rather small and surrounded with callus, or when
it occurs in cachectic broken down constitutions; discharges sanious yellowish-white ichor, and there is much proud flesh.  Sulph.
when the fistula is surrounded with pimples; throws out proud
flesh, rather destitute of sensibility, and discharges a yellowish
pus. The attending sympathetic or organic disease of any organ
or organs, must be carefully considered in the selection of the appropriate medicine.



FISTULA IN ANO.                     367
It not unfrequently happens that when we are called on to
treat a long neglected or mistreated case, the patient is laboring
under severe pulmonary difficulties, or even already in an advanced stage of consumption. This is the condition in which, according to the books, to cure fistula would be wrong! -the complication which renders even "the simple operation" not advisable.  The removal of the disgusting local nuisance by the knife,
has been followed by fatal consequences.  The damming up a
crevasse in the river's bank, without clearing out the natural channel, has been found worse than useless. Therefore, nothing ought
to be done! The soul's lease-hold of "the house it lives in"
now depends on not venturing to obviate the inconvenience of a
smoky chimney.
But be assured that a proper cure of the fistula in ano will be
the best chance of preserving the lungs and the life of the patient.
Even where the case is too far gone for a restoration to perfect
health - where the object is only to retard the fatal progress of
consumption, the first step toward it is to restore as far as possible
the healthy function of every other part, and put an end to every
source of irritation and aggravation.
As to the danger of " drying up a long-established drain," it
will be observed that in our mode of "curing up" fistula, instead
of at once arresting, we for a long time increase the drain from the
affected part, changing it, at the same time, from a self-perpetuating sanious and fetid character, to a soothing, self-limiting and
sanative suppuration.
When the lungs are not so seriously affected, their disease subsides as soon as the free and healthful discharge is excited about
the anus. In numerous cases, where the sufferers seemed far gone
in consumption, the simple local treatment of fistula was all they
required to arrest the pulmonary disease.
A gentleman went from the northern part of the State to Cincinnati, so reduced by apparent consumption, as well as anal fistula,
that his friends took their last farewell of him, fully persuaded that
he left home but to end his sufferings in death. In four months,
he was restored to them in perfect health, as fleshy as he had ever
been in his life, and he has since continued to enjoy better health
than before his "latter end" was so doubly threatened.  His



368                 PILES OR HEMORRHOIDS.
" consumption " was indeed deeply seated- fundamentally fixedbut fortunately in the pelvis, instead of the chest.
We might cite many other such cases, but one more must
suffice. A gentleman treated by Dr. Hunt, in connection with the
late Dr. Morrow, whose lungs appeared affected, had, during the
treatment, no less than eight fistulous pipes; he was entirely cured
and continued healthy until lost sight of (about three years), nor
do we recollect one instance out of the large number treated either
by ourselves or the late Dr. Morrow, in which the patient appeared
to suffer any inconvenience from not having fistula!
CHAPTER XXXIII.
DISEASES OF THE ANUS AND RECTUM, CONTINUED, —PILES, PROLAPSUS, FISSURE AND STRICTURE.
HEMORRHOIDS or Piles -Meaning and use of words - Treatment when inflamed -
Soothing applications- Hard cases - Ligature preferred to excision - Directions for applying - Case.
PROLAPSUS ANI — Mode of procedure in replacement — Precautions against relapse.
FISSURE OF THE ANUS AND RECTUM - Trouble, danger.
STRICTURE OF THE RECTUM - Causes, constipation and purgatives - Directions for
using the Dilator- Concomitant and subsequent measures.
PILES OR HEMORRHOIDS.
THESE words are used indiscriminately to express the same
affection, - or, rather, several connected affections of the same
part; though the prominent idea conveyed by the popular term is
that of tumor, and by the more learned expression, that of
bleeding.
SWELLING and BLEEDING at the anus are both common affections, very generally occurring in the same individual, and obviously connected,-often as cause and effect, directly or inversely.
Either symptom may exist, however, without the other. Tumors



PILES OR HEMORRHOIDS.                  369
which do not bleed are distinguished as " blind Piles,"- such are
out of sight within the anus. These internal piles are often of considerable dimensions, because not so liable to burst as the external,
which are often called "Bleeding " or "Open Piles."
A person is also said to have piles who is troubled with hemorrhage about the extremity of the rectum, though unconnected
with any sensible swelling there, transient or permanent; and tumors or occasional tumefactions occurring there, are spoken of as
hemorrhoids, whether they are known to relieve themselves by
bleeding or not.
The veins of this part are themselves called hemorrhoidal,
from their great liability to become engorged and discharge their
contents. This liability is occasioned by the anatomical peculiarities as well as the physiological changes of the connected parts.
Over distension by costiveness impeding the venous flow, followed
as it is by excessive relaxation on the rectum being suddenly evacuated by drastic cathartics, is, no doubt, the most frequent cause.
Costiveness may be an effect as well as cause of piles, the patient
suffering so much from soreness of the rectum that he is disposed
to neglect the calls of nature.
The temporary distension or permanent varicose condition of
these veins, may be the only tumors in the case; or they may
themselves be transformed into real tumors, or their extravasated
blood become enclosed in permanent cysts.
These tumors are from the size of a pea to that of a hen's egg,
and may be very numerous. When small and few in number, they
may exist a long time without serious inconvenience, - and be, of
course, neglected. Their becoming painful is often an advantage
to the patient. Besides the obvious danger of excessive hemorrhage (from which several distinguished men are said to have
died), long-neglected piles may excite inflammation of the neighboring organs, or by immediate ulceration occasion fistula (as was
noticed in the last chapter).
In bleeding piles the discharge appears sometimes at regular
periodic intervals. Sometimes the sensation resembles that of the
passage of wind; but frequently it runs from the patient in a
stream, rapidly prostrating him. Generally at first, there are premonitory symptoms, such as some pain in the small of the back
47                                    (PART I.)



PILES OR HEMORRHOIDS.                     371
We shall not undertake here to give directions in full for treating
common acute cases of "piles," as the directions for the use of
such remedies as are relied upon by the profession generally, will
be found in all the homeopathic works on practice. We shall only
treat, particularly, upon those old hard cases which are rarely, if
ever, permanently relieved by internal remedies, - such as require
the interference of surgery for their radical cure.
China should be used for the debility consequent upon a severe
attack of bleeding piles.
Nux vom. is a valuable remedy for old cases, where there is an
irregularity of the bowels, alternate costiveness and diarrhea.
Podophyllum, 2d trit., is very useful where there is much prolapsus ani, with piles.
Sulphur, where there is burning and itching in the rectum,
with pressing-down sensation, especially in scrofulous patients.*
Prof. C. Neidhard, in an article furnished us on this subject
says:
" Nux vomica. - The indications for Nux, are a tendency to
constipation of the bowels and a burning, stinging pain with palpitation of the hemorrhoids after the passage of the bowels; they are
swelled and may bleed or not.
" Sulphur is the constitutional remedy against piles, because
its symptoms may be found in all cases of hemorrhoids; it has
rending in the rectum, burning, stinging, there can be no doubt
that in a great number of cases it will be one of the most important remedies, but we have to investigate whether piles have not
some connection with herpes, scrofula, sycosis, syphilis, and choose
Sulph. or some other remedy accordingly.
"Acidum, muriat. and nitric. - These two must be mentioned
together, because their action is very similar. I will illustrate
their action by a few cases from my practice:
"Miss M           had, some time ago, an operation performed for,
as she thought, the radical cure of her piles, but in a short time they
returned again.  There was particularly one pile on the verge of
the anus, from which she suffered great pain for an hour after the
bowels are opened, with sharp stitches. At the same time, she has
* A number of cures have been reported to us effected by the use of the Buckeye (nut) JEscalus Glubra, taken in repeated small doses.



372               PILES OR HEMORRHOIDS.
a throbbing in the back and a throbbing and aching in the back
of the neck; a short time before and during her catamenia. Cale. c.
gave some relief to the back, but it was only the persevering use
of Nitric acid which finally cured her. This lady was of dark
complexion.  Her sister, who was of light complexion, and who
was also afflicted with piles, with very similar symptoms, was not
benefited at all by Nitric acid, but had to take Muriatic acid for
the cure of her complaint. This led me to investigate the difference between the indication for Nitric and Mur. acid in piles. To
my great satisfaction the above-mentioned fact was also corroborated in other cases, where the symptoms seemed to be very similar in two cases.  For many years I have suspected that the
symptoms are not everything, that they are only important as disclosing the internal nature of disease and the remedy, but there
was generally some great characteristic circumstance, which, if it
were only disclosed to us, would be the deciding point for the choice
of the remedy. It was Hahnemann who first remarked that Nitric
acid was more indicated in persons of dark complexion, which led
me to the natural conclusion that Mur. acid might be indicated
in those of opposite nature, and I found this supposition corroborated by several facts. A very decided symptom with me for the
use of Nitric acid is also the constant weight and pressure complained of by the patient, worse on exercise, sometimes bleeding,
and with mucus, constipation.
" Aloes in the 2d or 3d trit. is a favorite remedy of mine where
there is a constant bearing down low in the rectum, with the piles
hanging out of the anus like a cluster of grapes; they are also
bleeding.
" Graphites. - My characteristics for this remedy, are piles accompanied by giddiness, burning, itching in the anus, with discharge of mucus or blood. According to other observers, there
is also a sensation of heaviness in the abdomen, chronic constipation with induration in the region of the liver, prolapsus of the
rectum.
"In mucous piles, according to my experience, there is no
remedy superior to Antim. crud., in the 2d or 3d trit.; the pains
are pricking, burning.



PILES OR HEMORRHOIDS.                  373
"In all piles the palliative aid of cold water can never be dispensed with." *
When the PILES have become hardened, they are nearly insensible unless when inflamed. We have been called on to treat many
such chronic cases in which the tumors wore a very malignant appearance, and had already occasioned ulceration to a very considerable extent. The course of treatment which has been successful
in every such case, is this:
Place a LIGATURE round the tumor, or round two or three if
there are many, passing it through a cork, as recommended in the
case of fistula in ano, and tightening it every day, till the strangulated tumors slough off. The patient meantime should constantly
keep on an elm poultice, and rest as still as possible, -the bowels being loosened by enemas.
The best mode of tying, is to have the patient strain down the
tumor, over which the silk or linen cord is put as a loop, having
been previously passed through the cork.
After the tumors have come away, the surface should be washed
daily with Aqua calendule until the soreness and tenderness
subsides.
The ligature, as a means of removing large hemorrhoidal tumors, is' far preferable to the knife. It is not so alarming to the
patient and gives him no pain except on the first application, and
for a few moments after each tightening. It avoids all the danger
of inflammation, and the still greater danger of hemorrhage. The
books are full of instances where patients have sunk under or immediately after the operation.
The disease rarely returns after removal by ligature, even
though the patient should neglect himself and become costive.
But no mode of local treatment - at least none short of this operation by ligature - will effect more than temporary relief, unless
proper constitutional remedies are at the same time applied.
We have treated several cases which had been of many years
standing, with very large and numerous tumors, all of which had
been before subjected to other treatment without anything more
* In highly inflamed piles, according to our experience, warm water orvapor
is preferred to cold water.



374                    PROLAPSUS ANI.
than temporary relief. In one instance, on placing the patient on
his hands and knees, and directing him to strain, a mass of tumors
was thrown out on one side of the anus as large as a goose egg,
while several smaller ones appeared on the opposite side. In this
large mass were several sinuses, from which issued a considerable
quantity of thin yellowish matter. The whole tumor was of a dark
purple color and extremely tender to the touch. We applied a
ligature around the largest one, by means of the cork and loop, as
before advised; and although it gave extreme pain, we drew it
down with great force and secured it. A large slippery elm poultice was applied (as should be done in all cases to prevent excessive inflammation). The patient soon became easy, and suffered
but little pain on subsequent tightening, which was done every
day. In a week the ugly mass came away, and all the other tumors disappeared. The patient was entirely cured of a difficulty
under which he had been laboring for twenty years. Generally
the tumors are smaller and will slough off sooner than this did.
The compression of the tumors and cauterization with Vienna
paste has been recommended by some, but from what we know of
cases thus treated we greatly prefer the ligature.
PROLAPSUS ANI
-often exists in connection with piles, especially the variety
distinguished as Bleeding Piles. It doubtless often precedes and
causes both varieties.
A similar constitutional TREATMENT is generally required to
that recommended for piles, though it may not often be necessary
to carry it out so fully or so long.
When called to a case, if the prolapse be present, the first
thing to be done is to replace the protruded bowel, so as to prevent any longer exposure to air and other irritating causes. In
ordinary cases the patient can do this for himself. The swelling,
however, may be so great that immediate replacement is impossible
or unsafe.  In such an event subject the part to vapor of water.
This will generally produce such a softening and diminution, as to
render the return of the part quite easy.  If not, subject it to a
stream or jet of cold water. This will generally cause an immediate return.  If this fail, apply Arnicated water and cover the



FISSURE OF THE ANUS.                  375
surface with wet cloths and keep it warm. After these various
means have sufficiently allayed the irritation and substituted a relaxed condition,
- place the patient on his knees, with his hips elevated and
head down, and grasp the tumor with a cloth wet in warm water
in your hand, gradually compressing and pushing it back with
your fingers.
After such an occurrence, the patient should be kept very still
for a day or two. If he gets up at all, he should wear a " T"
bandage, with a compress on the anus.
For some time to come, the rectum should be every day washed
out and invigorated by a cold water injection. The cold water
applications should be made daily or oftener.
We have found that lubricating the rectum by an injection of
Linseed oil, just before an evacuation of the bowels, may prevent
the occurrence of prolapsus, especially when the water irritates, as
is sometimes the case.
Either Nux v., Ign. Mere., or Podophyllum, will, in nearly all
cases, soon relieve.
Nux, when the patient is habitually costive.
Ign., when there is much smarting and burning in the rectum
in persons of mild temper.
Podophyl., when the bowels are too loose, affected with diarrhea or dysentery. We look upon this as the best remedy in this
disease.
iMercurius for children with enlargement of the abdomen, attended with much tenesmus.
Nit. acid will often be found serviceable, especially with smarting and burning in the anus.
FISSURE OF THE ANUS.
This, as the name implies, is a crack or groove in the rectum,
extending up from the orifice, sometimes more than two inches.
It is very irritable and tender to the touch, though the edges become thickened and hardened. A  sanious fluid is continually
exuding.
This affection is as distressing to the patient, as dangerous to



376             STRICTURE OF THE RECTUM.
health, and not unfrequently as hard to cure as fistula at the satne
place.
The most reliable remedies for this disease, are Nit. acid, Ign.,
Nux v., Phos. and Ars.
Nit. acid, when there are soreness and smarting in the anus,
or pinching, burning and pricking, or itching as from ascarides,
with smarting, cramp-like contractions.
Ignatia; sore pains in the anus between stools, swelling of the
margin of the anus, painless contractions of the anus. The fissure
bleeds easily; great tendency to prolapsus ani. This remedy frequently follows Nit. acid with advantage.
The best plan is to give the remedy one dose daily for ten or
twelve days. If the patient improves, continue the same remedy
at longer intervals, if not, use another in the same manner.
Nux v. will be found useful when there is a great tendency to
constipation and the anus is extremely sensitive to the touch, so
that it is difficult to make an examination.
Phos. will be beneficial in scrofulous persons when there is a
purulent discharge from the fissure. It sometimes follows Nit. ac.
or Ign. advantageously.
Ars. is more particularly useful when there is great constriction of the rectum and the constriction extends to the urethra obstructing the passage of urine.
If the anus is at any time much inflamed and very painful,
Nit. acid or Ign. should be given as often as every four or six hours
until relief is obtained. The parts may also be subjected to the
vapor of water, and a compress of lint wet in hot water should be
applied to the anus.
STRICTURE OF THE RECTUM
-is of two kinds, spasmodic and permanent. This is a very
troublesome, and often a very serious disease. The permanent
stricture comes on gradually, and much harm is often done, as well
as valuable time lost, by its being confounded with constipation.
This is indeed its common but remote cause; and temporary removal of the cause can not undo the lasting effect. The ordinary
means resorted to by others than homeopaths and hydropaths, as a



STRICTURE OF THE RECTUM.                   377
remedy for costiveness, are but too likely to insure a return and
a continuance of it.
Persons who lead sedentary lives, and neglect the calls of nature, are by far the most liable to stricture. The feces, being habitually retained by a forced action of the sphincter, accumulate
in large quantities and distend the greater part of the rectum,
while the extremity is firmly contracted. Under these circumstances, the thickening and hardening of the gut is but a protection on the part of nature against the unnatural burden.
In some instances, the rectum becomes diminished in its caliber,
by thickening or a deposite into the submucous cellular tissue, to the
extent of several inches. Frequently, however, a small callus ring
is formed round the bowel, just within the anus, of not more than a
quarter or half an inch in width. The difficulty may indeed occur
in any other part of the bowel; we have seen it just within the anus
in some cases, and in others five or six inches above.
The SYMPTOMS are sometimes difficult to determine, the patient
being seldom able to describe his sensations with sufficient exactness; constipation is the first indication of the disease.  The patient experiences a difficulty in evacuating his bowels, and is
obliged to use considerable straining, although the feces appear
not to be unnaturally hard. Still the obstruction continues, the
passage growing constantly smaller; and the fecal matter at last
passes off in a fine stream with some pain, which does not remit as
in the spasmodic variety. The swelling being sometimes larger at
opposite sides, the discharge takes a thin, flat, tape-like form.
This happens after the stricture is well established.
An obstruction may sometimes occur without any thickening
in the rectum itself, in consequence of an enlarged prostate gland.
When this is the case, the feces will present an indentation or
groove on one side only, produced by projection of the gland into
the gut.
In cases brought on by sedentary habits, the feces, in the earlier
stage of the disease, will pass off in a bulky mass at the firstafter a great effort, the latter part of the discharge becoming small
and contracted.
For distinction between permanent stricture and cancer of th
rectum, see Cancer.
48                                      (PART J.)



378              STRICTURE OF THE RECTUM.
Insert this dilator past the stricture, and fasten it in that position by a " T" bandage, requiring the patient to keep it on as
long as he can bear it. The bandage should be made of gum elastic, so as to cause a slight but constant upward pressure on the
instrument.  A short dilator that will pass entirely within the
sphincter ani muscle, will be preferable if it can be retained. It
need be worn but a short time (ten to fifteen minutes) at each application.
TREATMENT.
In this, as in many other forms of disease, is seen the superiority of homeopathic medication. The spasmodic stricture very
promptly yields to Nux v., Opium, Plumbum, or Sulph.
If hemorrhoids are present and aggravate the disease, Nux, or
Sulph., is generally applicable.
Ignatia, or Nux Mosch., is especially applicable if it occurs
in hysterical females. A suppository of tallow at night will frequently be of service, though an enema of cold water, night and
morning, answer a much better purpose than either it or the
bougie.
[Query?  The extract'of Belladonna applied to a rigid os
uteri, causes it to dilate - would not it be serviceable in stricture
of the rectum?]  Warm sitz baths should be used once or twice
daily.
In the treatment of permanent stricture, the great remedial
means relied on by surgeons, generally, is the bougie.  This is,
however, but rarely necessary with homeopaths. We have agents
that are capable of exerting a specific influence on the diseased
structure and causing its absorption, and are thus enabled to cure
many cases where the bougie can not be employed; as in those
instances where the stricture is so high up in the rectum that it
cannot be reached by the bougie, or it is inadmissible from the
great irritability of the stricture or the presence of fungous
growths.
Nux v., Plumb., Sepia, or Sulph., will generally remove the
first stage of the disease. When, however, the strictured portion
has become inflamed or suppurated, as may be known by the pain
being severe, and there is a discharge of blood or pus, much benefit



STRICTURE OF THE RECTUM.                 379
has been derived from a few doses of Aconite, followed by repeated
doses of Sulphur, and when this had ceased to act, the exhibition
of Nat. m., Lack., or Ignatia, in accordance with the symptoms,
should be given.
Ignatia, when there was present a shuddering after each
evacuation.
Lachesis, when the pain in the anus was accompanied by a
throbbing.
Nux v., especially if in a male or in a person of sedentary habits, addicted to the use of intoxicating beverages, highly seasoned
food, or afflicted with hemorrhoids.
Carbo. an. is an excellent remedy in all indurations of mucous
membranes.
Enemas are of primary importance in this disease. As a general rule cold water does the best, but from the peculiar irritability
of parts in some cases, the cold can not be borne when warm water
may be used.  They will often overcome stricture which does not
yield to the internal remedies, and for which indeed the common
practice, the bougie or knife, is deemed the only remedy. These
should be repeated once, twice, or three times daily, according to
the character of the case; less frequently when there is great irritability. Taken on retiring at night and rising in the morning will
generally be sufficient. The quantity thrown up should be as large
as can be retained, but it should be done with a small pump
syringe, through a small pipe, so as to fill the rectum gradually,
else the sudden pressure will cause an immediate contraction of the
bowels for its expulsion. If there is ulceration of the bowels, the
fluid should be warm.  Aqua Calen. should be used in this case
in place of simple water.
The diet of the patient should be strictly attended to. No
solid or indigestible substance, such as the hard seeds of grapes,
raisins, and other fruits and berries should be allowed. The bran
of unbolted flour is often injurious in this disease.
Entirely fluid food, such as milk, soups, &c., is preferable. As
an excellent means of obviating costiveness, direct the patient to
drink freely of cold water early in the morning, an hour or more
before eating, also upon retiring at night.
The following remedies may be consulted with advantage in



380                    URETHRAL DISEASE.
this disease — Sepia, Natrum  m., Staph., Calc., Cal., Lycop.,
Ars., Rhus., Hepar, and Mezereum.  If, however, the case does
not yield to the medication or enemas, and the stricture is within
reach and free from ulceration or any malignant appearance, the
bougie dilator may be resorted to; one of gum elastic is altogether
preferable.
CHAPTER XXXIV.
STRICTURE OF THE URETHRA, URINARY FISTULA, AND DISEASES OF
THE PROSTATE GLAND.
STRICTURE OF THE URETHRA-Retention and suppression of Urine-Spasmodic
and permanent stricture -Causes and progress -Absorption —DilatationCauterization - Revulsion - Artificial blennorrhea.
FISTULA IN PERINEO- Mechanical cause and condition of cure - Other means and
precautions.
ACUTE PROSTITIS-Cause and symptoms -Connection with gonorrhea, or its
" cure."
CHRONIC PROSTITIS OR ENLARGEMENT -Causes and liability - Symptoms - Artificial gonorrhea.
STRICTURE OF THE URETHRA.
THIS is a very common and very important subject.  The
number of men who die from  neglect or mal-treatment of this
originally simple affection, would surprise the profession as well
as the general public, were there, as there should be, any means
of ascertaining the point and making it a settled matter of fact
instead of opinion.  "Bills of mortality" are the final test of all
medical practice, and should be made use of for its correction and
perfection.
RETENTION OF URINE, caused by stricture, gravel or other similar mechanical impediments, must not be confounded with suPPRESSION, which always implies inactivity and disease of the kidneys.  This fatal affection, however, may be a result of the
former.  When the retention, or mere "stoppage of water," is
complete, occasioning immediate danger or inconvenience, the first



STRICTURE OF THE URETHRA.                381
measure should be, of course, relief by the catheter. In such a
case, the distended bladder can be felt as a tense, round tumor
above the pubes; and unless it be relieved of its burden (by relaxation of the spasm, if that be. the cause, by the giving way of the
urethra behind the point of obstruction, causing fistula in perineo,
or by art as directed), it may finally burst into the peritoneum.
The MEMBRANOUS portion of the urethra, between the bulb
and the prostate gland, is the PART most liable to be strictured;
but the accident or disease may occur at any point between the
bladder and the glans penis. The closure of the urethra may be
either sudden and temporary, or gradual and permanent; or there
may be a constant partial stricture, aggravated or made complete
by spasmodic action.
In the merely SPASMODIC STRICTURE, there is no diminution of
the caliber of the urethra, but a temporary obliteration of it from
the sides being pressed together by contraction of the surrounding muscular fibers. The irritation occasioning this may be in the
mucous membrane, where it is often caused by gonorrhea. When
the urine reaches the irritable spot, or after a small amount has
passed it, the irritation is communicated to the muscular tissue,
and the closure ensues.  The patient has to urinate very frequently, and is generally in a great hurry about it —the stream
coming with force and entire freedom for a few seconds, and then
suddenly stopping.  The difficulty may be experienced in coitus
as well as in urination; the semen being unable to advance through
the urethra, or to return into the ductus ejacalutorius, is driven
backward into the bladder, where it remains until that vessel can
discharge itself. The irritability of the part will of course be
greater at some times than others. A greater or less liability to
this sort of inconvenience may continue for many years, without
any material change; but, generally, the functional will induce
organic disease, -the "spasmodic" will occasion "permanent
stricture"- by the thickening of the coats of the urethra, and
diminution or obliteration of its channel. Sometimes the morbid
irritability continues after the thickening, so that the stream of
urine when it passes is both small and inwrrupted. As the thickening progresses
-in the Organic or PERMANENT form of STRICTURE, the pa



STRICTURE OF THE URETHRA.                383
In cases of spasmodic stricture following gonorrhea, we have
had the most satisfactory results from Nux v. In one case treated
by us in Cincinnati, when the patient had been obliged to use a
catheter every time of urinating for many years, the urethra closing instantly on the urine passing the irritable point, Nux v. tr.
in drop doses every night, cured him in ten days. One year after,
he had had no return of the stricture. Warm sitz baths were
used twice daily, and a cold wet compress kept on the perinaeum
at night.
Cannabis and Cantharis have been most successful in spasmodic
stricture arising from other causes, especially in old persons. One
case, a man of seventy, where there had been stricture, at times,
for several years, and there was present great irritation of the
bladder, bloody urine, with an extraordinary quantity, and complete obstruction by spasm of the urethra,Cannabis, tr. in drop doses, three times daily, brought perfect
relief in three days.
Cantharis is most serviceable when there is burning pain in
the urethra, scalding of the urine, and the spasm causes great
pain.
Petroselinum is useful, particularly when there is still some
gleety discharge with burning and tingling in the urethra. We
have used it successfully in some bad cases in the form of an infusion, in doses of a table spoonful three or four times daily.
In cases of spasm from irritation and inflammation brought on
by over exertion, stimulating food or drinks after badly treated
gonorrhea, we have seen, in numerous instances, immediate relief
given by the warm infusion of Althwea offic. drank freely.  In
very bad and dangerous cases, where urination was impossible,
and the irritability so great as to forbid the use of a catheter, this
remedy taken, as above directed, has allayed the irritation in a
short time, so as to allow of free urination.  The green root is
the best for this purpose.
Sulphur is valuable to remove any latent taint in the system
that might predispose to a return of the disease.
Carbo an. seems to be better adapted to the permanent stricture, when there is a hardness and thickened condition of the
mucous membrane of the urethra.



STRICTURE OF THE URETHRA.                 385
paths, that "old inveterate cases of permanent, cartilaginous
strictures " are incurable except by mechanical means.
THIS COMMON MODE of relieving this condition is purely mechanical; the urethra is stretched wider by means of bouigies.
These should be very smooth and well lubricated before being used.
The best material for them is gum elastic or gutta percha. It may
be necessary to begin with one so small that a common cat-gut
fiddle-string will be the most suitable article.  Substitute for this
a larger one as the parts admit of a change, and that again for
others, going gradually from No. 1 to No. 12, or even 16, of the
regularly graduated bougies. Let each be kept in and worn constantly or as much of the time as possible, for a day or two before
one of the next larger number is inserted.
This DILATATION of the urethra may succeed so far as to
remedy the merely mechanical inconvenience for awhile, but it is
by no means to be regarded as a cure for the disease of stricture.
Enlarging the caliber of the urethra does not necessarily rectify
the abnormal condition of the mucous membrane.
The stricture may be destroyed by the application of caustic
directly to the part. The constricted part is generally very small.
It may be but like a thread or ligature drawn round the urethra:
or it may extend for from half an inch to an inch along its course
— rarely more than that.  There maybe more or less obstruction
at several points. The most convenient method of cauterizing any
part of the urethra, is to use the modification of Lallemand's portecaustique (Fig. 16).  Some nitrate of silver is melted into the
FIa. 16.
groove at the end of the movable rod, and scraped down smooth
and round like the rest of its surface, so that it can be drawn back
into the sheath.  When the latter is inserted up nearly to the
strictured point, the armed rod is pushed out, turned two or three
49                                         (PART i.)



386             STRICTURE OF THE URETHRA.
times round, and sheathed again.  This instrument can be used
with perfect safety, the caustic being so effectually fixed in the
notches at the ends of the groove, that it can not fall out, and so
covered by the sheath when drawn back, that it can not touch other
parts.
But we have had several cases that had undergone the whole
course of treatment with this cautery, as well as the bougies, with
but slight benefit; and have succeeded with them, as with other
cases, by different means.
As it regards cases caused by gonorrhea, our practice may require some defense or explanation. It has been known that such
cases were sometimes unexpectedly cured by the re-establishment
of gonorrhea in the natural way.  Taking this hint from nature,
and reasoning from the analogy of chronic disease in the mucous
membrane of the eye, and the effects of stimulants upon it, to that
of the urethra, we determined on a new and peculiar course of
treatment.  Our plan was, to re-establish a discharge from the
parts, resembling, as near as possible, the original gonorrhea; and
necessarily accompanied with more or less of acute inflammation,
as in that disease. We found the solution of the Sesqui-carbonate
of potash, injected by means of a syringe through a catheter, answer this purpose effectually. When this lotion is used two or three
times a day, it produces considerable irritation of the urethra and
a discharge so nearly resembling a gonorrheal one, that it would
be mistaken for it by any person unacquainted with the actual exciting cause. The solution should be weak at first, and gradually
increased to a saturated one, if the desired effect is not sooner
produced.
If the bladder is at the same time involved in the disease, the
injections should be carried up into it also; but, in such a case,
it is better first to inject warm water into the viscus, that the caustic solution may be more diluted there, than at the original seat
of the disease.
This ARTIFICIAL BLENORRHEA may be continued until the
proper change is produced in the urethra. This may be known
by discontinuing the remedy, at any time, for a few days, and
using instead, a simple injection of cold water, with perhaps a little mucilage of slippery elm or gum arabic. Then if, on entering



FISTULA IN PERINEO.                   387
a bougie, any symptoms of stricture be still found, renew the
caustic injections, until they are no longer necessary.
The tincture of Sanguinaria will produce the same effect as
the mild caustic, but is objectionable, inasmuch as it occasions a
bloody as well as proper blenorrheal discharge, and, for a time,
even aggravates the stricture. A few applications, however, repeated every day or two, if the patient can be induced to submit
to it, and followed up by soothing applications, will accomplish the
cure more speedily than the caustic solutions.
We have found this mode of treatment equally effectual in cases
not caused by gonorrhea.
FISTULA IN  PERINEO.
A passage of urine into any part of the perineum is generally
a consequence of urethral stricture. It is never a simple opening
or artificial urethra. The discharge of so irritating a secretion into
parts so lax, occasions extensive ulcers with very offensive suppuration. The case is so plain as to need no special description.
If the cause be stricture, that must be first attended to. After
sufficiently dilating the urethra, - or in the first place, if no stricture exist, -
- a gum-elastic CATHETER, or, better still, one of gutta percha
should be placed and left in the bladder. When this is constantly
worn, as it should be, the patient can move about but little -which
is all the better for his chance of successful treatment.
The ulcer thus protected should then be washed with soap and
water three times daily for two or three days, until the inflammation consequent upon the irritation of the urine, has subsided.
The surface should all the time be covered with an emollient poultice. It will not take long for the inflammation to subside if the
part is protected from the urine, well cleansed and shielded by a
warm emollient from the air.
This disease is quite different in its character from fistula in
ano.  It tends to spontaneous recovery, when the irritating cause
is removed, whereas the other has no such disposition.
After the subsidence of inflammation, if the sore appears
healthy, keep up the simple dressings and let it heal. If, however,
it still looks unhealthy and does not incline to heal, apply Aqua



388         DISEASES OF THE PROSTATE GLAND.
Calendulse and give the dilution internally. Frequently subjecting
the parts to the vapor of water, will assist in allaying the irritability and aid the action of the remedies.
If the ulcer remains indolent and indisposed to heal, Petroleum
internally and applied to the sore, will soon change it to a healthy
condition.
It must be borne in mind, that the entire protection of the ulcer from contact with the urine is absolutely essential to success.
The patient must observe perfect rest in a recumbent posture as
far as practicable. The urine should be frequently voided so as
to obviate any danger from accumulation.
DISEASES OF THE PROSTATE GLAND.
ACUTE PROSTATITIS
May be caused by external violence, but is much more frequently
a result of gonorrhea.
The SYMPTOMS are a sense of weight and a throbbing pain
about the bladder; tenderness of the perineum and a tumefaction
of the gland (which last can be best ascertained by examination
per rectum).  There are also frequent attempts to urinate, accompanied with violent pain.
Should the patient be altogether unable to pass his urine, a
small gum elastic catheter may be used; though this is an operation which should be avoided if possible. Warm sitz baths will
be of great service in allaying irritation.
If the inflammation is the result of external violence, in the
early stage, use Arnica; but if later, when there is much swelling and burning or throbbing pain, Conium will do better, or these
may be advantageously alternated.
If there is present a general feverish condition, Aconite may
be advantageously used, followed by Conium, if the inflammation
is not relieved.
The patient should be kept very quiet, and eat but very little;
the bowels gently moved by warm enemas.



DISEASES OF THE PROSTATE GLAND.             389
If gonorrhea be the cause, Cantharis, Puls., or Thuja will be
the best remedies.
If GONORRHEA be present, measures should be taken to "cure"
this disease constitutionally. Better let it run on and run itself
out, than merely stop it by astringent injections. No more certain means than these could be devisedfor insuring chronic and
permanent disease of the prostate. The virus should be removed
from the system, and not locked up in it.
If the gonorrhea has been suppressed, use Puls. to restore it.
At the same time repeat the hot sitz bath, and apply a wet compress to the affected part.
With the restoration of the gonorrheal discharge, the prostatic
inflammation will generally subside. If'not, use Thuja. If the
discharge is bloody and burning, use Cantharis.
Should the inflammation have advanced too far for resolution
before you are called, the fact will be indicated by rigors and a
considerable swelling of the perineum, soon followed by symptoms
of acute inflammation of the external surface. In such a case,
as soon as you are satisfied that
— matter has formed, puncture at once, lest the abscess extend
and burst into the rectum or urethra, when the consequences may
be serious and the cure difficult. After the matter has passed off,
frequently wash out the abscess with Calendula; and if the patient's constitution be good it will soon heal. Gentle compression
over the parts will aid the process.
If, however, the abscess open into the urethra, which will be
known by the sudden discharge of pus through the latter, the
urine should be drawn off by catheter and slight compression
made on the affected part until it heal. The better way, however,
would be even then to puncture through the perineum, and evacuate the abscess, so as not to allow any more matter to pass through
the urinary channel. The urethral wound will soon heal, if precautions are taken to prevent the further passage through it of
pus or urine.  This may be more effectually insured by the patient's constantly wearing the catheter, if he can bear it.
CHRONIC INFLAMMATION of the part in question is seldom the
object of medical treatment or observation, except as it results in
inconvenience from



390          DISEASES OF THE PROSTATE GLAND.
ENLARGEMENT OF THE PROSTATE GLAND.
This is a not unfrequent disease, though comparatively little
attended to in ordinary practice.
Although when it occurs in young men, gonorrhea or its mistreatment may have been the original cause, it often comes on in
advanced life, when there is no ground for such a suspicion.
The gland sometimes attains five or ten times its ordinary size.
It is also much harder than natural.  The middle lobe usually
projects into the bladder, and alters the shape and direction of the
urethra. It produces but a slight degree of dysuria, but its diagnostic effect is that the bladder is never completely evacuated, and
the urine rendered turbid in consequence.
The first SYMPTOM noticed will probably be a difficulty in passing urine, though the desire for it is more urgent and frequent.
There is also a sense of weight in the perineum, which increases
as does the obstruction.  Finally the patient is never able completely to evacuate the contents of the bladder. Total retention
of urine is apt to occur occasionally, especially if the individual
is addicted to excesses of any kind. The too long detention of
the urine in the bladder may occasion calculous deposites.
The prostatic disease may go on until it extends to the bladder, and all connected parts, producing abscess, ulceration and
death.
An additional measure of great efficacy is to establish or reestablish from the mucous membrane of the urethra, a discharge
similar to that of gonorrhea. This may be done by
-filling the urethra with a strong solution of a mild caustic
(Pot. Sesqui-Carb.), through a silver catheter passed up to the
neck of the bladder and gradually withdrawn, while the injection
is being introduced. This is to be repeated two or three times a
day until the suppuration is excited, and occasionally afterwards:
it is to be kept up for several weeks. Taking care, however, before each caustic injection to nearly fill the bladder with warm
water, mucilage of slippery elm, or gum arabic.
This artificial gonorrhea is quite sure to cure the patient when
his disease is only the result of " drying up a clap" too suddenly.
It is a restoration of the original disease in order to have it really



SPERMATORRH(EA.                           391
cured. If the prostatic affection proceed from other causes, this
urethral drainage, though not so necessary, will still greatly facilitate its removal. The tincture or infusion of Sanguinaria may
be used instead of the alkaline solution, but we have found it occasionally too irritating.
CHAPTER XXXV.
SPERMATORRH(EA.
IMPORTANCE of the seminal fluid and of the disease in question- Slight notice of
it by medical writers generally - Various and anomalous symptoms - Particularly the nervous and mental -Difficulty and delicacy of various opinions —
The physician's confessional.- Causes independent of onanism -Nocturnal and
diurnal emissions- Conditions under which emissions take place - Examination
of urine - Microscope - Spermatozoa as a means of diagnosis and prognosis -
The analagous disease in females —Results, Impotence, Insanity, Catalepsy,
&c. - Great prevalence of S.permatorrhoea and its most common cause. - Condition and measures of treatment- Regimen, physical and moral- Affections
of the prostate and rectum - Case of ascarides.
UNDER this head, we shall include all affections or symptoms
connected with losses of the seminal fluid, -whether they take
place in a natural, artificial or involuntary way -that is, by excessive sexual intercourse, by masturbation or by spontaneous
emissions.
The semen appears to be pre-eminently a vital fluid, and to
have a very close connection with the nervous system; for the
most disastrous consequences to that system, and all the functions
more directly dependent on it, follow from any immoderate seminal discharges.' If this take place in early life, it generally retards the growth.  It always impairs the mental faculties and
brings on premature old age.  It manifests itself in very serious
affections, presenting strange and anomalous features. Nosologically considered, it is a host in itself. The patient not unfrequently exhibits symptoms so many and multifarious, as to author



392                    SPERMATORRH(EA.
ize the statement that he is suffering under the whole catalogue
of human maladies.  To enumerate precise symptoms would be
like attempting an exact description of hysteria.
"Spermatorrhcea" is a new word in medical nomenclature.
It is mentioned as a disease by few, if any, systematic writers.
No standard author, certainly, whose work was published in
America, prior to 1848, has noticed the subject in a manner calculated to arrest the attention of the practitioner; or to give him
any correct knowledge of the disease or its symptoms.  Some
" medical authors " have even deprecated the idea of mentioning
the subject at all!  One work, —an acknowledged text book in
many of our colleges, -thus speaks in regard to it: "It is certainly not very consistent with our national character to dilate so
freely on a subject, which in a great majority of cases, can only
be treated of as the result of the most degrading vice."
Without attempting to give any formal DESCRIPTION of the
disease, or to divide it into varieties or stages, we shall name the
SYMPTOMS of it as they have presented themselves to our notice.
Though this may seem an unsystematic way of proceeding, we hope
to enable the practitioner to discriminate the disease, when it shall,
as it undoubtedly will, fall into his hands in every day practice.
In some cases the only complaint the patient will make is, that
he is suffering under a kind of continual fever. He will probably
present a hot dry skin, with something of a hectic appearance.
Though all the ordinary means of arresting such symptoms may
have been tried, he is none the better.
The patient will present no evidence of organic disease.  Iis
lungs are sound; and his liver appears to perform its office tolerably well. On strict inquiry, however, it will be found that he
is generally inclined to be costive, - has probably been in the habit
of taking some kinds of aperient pills.  sDyspeptic symptoms also
are not uncommon, in connection with excessive languor and debility.
The languid or tired feeling is especially manifest, with tremblings
of the limbs perhaps, on first rising from bed in the morning.
The SLEEP seems to be irregular and unrefreshing, - Restlessness during the early part of the night, and, in the advanced stages
of the disease, profuse sweats before morning.  There is also frequent starting in the sleep, from disturbing dreams. The charac



SPERMATORRH(EA.                  393
teristic feature is that the patient almost always dreams of sexual
intercourse.  This is one of the earliest as well as most constant
symptoms. When it occurs most frequently, it is apt to be accompanied with painful priapism. A gleety discharge from  the
urethra may also be frequently discovered, especially if the patient
examine when at stool or after urinating. This may be more frequent with those who have had gonorrhea, but is by no means confined to such.
The patient may confess to being a very nervous subject. He
has not only frequent attacks of nervous HEADACHE, but occasional
sensations of giddiness, or vertigo ringing in the ears, &c., with
perhaps a fixed dull pain in the back of the head, where a preternatural heat may almost always be discovered. Connected with
this will be a stiffness in the muscles of the neck, and darting pains
through the forehead. Extensive SPINAL IRRITATION is a frequent
accompaniment.  Some patients will speak of a peculiar aura, like
water running over the body, or a sensation resembling the crawling of insects under the skin, especially down the outside of the
thighs. Weak eyes (as well as weak back), are among the common symptoms. But as might be expected from the direct implication of the nervous systemj the MORAL and MENTAL SYMPTOMS
are perhaps more to be relied on than any very obvious bodily
peculiarities.  The disease is well known to be one of the most
frequent causes of insanity; and one of its earliest symptoms is
incapacity for concentrated attention. If the sufferer attempt to
pursue any mathematical study, he will fail. He manifests more-over an excessive want of confidence in his own abilities, even where
they do not seem to fail him: he has very often "no mind of his
own."  He is much afflicted with awful forebodings, though he
can not tell of what. Some indescribable evil is always about to
befall him. In this and several other particulars, the disease very
closely resembles delirium tremens. It may be confounded with
hypochondria.
One very frequent and perhaps early symptom (especially in
young females) is solitariness, - a disposition to seclude themselves
from society. Although they may be tolerably cheerful when in
company, they choose rather to be alone.
The countenance has often a gloomy and worn down expres50                                        (PART i.)



394                    SPERMATORRH(EA.
sion.  The patient's friends frequently notice a great change.
Large livid spots under the eyes is a common feature. Sudden
flashes of heat may be noticed passing over the patient's face. He
is liable also to palpitations. The pulse is very variable, generally
too slow. Extreme emaciation, without any other assignable cause
for it, may be set down as another very common symptom. If the
evil has gone on for several years, there will be a peculiar expression of the countenance -la general unhealthy appearance of a
character so marked, as to enable an experienced observer to recognize such a case at the first glance, as readily as a banker
would a counterfeit bill. In the case of onanists, especially, there
is a peculiar rank odor emitted from the body, by which they may
be readily distinguished. One striking peculiarity of all these
patients is, that they can not look a man in the face! Cowardice
is constitutional with them.
Whenever we find any considerable number of these more
prominent symptoms in the same person, we may suspect the nature of the CAUSE. We may encounter difficulty, however, in our
attempts to ascertain more.  Much delicacy and circumspection
are sometimes requisite. By some morbidly sensitive subjects, indirect questions will be evaded when their bearing is surmised, and
a too abrupt charge denied. The best plan then is, after carefully
comparing enough of the symptoms to give a moral assurance, and
otherwise securing the patient's confidence, to let him understand
that we already know the nature of the difficulty, and that his life
depends on our being allowed to know more - to know, indeed, all
about it. At the same time he should appreciate the reciprocal'
obligations of such professional confidence, which are the same as
between lawyer and client. Secrecy on the part of the practitioner
is not less a duty than candor on the patient's. The physician's confessional should be as sacred as the priest's. All sufferers will not be
equally penitents, or ashamed of their weakness. To none, however, can we expect the subject to be a matter of the same indifference that it is, and ought to be, to us.  We are to speak of it only
as a disease, a misfortune - except in the case of continued masturbation, when we are justified, in the said character of fatherconfessor, in using all needful severity of speech, and withholding
all hope of absolution, i. e., of health, except on the condition of



SPERMATORRHOEA.                     395
effectual repentance, i. e., of entire abandonment of the physiological sin, and implicit submission to whatever penance may be
enjoined in the way of medicine or regimen.
The original or predisposing CAUSE, moreover - and this ought
to be always borne in mind -may have been, as the still exciting
and perpetuating cause very generally is, some purely physical disease. Spermatorrhoea may be altogether unconnected with onanism, or anything the sufferer ought to be made ashamed of. It
will, nevertheless, be always attended with many of the same
characteristics.  In moral judgments, as in legal, the doubt must
be given in favor of the accused or suspected. The giving way in
our own mind - and much more the giving currency from a mean
love of depreciation -to the moral prejudice (i. e.,pre-judgment),
must be often as unjust to the individual concerned, as it is always
in itself unjustifiable and unprofessional.
Several of these causes, or classes of causes, that may bring
on this deplorable state of things, independently of masturbation,
we will enumerate: -Ascarides or other accidental sources of irritation in the rectum; piles, fistula, or other diseases about the
same part; spinal irritation; irritation or chronic inflammation in
the prostate gland; or the same state of things in the urethra
itself (often, like the prostatic disease, a consequence of gonorrhea); and mere excess in lawful sexual indulgence.  Sometimes
the difficulty is hereditary.
On closer INQUIRY and EXAMINATION we will often find that
"nocturnal pollutions " occur almost regularly.  We have treated
cases when they happened as often as five times in one night.
Many will have the still worse symptom of "diurnal pollution."
Soreness and enlargement of the prostate may often be detected.
The best mode of examining the state of this important organ, is
by introducing a finger into the rectum. In attempting to pass a
bougie, the urethra will probably be found so irritable as to contract irresistibly upon it. The bladder may also be very irritable,
necessitating a frequent discharge of its contents. The penis very
generally shrinks up, in its relaxed state, much more than with
other men; and in many cases, but not so frequently, the testicles have dwindled in size.
The emissions occurring at night will generally wake the



396                    SPERMATORRHOEA.
patient, but sometimes they are only known by the stains upon the
linen, and the debility and lassitude felt upon the next day.
Emissions of semen during the day may be excited by the society
of females, impure imaginations, or during stool, or they may
follow immediately upon an emission of urine, or the spermatic
fluid may pass, off mixed with the urine. The latter is the most
obscure, insidious, and therefore dangerous form of the disease.
Should there be any doubt as to the character of the case, a careful
examination of the urine will remove it. Upon collecting the urine
in a vessel, it will become slightly turbid, and small globular bodies
or flocks of various shapes will be perceived on the bottom of the
vessel. Filtering will leave the spermatozoa and other flocks upon
the filter; when an examination with the microscope will show the
spermatozoa and their condition.  The number, activity, and size
of the spermatozoa, will show the extent of the disease, as well as
the progress of the recovery.
Where marasmus sets in, the spermatozoa disappear entirely,
and nothing is perceived except roundish, little shining bodies, the
heads, probably, of the extinct spermatozoa. The prostatic fluid
may be distinguished from semen by the absence of the spermatozoa.
The formation of crystals of the oxalate of lime in the urine
is a valuable diagnostic in spermatorrhoea.
In FEMALES, this disease - or rather an analogous one brought
on by masturbation — displays itself more in nervous symptoms
and less in mere debility.  "Spermatorrhoea" does not of course
strictly apply to their case, or that of boys diseased by irritation
of the genital organs before puberty. The injurious effect on their
systems is independent of what in adult men appears to be the
chief evil- loss of the vital or virile fluid.  In both these cases,
therefore, the ultimate danger to life is less. If the patient, however, is attacked by any common acute disease, it will prove more
obstinate than underordinary circumstances; and the practitioner
may be much puzzled to know why his remedies fail of their wonted effect. 
The female onanist is often "hysterical," adding another difficulty to the diagnosis and treatment of cases so called. We have
been frequently called to such persons suffering under some slight
and commonly manageable attack, which resisted all usual reme



SPERMATORRH(EA.                     397
dies. Individuals confirmed in the destructive habit, will continue
it even when confined to their beds by other severe diseases, or
perhaps by its very consequences.
Insanity is a more common result to men than women, on account of the greater evil of "spermatorrhoea" proper.
Impotence is most probable; epilepsy and apoplexy are, also,
not unfrequent terminations.
CATALEPSY, too, should be enumerated as a result. In fact,
we are inclined to believe that a large proportion, if not all cases
of this mysterious disease, are referable to the source under consideration. Four instances have fallen under our own observation;
all of which showed conclusively, to us, that masturbation was
their cause.
SPERMATORRHCEA is a malady much more common than many
seem to suppose.  Married men are by no means to be presumed
exempt.  Whenever there are sufficient symptoms to indicate its
existence, we should not be deterred from pursuing our investigations. When the affection is only slight or occasional, a moderate healthful indulgence of the sexual propensity is often beneficial. Hence marriage itself has often been prescribed as a remedy.
Unwonted or excessive stimulus of the parts may, however, aggravate or bring back the disease. Moderation must always be enjoined, if not sometimes total abstinence for a time.
ONANISM (which is also to be itself regarded as a disease,
whether it bring on spermatorrhoea, strictly so called, or not) is
most deplorably prevalent. Both sexes, and it might almost be said
all ages, are guilty of it or subject to it. It is to be regretted that
parents and teachers are so generally ignorant or falsely delicate
upon this subject. We are inclined to think, also, that few physicians are fully informed upon it, or act up to their responsibility
in taking proper opportunities to inform and caution others about
it. Instances are met with of persons who have indulged in the
vice, unchecked and scarcely suspecting any evil, from their earliest
recollection. The practice often begins long before the age of
puberty.  One young lady of most respectable character and connections, whom we had to treat for it, informed us that she was sub.
ject to leucorrhea when only nine years of age, and to distinct sexual
desire before eleven -though her catamenia did not appear be



398                   SPERMATORBRHtA.
fore she was twelve! The prognosis in all cases where we have
the co-operation of the patient is favorable.
TREATMENT.
If the practice of self-pollution is ascertained, it must be abandoned at once and forever. We must point out inevitable destruction as the consequence of its continuance; and encourage and
strengthen the patient's resolution by assurance of ultimate recovery.  We must not ourselves be discouraged at having to do this
frequently.  We have to bear in mind that the patient's memory
and resolution are greatly enfeebled; and he will often find himself relapsing before he is aware of it.
Remove all CAUSES that are found to excite the genital organs,
whether through the mind or body.  All association with the opposite sex is sometimes interdicted; but the policy, as well as propriety, of this may well be questioned. The society of those whom
we respect, is.the surest means of strengthening self-respect and
self-control. Lascivious books, pictures and conversation, are of
course to be denounced —on medical grounds, which are here one
with the moral.
Let the patient take as much EXERCISE as he can in the open
air (especially in the country). It should, if possible, be of a kind
that is profitable as well as pleasant, and such as will engage both
mind and body.
The diet must be carefully regulated; all stimulants, tea, coffee,
spices, wines, meats, &c., avoided. In one very bad case, after
unsatisfactory treatment, with a mixed diet, we found great benefit
from the exclusive use of vegetable food; milk, fruits, and farinaceous food should constitute the diet. Supper, if partaken of
at all, should be eaten early, and the bladder and rectum evacuated just before retiring to rest, and the urine frequently voided.
The patient should sleep upon a moderately hard bed and rise early
in the morning, and think as little as possible about his genital organs or disease.  General cold bathing —cold hip baths and
injections of cold water —should be daily made use of.  Occasional wet-sheet packs should also be employed.
If nocturnal emissions are the great evil, direct the sufferer to
avoid lying on his back.  He often discovers for himself that he



SPERMATORRHCEA.                    399
rarely escapes when asleep in this posture, and rarely has them
in any other. That he may not turn over on his back while asleep,
let him fasten something to his body that will prevent it or awaken
him on the attempt, such as a hard ball upon the spine attached
by a banpage.
If there is any soreness of the prostate gland on pressure
through the perineum or rectum, it must be removed. Cauterization of the urethra is often resorted to, but in a very large majority
of cases does much more harm than good.  Some of the worst
cases we have had to treat have been made so by previous cauterization. Internal remedies, with soothing and invigorating injections and proper baths, and wet compresses, will be sufficient.
The cure may be facilitated in some cases, however, by pressure.
Its efficacy in allaying chronic inflammation of other parts is
well known. A pad is applied around the base of the penis so as
to bear upon the seminal ducts, "with a silver' jugum (yoke), encircling and removing all pressure from the private parts," and secured by a gum elastic strap passing over the body, before and
behind, and over each shoulder and buckled in front. According
to Dr. Dixon, this is only necessary, in most cases, to be worn
during the hours of sleep; and the more active forms of the disease will yield to it alone.
In cases arising from, or aggravated by,
- HEMORRHOIDS, fistula or other affections of the RECTUM (and
strict examination should always be made to ascertain whether such
an influence is not in operation), such diseases or affections must be
removed, before any hope can be entertained of effectually curing
the sexual derangement.
If ASCARIDES be the cause, they must be got rid off. The itching about the anus, which is the characteristic effect of this kind
of worms, is worse at night, and apt to be aggravated by whatever overheats the body. During the day they will be felt most
hungry and troublesome about two or three hours after the patient's
usual times of eating, particularly after the morning meal, or about
nine or ten o'clock.
~If the internal use of Aconite, Ignatia, or Sulphur, is not
sufficient, use injections of oil. or even a solution of Aloes, which
will soon remove them.



400                    SPERMATORRHIEA.
Quite a number of remedies have been recommended for
the various forms of this disease, and have been used beneficially with them in connection with hydropathic, dietetic and
moral treatment; but they have exerted a conservative rather
than a radical influence.  They have erected a barrier against
the desolation of the swollen stream, but not emptied the clouds;
they have girdled the tree, but not plucked it up by the roots.
This want of specificness led the authors of the repertory to
say, that "For spermatorrhoea properly so called, or emission
of semen without erections, there is no remedy which has yet
received the sanction of experience."  We have one, however,
to propose for trial —it is the Eryngium aquaticum - which has
two remarkable cures reported by Dr. Parks (pharmaceutist,
Gin.), to recommend it.
Case 1. A married man injured his testicles by jumping upon
a horse; this was followed by a discharge of what was considered
semen for fifteen years, during which time he was treated allopathically and homeopathically.  Dr. P -        exhibited a number
of the usual remedies without permanent benefit. He then gave a
half gr. dose three times a day, of the third decimal trituration of
the Eryngium aqua.  In five days the emissions were entirely
suppressed, and have not returned to this time (over two years).
The emissions were without erections day or night and followed by
great lassitude.
Case 2. A married man, not conscious of having sustained any
injury, was troubled for eight or ten years with emissions at night
with erections.  The semen also passed by day with the urine.
The loss of semen was followed by great lassitude and depression,
continuing from twelve to forty-eight hours. There was also partial impotence. Had been treated allopathically. Dr. P- -  gave
him Phos. ac. for two weeks without material benefit. He then
exhibited the Eryngium as above, with like excellent and prompt
result.
China, Nux. v., Phos., Phos. ac., Sulph., and Electro-magnetism, are our most important remedies.
The efficacy of China in removing the disorders induced by a
loss of humors is well known to every homeopath. It is particularly indicated where the seminal losses have produced or are



SPERATOARHSAC.                      401
causing great sensitiveness of the nervous system, disordered digestion, sleep disturbed by frightful dreams, and physical and mental depression.
Phos. ac.; excessive nocturnal emissions followed by great
weakness of the nervous system, the patient feeling chagrined and
mortified at his condition.  In all cases of spermatorrhoea, there
is more or less low spiritedness and distress of mind, as well as the
derangement of the digestive apparatus; and the spheres of China
and Phos ac. are so nearly alike that they are usually recommended to be given in alternation. The distinctionf we have been
accustomed to draw is that in that of Phos. ae., the moral sentiments are more involved. It is not so much the loss of health that
afflicts the patient as the idea of the debasing way in which it was
lost. Oh! that I had a disease of which I need not be ashamed,
he exclaims. In that of China he is distressed; in Phos. ae., he is
grieved.
Nux. vom.; where the patient has been in the habit of indulging in stimulants, or is of sedentary habits, and constipation or
hemorrhoids are present, or previous to the exhibition of Phosphorus to diminish the excitability of the nervous system.
Phosphorus;  after the excitability of the nervous system has
been allayed by China or Nux. v., when there is very great nervous prostration or tendency to the development of phthisis.
Aconite, in the form of tincture, one or two drops in a tumbler
of water, a teaspoonful every three or four hours, until there is
a decided improvement, is recommended by Dr. Hempel for great
nervous derangements, sudden starting at the least noise, fitful
mood, depression of spirits, apprehensions for the future, dizziness,
intense frontal headache, either every forenoon or constantly, dryness of the mouth, coated tongue, distress in the pit of the stomach, vomiting of the ingesta, wakefulness at night, drowsiness in
the day time, nightmare, copious and exhausting emissions every
night, costiveness.
Electro-magnetism is one of our most efficient remedies in this
disease: says Gollmann, "I look upon it as indispensable in the
treatment of this affection. I commence the treatment by first inducing with my hand an electro-magnetic current along the back
of the patient; after a time I substitute the cylinder in the place
51                                         (PART I.)



402                   SPERMATORUHEA.
of the hand, and lastly resort to the electro-magnetic baths. The
passes have to be made along the whole length of the spinal column.  Somtimes I apply one pole to the perineum, and the other
to the lumbar region.  The current has to be induced very methodically.  The first application should not last longer than five
minutes; afterwards, every application should be increased by one
or two minutes, until we gradually prolong it to about fifteen minutes, after which every succeeding application should be decreased
and shortened again by one minute. Already, after the first days
of the treatment, the patient will perceive an amelioration; his
apathy and his indifference to the enjoyments of life will be succeeded by a feeling of ease and physical well being; the seminal
losses will either diminish or cease entirely, and all the other morbid phenomena will mend considerably. But even if the improvement should be ever so striking, the treatment should not be discontinued all at once, for their affection is disposed to return; it is
therefore advisable to continue the treatment some two or three
weeks even after the patient should seem perfectly restored."
Sulphur and Calcarea at long intervals are recommended to
eradicate the inclination to the vice of masturbation.
The following remedies may also be consulted:
For seminal emissions without erections, Trios. per., Bell.,
Coloe., Nux. v.
For emissions with amorous dreams, Arsen., Aurum, Argen.,
China, Coloe., Olean., Phos. ac., Staph., Spigel., Samb., Viol.
Tri.
For those without amorous dreams, Anac., Argen., Bell.,
Carbo. veg., C(icuta., Bismuth, Guac., Mere. sol., Puls., Ruta,
Verbas.
For discharge of prostate fluids, Anac., Calc., Con., eepar,
Natr. carb., Nit. ac., Phos. ac., Sep., Silic., and Sulph.



VENEREAL DISEASES -GONORRHEA.                   403
CHAPTER XXXVI.
VENEREAL DISEASES -GONORRHEA AND SYPHILIS.
GONORRHEA - Symptoms and cause - Relation to Blenorrhea (benigna or common)
-Difficulty of forming and stating opinions- Gonorrhea not a merely local disease - Consequences of the common treatment - Ricord's treatment - Homeopathic ditto -Complication -Other modes of treatment and particular specifics.
SYPHILIS -Primary, Secondary, Tertiary - Chancres, their varieties - Inoculation - Allopathic use of mercury, a cause of Tertiary Syphilis - Ricord's treatment; Homeopathic ditto- Bubo, inflammatory and indurated - Treatment of
Secondary and Tertiary Syphilis.
GONORRHEA.
THE too well-known disease, so called, -  or what is now named
by some with more etymological propriety, virulent BLENORRHEA,*
-  may be defined as a specific inflammation, produced by the immediate contact of a virus, the product of the same inflammation,
with the mucous membrane of the urethra.
The first symptom is an itching or tingling at the orifice of the
urethra; this usually commences from the second to the eighth
day after an impure connection, and will probably be first noticed
in urinating. It increases in intensity until the patient suffers
severe pain, particularly upon urinating. The lips of the urethra
become inflamed and swollen, and if the inflammation  is not
checked, the glans become also involved, and the inflammation extends up higher, successively involving the entire spongy, membranous, and prostatic portion of the urethra, and finally the neck
of the bladder. The discharge is at first mucous, but soon becomes thick, purulent, and of a yellowish color. Sometimes it is
tinged with blood. In some very severe cases the color of the
discharge is greenish, ir others the discharge is suppressed, constituting dry gonorrhea. When the inflammation has involved the
whole of the spongy portion of the urethra, there is frequent involuntary and spasmodic erection, with a curvature of the penis
* "Gonorrhea " originally meant what we are now obliged to find another word
for - Spermatorrhea.



404           VENEREAL DISEASES — GONORRHEA.
downwards.  This species of priapism is called chordee.  When
the membranous portion is implicated, there is pain more or less
severe in the perineum, with a dragging sensation behind the scrotum during erection, which is not diminished by drawing down the
penis.  If the inflammation extends to the prostatic portion, the
pain in the perineum becomes more intense, preventing the patient
sitting down cross-legged, the testes become painful, and urination
is attended with scalding, commencing from the posterior portion
of the canal, and frequently a twisted or branched stream. In
implication of the neck of the bladder there is very frequent and
urgent desire to urinate, almost amounting to incontinence.
When the disease is not arrested, it becomes chronic - secondary gonorrhea or gleet,-the pain entirely disappearing, and a
muco-purulent discharge alone remaining: sexual intercourse,
dissipation, or exposure, will cause a relapse. Authors are generally agreed as to the infectious nature of gleety discharges.
The prepuce occasionally becomes enormously swollen, and
phymosis (i. e., inability of drawing the prepuce back over the
glans) or paraphymosis (i. e., where the prepuce has been drawn
back behind the glans, but in consequence of constriction it cannot
be returned) may be the consequence. Either of these greatly aggravates the disease.
The lymphatic glands in the groin may swell, giving rise to
buboes, though these, it should be remembered, may result from
any other irritation.
The constitutional symptoms are in general but slight.  In
certain states of the system, however, considerable sympathetic
fever may be developed.
A  first "clap" is generally more severe than subsequent
ones.
Its more serious occasional results are inflammation of the
glans, penis and  prepuce, of the testes, prostate  gland or
bladder.
Acute rheumatism  and gout are set down in the books as
among the sequele of gonorrhea; but we are inclined to refer
them, with other unfavorable results, often rather to the treatment
than the disease, though it may sometimes excite a dyscrasia giving
rise to these and other difficulties.  Orchitis may result from ex



VENEREAL DISEASES -GONORRHEA.               405
tension or metastasis. In that case there is often considerable
hemorrhage through the urethra.
As to the CAUSE, - although gonorrhea proper never, in all
probability, occurs but as the result of infection through an impure coition, - it must never be forgotten that there are many other
affections which very closely resemble it, and give rise to a similar
discharge, then distinguished as
— BLENORRHEA (or blenorrhea benigna) of the urethra.  This
may occur from any cause of local irritation or violence, such as
the introduction of the catheter. Metastasis of rheumatism and
gout may excite the mucous secretion in question.  Any cause
tending to produce stricture in the part may also have this result.
We have known it to result from hemorrhoidal irritation, and disappear of itself when that affection was cured. When mechanical
violence is the cause, the mucous inflammation may not show itself
for a long time, and thus become the more suspicious.
This PgEUDO-GONORRHEA may be brought on by excess in venereal indulgence, where there can be no suspicion of any impurity.
Contact with the menstrual fluid sometimes occasions urethral inflammation in the male, with most of the other suspicious symptoms.  Leucorrhea is still more generally believed capable of the
same result, -is believed indeed by some speculators to have originally produced, and to be still reproducing, the true gonorrheal
virus.
Gonorrhea in females so nearly resembles some forms of severe
leucorrhea, that'it is in many instances extremely difficult, if not
impossible, to distinguish them. Simple gonorrhea in them may
also be confounded with a discharge accompanying syphilis. The
two diseases may coexist and infect any persons exposed, according
to their susceptibility.
The DIAGNOSIS, therefore, of this too familiar disease, would
often be a very questionable matter, but for the ascertainablefact
of exposure.  (The inverse test, by inoculating others, -sometimes confiding wives, or still more confiding females, - ought to
subject every man who tries it to castration, or some other sort of
castigation at the hands of his physician.)
The practitioner ought then to be very reserved with his opinions in these cases; or, rather, he should learn to observe a scru



406           VENEREAL DISEASES - GONORRHEA.
pulous silence as to causes, unless where the ends of justice require
him to speak, when he should adopt the rule of law which gives
every doubt in favor of the accused. It is very seldom that any
good is to be gained by insisting, even with patients themselves, in
tracing these things to criminal origin.
The physician's business is not with the causes, but with the
consequences. Though the disease should be found to have affected
others, it is still not proof positive that it was of illicit origin. In
the case of suspicious leucorrhea, this consideration is important.
Gonorrhea is generally regarded, and too much treated, as a
merely local disease, sometimes even by homeopathic physicians.
But we are satisfied, as the result of considerable observation, that
this is no more exclusively a local affection, than rheumatism or
gout. It might as well be said, that these are respectively only an
inflammation of the small or large joints, - or say that small-pox
is a simple disease of the skin, as that gonorrhea is nothing but a
diseased condition of the mucous membrane of the part where it
shows itself.
Holding this view of the subject, we were always in the habit of
prescribing a very different course of treatment from that which
is commonly followed, under the idea which we wish to correct.
Although the symptomatic fever and other general symptoms may
be but slight, and the local symptoms may be easily arrested by a
treatment merely local, - the sad results of gonorrhea, years after
such " cures " of it, are far too frequent to sanction the opinion
that the virus in question can be so readily removed from the system.  On the contrary, we have no doubt that it remains ready
to develop itself in the same or some worse form whenever any
sufficient exciting cause may operate. Thus, on over exercise, it
may render the patient much more liable to rheumatism; or, on
exposure to malaria, be more certain to bring on an attack of intermittent fever.  We have known an instance, when the urethral
discharge, with all the primary symptoms of gonorrhea, reappeared
during the progress of a bilious intermittent, - and this, ten years
after the original infection, and where we were satisfied that there
had been no subsequent exposure.
The reappearance of the disease after violent over-exertion, is
by no means uncommon. Loss of sleep, any thing that causes



408           VENEREAL DISEASES- GONORRHEA.
should be employed. If the discharge does not cease with the subsidence of the inflammation, it will be necessary to give a few doses
of Mere. or Sulphur to complete the cure.  The former when the
discharge is greenish or puriform, the latter when it is serous.
They are also particularly useful when the patient has been previously subjected to the allopathic use of Copaiba and Cubebs.
When the inflammation has progressed so far as to involve the
whole of the spongy portion of the urethra, and chordee is present,
Canth., Mere., or Can. alone, or in alternation, will control it:
where, however, there is much constitutional disturbance, Aeon.
should be given alone or in alternation with Canth.; sometimes it
may be advantageously followed by Sulphur.
Tussilago petastitis, the expressed juice, in teaspoonful doses,
is recommended both for acute and chronic gonorrhea.
Hartmann prefers for the inflammatory stage, the mother tincture, three doses a day; while Jahr. recommends three pellets of
the 30th dilution, allowing them to act for a week. The general
experience of the profession favors the use of the mother tincture.
Petroselinum, Cinnabaris, Copaiba, Puls., Thuja, have been
recommended; to which we would add, Blue ash (Fraxinus quadranglata) and Phytolac. dec. —the last especially if there are
rheumatic pains in the groin, or generally.
Nux vom. is adapted to gonorrhea with hemorrhoids, or where
the patient uses stimulants.
Puls., in connection with a cold wet compress over the lumbar
region, when the discharge has been suppressed. Sometimes an
injection of a strong solution of the Sesqui-carb. of potash into the
urethra will aid in re-establishing the gonorrheal discharge.
Dr. C. L. Miller of Leipzig, in his report of the homeopathic
dispensary of that place, says "The treatment of gonorrhea was
more successful this year than last. This is partly owing to the
employment of a new remedy, the Cochlearia armoracia, or horse
radish. I had a tincture of it prepared, and in many different
kinds of gonorrhea found it alone suffice to effect a complete cure,
especially where there was some smarting and burning, with difficulty of passing water, and not very copious discharge. It, also,
often produced a rapid cure, even in chronic and neglected cases.
I can, therefore, recommend this remedy to my colleagues, and



VENEREAL DISEASES -GONORRHEA.               409
shall only observe, that I employed, sometimes, the undiluted tincture, sometimes dilutions up to No. 6."
When Phimosis is present, the penis should be placed in warm
water for about half an hour each day, and very weak castile soapsuds frequently injected between the glans and prepuce.
In case of Paraphimosis, use the local bath, as in Phimosis,
and a poultice of Ulmus Fulva, which will act as an emollient
and relaxant, and prevent any difficulty from obstruction of the
circulation.  Hartmann, and some other authors, recommend the
immediate reduction of Paraphimosis by compressing the glans,
and at the same time drawing the prepuce back over it, for fear
of gangrene. This, he says, is very difficult, and he might have
also added very painful. Our experience has taught us it is quite
unnecessary. We have treated, and seen under the treatment of
others very bad cases of paraphimosis and never had any difficulty
from Gangrene.
For ischuria, Aeon., Canth., or Camph, and if the case can not
be managed without, the catheter may be introduced. If this is
held very firmly by the walls of the urethra, it is best to leave it
in and run the risk of inflammation and abscess on the outside of
the urethra, rather than the danger of being unable to introduce
it again. A few doses of Arnica should be given after the introduction of the catheter and occasionally repeated, if it is necessary
to leave it in the urethra.
For inflammation of the prostate, Aeon., Puls., or Thuja (for
this and where there is danger of abscess, see prostitis).
Hemorrhage from  the urethra, if from  the introduction of a
catheter, will yield to Arnica internally and as an injection in the
form of cold arnicated water.  In other cases, Canth., Canna.,
Sulph., or an infusion of Millefolium; cold external applications
and compressions are frequently sufficient.
For condylomata, Thuja, Nit. ac., or Cinnabaris.
For painful swellings of the lymphatic vessels, Hartmann recommends Calomel, and if no improvement in sixteen or eighteen
hours, Mlerc. prweip., Ruber.
Symptomatic buboes, also urethral chancre, yield to Mere. or
Carbo. veg.
For secondary gonorrhea Tr. Cantharis, Sulph., Mere., Agnus.,
52



410            VENEREAL DISEASES- SYPHILIS.
Caps., Fer., Nit. ac., Thuja, Nat. mur., Sep., Lye., Hep., SuL,
Conium, Silic., Psoricum and Syphilin.
Agnus for a whitish serous gleet, with absence or diminution
of the sexual appetite.
Caps., when the discharge is whitish and thick, with scalding
at the time of urinating. When the discharge is thin and watery,
whether irritating or not, Dr. Owens recommends Kali hydriodicum.  He states that in four cases it arrested the discharge
which was profuse in forty-eight hours. He used the 5th dilution.
Hartmann has succeeded in many cases with Tr. Canthar., one
drop morning and evening.  We have given the same in larger
doses and increased until symptoms of strangury, then ceasing
all medication; the discharge will then generally disappear with the
other symptoms.  In other difficult cases he has used an injection
of Acetate of zinc, ten or fifteen drops in five ounces of water, three
times a day.  Though a better injection is the diluted Pyroligneous acid, which we have found quite a specific; or the tinctures
of San. can., or Macrotys diluted, or Mere., one grain to the ounce
of water. These injections should be used three or four times a
day, and the patient should always urinate before using injections.
Hydras. can., in infusion, is a good injection in primary or
secondary gonorrhea.
If there are any symptoms of stricture, they are to be treated
as recommended for that affection.
SYPHILIS.
LUES VENEREA, "THE POX,
-THE FRENCH POX, morbus Gallicus, &c., were among the
older names of the more serious affection, often distinguished as
"the Venereal Disease."
This terrible scourge of the human race, for several centuries
past, seems to be a specific contagion, propagated almost exclusively during the act of venereal intercourse, though capable of
being communicated by any mode of contact with a susceptible
surface. It is a true inoculation; and may take effect through the
cutaneous as well as mucous surfaces.  This virus can never be



VENEREAL DISEASES - SYPHILIS.             411
touched with impunity where the cuticle is abraded, or more than
usually delicate.
The peculiar ulcer which this virus causes upon the spot where
it is deposited is called a chancre. This is the local effect of the
virus; its varieties constitute what is denominated a primary
syphilis.
By the terms Secondary and Tertiary, are designated the constitutional manifestations of this virus. The Secondary includes
the various affections of the skin and mucous membranes. These,
Ricord holds, are not capable of being transmitted by inoculation,
as are the primary, but may be hereditary. But Sigmund and
Waller deny this, and contend that secondary syphilis can be communicated to others. The Tertiary symptoms are not inoculable,
or hereditarily transmissible, but according to Lugol, engender
scrofula. They comprehend tubercles of the sub-cutaneous and
sub-mucous cellular tissue; nodes, inflammation of the periosteum,
exostosis and caries.
Chancres are most frequently located in the male on the glans,
penis and prepuce. In the female, about the labia nymphae and
clitoris, rarely on the os uteri or vagina.
Ricord, Acton, and others contend, that up to the fourth or
fifth day, the disease is purely local. This, say they, is proven
by the experiments on inoculation, as secondary symptoms never
follow chancres when they have been cauterized, prior to the expiration of that period.
The experiments of Ricord are exceedingly valuable, as furnishing us in inoculation with a sure means of diagnosing where we
suspect urethral chancre, or in suspicious and important cases. It
should never be employed in the gangrenous or serpiginous varieties of chancre, or where the patient can not keep quiet and be
temperate, and should always be destroyed on the third or fifth
day, by opening the pustule with a lancet and carefully removing
the pus, and then filling the cavity with Vienna paste. This will
form an eschar and finally come off, leaving the parts underneath
sound.
When the pus from a chancre is introduced under the epidermis of the same individual, the natural course is thus described by
Acton: "During twenty-four hours succeeding the operation, the



412            VENEREAL DISEASES - SYPHILIS.
inoculated point becomes red; in the course of the second and
third days, the surrounding parts are slightly swollen and assume
a papular appearance, or already traces of a vesicle are seen on
the summit; on the third or fourth day, a fluid, which is more or
less transparent, is observed beneath the epidermis, and a distinct
vesicle becomes apparent, where the papulae previously existed,
and a dark dot is seen in the center, owing to the coagulation of
the blood which had escaped through the puncture of the lancet;
from the fourth to the fifth day the vesicle assumes a pustular
character, and a distinct depression is seen in the center, so that
it represents very distinctly at this period the small-pox pustule.
The red areola, which has been hitherto gradually augmenting in intensity, now as gradually fades away, and the cellular tissue, which
was slightly cedematous, becomes infiltrated with plastic lymph. On
the sixth or seventh day the pustule is observed to be wrinkled
in consequence of the contents becoming thick, and ultimately
a crust takes the place of the pustule. If not interfered with,
this crust assumes a conical appearance, increasing always at its
base; it may ultimately fall off, or, if removed, leaves an ulcer
seated on a slightly cedematous base, in depth, equal to the thickness of the skin; the bottom of the ulcer is covered with a whitish
pulpy substance or membrane, which adheres so firmly that it can
with difficulty be wiped or washed off. The ulcer is generally
circular, and appears as if made with a punch. The margin, if
viewed by means of a microscope, will be found dentated and covered with a secretion similar to that seen at the bottom of the ulcer. The border is slightly oedematous and raised, and the areola
around it of a browner tint than at the previous stages. This
oedematous condition of the border occasions a slight eversion of
of the edges, and hence the ulcer may assume a somewhat infundibuliform appearance*"
The pus from  a chancre is usually thin, serous, and bloody.
Its peculiar characteristic, however, is its power of reproducing
this specific ulceration.
The appearance and character of a chancre is modified by the
treatment, constitution, habits, and circumstances of the patient.
This has accordingly led to a classification, as gangrenous or slough
ing, phagedenic, serpiginous, and indurated or Hunterian chan



VENEREAL DISEASES - SYPHILIS.              413
cre.  But in practice we find them  more or less blended together.
The first variety is distinguished by its inflammatory type and
the strong tendency to destruction of the parts. It is seen in robust plethoric persons.
The phagedenic occurs in broken-down cachectic constitutions.
The ulcer is usually superficial and tends to burrow. The edges
are brownish and undermined; the surface is uneven and granulations are pale or wanting; pus thin and ichorous.
The serpiginous variety, not very frequently met with in private practice, heals on one side while destroying the tissue on the
other. It has no dark areolae on their undermined edges, and the
base is firm, the secretion being purulent. It will sometimes appear as if it was going to cicatrize rapidly, then again commence
the work of destruction. This form, particularly, has hitherto
baffled allopathic surgeons.
The indurated is called Hunterian, from  John Hunter, who
first accurately described it. The edges are a little prominent,
but the peculiarity is the base, which is hard and does not pass off,
imperceptibly diffusing itself into the surrounding parts, but is
very circumscribed. Ricord states, that this induration rarely begins before the fifth or sixth day of the existence of the chancre,'and
is not to be feared if it does not commence before the fifteenth.
This form is almost invariably accompanied with enlarged inguinal
glands or bubo, which, it is said, never proceed to suppuration.
This variety is under allopathic treatment, almost always followed by secondary symptoms. The phagedenic occasionally, and
the serpiginous and gangrenous, but rarely.
Hunter held the opinion, that the disease ran its course without any effort of nature to throw it off, and that Mercury was the
antidote.  Hence, as soon as a chancre was perceived by his disciples, the patient was saturated with this poison, in order to prevent
the dire consequences of the disease; since ascertained to be the
effects mostly of the remedy. Sir Bransby Cooper says, " Of disease of the bones, which are said to result as a secondary effect
of syphilis, I can only remark, that I have for years doubted the
truth of the doctrine itself, as I have never known the bones to
become diseased unless Mercury had been exhibited; and I can



414            VENEREAL DISEASES - SYPHILIS.
hardly bring forward a better proof of this than the fact, that in
former times, when such enormous quantities of Mercury were
given for the cure of syphilitic diseases, the affections of the bones
were almost as common as syphilis itself; while now, on the contrary, when the employment of Mercury has been so judiciously
modified, disease of the osseous system are but of rare occurrence."
Sir Astley Cooper remarks, " I do not think that it is a rare occurrence for the penis to be destroyed by Mercury; for a chancre that has remained weeks in a healthy state, shall become irritable, and, by maltreatment, by the injudicious and improper use
of Mercury, shall slough off and end in the destruction of the penis; this is not a rare case, and is attributed to the venereal disease, but in reality is an effect of the improper use of Mercury."
From these admissions, the results of treatment in those countries where no Mercury is given for the disease, as well as no
treatment, and the experiments in armies and hospitals, it can not
be doubted at least, that tertiary symptoms are not in the large
majority of cases the result of Syphilis, but of Mercury.
In view of these facts, can any Homeopath subscribe to the
language of Hartmann in speaking of the treatment of phagedenic
chancres?  " The organism must be saturated with Mercury to
overcome the dire enemy.  Be not afraid of aggravations; away
with this foolish bugbear."
Ricord, as was before stated, contends, that chancre, for the
first four or five days, is a purely local disease, and if destroyed
by caustic, secondary symptoms will never follow. This, he states,
has been the invariable result of his experiments, in his large and
extensive practice. In the treatment of those cases of longer continuance, he is sparing of the use of the Mercurial agents, except
when the chancre exhibits signs of induration, when he considers
a free use of this mineral indispensable to prevent the occurrence
of secondary symptoms.  He is free, however, to confess that it is
not a certain preventative. In the tertiary form his chief reliance
is upon the use of Iodide of potassium.
Ricord also holds, that secondary symptoms can occur but
once; that there may be relapses, but if once they are cured, the
patient is ever after exempt. Also, that the syphilitic diathesis, if



VENEREAL DISEASES -SYPHILIS.              415
once established, can never be completely eradicated; remedies will
only produce an alleviation and modification of the symptoms.
The diet of a patient with chancre should be regulated by the
character of the ulcer and his constitution. Where much inflammation is present, it should be very spare, but in phagedenic chancre in debilitated, scrofulous persons (and in such it usually occurs), it should be nutritious. When a chancre is located upon
the penis, a suspensory bandage should be employed.
Inasmuch as Ricord declares that the cauterization of a chancre, if without induration within three to five days after its first
appearance, will invariably destroy the virus and prevent the development of any secondary symptoms; we would advise the
homeopathic surgeon to cauterize chancre if seen within that time
and there is no appearance of induration. Remove the pus with
lint and fill the ulcer with Vienna paste. If it heals without leaving a dark-red or bluish scar, there is no fear of any further difficulty. Usually, however, the surgeon is not called upon until too
late for the abortive treatment. The local applications should
then be nothing more than lint kept moist with simple water, or
a solution of the same remedy used internally. The lint ought to
be frequently changed; warm local baths or the vapor of hot water may be advantageously used when much inflammation- is
present.
The most valuable internal remedies for chancre are, Aur.,
Ac. nit., Carb. v., Cinna., Hepar s., Mer. sol., Mer. cor., Silic. and
Sul.
The preparations of Mercury were formerly, as was.before
stated, regarded by Hunter and his disciples, whether Allopaths or
Homeopaths, as the only specific for the syphilitic virus, and every
suspected sore called for the exhibition of the potent remedy. No
matter what the character of the chancre, there was but the one
remedy.
Ricord, however, has done much to put a stop to this unscientific practice, and to determine the cases proper and improper for
its administrations; and in acute phagedena, where Hartmann
recommends to saturate the patient, he directs us never, under any
circumstances, to give this mineral. He has limited its use almost
entirely to the indurated chancre.



416            VENEREAL DISEASES - SYPHILIS.
So also Laurie, in giving his treatment, recommends Mercurius
for the above; but in the other forms, Ars., Nit. ac., Sul., or some
other remedy, is spoken of as more beneficial. And we think, as
Homeopaths have a more correct idea of the importance and significancy of induration as a symptom, it will be found that the
sphere of Mercury in primary syphilis is in indurated chancres.
We rejoice in knowing that we can obtain all the beneficial influence of this agent without any fear of the often direful results of
its allopathic administration.  We also think that Mercurius cor.
will ultimately be found the best form of the mineral for indurated
chancre. Frick, of Hamburgh, produced an ulcer with induration
precisely similar to an indurated chancre, by placing some corrosive sublimate between the glans and prepuce. And Laurie speaks
of resorting to it successfully in cases where induration was present, when the other preparations had failed.  Goullon, of Weimar, particularly recommends it for chancres, but does not,
however, particularize the indurated class.
Simple uncomplicated chancres will soon disappear under a few
doses of Mercurius and water dressings.  When, however, inflammation is present, Acon., or Aeon. and Sul., may be needed; if
much irritability is also present, Ars., Ac. nit., Carb. veg., or ASu.,
will be required. Where there is a tendency to gangrene, Ars.,
Garb. v., or Lach., will be serviceable.  In the case of phagedena
the remedy must be selected with special reference to the state of
the constitution.
Acton speaks highly of the use of Iron.  In many of these
cases the patients have been subjected to the allopathic use of
Mercury, which is the real cause of the difficulty. Ac. nit. and
Hepar 8., will soon produce an improvement.
For the indurated chancre, Mercurius is undoubtedly the remedy.  Hartmann prefers the Mere. precip. rub.  Dr. Muller also
prefers it. Our own preference for Mer. cor. we mentioned before.
For the serpiginous variety, Hartmann proposes Thuja; benefit
may be also derived from Ars., Carb. v., or Sul.
Where granulation proceeds slowly, it may be promoted by
Ac. nit., Sil., or Sul.
Where there is a tendency to the production of condylomata,
inna., Thuja, or Nit. ac., should be given.



VENEREAL DISEASES -SYPHILIS.              417
Chancres situated in the urethra require the same treatment
as those in other parts.
Gollmann thus speaks of the various remedies for primary
syphilis:
" Among the remedies to be employed for the cure of chancre,
I mention, particularly, Acidum nit.; the specific effect of which
has scarcely ever disappointed me. I have found it particularly
indicated by the following conditions: chancres of the orifice of
the urethra, prepuce, margin of the prepuce; chancres with bloody,
fetid, ichorus pus; small chancres without inflamed borders,with flat
edges, considerable swelling of the glans and the meatus urinarius,
which are of a dark-red color and puffed up; small vesicles in the
meatus, on the inner surface and margin of the prepuce, which soon
break, suppurate, and form chancres; deep ulcer at the corona
glandis, with elevated, lead-colored, extremely sensitive edges; flat
little ulcers at the corona glandis, which look clean, but secrete a
strong-smelling matter, itching of the prepuce and damp places on
its inner surface; burning of the inflamed and swollen prepuce,
the inside of which is denuded of the epidermis and covered with
small little ulcers, secreting an ichor that has a pungent nauseous
odor, and stains the linen like bloody pus; simple flat chancre in
the vagina; it is covered with yellow pus and burns and itches;
and lastly, inflammation of the vagina and labia majora.
Accordingly, Acidum nit. will be found particularly adapted
to simple chancre, chancre in the meatus urinarius, and in the
vagina.
Arsenicum; Gangrenous ulcers with bloody edges, corrosive
pus; ulcers with copious secretion of watery, fetid ichor; painless
ulcers with hard edges; lardaceous, stinging, chancrous ulcers,
with white places in the middle of the ulcer, gangrenous chancre
on the glans and prepuce; sudden gangrene of the penis.
Accordingly, Arsenicum will be found adapted to phagedenic
gangrenous chancres, and accordingly to the indurated chancre of
Hunter.
Argentum nit.; Little ulcers on the prepuce, the tips of which
are at first covered with pus, and which gradually spread in extent and become covered with a tallowy or lardacious substance;
swelling and knotty hardness of the urethra, inflammation and
53                                    (PART I.)



418            VENEREAL DISEASES- SYPHILIS.
pains in the urethra, priapism, dysuria, haematuria (chancre in
the urethra).
Aurum met.; Chancres of the scrotum with fetid, ichorous
pus.
Calcarea car.; Chancres of the lower surface of the penis;
chancres with burning pain, having the form of rhagades.
Carbo. veg.; Readily bleeding chancres with secretion of
ichor.
Causticum; Chancres with acrid, corrosive pus, or watery,
greenish secretion, with jerking pain developed out of little blisters, complicated with gout, scurvy, and cutaneous eruptions, disposition to fungous formations (phagedenic chancre).
ifepar sul.; Readily bleeding chancres, with lardaceous edges
and feted secretion.
Iodine; Florid chancres with raised edges that are more or
less shaggy, watery secretion.
Mercurius Sol.; Red chancres on the prepuce; spreading and
deeply-penetrating ulcers on the glans and prepuce; pale-red vesicles on the glans and prepuce, forming small ulcers after breaking;
readily bleeding chaneres; distressingly painful chancres secreting
a quantity of yellowish-white fqtid pus; small chancres with a
cheesy bottom, inverted red edges; inflamed round chancrous ulcers with swelling of the vagina; chancres with edges resembling
raw flesh; not very painful ulcers, sensitive to the contact of
linen; vesicles at the forepart and on the sides of the glans,
spreading and penetrating more and more; ulcers of the glans and
prepuce with cheesy lardaceous bottom and hard edges; a number of small red vesicles at the tip of the glans behind the prepuce, breaking after a fortnight and forming little ulcers which secrete a strong-smelling yellowish-white matter that stains the
linen; afterwards the large ulcers bleed and are painful when
touched, from which the whole body was sympathetically affected;
they were round, thin edges looked raw, and the bottom of the ncers was covered with a cheesy matter.
Mercurius cor.; Chancres with ichor adhering to the bottom
of the ulcer so firmly that it cannot be removed by washing; ulcers
with thin pus, leaving stains upon the linen as from melted tallow.



VENEREAL DISEASES — SYPHILIS.               419
Staphysagria; Smarting vesicles on the inside of the labia
majora, pairful when touched; chancres with fetid ichor.
Sulphur; Chancres with lardaceous white spots and secretion
of fetid ichor; ulcers covered with scurf and looking like itchsores; chancres on the prepuce, resembling excoriations; superficial chancres, as if the skin were excoriated; red ulcers with lardaceous bottom, here and there lined with a thin matter that can
be easily removed; violently itching ulcers, impeding one's walk,
torpid ulcers complicated with scrofula, scurvy, gout, and cutaneous eruptions.
Thuja; Vesicles on the glans, erosions on the inner surface
of the prepuce, which secrete a humor and suppurate; red spots
on the prepuce; granular spots on the outer surface of the prepuce which change to ulcers, become covered with scurf, itch and
burn; pustules on the inside of the prepuce, depressed in the center, secreting a humor and suppurating, painful only when touched.
Burning pain at the corona glandis; flat, itching ulcers surrounded
with redness, with stinging pain, and unclean bottom; whitish
chancre with hard edges; chancres with shaggy edges and lardaceous bottom; chancres with sharply circumscribed edges and
clean flesh-colored bottom; chancres with thin fetid ichor."
Bubo, or swelling of a lymphatic vessel or gland, is sometimes an attendant of the primary ulcer. Chancres situated around
the frenum, meatus of the female, or at the anus, are generally
accompanied by bubo. Venereal buboes are of two kinds, inflammatory and indurated. In the first, usually only one gland is enlarged,
which rapidly proceeds to suppuration and becomes a chancrous
ulcer. In the latter kind, however, several glands are generally
enlarged, but manifest no tendency to proceed to suppuration.
They do not cause the patient any pain, and do not secrete, as the
inflammatory, an inocculable virus. Ricord states that they are an
almost invariable attendant of true indurated chancres, and are
hence valuable in determining the probability of the appearance
of secondary symptoms. And as they frequently, under allopathic
treatment, remain enlarged for some time after the chancre has
disappeared, they may sometimes in the case of suspicious erup.
tions decide their character.
Bubo requires in general the same internal treatment as the



420            VENEREAL DISEASES   SYPHILIS.
primary chancre. Garbo. v. is particularly useful in the indurated
form; it may sometimes be advantageously followed by Silic.
In inflammatory buboes, our aim should be to prevent suppuration; they may require Bel. when the inflammation is very severe; or when suppuration is threatened, Hepar and Silic. Where
it is evident from the fluctuations of the gland that pus has formed,
it should be evacuated by the lancet; cold applications and hot
fomentations are sometimes useful. Compression may also be beneficially employed to aid in preventing suppuration.
Secondary syphilis or the constitutional influence of the syphilitic
virus affects the skin or mucous membranes. Syphilitic eruptions
are distinguished by their reddish-brown or copper color - the absence of all itching except when they include the axilla, the parts
about the anus, &c., when the secretion often causes considerable
itching; and their circular form. In syphilitic affections of the
throat, the mucous membrane becomes covered with whitened
spots as though it had been touched irregularly with caustic, which
finally ulcerates. The previous existence of an indurated chancre,
or of a chancre with indurated, but not suppurating bubo, will be
pretty decisive as to the true nature of the disease.
For secondary symptoms the preparations of Mercury have
been regarded as most valuable. But in the large majority of cases
in which the patient has been under its allopathic administration,
an antidote is more needed. Even in some of these cases, however,
the protiodide may be used with great advantage.
Though Aurum, Ac. nit., Hepar, lod., Kreosote, or Styllin.,
Syl., will generally be required; Dr. Marcy recommends particularly the Muriate of gold. Dr. Teste, in a communication to
the Societe Gallica, reports some interesting cases, showing that
Kreosote has a specific influence in syphilis which would not be
divined from its pathogenesis. From his report it would seem to
be particularly beneficial in the secondary form.
Tertiary syphilis, according to Ricord, can neither be communicated or transmitted. It is then a diathesis which produces
scrofula in the offspring. It seldom occurs under six months after
the disappearance of the chancre -sometimes years may elapse.
What is often called and treated as tertiary syphilis is, as we
believe, in most cases, the effects of the Mercurial saturation,



422    ACOIDENTS AND DISEASES OF THKE EXTREMITIES.
2d. Its seat may be in the cellular or fibrous tissue between
the cutis and the sheath surrounding the tendons; or
3d. Within the sheath of the tendons, under the vaginal ligament of the fingers, or, it may be, upon the synovial surface: and
4th. The inflammation may originate within the periosteum,
between it and the bone. To this last, the appellation of " felon"
is restricted by Webster, in accordance with some surgical authorities; but the distinction is too obscure for a popular definition.
The distinctions are not very clear in many advanced cases.
The articulating surfaces may be either primarily or secondarily
involved. The latter may also occur in the first variety, which is
sometimes distinguished as "onychia."  The pain is likely to be
greatest or most acute in the first, the swelling in the second variety: it not unfrequently extends over the whole finger or hand,
and beyond, producing, by its irritation, soreness and even swelling
of the axillary glands.  In the third case, the pain is the greater,
though the swelling is much less, in consequence of the firmness
of the vaginal ligament. The progress of the disease is in this
situation very slow, and when pus is formed, it is a long time
making its way to the surface. The fourth variety is still slower
in its progress, and less acute in its symptoms, but commonly in
its results destructive to the bone itself. In general the deeper
the seat of the affection, the greater the danger of and from
ulceration.
The inflammation, though commencing in only one of the structures mentioned, may involve the whole. While in the cellular
tissue, near the surface, the pain is severe, and of a throbbing and
itching character. The parts are also swollen and red, the redness being diffused.  As the disease advances, the swelling determines to some point, generally near the nail. The fluid discharged
is commonly sero-purulent.
When deeper seated, the throbbing, the heat and the swelling
are still greater, and the pain also, after awhile. It is often so intense, so intolerable, as to allow the patient no sleep or rest.
It is of a darting character, frequently shooting up the forearm, and even above the elbow.  Considerable fever also often
attends.
The disease may involve only one bone, or the whole finger;



ACCIDENTS AND DISEASES OF THE EXTREMITIES.   428
or it may originate in the palm of the hand. In the latter case
the back of the hand may become enormously swollen.
If not properly treated, the inflammation will terminate in
suppuration in three or four days. In other instances, especially
when it is seated upon the bone, within the sheath of the tendons,
or under the annular ligament, it may be eight or ten days before
any well-marked evidence of suppuration takes place. Extensive
sloughing is apt to follow the suppuration. Not only cellular
membrane, the sheaths of the tendons, and the tendons themselves
may come away, but one or more of the phalangeal bones be lost.
When it occurs in the palm of the hand the disease may extend
to all the bones, and much impair, if not entirely destroy, the use
of the hand forever afterwards. Such serious results by no means
always follow; but neither are they of very uncommon occurrence
when the disease is neglected or illy treated. The surgeon will meet
with instances in his practice, of all degrees of injurious result, from
a very slight deformity to a total loss of one or more of the
fingers.
The CAUSE may be a bruise or external injury of any kind.
Poisons introduced by puncture have been known to produce it.
Very often, however, it can be traced to no known source.
The first SYMPTOM complained of is commonly a prickling sensation, as if a thorn or a brier were in the finger. The patient
will often attempt to extract the supposed offending cause with a
needle or the point of a penknife. This sense of soreness or prickling may continue for several days, without any other painful sensation.  This is the stage for treatment.  After visible swelling
and inflammation, it is more difficult to prevent the formation of
matter, or to cause the inflammation to subside by resolution.
The remedies which have been most successful in this complaint are, Alum, iepar, Mere., Phytolac., Silicea, Suip. and Rhus.
In the early stage, when the sensation of pricking and burning is present, with slight swelling and redness, especially on the
end of the finger, Alumina has proved more successful in our
hands than any other remedy. We use it internally and apply
the clay moistened to the affected surface, renewing or re-moistening
from time to time until the symptoms subside.
Phytolacca is more particularly useful when the disease is lo



ACCIDENTS AND DISEASES OF TIE EXTREMITIES.   425
When the corn is ripe, or rather completely formed, it has a
membrane situated between it and the true skin, so that it may be
removed without any abrasion of that surface.
As the first measure in the TREATMENT of corns, oblige the patient to wear boots or shoes large enough to relieve the toes from
all pressure, cutting a hole in the leather if need be. Leave them
for awhile, without being touched by anything unyielding.
The best of all prescriptions, then, for corns is, "go loose
shod." This is a certain preventive, and the indispensable condition of cure. Loose boots and shoes, however, will not always
be sufficient; and if too loose, so as to rub about, may be as bad
as tight ones.
If the parts around are inflamed, let them be soaked in warm
arnicated water for an hour or more at night, or two or three
times a day; and some soothing emollient be applied in the interval. Then, or at first when no preliminary softening is required,
shave off all the horny substance that can be easily removed; and
apply olive oil.
This will soon soften the corn, and if any soreness remains it
will soon be relieved by the application of Arnica. For bunions
use Silicea.
We have removed corns and warts in numerous instances by
the application of Vienna paste, and have never yet seen any evidence of the " serious constitutional" effects from it, spoken of in
some of the books.
Ant. er., Phos., Rhus, Bryo., Am. carb., Petr., Acid phos.,
Sepia., and Sul., are used for corns.
INVERTED TOE-NAIL -ONYXIS.
This is a very distressing disease of the great toe. The NAIL,
from some accidental bruise, or the wearing of a tight boot or shoe,
or both causes concurring, curls down at the sides, and becomes
embedded deeply in the flesh.  The whole toe inflames, swells,
and soon suppurates or ulcerates at one or more points about the
nail, whence large fungous growths frequently shoot out, which
are extremely painful and tender to the touch. The patient is
unable to wear a shoe or to use the foot. His sufferings are sometimes very grcat; -so much so, indeed, that he is deprived of
54                                         (PART I.)



ACCIDENTS AND DISEASES OF THE EXTREMITIES.   427
keep it freely wet in warm water. Some prefer wetting it in cold
water; but we have seen better effects from having it warm.
These tents will from time to time pass further and further under the nail, and completely separate the flesh from it. It should
be bathed and dressed twice a day all the while.
As portions of the nail become loose, let them be cut off, until,
by thus crowding the tents under at different points, and paring
off the nail, we have removed it all.
After the removing of the nail in this manner, the parts will
soon assume the appearance of a healthy ulcer, and readily heal
Nor does the disease, thus cured, return; whereas, in many cases
in fact, in most cases - when the nail is violently taken off, the
new growth is as bad as the old, and the patient continues to suffer
as before.
It will sometimes take several months to effect a cure by the
mode recommended, but it is not painful and is certain.  This is
substantially the mode pursued by Dr. Beach, which has been successful in all cases.
If called in the early stage, when there is but little inflammation, pare off the center of the nail so as to make it shorter than
the margins, also cut grooves lengthwise near each margin, nearly
through, then press the pledgets of lint, wet in Aqua calen., under the edges so as to elevate them; continuing the bathing with
warm water. This course will soon relieve and the nail will generally take such a form as to give no further trouble.






INDEX TO PART I.
PAGE
Amaurosis      -    -    -            -    -    -                     273
Anchylosis  -        -    -    -    -                                 168
Antrum, ulceration of    -    -    -    -    -    -    -              250
Bones, diseases of      -    -                 -                      145
"    caries of    -    -           -    -    -    -                146
"   necrosis of            -    -                 -                147
"    treatment of -    -    -    -    -    -    -         -        148
Bronchocele             -    -    -    -    -    -    -               308
Burns   -    -    -    -    -    -    -                                98
Cancer       -    -    -    -                                         201
"  fungus haematodes                     -.        -.          -  213
"  eye   -         -    -..                   215
"  nose      -    -...                          217
"lip..........                219
"  tongue  -    -    --                  -     --  223
"  breast             -....                       225
"rectum         -..     - -        -  230
penis.    -    -    -.                231
"  testicle  -    -    -    -    -    -    -    -         -    -233
uterus                  -                                       233
Carbuncle      -    -. -                                             237
Cataract    -    -            -    -    -           -    -            278
Choking                    -    -                                     305
Cornea, opacities of    -    -    -            -                      283
"    nebula            -    -    -    -    -    -                 283
"    ulcer of  -          -    -    -    -    -    -              284
Corns -    -    -       -     -    -     --                     -    424
Dropsy of the eye   -    -    -            -                      -  286
"      "   joints          -    -                                  166
Encanthis            -    -    -    -    -                        -  289
Epulis-    -    -    -    -    -    -               -     -           301
Exostosis      -    -                 -          -    -    -.  190
Felon  -                   -    -    -         -..421
Fistula Lachrymalis -    -    -    -    -                    -    -  253
"   in ano                -    -    -    -    --    354
"   in perineo   -    -         -                                 387
Fissure of the anus    -      -          -    -                       375
Ganglion       -    -    -                    -.189
Goiter                             -    -    -    -    -             308
Gonorrhea      -           -    -    -    -                          403
Gums, tubercle on       -    -    -    -.                       -    301
Hemorrhoids  -    -    -           -    -                            368



INDEX.                                 431
PAGE
Staphyloma..  -                   ---  285
Sty        -....                                    290
Syphilis        -         -.-                                   -  410
Tetanus       -        -....          79
Teeth, affections of            -....           -  292
Tinea capitis             -     -        -     -245
Tonsils enlarged       -        -     -     -                               302
Traumatic Erysipelas.                  --                  82
Tumors  -                       -..-                 -.181
"   adipose.-           -     -                  -                 182
"   fibrous              --.           -  -   -         184
"   cellular    -                 -                                     185
"   various                  -                                          186
malignant.     -     -      -           -     -            187
vascular.      -           -   -                    -         187
Tubercle of Gums                      -      -     -     -                  301
Ulcers          -     -.                 -                        -  112
"   irritable.-       -      -           -           -            113
"   indolent        -     --                -      -     --  114
"   varicose     -     -      -                                          114
specific  -      -     -                              -  -     -      115
"   chronic      -.      -.     -                              121
Varicocele      -      -                             -      -           -  348
Wounds in general.     -   -                    -           -       40
"    incised      -      -     -           -     -                       43
"    punctured        -     -     -         -.                           46
penetrating.-.-..   47
"    lacerated -.....               -       48
"    contused    -      -      -     -                 -51
"    gun-shot.       -     -...                               61
"    poisoned    -       -     -     -                  -66
"    crysipelatous   -                  -      -                 -       82
"    of head       -....    83
"    of neck   -      -     -.-                  93
"    of chest    -       -     -     -              -           -        93
"    of abdomen    -        -     -     -            -           -       95
"    of joints    -      -..                             97
White Swelling         -     -     -                  -     -           -  163
Whitlow       -. -..           421






PART II.
OPERATIVE SURGERY.






CHAPTER I.
OF OPERATIVE SURGERY- GENERAL PRELIMINARIES AND MINOR
OPERATIONS.
ALTHOUGH external and more or less mechanical treatment is
what primarily distinguished Surgery from  the general "Practice
of Medicine," its more technical and peculiar part, particularly
that requiring the use of the knife, is again distinguished from the
more medical, as "Operative Surgery."  Much evil as well as
good has arisen from  the division.*   Physicians have thought
themselves privileged to be ignorant of the most necessary resources for external accidents and diseases; and in some countries,
they even look down upon the business of the surgeon as a mere
trade, while that of the physician only is " the profession." While
the ordinary run of surgical cases are thus left in the hands of a
presumed inferior class - (regularly educated surgeons being still
in some parts of Europe obliged by law to reckon shaving among
their operations, and to keep by them the necessary implements,
as honorable members of the ancient craft of "barber-chirurgeons")- the more serious cases presumed to require operations,
have been transferred to a set of first class surgeons, whose business was only to operate.  Hence, while their art has been advanced to the highest point of excellence, medical surgery, the
proper treatment of slighter cases, and the prevention of the necessity for dangerous operations, has been shamefully neglected.
In this country, Surgery stands higher than Medicine in popular estimation, every man who chooses to " doctor" being of course
* This opinion is confirmed by the distinguished German author, quoted in treating of Fistula in Ano. "It is quite an erroneous view, which has long prevailed,"
says Blasius, "that of regarding the operative surgeon as a mere assistant, who
has only to come in and execute the mechanical part of the business, as the physician shall judge it necessary. This view can only lead to mischief." He goes
on to show why the operator, as soon as he takes a patient in hand, ought himself
to be the physician. " The mere physician does not understand the operation, the
local and constitutional reaction it occasions, the special medication or modifications
of medical treatment it may require," &c., &c. - [Akiurgie, B. i, s. 5and 6.]



4              OPERATIVE SURGERY IN GENERAL.
a physician, though he cannot so easily profess to be a surgeon,
that requiring more anatomical knowledge than mere amateur doctors can easily attain, and false pretensions to it being more certain to be exposed. Few even of the thousands that yearly graduate in our medical schools, give attention enough to their professors
of surgery to practice all its departments.  Most of them remain
shamefully ignorant of even what is most necessary and indispensable in the emergencies of general practice. As, however, the
more serious operations will undoubtedly continue to be generally
performed only by those who are specially qualified for them, both
by nature and education, some DISTINCTION of cases and practitioners seems absolutely necessary.* That distinction should depend,
however, not so much on the difficulty or danger of the operations
themselves, as upon the necessity of immediate attention, or the
practicability of their being deferred. In all serious cases, admitting of sufficient delay and needing special skill, the general practitioner of medicine is justified in calling in the aid of a professed
surgeon, or a brother practitioner, who has had better opportunities of getting ornproving more skill in this department. What a
man is known to have done, he will always be thought better able
to do than one who has not had the same advantage.
But no man is morally justified in holding himself out to any
community as a physician, who is not able and ready to act in all
the ordinary emergencies of danger to life or limb. Those operations, then, that like the dressing of wounds, ligating arteries for
the arrest of haemorrhage, adjusting fractures, reducing dislocations, &c., cannot, without greater or less risk, be put off to another
time or given over to other hands, should be performed by every
medical man at the moment they are needed.  For these, then, he
should specially prepare himself. Othler operations, that allow of
time for "reading up," or refreshing his memory, he can perhaps
afford to be less familiar with; or even, if he prefer, transfer to
more ambitious or thorough-going rivals.
Keeping this distinction in view, we shalt proceed to give the
practitioner the necessary information for acting for himself in all
cases, enlarging most on those in.which he must act or be disgraced,
- as he ought to be.
It is not every man, or every medical man, that has the QUAL



HOW MUCH MUST BE PRACTICED -PREREQUISITES.           5
IFICATIONS for becoming a GOOD OPERATOR. These we will enu
merate, as they stand registered, with true German precision, in
the elaborate work of Dr. Blasius. " One may be," as he premises,
" an excellent physician, without being cut out for an operator, -
may even be well enough acquainted with the principles and technicalities of operative surgery, without being himself able to put
them in practice." First, then, " The operator must have had a
complete medical education, and have devoted himself more especially and minutely to the study of anatomy." He is moreover to
possess a " knowledge of mathematics and physics," and especially
their application in "mechanics."  2d. He requires acute senses,
(scharfe sinne), particularly that of tact or touch, " good eye-sight,
or that which is good for near objects, adroit but steady hands,
and general bodily agility."  3d. In respect of " spiritual qualities,
he is to be a man of courage and resolution, which, however, must
not have degenerated into temerity, but be a union of the highest
degree of calmness, circumspection and intrepidity." 4th. To all
these natural and acquired endowments, he must add " great practical skill, (fertigheit), to be acquired only by repeated operations
in the dissecting room, without which preparation none should venture to operate on the living. Even he who has begun to practice
operative surgery, should continue these exercises on the dead, in
order to keep himself prepared for the rarer operations."  We
have given only the texts of this author, omitting his elaborate
commentary upon each, lest the student should think it our purpose to deter him from the work, in which it is our business to
encourage as well as instruct him.  Some may think we have
already quoted enough to prove that no man can ever be a good
operator!"*
In order to be prepared for every emergency, the practitioner
must have the necessary means as well as knowledge. A surgeon
altogether without instruments is in almost as absurd a predicament as a physician without medicine. He may and should himself
be able to make, or to direct the construction of, such apparatus
as can or must be made where they are needed.  He must also
possess, as well as be able to use, such as can only be furnished by
a regular manufacturer.  His armamentum chirurgicum need not,
* Akiurgie, B. i, s. 5 et seq.



6              OPERATIVE SURGERY IN GENERAL.
indeed, be the formidable and costly array that was once supposed
necessary.  A good workman requires few tools.  In proportion
as the art of surgery has been really perfected, its means as well
as modes of proceeding have been simplified. Intelligent principles have taken the place of empirical rules; and a few instruments, of general availability, have superseded all the ancient
cumbersome apparatus.  A portable case now contains all that the
surgeon needs, instead of a wagon-load, which his armory once
amounted to.
The POCKET CASE, indeed, will hold all the practitioner absolutely needs to have always at hand. This should contain abscess
lancets, bistouries (straight and curved), scissors, forceps (the simple dissecting, and the dressing or ring forceps), tenacula, probes,
(the common eyed and the gun shot), directors, needles (straight
and curved), ligatures, lint, adhesive plaster, &c., &c. The varied
uses of most of these articles are obvious, to any one who has
sense enough to use them at all. A catheter, a portecaustique,
or any particular article may be added to this list, as the individual's judgment or occasions may require.
Besides this pocket case, a " surgeon" should always have accessible dental forceps, cupping and scarifying instruments, a tourniquet,
sponges, bandages ready rolled, and a good assortment of common
splints wrapped ready for use. He will also have to be provided
with ether and chloroform, as he knows not at what moment he
may be called upon to perform  operations when the pain and
dread would endanger life. It is not yet generally appreciated
how much the risks as well as the horrors of operative surgery
have been lessened by the discovery of anaesthesia.
Any other instruments or appliances than those usually carried
in the pocket case, or just mentioned, are always named, if not
described, when giving directions for the particular operations requiring them. Of these instruments, huge folios of plates and
descriptions are still being constantly published. These works are
for manufacturers and professors, or inventors and improvers interested in particular parts.
The act of "doing up" or adjusting a wound or accessible
diseased part is technically called DRESSING, and the appliances,
medicinal or mechanical, are the



INSTRUMENTS, APPARATUS AND MATERIALS.            7
DRESSINGS.
Of any means used by the operative surgeon, few are of more
importance, or require more skill and practice, than the simple
roller or BANDAGE. Its usefulness irdeed not being confined to
this part of surgery, has been repeatedly insisted on, in the first
part of this work. The technical varieties of " starched and laced
bandages," the "suspensory bandage" (or sling), &c., &c., are all
contrivances of obvious significance. When any of them seemed
to demand particular explanation, it has been given when directing
their use.  A French savant has shown, with much ingenuity,
that the " square bandage" or common pocket or neck handkerchief, may be so used as to answer all the purposes of all the manynamed varieties and modifications of the roller, used or imagined
by all our surgical writers.  M. Mayor contends, that besides
other advantages to result as he believes from the adoption of his
" handkerchief system," great good would ensue from the general
knowledge that means so simple were those which the surgeon
would apply, and any person, in his absence, might —at least
provisionally. For the profitable study of reducing things so complex to simple principles, we would recommend our readers to
Smith's Minor Surgery (pages 120-180), where a full account of
Mayor's method is given.
Some of the other most important materials for dressings may
be here mentioned. First and foremost, the water-dressing should
never be slighted for its simplicity. The mere use of water as a
detergent is not what is here meant, but its continued or repeated
application as a refrigerant, emollient and anodyne.  For the last
object warm water is indicated; for the second tepid. Cold water
we do not recommend so much as some for directly counteracting
inflammation; but as a styptic for the suppression of hemorrhage
from small vessels, and as a tonic applied to debilitated parts, its
value can scarcely be overrated, even by exclusive hydropaths.
LINT, cotton and flax-tow, are all in use as applications to raw
surfaces. The last article is much too coarse, when any thing
better can be had. Cotton is now in little esteem, except in case
of burns or scalds. One objection to it is, that it is apt to be
"fly-blown," and engender "maggots."  If used, therefore, it



8              OPERATIVE SURGERY IN GENERAL.
should be perfectly free from specks. Good lint can always be
made for the occasion, by scraping off with a knife the fine nap of
old linen cloth. A supply of the manufactured or "patent lint"
saves this trouble. Charpie is a sort of lint originally prepared
in France, and much used (especially the coarse kind) as outside
dressings, and for insertion into deep wounds, sinuous ulcers, &c.,
as an absorbent, compress or medium for applying medicament.
TENTS and PLEDGETS are such masses of charpie or other suitable material, the former of a conical shape, the latter cylindrical.
Other modifications of form or size are sometimes nicely distinguished as "rolls, meshes, and pellets." As an inserted absorbent the sponge tent is a convenient expedient. It is a piece of
sponge that has been saturated in bees-wax, which melts again and
runs together, by the heat of the parts, leaving the pores of the
sponge free to absorb other matter. Nothing of this kind, however (except where mechanically better for the sake of extraction),
is superior to the slippery elm powder or flour.
TAMPONS are a larger kind of tents, used more especially for
the purpose of applying distension or pressure, so as to prevent or
suppress hemorrhage. The common puff-ball (Lycoperdon bovista,
also the Boletus igniarius) makes a good one.
A COMPRESS is a sort of pad, generally made of folded linen, or
other cloth, and used for the purpose of equalizing pressure under
the roller, or of bringing it to bear on a particular point. Various
shapes and forms of compresses are occasionally mentioned by very
precise writers, -" the triangular, the square, the cruciform, the
graduated and the pyramidal."  Sufficient good sense, at the right
time, will recollect or re-invent the kind that best suits the case.
The sieve-like or "cribriform compress" is very useful in allowing
the escape of pus, and preventing other dressings from sticking to
the wounded part.  "The perforated compress" or a pad with a
central hole in it, is very convenient for applying pressure around
a sore.
Among the means for keeping divided parts in the requisite
proximity, the recently discovered or invented article, collodion, is
by far the most convenient in slight cases, like small cuts or abrasions.  It is an artificial cuticle, with the advantage of transparency and considerable tenacity. In the case of longer incised



10                TRAUMATIC HEMORRHAGE.
FIG. 17.   through the lips of the wound, at right angles to
its course (or to that of the vein or other part
-~     ~" to be compressed), and left there transfixing them.
The thread is applied round under the point and
— ~    ~ -head or eye, in successive coils, crossing each
other over the middle in the form of a figure 8.
It is to be drawn tight enough to bring the divided or desired parts together, and keep them
smoothly so; and then tied with a square knot in the center,
(fig. 17).
The INTERRUPTED SUTURE is, in reality, like the former, but a
substitute for sewing. The needle is only used to introduce the
thread or ligature; and each stitch, or rather tie, is unconnected
with the others.  Only one of these may be used: it is seldom
that many are needed, when adhesive straps and other means are
brought to aid. The curved needle, used for the purpose, should
never be pushed so deep as to include more than the skin and a
very small portion of cellular tissue beneath. Taking up anything more is avoided by making the puncture, as you always
should, from  the inside outward.  In this direction it passes
through much more readily, and gives less pain.  To get the
thread in this way through both lips more readily and conveniently, you should have a separate needle at each end. One being
passed through from the inner side of each lip, they are both removed, and the thread tied just tight enough to keep the edges
together, the ends being turned twice over each other at the first
knot, to prevent slipping while the second is being made.
TRAUMATIC HEMORRHAGE
— is an occurrence which ought rarely to be allowed to run on to
a fatal or serious extent. Every person, let alone surgeons, should
understand enough of anatomy and surgery, to render at least
provisional aid, until the requisite professional means and skill can
be obtained.  Arterial hemorrhage may be distinguished from
venous (which latter seldom requires the same precautions) by its
brighter color, greater amount, and, when the parts or vessels are
exposed, by its partially interrupted gushes corresponding with the
beating of the pulse. All who know that blood comes from the



COMPRESSING AND TAKING UP ARTERIES.            11
heart, should know whereabouts to put their finger on the main
canals or conduits; and when they feel them pulsating, to press
down on them toward the nearest bone.  If the bleeding is from
the upper extremity, it can be stayed by thus pressing upon the
brachial artery on the inner side and a little above the middle of
the upper-arm. If the injury extends to or above this point, the
sub-clavian itself may be controlled by proper care,- pressing it
with your thumb, or a large key wrapped in cloth, against the first
rib from above and behind the collar-bone.  When the alarming
bleeding is from the foot, leg, or thigh, the pressure should be
made in the hollow of the groin, just below Poupart's ligament.
When you want to secure permanent compression, and have not a
tourniquet, fasten a handkerchief round the limb, at or near the
points indicated, with a hard pad on the course of the artery, upon
which sufficient pressure may be made by twisting the handkerchief with a stick.  When a main trunk leading to the opened
branch cannot be come at, let the divided extremity or wounded
part of the artery be compressed with the finger until it can be
" taken up."  Even this last operation, when it is urgent, ought
not to be delayed for want of means. Common needles and thread,
at least, are always procurable.
Bleeding from wounds, however, when only the smaller veins,
and smallest arteries are concerned, will generally soon cease
of itself, or be restrained by simply confining the blood, pressing
on the part, or applying cold and other styptics.  (See under
WOUNDS.)
THE APPLICATION OF LIGATURES.
By " the ligature," is meant any string tied round a vessel or
part for purposes of compression..By far the most important of
these purposes is the suppression or prevention of hemorrhage.
Arteries are also sometimes tied for the purpose of cutting off
supplies to morbid growths or hypertrophied parts. Veins sometimes require the ligature, though this is fortunately rare, as its
application to them is comparatively a serious operation, from
their greater liability to diffuse inflammation. Ligatures for the
purpose of strangulation, or the removal of tumors and diseased
parts, have been described in speaking of tumors.



14            MINOR AND GENERAL OPERATIONS.
such as is likely to require much treatment, the potassa pencil is
more than a substitute for the "abscess lancet."  When it is
necessary or desirable to lance, it should be done freely, -you
should really "open" so as to allow an easy escape for all the
pus already formed, and keep open for the immediate exit of that
which may afterwards accumulate,- or till healing by adhesion
or granulation be complete. It is proper also in all cases, but
especially where the incision is large or deep, to make it in the
direction of, or parallel with, the muscular fibres of the part, -
or with tendons, ducts or blood vessels. Precautions of this kind
are sometimes very important.  (See MAMMARY ABSCESS.)
All lancing is sometimes called puncturing; but generally
when the lancet is required at all, much more than its point is
brought into use.  In opening buboes and other large abscesses
the bistoury is often a more available instrument. Mere puncturing is occasionally all that is required, as in certain operations on
the eye, and in letting off serum from other parts, in anasarca for
instance. But the needle, lancet and bistoury are not the only
instruments which the operator should be skilled in the use of, for
DISSECTING
— is sometimes necessary on the living body, as well as the
dead.  In taking out certain tumors and making deep incisions
for other purposes, a careful and skillful use of the scalpel is indispensable.  The mode of proceeding is the same in dissecting
for the practical study of anatomy and in practical surgery.
" Dissecting," then, should mean the accurate separating of parts,
with as little cutting as possible. It is well to practice three distinct ways of holding and using the scalpel: - 1st, between the
thumb and two fingers, as a pen in writing (Fig. No. 18), which
FIG. 18.. Villls



DISSECTING - CAUTERIZING - SETONS, &C.         15
is generally the most proper and convenient position; 2d, when
the instrument is held in the hand like a common table fork
(Fig. No. 19); and 3d, at the points of the thumb and two or
more fingers, like the bow of a violin.
The webs of cellular tissue, or more membranous fasciae, are
to be raised and kept tense, so that the smallest possible cut at
the right point may suffice. For holding up these parts, in operating on the living flesh, the fingers should be made use of,
where practicable, instead of the forceps or tenaculum, as pinching with these is not only
likely to give pain, but to            FIG. 19.
injure or kill the parts
contused.   The  fingers
should also be made as
far as may be, to do the                   / 
work of the scalpel itself.
When  the different tissues or layers are torn,
instead of being cut asunder, the division is more
likely to be, in the sense
we are now using  the
word, a true " dissection,"
and injury of even the 
smallest nerves and vessels less likely to occur. When small vessels are torn, they will
not bleed as when they are cut.
ISSUES, CAUTERIES, INOCULATION, &C.
When it is designed to set up and keep up a suppurative
drain from a particular point, the object is sometimes effected by
simply opening the integuments with a lancet, and inserting some
foreign substance, as a pea, to act as a constant irritant. These
mechanical issues may prove very mischievous if too near a bony
prominence, or where they would interfere with the free play of
the muscles or tendons.  A somewhat less objectionable means
for getting up a suppuration, but still too mechanical, is the seton.
This was much practiced by the older surgeons. A portion of the



16             MINOR AND GENERAL OPERATIONS.
integument is.pinched up, and a very large needle, called "the
seton needle," is run through, leaving behind it a whole skein of
silk or other thread. This irritant is pulled a little in one or
other direction every day, or as often as is required to keep up
the suppuration. These old horse-doctoring practices, with knife
and rowel, are quite unnecessary. They are constant sources of
pain and irritation, while acting, if not permanently injurious.
Whereas
-the CAUSTIC ISSUE, when any is needed, causes no more
pain in the first place, and none at all afterwards, while a constant drain can be much more easily kept up from it; the irritating plaster, spoken of under Hip disease, is far superior to any
other species of continued counter irritation, and insures any desirable amount of suppuration.  When it is designed to have this
plaster act speedily over a larger surface than it would be proper
to prepare for it by the caustic, a common fly blister or any of
the quicker vesicants (like ammonia or acetic acid) may be previously used.  Abscesses may be not only opened, as they often
should be, by caustic issues, but encouraged by them to point the
sooner, while they draw off excessive irritation from within.
The ACTUAL CAUTERY, i. e., literal burning, is a relict of the
surgery of barbarous times still occasionally resorted to, though
no well-informed surgeon of the present day need ever have recourse to it.  It is directed to be performed by means of red or
white hot iron. The MOXA is a modification or slower application
of this, introduced in recent times from the Chinese " practice of
surgery," where we are told it is a prominent operation or charm.
ACUPUNCTURE is another oriental practice, which has been
resorted to by allopaths with apparent advantage, in neuralgia
and other obstinate affections. It consists simply in thrusting
deep into the affected part several needles, giving them a rotary
movement.  They have been pushed, it is said, into the most vital
organs, without injury.
ELECTRO or GALVANO PUNCTURE is when two needles, so inserted, are made the discharging and receiving points of the
current, so as to oblige it to pass through a desired part. Various
kinds of metals have been used in these experiments and with
very various success



PUNCTURIN — INOCULATION, &C.               17
Vesication is sometimes produced as a means of introducing
medical substances or influences into the general system. It is
called the endermic method of medication.  The Homeopathic
surgeon will rarely, if ever, have need to resort to these means.
INOCULATION is a mode of artificial or prophylactic poisoning,
analogous to endermic medication.  It means the insertion of contagious matter for the purpose of exciting the same specific disease that produced it. It has been experimented on and proposed
in a great variety of diseases; and was really of great use, and
greatly needed, for small-pox, before Jenner discovered a substitute for it in the cow-pox, giving rise to the particular kind of
inoculation, hence called
VACCINATION.
This is an operation which every practitioner of medicine
ought always to be prepared with the means of performing. The
MATTER so called (which, however, should be clear lymph taken
before the vesicle has reached the suppurating stage, or has any
inflamed areola, and from an otherwise healthy patient) should be
very carefully preserved from the air, when it is intended for future use. A common and convenient way of keeping it is in
bees-wax. The best plan, when convenient, is to have the person
to be vaccinated and the person to be vaccinated from, both together, and prepare the former for the immediate insertion of the
virus before it is taken from the latter. Some vaccinators scrape
off the cuticle, others make a good deal of cutting and scarring.
These are both unnecessary and cause superfluous irritation. It
is sufficient to make a few oblique punctures with the point of the
lancet, about the eighth of an inch in length,- if without drawing any blood, all the better. Then wet the point of the instrument in the fresh lymph, to reinsert it for a moment into each
puncture. If you have only the scab or dried matter, it may be
dissolved in water or slightly moistened, and a minute portion inserted into each orifice, allowing it to remain there for a short
time, at least, without disturbance. To avoid irritation, the part
had better be loosely bound up, or have court plaster over it after
getting dry. A dose of the Homeopathic preparation of sulphur
should be given after the maturation of the scab, to remove any
3                                       (PART II.)



20             MINOR AND GENERAL OPERATIONS.
ous circumstance to demand the same precaution. The best mode
of operating in such a case, is to fix a tenaculum, or the three
chain hooks of a common dissecting case, to the top of the tumor.
Pull firmly upon the tenaculum or hooks, so as to put the skin
and cellular tissue violently upon the stretch. Then with a scalpel
or bistoury make a circular incision, through the skin, around the
base of the tumor large enough to extend at least three-fourths
of an inch, if practicable, beyond all trace of the disease or discoloration.  Continue to pull on the tumor, and if possible, by
moderate force, pull it off.  But if it adhere too firmly, separate
the cellular tissue with the knife. If any arteries are cut (which
is less likely to occur in this mode of operating), take them up -
apply an elm poultice to the surface, and promote suppuration
and granulation.
These rules apply of course to all CANCERS or CANCEROUS TUMORS, where the knife is only used as auxiliary to the cure, by
removing a portion or all of the diseased mass at once, instead of
doing it by the slower means, -which, however, are afterwards
indispensable to a safe treatment.  (See CANCER.)
In nearly all cases of large tumors, it will be better to have
the patient under the influence of ether or chloroform; and it
may be very necessary in quite small ones. Even for the operation of the caustic, if the patieht's resointion can not be sufficiently
roused, there will be far less risk from the ansesthetic agent than
from the nervous excitement and shock of fear.  The danger to
life from the ether, it should be remembered, is little if any, and
even the chloroform iciay by iroper precautions be disarmed of all
its terrors.  The person who acniitisters it should always have
ammonia ready at hand to use as aS  anitidote, in'ase the insensibility threaten to be that of deathi.
ANEURISM.
Aneurism is a diseased state of an artery, inducing dilatation
and subsequent rupture.  Some suppose rupture of the internal
coats, if not also of the externtal, to be a first or early occurrence.
Whether formed by and within, or only from and about the vessel,
an enlarging and ptulating "m4 morP' is the characteristic result.
-When munh of its capsule ot saic iS not contituted of any of the



ANEURISM -NATURE AND TREATMENT.                21
proper coats of the vessel, but of a cyst produced from the effused
lymph surrounding an orifice through which it receives its deposite
of blood, it is called FALSE ANEURISM. When there is no such
covering, the artery only continuing to pour out its blood into the
cellular tissue, it constitutes DIFFUSED ANEURISM. When the effusion runs along between the coats of the artery itself, it is sometimes distinguished as a dissecting aneurism. The exciting CAUSE
may be local injury, violent bodily exertion or strong mental emotion.  The patient often refers to a strain when "something was
felt to give way."  There is generally a predisposing cause in
some form of cachexia, such as syphilis or mercurialism.
The DIAGNOSTIC SYMPTOMS are obvious: — The swelling beats
synchronous with the artery, along the course of which it occurs,
and can be emptied of its contents by simply pressing on the vessel above it.  The pulsating is noticed from  the first while the
swelling is small and soft, thus distinguishing the case from a
tumor proper, which generally begins hard, and only pulsates
while pressing on the artery.  The latter is also unaffected by
compression on the artery, movement of the part or the patient's
change of position.
In its PROGRESS, the coats or boundaries of the aneurism may
for a time be strengthened by adhesion with surrounding parts,
but these are absorbed as the dilatation proceeds, even bone presenting no obstacle, When it reaches the surface, a mucous canal
or internal cavity, it bursts, and fatal hemorrhage is often the
consequence.  Aneurism  may become its own cure by more or
less complete coagulation of the blood; by sloughing, in which
the artery is included so as to block it up, the same as when small
branches are cut through; or by pressure of the effused blood
upon the vessel, with a similar result to that of tying it up.  This
last occurrence is the indication of cure; for in
— TREATMENT, compressing should be the rule, ligating the
alternative. Compresses should be applied along the course of the
artery, and perhaps to the tumor, in the early stage, but not so
firmly as to promote absorption or favor inflammation.  Contrivances for these purposes will readily occur to the practitioner.
The great difficulty is to prevent their being removed or disturbed
by the patient.  The aneurism tourniquet, lately devised, prom



22            MINOR AND GENERAL OPERATIONS.
ises to be an available resource, possessing the peculiar advantage
of a lock and key. The surgeon after securing it can put the
latter in his pocket. It is better to have the pressure bear most
on two points, both above the aneurismal sac, so that one may be
a little slackened without allowing free course to the blood.'Compression has been at various times the fashion, but again abandoned, apparently from indiscreet and injudicious modes of using
it. When the sac is very large, with thin walls and degeneration
of the surrounding parts, it manifestly requires caution. As to
the mode of applying it, gradual compression seems, in some
hands, to have better success, probably from inducing coagulation,
than the attempts to at once obliterate.
In many cases and in many parts of the body, however, the
LIGATURE is the only resource.  There are three principal ways
of applying it: -below the sac, with the view of inducing coagula, - both above and below, the sac being then opened, - and
that of Hunter, now generally adopted, which consists simply in
ligating the vessel at some convenient point between the affected
part and the source of circulation.  The second method, tying
below as well as above, is necessary in varicose aneurism (as after
bleeding, when the venesection has been also arteriotomy), when
the blood is diffused or ready to burst out and become so, and
where there are numerous anastomosing vessels, as in the back of
the hand and foot. Tying beyond or below the sac alone, may be
proper where it cannot be done above. The greatest triumphs,
however, of modern surgery, have been from the simple operation
of Hunter.  It is contraindicated in false aneurism of great extent, in general disease of the arteries or the aneurismal diathesis,
and when nature has fairly taken the case into her own hands by
the circulation ceasing in and below the part, or by gangrene or
caries occurring in its vicinity. Where the neighboring vessels
have become thickened and unfit for additional vicarious duty,
success will be questionable.
In operating, cut or dissect down at the point chosen with a
scalpel or bistoury, and when you have reached the surface of the
vessel, work round it with the blunt end of the ANEURISM NEEDLE
(see plate, Fig. 20), separating the accompanying nerve or vein
from the artery, by pushing rather than cutting through the cel



ANEURISMAL VARIX, VARICOSE VEINS, &C.          23
FIG. 20.
lular substance that connects them, thus avoiding the danger of
puncturing such vein or nerve. This is especially necessary where
a large vein or nerve is inclosed in the same sheath with the artery, as in the neck or thigh.
It would be difficult to say how far, or how high, this operation may be carried. After the operation, a general expansion
of the branches or other arteries supplying the same parts, ensues, and their complete circulation is soon re-established by
anastomosis; but, after a time, a few vessels only take on the
duty of increased supply, and the rest contract again to their
original dimensions.  The subclavian has now been frequently
tied, and saved life, where nothing else could have done so. Both
common carotids have been successfully obliterated; and Sir Astley
Cooper even tied the descending aorta with, it was believed, good
results, -for a time.
VARICOSE ANEURISM and ANEURISM ALVARIX (results of " venesection" into an artery, permanently connecting it to the vein,
with the addition, in the former case of a "false aneurism" between them) require, like false aneurism in general, and large
diffused aneurism, the double ligature.
NiEvus, often congenital, appearing as a red shining spot on
the skin, and liable to enlarge and bleed profusely, is a similar
condition of the small arteries to that of the veins in varix.
Large nsevi are called " aneurisms by anastomosis." The tumors
they occasion are distinguished by their pulsation, their gradual
enlargement, and final frequent ulceration. [Their treatment was
given under the head of VASCULAR TUMORS.]
RECICATRIZATION AND RHINOPLASTICS.
Still another kind of general operation may be mentioned in
this place. It belongs to restorativei though not at all to medical
surgery: unlike most operations, it is constructive instead of



RHINOPLASTICS AND RECICATRIZATION - LUXATIONS.   25
methods.  The general principle in these transplantings is, that
the part removed must be kept for a time in connection with both
its old and new locations, in order that some circulation may be
kept up until the vascular reorganization is complete. (See further
in connection with particular localities.)
CICATRICES from wounds, ulcers, and especially burns, sometimes take place in such a way as to occasion much deformity, if
not deficiency in the use of the parts. The general cause of this
is permanent muscular contraction, as that of the platysma myoides forming " wry-neck."  Such a state of things may sometimes
be remedied by simple incision, dividing the contracted fibres; but
more generally the old cicatrix has to be completely dissected out.
Care must be taken in dressing the new wound, and regulating the
position of the parts during healing, that a repetition of the accident do not occur.
CHAPTER II.
DISLOCATION OR LUXATION-GENERAL DIRECTIONS FOR REDUCTION
AND TREATMENT.
THIS is a subject which requires the special attention of the
general practitioner of medicine. There are few accidents which
demand more prompt redress, and in which professional skill or
the want of it, is more manifest. It is a department of operative
surgery that cannot be safely or conscientiously neglected by any
who intend to practice medicine.
By "luxation" or "dislocation," which almost defines itself,
is meant the displacement of a bone from the surface of another
bone, to which it is naturally articulated. Its distinction from
"fracture" is sufficiently obvious in the abstract. When, however,
the two accidents occur at the same time, doubt and difficulty may
arise.  These cases, called compound and complicated, will be
taken up separately, after drawing your attention to Simple Dislocation and Simple Fractures.
4                                        (PART II.)



26              OF DISLOCATION IN GENERAL.
The readjustment of the separated bones is called the " reduction."  If any considerable time has been allowed to elapse, before
this is effected, the operation becomes very difficult and sometimes
impossible.
The true nature of the difficulty is not always obvious; and
the consequence of the medical attendant's failing to ascertain it
in time, is that his patient must remain crippled for life.
The student must not rest satisfied with understanding and
recollecting the bony frame work of the joints, but study their
whole mechanism, including the arrangement of the cartilages and
ligaments, and the insertion and action of the muscles. The uses
as well as structure of every joint, the play as well as position of
every muscle, should be familiar to the mind. The fact of dislocation is as often ascertained by the unnatural position and limited
motion of the limb, as from the changed appearance at the joint
itself. This is the case, for example, with the shoulder, elbow, and
hip.  The precise nature of the displacement, if not the fact of
any displacement at all, can often be certain only to one who has
an exact anatomical knowledge of the parts in all their connections. It is, however, important that the surgeon be familiar with
the external shape and appearance of the joints, in the living subject as well as their structure and connections from investigations
on the dead.
It is sometimes a very difficult matter, even for the most skillful and experienced, to discover the real nature of the case, in
consequence of the swelling that is apt to occur. Hence the importance of examination and adjustment as soon as possible after
the accident. Too often, however, the surgeon has not an opportunity for this. The direct injury done by the violence, which
caused the luxation, or the subsequent irritation from the unnatural
position of the parts, has brought on inflammation, which completely
prevents any opinion being formed from  external appearances.
Even the position and movement of the part are sometimes insufficient criteria, as fractures and even sprains may simulate dislocation. In such cases the practitioner should be cautious of giving
a positive diagnosis, until he has so far reduced swelling and inflammation as to be able to make the proper examinations.



IMPORTANCE   GENERAL SYMPTOMS AND RESULTS.    27
The SYMPTOMS of dislocation, it must be born in mind, may be
a change in the outward form of the joint, a greater or less alteration in the length of the limb, or in the direction of its axis.
This last symptom, the altered axis, or position of the limb, is
chiefly referable to muscular action on the parts in their abnormal
position, since the ligaments are generally so extensively lacerated
as to retain but little influence. The form of the head of the bone
has a considerable effect on the direction of the limb. Thus, when
the head of the thigh bone is thrown up, on the ilium, its easy
mobility under the action of the adductor muscles, occasions the
knee and foot to turn inwards.
Immediately after a dislocation has taken place, the individual
not unfrequently retains the power of moving the limb: he is
neither so crippled nor deformed as to manifest the serious nature
of the injury. But in a very short time the muscles become contracted and rigid, and the limb appears permanently deformed.
In some dislocations, the limb being shortened, most of the
muscles are relaxed; while in others the limb is elongated and the
muscles put upon the stretch, so much so in some cases, as to cause
them to be ruptured.  The consequence of such complications is
great effusion as well as inflammation. The amount of effused
blood will be in proportion to the injury done to the muscles, or to
the blood vessels themselves.
Severe pain may be occasioned by pressure of the bone on
sensitive parts, or its exciting inflammatory susceptibility in parts
otherwise insensible.  In this way it may even endanger life.
Paralysis by pressing on a nerve is not unfrequent. In dislocation of the head of the humerus into the axilla, for example, it may
not only impede nervous communication with the arm, but cut off
the due supply of blood, and in this manner cause atrophy as well
as paralysis. The dislocated clavicle may press on the windpipe
or esophagus.
The external prominence caused by the head of a bone may
be transferred to a considerable distance from its accustomed place,
and the depression in the latter place becomes a corroborating
symptom, as well as the mobility of the new prominence.  This
displaced prominence may be greater or less than the original one.



28              OF DISLOCATION IN GENERAL.
The protuberance of the trochanter, for instance, is diminished by
the new location of the head of the femur; that of the elbow is
greatly enlarged by a backward luxation of the ulna.
If the dislocation has been allowed to remain a considerable
time unreduced, there will be more or less effusion of adhesive
matter into the joints and surrounding tissues.  This adhesive
effusion, or actual adhesions of the tissues, may cause a sensation
of erepitus on motion, which may easily be mistaken for fracture.
But close observation will generally enable the practised ear of
the surgeon to distinguish this from the crepitus of loose bone.
The CONSEQUENCES of unreduced luxations, and the changes
that may supervene in the bone and contiguous parts, are worthy
of attention. Sphacelus, as a termination of the inflammation excited, may come on after the reduction as well as for want of it.
Its danger to the limb or life of the patient is obvious. But when
this danger is escaped or warded off, the principle of adaptation,
so observable throughout nature, comes into play.  The displaced
bone not unfrequently forms a new socket, so that a considerable
degree of motion, with the requisite pressure upon it, is regained.
The particular result will depend in a great measure upon the
length of time since the accident, as well as upon the peculiar
structure of the parts where the head is lodged. If it is among
muscular matter, the cartilage remains entire and new cartilaginous deposites take place around it, connecting firmly with the
neighboring parts.  Within this new formation the head of the
bone freely moves. If, however, the dislocated head be in contact
with another bone, - or there is but a thin muscle between them,
which is soon absorbed in consequence of the pressure bringing the
bony surfaces in contact, -a remarkable change takes place in
the dislocated head. The articular cartilage and the rounded end
of the bone are both absorbed, the latter being flattened or hollowed out so as to adapt itself to the contiguous surface, which is
also sometimes modified to receive it. Ossific deposits frequently
take place around the cavity, forming a deep cup, confining the
bone in its new place and allowing it considerable freedom of
motion. The muscles become diminished in length in proportion
as the limb is shortened.
The CAUSE of dislocation occurring is generally a force exerted



CAUSES AND MODIFICATIONS.                 29
on the bone when it is in an oblique direction with respect to its
articulating connection, and when the muscles are relaxed and unprepared for resistance. In such circumstances very slight force
may be sufficient; though to produce the same result, an immensely
greater force would be necessary, were the individual on his guard.
When this is the case and the injury has been brought about in
spite of resistance, "by main force," extensive laceration as well
as luxation occurs.  On the contrary, little if any injury is done
to the surrounding parts, when the bone has slipped, as it were
accidentally, out of its place.  Such a dislocation may occur from
paralysis of one set of muscles, the other retaining their force;
or the spasmodic action of the muscles upon either side, may easily
effect it, when the antagonistic ones, with the ligaments of the
joints, are in a state of relaxation.  Ulceration may also be the
cause, by detaching the ligaments, as in the Hip Disease.
Dislocations may be connected with fraeture.  This is almost
invariably the case when the ankle joint is the one concerned, the
fibula rarely escaping fracture. The olecranon process of the ulna
is also not unfrequently torn off, when that bone is "put out of
joint."  Luxations of the head of the humerus are often accompanied with fractures of the scapula. Dislocation of the spine
and of the ribs must always, in our opinion, be attended with fracture.
"Compound dislocation" is technically used to imply a dislocation accompanied with laceration of the surface and capsular
ligaments, exposing the displaced end of the bone. In such a case,
there is generally more or less hemorrhage, with an immediate escape of the synovial fluid.  These dislocations are dangerous.
Extensive inflammation and suppuration are likely to ensue.  The
cartilages very soon inflame, suppurate and pass off. The denuded extremity of the bone, even when replaced, only adheres at
the joint, and anchylosis is the least unfavorable result.  Unless
great care is taken immediately after such an accident, to prevent
the occurrence of much inflammation, and after resolution to effect
early adhesions of the soft parts lacerated, serious evil may be
apprehended.
Some joints are more liable to compound dislocation than
others. The ankle, the wrist and the elbow, are perhaps the joints



30               OF DISLOCATION IN GENERAL.
most frequently subject to this form of accident.  It rarely happens with the knee.
PARTIAL DISLOCATIONS may occur.  The tibia, for example,
may be thrown forwards on the metatarsus, while partially retaining its proper basis. One bone of the elbow may easily be thrown
out of place, while the other remains in position.
LIABILITY to dislocation varies in different parts, and also with
the age of the individual. Those joints which have the most extensive and varied movements, are the most exposed to this accident —the shoulder more than any other.  Very old and very
young persons are less liable than others; the former in consequence of the greater fragility of their bones suffering fracture;
while in the latter, imperfect ossification allows the separation of
their epiphyses from the body of the bones.
The DIAGNOSIS between a fracture near a joint and a dislocation of that joint, is sometimes very difficult. In dislocation the
bone is not only incapable of its proper motions in the joint, but
is generally immovable beyond a certain point or in certain directions, even by the efforts of others. In the case of fracture, on
the contrary, there is a loss of control in the direction of motion;
but the muscles still act and even move it more freely, while the
limb, if it be a limb concerned, can be easily moved by the surgeon.  If proper extension and adjustment be made, a limb will
remain extended, when it has been only dislocated; while in fracture, if it be not immediately secured, it will be drawn back into
its former position. In the latter case, moreover, crepitus can
generally be heard over the broken ends of bone; whereas no
such phenomenon is to be expected in dislocation; nor anything
that can be mistaken for it, unless from adhesion or effusion, as
already mentioned.
The principal DIFFICULTY the surgeon has to encounter in reduction, is the resistance of the contracted muscles; and this will
generally be the greater in proportion to the length of time that
has elapsed since the accident occurred.  The muscles have a
greater contractile force, independent of volition. This is true
even of the otherwise voluntary muscles.  When a muscle is
divided, its separate parts both contract: so in partial paralysis,
or loss of voluntary control of motion, the muscle still contracts,



DIAGNOSIS - EXTENSION, &C - ADHESIONS.           31
and permanently draws the part with which it is connected in a
given direction. This sort of contraction will continue an indefinite length of time; for it is not followed by fatigue, as is the case
with contraction excited by volition. Moreover, when a muscle
has been long thus involuntarily contracted, it becomes incapable
of being again extended; the new position isthen the natural one;
its contraction has become an actual shortening.  Thus, when a
bone is dislocated, the contraction of a muscle removes it far from
the joint, and there it is retained. After it has been long thus
relocated, no power short of that which will rupture the muscle is
sufficient to replace the bone in its original position. In reduction,
then, the surgeon has to overcome this increasing contraction or
shortening of the muscles. This is generally effected without much
force, if extension be made soon after the accident (which should
always be done, even when complete reduction is not at once effected). If only a few days are allowed to elapse, great difficulty
will attend the operation.
An additional difficulty, in cases of long standing, results from
adhesions of the surrounding parts, by which reduction is often
rendered impossible, independently of the contraction of the
muscles.
Or, as a third obstacle to reduction, the socket from which the
bone has been displaced, is more or less occupied with effused matter, so that if sufficient extension can be effected, and the head of
the bone brought back to its original position, it cannot re-enter
its socket. The matter deposited may even have been ossific, and
the original cavity be entirely filled up with solid and resisting
substance.
Or, again, a new socket may have been formed for the head of
the bone, as well as corresponding adhesions or cartilaginous connections. In this way, the head of the bone may be so completely
fitted to its new position, that it would be equivalent to a fresh
dislocation to remove it, even if you were sure of getting it back
to and into its original place.
FORCE alone cannot, then, be depended on in the reduction of
dislocations. Constitutional as well as local means must be resorted to, -physiological, as well as mechanical, principles must
be brought to our aid, - especially when any considerable time



32              OF DISLOCATION IN GENERAL.
has elapsed since the accident occurred. In nearly all cases, however, physiological as well as anatomical considerations are involved,
and more or less constitutional management is requisite. The surgeon must take into account the natural action of the large muscles, and the direction in which their contraction has a tendency
to draw the limb or bone. This, in ordinary cases, and for a long
time, is the principle source of difficulty. Every surgeon, therefore, should be well acquainted with the anatomy of the parts,
should know individually every considerable muscle connected with
the joint, and how much extending and counter-extending force is
necessary to overcome its resistance.
The CONSTITUTIONAL MEANS, necessary in some cases to be
employed, are such as will immediately bring about a general relaxation of the muscular system.  These means are required not
only to overcome, what may be called the instinctive resistance of
the voluntary muscles, but any spasmodic action that may occur.
It is for this reason that blood-letting and antimonial nauseants are
generally recommended.  But, inasmuch as we have abundant resources, which will produce the desired effect as certainly, and
much more safely for the patient, we are not under the necessity
of resorting to these objectionable means.  The warm bath is a
valuable auxiliary; but nauseants, after all, must be chiefly depended on. Antimonial nauseants, however, always objectionable,
are here particularly dangerous; for they must be given to a sufficient extent to produce complete relaxation, which cannot be
done without excessive prostration and danger of irritation, or
even inflammation of the stomach and bowels. In the much decried and much abused article lobelia, we have a nauseant far superior to tartarized antimony. Not only are its direct effects on
the system far better for our purpose, but the most extended experience has proved that it is free from all danger of irritation or
too long continued a prostration.
Let the patient then be subjected to a simple warm bath or to
a vapor bath, till free perspiration is excited. If not sufficient
relaxation, give also the lobelia, either in the form of infusion or
of an acetous tincture, —give it in small and frequently repeated
doses, increasing the quantity until the patient is very much nauseated. If actual vomiting is caused, you can lessen the quantity



RELAXANTS- APPLYING FORCE- MODE AND AMOUNT.  33
or increase the interval between the doses, but should not discontinue the operation until complete relaxation is effected. This
may be carried indeed to such a point,- and with perfect safety,
too,- that the patient's limbs and whole voluntary muscular system will be as flaccid, or nearly as flaccid, as those of a recent
corpse.  Yet from these and other "alarming symptoms," the
subject of them will invariably and spontaneously recover in the
course of a few hours.  Tobacco has been recommended by some
surgeons to produce this relaxation; but it is dangerous as well as
unnecessary.
When the proper relaxation has been brought about by these
internal and external means, the mechanical operation of REDUCTION should be at once effected. This consists mainly in what is
called extension and counter-extension. The direct extension is
usually made by the surgeon's own hand and muscular force.
The counter-extension, or fixing of the body so as not to yield to
the extending force, may be intrusted to assistants or to properly
arranged machinery.
The extending force should never be suddenly applied. Begin
gently, and gradually increase the strain, until the muscles are
wearied or give way.  Very great resistance may thus be overcome by a comparatively slight force long continued, and no violence or permanent injury done; whereas the requisite amount of
force, if applied all at once, would be sufficient to tear the muscles
asunder..The counter-extension requires considerable care, so that when
extension is made, the socket into which reduction is to be effected,
will remain fixed and unyielding.  The requisite force for this
purpose is, in many instances, better supplied by mechanical
means, the resistance of which is more firm and steady, and more
to be depended upon than any amount of manual force.  The requisite machinery and the best, when it does not require the loss
of too much time to procure it, consists of a set of pulleys fixed at
some point in the direct line of the intended extension, or Jarvis'
adjuster.
The limb should if possible be kept in such a position as will
of itself produce relaxation of the stronger of the opposing muscles.
As a general rule it should be partially flexed.
3                                        (PART II.)



34              OF DISLOCATION IN GENERAL.
In some instances the extension should be made directly upon
the dislocated bone. In other cases it is better to apply your
force to the bone next beyond, as to the fore-arm in dislocations
of the shoulder joint. In dislocation of the hip, on the contrary,
the extending bandages should be applied above the knee, as their
object requires the limb to be bent.
The state of the patient's MIND, independent of conscious volition, exerts much influence over the muscular system, and is a
consideration of great practical importance. Resistance to external force is an instinctive or reflex and involuntary act.  The
adroit surgeon will contrive to divert the patient's attention as
much as possible from the operation. He may, for example, have
some piece of good or bad news, some surprising intelligence communicated, or some striking "accident" purposely brought about,
at the desirable point of time. The arrival of some long absent
friend may be spoken of, or some article let fall with alarming
violence. We have succeeded, in otherwise difficult cases, by having an assistant attract the patient's attention by dashing his
hand, or something, suddenly through a pane of glass, just at the
favorable moment, when everything was ready for effecting the
object,- except the patient's mind.
The SUCCESS of your efforts can generally be known by the
limb having suddenly regained its original shape and capacity for
motion.  The entry of the head of the bone into its proper socket
can, besides, be commonly both felt and heard; it " snaps" like a
lock when the key is turned. When pulleys are used, however,
or when the muscles are very much relaxed, this snapping of the
bone into the socket will not be noticed.
After the dislocation has been reduced, the limb should be
kept in its original position by bandages and, in some cases, splints
also; otherwise a very slight force may throw it out of place
again. All the TREATMENT generally necessary, after this, is to
keep the bandages over the joint constantly wet with cold water,
to which has been added the Tincture of Arnica Montana.  We
generally add a teaspoonful to each pint of water, and attend to
such constitutional symptoms as may arise. As the patient is
obliged to keep quiet for a while, his diet should be regulated accordingly.



AFTER TREATMENT.                     35
We have said that this is generally all that is necessary, but
we would recommend in all cases of dislocation, for Arnica Mon.
and Rhus. Tox. to be given internally, in alternation, once in from
three to six hours. We have usually employed the third dilution.
The virtues of Arnica in mechanical injuries are so well known,
that even others than Homeopaths now frequently use it.  There
is, however, in dislocations such violence done to the tendons and
ligaments as to require the use of the proper specific Rhus Tox.
We have found their alternate use to succeed better than when
given singly. And in those cases where they have been employed,
the patient has not been left with that weakened, lame, irritable
condition of the joint; which often, especially in old persons, renders the limb for a long time comparatively useless. But, on the
contrary, they have speedily recovered the use of the limb in all
its former vigor. All thanks to Homeopathy in developing the
specific virtues of remedies.
If the above treatment is faithfully employed, inflammation
will not arise from dislocation (at least it has not in our practice). Should it, however, be present when the surgeon is called,
or make its appearance at any time, Aconitum  should precede
the other remedies.
Suppuration about the joint must be carefully guarded against.
Hence, as a general rule, emollients are to be avoided. Resolution is here the only safe termination of inflammation. If you
would therefore escape ulceration and destruction of the joint, do
not allow the lately dislocated part to be moved for some time to
come.  Too long inaction may indeed occasion some stiffness of
the joint; but the danger from this source is little or none compared with the other; and the inconvenience and anxiety of
friends may be easily overcome by gradually attempting motion,
when the proper time for it has arrived.
As to the exact TIME, after which an attempt should not be
made to reduce a dislocated bone, no positive rule can be laid
down. In some instances limbs may be put in place months after
the accident.  Reduction has been in some rare cases effected
even after years of neglect or unsuccessful effort. But as a general rule, the lapse of a few weeks will render the success very
doubtful. Reduction, in such cases, even when effected, is at the



86              OF DISLOCATION IN GENERAL.
risk of serious injury to the patient. Sir Astley Cooper fixes
three months for the shoulder, and eight weeks for the hip, as the
periods, after which it will be too late to operate,-unless in persons of very relaxed fibre or advanced age. But such rules are
subject to many exceptions, however great the experience of the
person who makes them.  They are at best only probabilities and
rules for prognosis.  In many instances a much shorter period
than he mentions, will make it too late; while in other cases, besides those he excepts, you may succeed after a much longer interval.  The degree of approximation toward a new and useful
joint, will often be a better criterion than the amount of time
elapsed.
Inasmuch as COMPOUND DISLOCATIONS are of much more serious importance than simple ones, the practitioner should well
understand the necessity for medical treatment in these cases,
aside from the mere mechanical operation of reduction. According to the definition before given, these cases imply that the surrounding soft parts are to a greater or less extent lacerated, with
some portions of the dislocated surfaces exposed. The first object,
therefore, will be to arrest hemorrhage and remove all foreign substances from the wound. After that the bone should be restored
to its natural place and the wound closed as soon as possible. Special care should be taken in this kind of wounds to promote healing by the first intention, bringing the parieties of the wound as
nearly as possible into their original position and keeping them
there by bandages and compresses. Sutures should never be used.
Some authors recommend us to wrap the wound in lint dipped
in blood. But if the bandages applied be first dipped in cold
water, and afterwards kept wetted, this singular recommendation
will be quite unnecessary —a plan by the way, which, besides
being so troublesome, is frequently found rather to aggravate or
promote than to retard inflammation.
Let the limb be placed in whatever position is easiest, and apply moderate compression.  The best means for doing this is the
Gum Shellac splint [described in speaking of Hip Disease], or
Gutta Percha. This should be adjusted to the whole limb, —leaving, however, an open space at the wound, so that it can be prop



AFTER TREATMENT   COMPOUND DISLOCATIONS.          37
erly dressed,-and fixed on by the roller.  A  more equable
pressure can thus be brought to bear than by any other means.
The WOUND itself should be kept constantly covered with lint,
over which are laid cloths wet in cold water, mixed with an equal
quantity of the Tr. of Calendula Offic., or the Tr. of the apple
(Momordica Balsamina), while the same should be given internally
in drop doses two or three times a day. Before embracing Homeopathy we employed, in some bad cases, with excellent results, a
lotion of equal parts of whiskey and water saturated with salt,
with the addition sometimes of about one-sixth part of the Tincture of Camphor; but since, we have had no occasion to use other
than Calendula, Momordica Balsamina, Arnica, &c. The Calendula
Offic., it would seem from the trials made with it, fills a very important place hitherto unoccupied -that of so controlling the inflammation, so likely to arise from lacerated wounds, as to cause
them to heal by the first intention. The Momordica Balsamina
we regard as in no respect inferior to the Calendula, and would
recommend a trial of it by the profession.
If the dislocation be properly reduced, and the lacerated parts
adjusted, the above treatment will almost always bring about adhesion, without suppuration, or even extensive inflammation.
If the BONE be injured as well as dislocated, and there be any
broken portions in the wound, these must be scrupulously removed,
as, if left there, they will become a source of irritation and prevent healing.
POULTICES, as was before remarked, should be avoided, especially in the earlier stage of treatment, as they tend to promote
suppuration and counteract the object of speedy adhesion. Yet,
when severe inflammation has set in, notwithstanding the precautions mentioned, and suppuration is inevitable, you should use
emollients, to bring it about as speedily as possible. Among other
advantages, they will then help to ward off the danger of tetanus,
which is very apt to occur from severe inflammation about a joint.
If ABSCESSES should form, they should be opened as speedily as
possible, and no pus be allowed to accumulate about the joint, as
it might occasion serious local injury, as well as. symptomatic
fever.     [For treatment, see ABSCESS.]



38         GENERAL DIRECTIONS - "BONE-SETTERS."
The patient should have nutritous diet, though only such as is
unstimulating. It may even be necessary to give a little ale or
wine, when the discharge of large quantities of pus occasions debility.
Attention to the cutaneous function is of great importance.
The Alkaline sponge bath should be used every two or three days,
and the surface freely sponged with cold water two or three times a
day, guarding, however, against a chill by not applying the cold over
too much of the body at the same time, or to any part, before reaction is established by the drying, friction and covering of the
part last bathed.
Notwithstanding that laceration about the joints, in connection
with luxation, is generally looked upon as requiring AMPUTATION, if such a course of management as above directed be resorted
to, and proper care and attention given, the limb may generally
be saved. Amputation ought to be confined to those lacerations,
attended with a very extensive crushing of the bones, such as result from being run over by heavy wheels, getting entangled in
machinery, and the like.  We have employed the term  "very
extensive crushing," since we are persuaded that the surgeon employing Homeopathic medication can save many of those useful
limbs now handed over to the tender mercies of the knife. We
have had the pleasure, on more than one occasion, of thus exhibiting the superiority of curative over operative surgery.
The surgeon's attention should not be confined to the palpable
injury.  He should make strict examination into all other parts
of the system. Severe bruises, and even fractures, of other less
sensitive parts may have occurred, and the patient not be aware
of it, his attention being engrossed by the manifest injury.
We will take this opportunity of mentioning the " Sweet plan
of Reduction,"- which, although originating with a man supposed
to be ignorant of anatomy, is not to be despised by those who
think themselves better informed.* There may have been much' humbug" in the practice of professional bone-setters; but the
way to put down that and all other humbugs, is to ascertain and
* We were credibly informed that the Sweet family practice upon domestic
animals, dislocating their limbs, and then reducing the dislocations.



OF PARTICULAR DISLOCATIONS.               39
publish, so that all may distinguish, what little truth and good
may be mixed up with the trickery.  Unadulterated humbug is
seldom long successful.
The " Sweet plan," then, consists in first extending the limb,
so as to draw it as much further out of place as possible, and then
while the patient's attention is adroitly directed to something else,
making a sudden rotary motion, in the course of which the limb will
slip into its place,-though the operator himself may not even
know exactly where that place is.  This mode very frequently
succeeds, when more "scientific" methods have failed;- and the
end is of more importance than the means.  The plan, however,
may be defended on physiological as well as mechanical principles.
Whatever may be thought of it, we are happy to acknowledge our
indebtedness to it on several occasions. Dr. Hill was sent for in
the night to an Irishman, who had fallen through a scuttle on a
pile of barrels in the slaughter-house of E. Wilson, on Deer creek,
in Cincinnati. He found him suffering much pain from a forward
dislocation of the humerus.  He immediately pulled the arm as
far back and up as he could, causing the head of the bone to protrude more than before under the clavicle, and then with very
slight extension, and a violent rotary movement, it snapped into
its cavity.  In another case, the plan succeeded equally well,
where the femur had been dislocated upwards upon the dorsum of
the ilium, and remained in that position for fourteen days. The
patient was a daughter of Mr. Williams, of Covington.
Dr. Hunt, by the Sweet plan, succeeded, unassisted, in reducing a forward dislocation of the humerus of a stout, athletic
man, that had existed for several days. The swelling and inflammation was first partially subdued by the internal administratiOn of
Arnica and Rhus. third, in alternation, and the constant application of cloths wet in cold Arnica water. The late professor Morrow likewise successfully applied this rotary principle,- in one
case, when the limb had been left unreduced for a much longer
time than in either of the above cases.



40              OF PARTICULAR DISLOCATIONS.
CHAPTER III.
PARTICULAR DISLOCATIONS —OF THE JAW, CLAVICLE, RIBS, &c.
THE general management of dislocations has been so fully
dwelt upon, that in treating of those of particular joints, it will
be necessary, for the most part, only to speak of the peculiar attention they may require in a mechanical point of view. Bear in
mind, therefore, all through, what has been already said respecting
internal as well as local treatment, so far as it is medicinal. We
would also again impress upon the mind of the surgeon, the absolute necessity of accurate anatomical knowledge. It is impossible
to teach surgery and anatomy in the same work, or to teach the
former without presuming that the latter is already sufficiently
known. In but few cases shall we step aside, to recall to the mind
some facts which ought never to be absent.
DISLOCATION OF THE JAW.
This alarming, but not very serious, and even sometimes rather
ludicrous, accident, may occur spontaneously, while the person is
in the act of yawning, or very easily from a blow on the chin when
the mouth is wide open. This you will readily see by recalling to
mind the shape and action of the joint.
In front of the glenoid            FIG. 21.
cavities, into  which  the
condyles of the lower jaw
are *ticulated, there is an 
eminence of the temporal'                                Si
bone which in fact forms
part of the joint.  It is
covered with cartilage and
synovial membrane, and 
when the mouth is open
the condyle slips forward
and rests upon it. When
the chin is stretched forward as well as downward, the jaw rises



DISLOCATION OF THE JAW.                  41
to the summit and is on the verge of dislocation. If in this position it slips further forward, the condyle sinks into the depression
anterior to the prominence described, and cannot spontaneously
return (as is clearly shown in Fig. 21).
A further reason for the facility of this dislocation is found in
the great variety of motion permitted by the joint. Mastication
requires the lower jaw to be moved forward and backward, and
transversely, in addition to upward and downward as in opening
and shutting the mouth. The same muscles assist in several of
these movements. The platysma myoides, digastricus and others
of the neck, pull it downward. The masseter acts both in the forward, backward, and upward motion. The pterygoid muscles impart the grinding movement, and concur in the protrusion forward.
The SYMPTOMS (Fig. 22) are very obvious. The patient is in
a continuous yawn, - only a little more so, the teeth of the lower
jaw projecting beyond the upper. A very little motion is still
possible in either direction, but no effort of the patient, or mere
pressure on the chin, can shut the mouth. The posterior part of
FIG. 22.           the cheek is sensibly protuberant
from pressure of the coronoid prooess on the buccinator muscles,
~~~~~/ X;  i        while behind it, just before and
/f]'. |   I _  below the opening into the ear,
there is a sensible depression.
The saliva is running out of the
2~ ~~ a)id~~ ^mouth, there being an increased
secretion from  irritation of the
glands. The pain is sometimes
very severe and alarming to the
patient and friends, but the accident is rarely, if ever, dangerous.
The CAUSES, besides those already noticed, may be any spas/' f(              modic action when the mouth is
open, or the attempt to bite something too large. It has occurred
during the attempt to extract teeth, and in yawning.
The whole TREATMENT consists in doing for the patient what
6                                       (PART II.)



42             DISLOCATION OF THE CLAVICLE.
he cannot do for himself,- " shutting his mouth " for him! The
slightest mechanical skill, with any knowledge of the relative position of the parts concerned, will suggest how this is to be effected.
The only thing to be feared if the surgeon proceed to do this in
the readiest way by manual means, is, that the patient will bite
his fingers off for his pains.  When the dislocated condyle is
raised over the obstacle, it slips back and the mouth closes with
great violence.
A very simple and effectual mode of accomplishing the object,
is to place two large corks or pieces of soft wood, instead of your
two thumbs, between the teeth, as far back as possible. Then
using these as fulcrums, having previously had the head fixed or
held by assistants, sieze the jaw and press the chin steadily upward and backward. A sudden force has sometimes succeeded,
but this is not necessary nor desirable.
Other treatment is unimportant. As the accident is liable to
recur, bandages or broad ribbons should be tied on, so as to keep
the jaw in its place, and for awhile to allow of as little motion as
possible.
When only ONE SIDE of the jaw is dislocated, - as happens by
violence downward and laterally when the mouth is open,- there
is a similar inability to shut the mouth, but it is not kept so widely
open; and the lower incisor teeth not otily project beyond the upper, but are no longer in a line or parallel with them. The reduction in this case is effected on the same principle of leverage with
the jaw itself as in the former: place a cork as far back as possible and raise the chin.
PARTIAL or SUB LUXATION often occurs, the bone slipping
from its inter-articular cartilage. It falls back spontaneously with
a crack.
DISLOCATION OF THE CLAVICLE.
The collar bone may be separated from its attachments with
those of the breast or shoulder, in the former case being pushed
forward or backward, and in the latter almost always upward.



REDUCTION - CLAVICULAR LUXATIONS.              43
At its Sternal Extremity.
The FORWARD protrusion of the end of the clavicle that connects with the sternum is very distinct, the dislocated end rising
on the upper part of that bone —(see Fig. 23*). By throwing
FIG. 23.                       FIG. 24.*
the shoulder back this elevation disappears, but returns again on
releasing the shoulder: it descends when the scapular end is
raised, and rises toward the neck when that end is depressed.
Moving the shoulder, however, gives the patient great pain, and
it is with considerable difficulty that he can move it at all. The
shoulder looks somewhat flattened, especially if the patient be thin
in flesh,- in which case there will be no difficulty in recognizing
the nature of the injury at first view. But in very fleshy individuals the diagnosis is sometimes attended with considerable uncertainty. The patient complains little except when he attempts to
move the shoulder.
The CAUSE of this accident is generally some force applied to
the shoulder in such a way as to push the clavicle upwards and
backwards, so as to press the other end of the clavicle against the
sternum, but with a tendency to slip forward and upon it. It may
happen from a fall upon the elbow, when projected from the side
and forward.
This dislocation may be but PARTIAL.  Some portion of the
* Fig. 24 shows, in contrast, a common form of the fractured clavicle.



44             DISLOCATION OF THE CLAVICLE.
capsular ligament may not have been ruptured, and the bone thus
be prevented from rising entirely above its proper articulating
position. Generally, however, when the anterior part of the ligament gives way, the rest also yields, and the dislocation is complete.
The REDUCTION is very simple. If you pull the shoulder backward, the clavicle is drawn down to a level with the sternum, the
head falling necessarily into its proper place. The shoulder should
be drawn outward also as far as practicable while some downward
force is exerted on the clavicle. The arm is to be supported to
prevent its weight affecting the direction of the clavicle.
The keeping of the bone in place is a matter requiring more
consideration than the getting of it there. For this purpose a
particular contrivance is resorted to, called the CLAVICLE BANDAGE, being in effect a sort of "stays" or corsets, buckled round
the body and round the shoulders, with a pad or cushion in each
axilla.  [For illustration and mode of applying, see under Fracture of the clavicle.] The arm should be carefully adjusted in a
sling, extending from the elbow to the wrist,
[The risk of deformity will be noticed after describing the dislocation at the shoulder.]
At the Scapular Extremity.
The clavicle is stated to be much more frequently separated
from the SHOULDER than from the sternum, though much greater
force would seem to be necessary to produce the result. The
CAUSE is almost always a fall upon the shoulder in such a way
that the scapula is pressed inwards upon the ribs, and the clavicle
separated upwards.  A very few cases have been recorded of the
clavicle getting under the acromion.
SYMPTOMS. -As the scapula is partly supported by the clavicle, when that support is withdrawn it naturally descends. Hence
the shoulder on the dislocated side is found to be depressed when
compared with the other, and also contracted or drawn inwards
towards the sternum.  This can be accurately ascertained by
measurement from the centre of the sternum to the point of the
shoulder. On placing the finger upon the spine of the scapula
and tracing it along towards the acromion process, the finger is



FROM THE SCAPULA —DEFORMITY TO BE AVOIDED.   45
stopped by the projection of the clavicle. If the shoulders are
drawn back, the point of the clavicle sinks into its proper place,
but as in the former case, the deformity reappears on letting go
the shoulder. The pressure of the dislocated end of the bone
against the integuments occasions a good deal of pain. This, as
well as the rupture of the ligaments, which is necessarily considerable, soon brings on inflammation and tumefaction.
In REDUCING, the surgeon stands behind the patient, placing
his knee between the shoulders, and drawing them both back until
the clavicle sinks into its natural position. Cushions are then
placed in each axilla, so as to raise the scapula and keep it from
the side; they also serve to protect the arm-pits from irritation
by the bandage. The Clavicle Bandage is then applied so as to
press upon the clavicle, the scapula and the upper part of the humerus. The clavicle and scapula are thus effectually kept in their
proper relative positions.  The arm should be not only supported
in a sling, as in the former case, but so secured as to keep it all
the time pressing slightly upwards and backwards.
SLIGHT DEFORMITY almost always results from these accidents,
notwithstanding the utmost skill and care of the surgeon. The
adjustment and reunion can very rarely be exact; and the situation of the parts renders the defect manifest. Hence surgeons
are always advised to inform the patient and his friends of the
great liability, and even probability, of some change from the natural form of the part,    though no serious impediment to motion
need be apprehended. We have, however, succeeded in three
cases of clavicular accident in so adjusting the parts that not the
least deformity could be afterwards discovered.
Two were cases of simple dislocation, the other of compound
fracture, where a portion of the bone projected for an inch through
the skin. The patient, in the latter case, was a large athletic
man, residing in Cincinnati. The accident happened in the spring
of 1844. The bone was adjusted and dressed, with the assistance
of a student, in the manner hereafter to be described. In the
course of a few weeks, the patient went about his business, which
was that of a whip-sawyer, without the least difficulty, and it is
now impossible to see on which side the accident occurred, except
from a slight scar in the skin.



46            DISLOCATIONS- OF THE CLAVICLE.
Of the other cases alluded to, one was a dislocation of the
sternal extremity of the bone. One subject of it was a young
man, -the cause, a fall from his horse.  The deformity before
the reduction was very great. It is now nearly five years since
the occurrence, and no trace of it can be seen or felt.
The remarkably successful results in these cases were owing to
some peculiarities in the applications made. In the first instance,
a very thick and firm piece of leather was fitted to the part and
spread with adhesive plaster. Pretty strong compression was applied over this, so fixing the muscles and integuments as to render
them incapable of motion. No disturbance of the parts was permitted, nor were the compresses and bandages removed for eight
or ten days. In the second case the Gum Shellac cloth was fitted
and spread over the part and shoulder, by which every thing was
perfectly secured. And in the third, which was that of a young
child, the Gutta Percha was fitted and bound on.
DISLOCATIONS OF THE RIBS AND VERTEBRA
-are sometimes sppken of, but these are accidents that can
scarcely happen without fracture.  "Breaking the neck" or
"breaking the back," then, must be really breaking, as well as
separating the bones, of the spinal column. When such a separation really happens, there is seldom any use for a surgeon, —
unless to tell exactly what has been done. Both these subjects,
as also the rare occurrence of partial.
DISLOCATION OF THE PELVIC BONES
or separation at their symphyses, - will be taken up in connection with Fracture.
CHAPTER IV.
PARTICULAR DISLOCATIONS CONTINUED —THOSE OF THE HEAD OF
THE HUMERUS, OR OF THE HUMERUS FROM THE SCAPULA.
THE SHOULDER JOINT.
— from its exposed situation, the great range and variety of
motion which it allows of, and the consequent shallownesss of the



DOWNWARD LUXATION- INTO THE AXILLA.             47
socket, is more liable to luxation than any other,- perhaps than
all others in the body. There are to be clearly distinguished, at
least three ways or directions in which the accident may be brought
about. What is sometimes called the fourth, is only a partial dislocation.
THE HEAD OF THE HUMERUS on escaping from the glenoid cavity, may be pushed or pulled downwards, forwards, or backwards:
- In the first variety, the head of the bone is found in the axilla,
or resting under the lower side of the inferior costa of the scapula. In the second, it is thrown forward upon the pectoral muscles, below the middle of the clavicle, between the coracoid process and the sternum. In the third case, the head is thrown up
to the higher and back part of the inferior costa, or dorsum of the
scapula, where the large protuberance can be distinctly felt and
seen.  " The fourth " or the partial dislocation upwards, is always attended with a rupture of the capsular ligaments, the head
of the bone resting against the outer side of the coracoid process
of the scapula. It is difficult to conceive how this should ever
happen without a fracture of the acromoin process.
DOWNWARD LUXATION -INTO THE AXILLA.
Among the SYMPTOMS, in this case, - besides the obvious one
of the large hard tumor-like protuberance, which can be distinctly
FIG. 25.
C-A=



48         HUMERUS DOWNWARDS  REPLACEMENT.
felt in the arm-pit when the arm is raised, — there is a corresponding hollow below the acromion process, in consequence of the passing of the head of the humerus out of the glenoid cavity —(see
Fig. 25). The natural form of the shoulder is changed, the muscles being flattened, and the arm seemingly elongated. The elbow
cannot without great pain be brought to the patient's side, in consequence of pressure of the head of the bone upon the axillary
nerves; the patient is inclined to separate his arm from the body
and support it with the other hand.
When some time has elapsed, and there is inflammation with
much swelling, the bone cannot be readily felt; and to bring its
head low enough down for this purpose, the arm should be raised
as high as possible. The patient himself can move his arm but
little; and even when others raise it for him, the movement is accomplished with difficulty and gives much pain. The patient cannot rotate his arm, nor can he raise it to his head, though he can
move it directly backwards and forwards with considerable ease.
Some patients, however, will have much more motion than others,
the spasmodic force of the muscles differing much in different individuals. If the dislocation is of long standing, a crepitus can
be heard on moving the arm. This results from the effusion of
lymph into the joint, and synovial fluid into the cellular tissue;
and can be readily distinguished from the grating sound of fracture,-which latter continues, while this crackling ceases, if the
movement is kept up for any length of time.
Among the most definite symptoms should be noticed the change
of axis. A central line, going lengthwise through the arm, would
strike the body lower than in the natural position. In some cases
the fingers are very much benumbed in consequence of the pressure of the bone upon the axillary plexus. If the arm continues
out of place, the compression of the nerves and blood vessels may
occasion complete paralysis and atrophy of the limb.
All the symptoms stated or alluded to, will not often be necessary to determine the nature of the accident. When, however,
much time has been lost, any or all of these signs may be so obscured as to render diagnosis difficult; and it will often be necessary to first reduce the tumefaction before offering a positive
opinion. In very young or fleshy persons, the exact state of the



DISLOCATIONS —-AT THE SHOULDER.             49
case may not be easily ascertained, even immediately after the
displacement has occurred.
In REDUCING axillary luxations, the plan generally adopted by
the best surgeons of the present day is this - [illustrated by the
accompanying cut, Fig. 26]:-the patient is placed in a recumFIG. 26.
bent position upon the floor or a couch; and the surgeon sitting
before him puts his unshod heel on the head of the bone in the
axilla, and presses it upwards, while he pulls steadily and firmly
on the arm, until the head of the bone slips into its place. By
this rough-looking management he is generally able to effect his
object without assistance.  If not, more force may be applied to
the arm by means of bandages and straps, which may be lengthened to any extent and placed in the hands of assistants standing
behind the principal operator,-he being thus able to direct or
deflect the extension, while his heel is still kept firmly pressed
against the head of the bone.
These means are commonly sufficient, and may always be tried
in the first instance. If they fail resort must be had to others,
by which still
- GREATER FORCE can be brought to bear.  Place the patient
in a chair (as represented in Fig. 27), and secure the scapula by
counter-extending bandages, so applied as to let the arm  pass
7                                       (PART II.)



50        REDUCTION BY FOOT, KNEE, EXTENSION, &C.
through them. These bandages round the shoulder may be made
of any strap or girth, buckled or sewed on. They are to be fixed
FIG. 27.
behind and somewhat above the patient.  The counter-extending
apparatus may be fixed round the body under the arms, though
this does not secure the scapula as when it is closely fixed about
the affected shoulder itself.
For the extension, a wetted roller should be placed round the
arm just above the elbow, so that it cannot slip, with straps or
slips of cloth attached. The arm is then to be raised to a right
angle with the body, or it would be still better to raise the elbow
above the horizontal line with the shoulder, so that the deltoid and
spinatus muscles may be more completely relaxed. With the arm
in this position, let two or more assistants make extension upon it,
a sufficient force being at the same time exerted in the opposite
direction upon the scapula bandage. The force must be gradually
applied and steadily kept up; for if any jerking occur, alternately
relaxing and extending the parts, nothing will be gained but much
injury inflicted. When the strain has been kept up for a short
time, the surgeon, having his foot resting on the patient's chair
or some other convenient support, pushes his knee into the axilla



DISLOCATIONS-AT THE SHOULDER.               51
(see Fig. 28) and presses up the head of the bone, while at the
same time he presses down with one hand on the acromion. The
reduction may sometimes be much facilitated by making slight
rotation upon the arm. In this, as in other cases, it should be
remembered that much depends upon the state of the patient's
mind. If, while extension is being made, his attention can be
diverted from  the operation, though but for a moment, much
trouble and suffering may be saved.
In cases of very long standing, more force, or a longer continuance of the strain, may be required than could be safely trusted to
assistants. The object, it must be borne in mind, is to weary out
the contracted muscles; and this would be defeated if the assistants themselves should become weary and let go. Machinery can
therefore be used with much advantage [as was represented in
both the figures last given, Nos. 26 and 27].
When pulleys are made use of, as they may be, both for extension and counter-extension, they must be securely fixed to rings
or staples; and the surgeon should begin the extension himself,
giving the pulley into the hand of an assistant as soon as he thinks
it time to direct the head of the bone.
In RECENT CASES, the arm may frequently be restored to its
place without any extension, or any considerable exertion of force.
Seat the patient who has just met with the accident in a chair;
spread out the dislocated arm as far as possible from the side; insert your knee into the axilla [in the same manner as represented
in Fig. 28, where, however, the pulley and counter-extending
bandage are also represented, as they may be used, if necessary],
your foot being fixed on a chair for the purpose, and the heel
raised, so as to press the knee upward; grasp the humerus just
above the elbow with your hand, pressing down at the same time
upon the shoulder. If the little knowledge requisite for this simple procedure were generally diffused, a great deal of unnecessary
suffering would be prevented, and the usefulness of many an arm
restored which is now lost to society. Why should not all intelligent or educated men be surgeons enough for this and other simple operations, that become difficult only because people have to
wait till professional skill can be called in?
Dr. HILL once succeeded in reducing an arm by this unassisted



52            DISLOCATIONS —-AT THE SHOULDER.
means which had remained some time out of place and resiste 
other attempts. The parts had become extremely tender, and the
contraction and resistance of the muscles were also very great.
FIG. 28.
The patient was a drunkard, though sober at the time; and as
he obstinately refused to take other medicine for the purpose of
bringing about relaxation, -he gave him  a pint of whiskey at
once, and soon had him "dead drunk."*  In that state, he proceeded to the reduction, and soon effected it, without the least difficulty, or the patient giving any sign of pain. On visiting him
the next day, he succeeded in a still better operation, - cured him
of a worse disease: he persuaded him "to sign the pledge," which
he has faithfully kept.
FORWARD LUXATION —- UNDER THE CLAVICLE.
The SYMPTOMS of this accident are very distinct.  The head
of the humerus can be plainly felt, and generally seen, upon the
pectoral muscle, just below the clavicle. - The point of the acromoin process is very distinct, the hollow beneath it being considerable. The coracoid process of the scapula is on the outside of
* This was before the day of ether and chloroform, which may now be used in
such a case with many advantages.



FORWARD, BACKWARD, AND PARTIAL.              53
the displaced head, -which can be observed to move when the
arm is rotated. The elbow is thrown
further back than in the former case,      FIG. 29.
and still separated from  the side.
The arm  is also much shortened,
with its axis pointing inward towards the middle of the clavicle.
There is great difficulty in moving
the arm in any direction, in consequence of the resistance of the muscles, and by the obstruction of the 
clavicle above, and the coracoid process of the scapula behind.  The
pain, however, is not so great as           K
when the dislocation is in the axilla,
pressing upon the nerves.
The CAUSE is usually a fall upon the elbow when it is thrown
behind the central line of the body, so that the force comes from
behind and inwards.
The REDUCTION can generally be effected in a manner similar
to that of the former cases. The operator's heel, however (if it
is made use of), must here be brought further forward, while the
patient's arm is to be drawn obliquely downwards and slightly
backwards.  But, if much delay has occurred, the case may require steady and continued extension by assistants or suitable mechanical means.
For the extension and counter-extension, such bandages and
apparatus may be directed as before described. The arm, however, must be so raised as to relax the biceps muscle; and the
force applied in a downward and backward direction, instead of
horizontal, to prevent the head of the bone being brought against
the coracoid process of the scapula. It may be necessary to keep
up extension much longer, as the resistance is much greater than
in axillary dislocation.  When the head of the bone is observed
to move, is the time for the surgeon to place his knee or heel
against it, and press it backwards into the glenoid cavity. This
pressure directly on the head of the humerus can do no good
until it has been drawn below the level of the coracoid process.



54            DISLOCATIONS   AT THE SHOULDER.
After the reduction, the arm should be fixed by proper bandages, and hung in a sling, so that no motion be allowed the shoulder joint for some time. Very little force may at first renew the
difficulty.
[For cases of this variety of dislocation, reduced by the rotary
or " Sweet plan," see the conclusion of the Chapter on Dislocation in General.]
BACKWARD LUXATION - UPON THE DORSUM OF THE SCAPULA.
The projection of the head of the humerus in this position, can
be noticed at first sight; and when
FIG. 30.         the elbow is rotated, it is seen to
move. It may also be felt by apll\ ~  \plying the finger just below the
spine of the scapula.  (See plate.)
The motion of the arm, although
rllllllm        ^not so much affected as in the
Il l1" | ffformer case, is greatly impaired.
The change in the axis of the limb
will be obvious.
This variety of displacement is
very rare. But two cases are said
to have occurred in thirty-eight.^' fi Y eyears at Guy's Hospital, in the
very centre of London.
The REDUCTION is described as being easy.  The shoulder is
fixed, and gradual extension made directly outwards, the head
of the bone being moved slowly forwards into its place. It has
been reduced by simply raising the arm, and turning the hand to
the back of the head.
PARTIAL DISLOCATIONS
- of the humerus are to be treated on the same principles as
the complete. The nature of the injury and the distinct varieties,
are not so obvious, but the difficulty of replacement proportionably less. Bandages, to prevent recurrences, are as necessary after partial as complete dislocation.



THE ELBOW —ITS COMPLEX DERANGEMENTS.           55
CHAPTER  V.
i'ARTICULAR DISLOCATIONS CONTINUED - TKOSE AT THE ELBOW
AND WRIST, AND OF THE THUMB, FINGERS, AND TOES.
OF THE ELBOW JOINT.
Without a minute knowledge of the anatomy and mechanism
of this joint, - of the ligaments and tendons connected with it, as
well as of the bones and muscles, -no practitioner can be safely
trusted in any injury of so complex a part. As the elbow is very
much "in the way " of accidents, this is equivalent to saying that
every practitioner of medicine ought to know all about it. If he
does not, he will often commit serious oversights and blunders, exposing himself to censure and to prosecution for mal-practice, 
though this last danger is not so great as it ought to be. Hence
the frequency of mismanaged or neglected cases.
There may be no less than five very distinct species of dislocation at the elbow, besides complications with fracture, &c., to be
noticed hereafter. Both bones of the fore-arm may be pushed
from their attachments with the humerus at the same time, either
backwards or to one side. The radius only is susceptible of being displaced forwards.  The ulna may slip back over the condyle of the humerus, without the radius; or the radius on its side
without the ulna, though this last case is not, properly speaking,
a dislocation of the elbow joint, but only of a connected bone at
the joint.
OF BOTH RADIUS AND ULNA BACKWARDS.
This accident, though attended with only a partial loss of motion, produces a complete change in the appearance of the joint
- (as seen in Fig. 31). The posterior projection of the elbow is
very prominent. The olecranon process is above the external condyle, instead of being on a level with it, as it should be when the
arm is extended. A deep hollow may be felt on each side of it;
while in front, under the tendons, the condyles appear like hard
tumors. The hand and fore-arm are in a supine position and can



56             DISLOCATIONS- AT THE ELBOW.
not be entirely turned.  Spontaneous rotation of the hand is almost wholly lost.
FIG. 31.
The occurrence is almost always brought about by the individual stretching out his hand to save himself in a fall, the pressure
coming on it before the fore-arm is entirely extended. Thus the
whole weight of the body, increased by the height fallen through,
is brought to bear on the joint, behind the axis of the humerus.
The REDUCTION is easily effected.  The surgeon places his
knee on the inner side of the elbow or at " the bend of the arm,"
pressing most on the dislocated bones so as to keep them from
bearing on the end of the humerus, and to separate the coronoid
process out of the posterior fossa of the humerus and allow it to
pass over the condyles - (a glance at Fig. 32 will give the reason
for this direction). Considerable force must be used in bending
FIG. 32.
the arm while the knee is strongly pressed upon it.  This force
should be applied slowly and steadily, however, the proper direction being given to the bones as it proceeds. It is frequently desirable to divert the patient's attention, while this flexion and extension are being made.
This dislocation may often be remedied a long time after its



BOTH BONES BACK OR TO ONE SIDE.              57
occurrence, in which case you should premise proper applications,
such as warm fomentations and emollients, before proceeding to
the operation.
After having accomplished the reduction, you should have the
joint kept wet with cold water, with Am., &c., and the arm suspended in a bent* position in a sling. It is still better to put on
a splint, which effectually secures the joint. It should not, however, be kept bent too long, - though the danger from this is more
to your own reputation than your patient's limb. Dr. Hill once
had a case where for fear of reproducing the dislocation, required
his patient, a boy of twelve years, to keep his arm in the sling for
several weeks. When he took it out the joint was stiff, and he
was severely censured for having, as the parents supposed, failed
to properly "fix the joint, "-though the real fault was in fixing
it too long. A few days' attempt at motion, with a suitable lotion, restored the proper use of the arm.
LATERAL DISLOCATION OF BOTH BONES.
This mode of displacement, whether outward or inward, is a
modification of the last, the bones being also  FIG. 33:
driven more or less backwards.
The CAUSE is generally the same as in
the last case, the force being directed more
to one or the other side.
The SYMPTOMS are still better marked.
When the dislocation is outward and back-         M 
ward (as in Fig. 33), the projection of the
ulna is much greater than when it is only
backward.  The coronoid process, instead
of sinking into the posterior fossa of the humerus, is fixed at the external condyle, and 
the flat head of the radius forms a projection behind and outside the elbow, with an
abrupt cavity above it.  Its turning can be 
distinctly felt on pronating or supinating
the hand.
In the inward and backward luxation
* See Dislocation in general.
8                                      (PART H.)



58             DISLOCATIONS-AT THE ELBOW.
(represented by Fig. 34), the head of the ulna is thrown behind or
over the internal condyle, and projects in that direction, while the
external condyle is made equally prominent
FIG. 34.      on its side, by the radius leaving its place
and occupying that of the ulna, its head resting on the articulating surface or posterior
fossa.
The REDUCTION of these cases is accomplished in the same manner as directed for
the simply backward luxation, - to wit: the
bending of the arm over the surgeon's knee.
Little or no difference of management is required in either case.  The operation may
I' l  leven be simpler than the one referred to.
There is not the same reason for first separfating the bones from the humerus, as when
the coronoid process is fixed in its posterior
/ I~ I~fossa.  The tendons of the biceps flexor
and the brachialis internus, moreover, being
stretched over the end of the humerus, tend
to force it back into its natural situation, as soon as the arm is
straightened in spite of them. Sir Astley Cooper thus speaks of
a case he treated by mere extension -" Finding that the tendons
of the biceps and (as I knew) of the brachialis internus, were put
upon the stretch, I thought I might make use of them to draw the
os humeri backwards, as by the string of a pulley, and I forcibly
extended the arm, —when the dislocation was immediately reduced."*
OF THE ULNA BACKWARDS.
The olecranon can be clearly felt behind the humerus. The
arm can be neither straightened, nor flexed to more than a right
angle. The distinguishing mark of the case is a backward projection of the ulna, together with a twisting inwards of the forearm and hand.
The same mode of REDUCTION may be directed as in the other
* Cooper on Dislocations and Fractures, p. 389.



OF ULNA OR RADIUS ALONE   REDUCTION.           59
cases. It is generally more easily accomplished.  The bending
of the arm is here the essential part of the operation, as the fixed
radius then acts like a lever to push the humerus back into its
place on the ulna.
OF THE RADIUS FORWARDS.
The fore-arm is found more or less bent, but it is suddenly
stopped, on attempting to flex it further, before it gets to a right
angle, the elevated head of the radius bearing against the fore
part of the humerus (see Fig. 35). In this place it may be felt
FIG. 35.
moving, if a finger be pressed into the "bend of the arm " when
the hand is rotated. The patient himself is unable to effect this
movement to any considerable extent, the hand being kept pronated.
The REDUCTION of this accident would seem to be difficult, if
we might judge by the number of unreduced cases, and the neglect were not rather to be attributed to failure of diagnosis, which
is still more inexcusable.
Let the surgeon, seizing the patient's hand by one of his, as in
"shaking hands," or by the thumb and fore and middle fingers,
make steady extension, while his other hand is pressed strongly
upon the ulnar side of the head of the radius, pushing it both outwards and downwards.  The arm had better be slightly bent, so
that the muscles may be relaxed. As the pronator teres tends to
draw the bone towards the ulna, force applied between the bones
so as to separate them, and at first slightly raise the radius, may
perhaps aid your operation.



60            DISLOCATIONS-AT THE WRIST.
OF THE RADIUS BACKWARDS.
The head of the radius may be both seen and felt behind the
external condyle of the humerus (see plate No. 36). The arm is
nearly straight and cannot be flexed; the hand pronate and cannot be turned. The surface in front of the joint is relaxed and
presents a sudden depression just below the external condyle. If
the front of the radius be traced from below upwards, the finger
will come in contact with the condyle; and if the side be traced,
the finger will pass over the head on to the olecranon process.
FIG. 36.
The'REDUCTION, if attempted early, is not generally very difficult; but these cases are frequently neglected so long that any
attempt to reduce will be fruitless, or result in more injury than
benefit to the patient.  Extension is to be made upon the radius,
with counter-extension upon the humerus, while firm pressure is
made on the head of the bone until it slips into its place. One
assistant can pull upon the hand, while another holds the upper
arm, and the surgeon directs the movement of the bone.
LUXATIONS AT THE WRIST, JOINTS OF THE HAND, &c.
THE WRIST JOINT is liable to several displacements.  Both radius and ulna may be dislocated together, either forwards or backwards, or each of them may be separately displaced in either direction, -thus making six varieties of luxation. First,
OF BOTH BONES FORWARDS: - The projection of the bones of
the arm under the carpus or forwards, happens from falling upon



DIAGNOSIS - REDUCTION - AFTER-TREATMENT.         61
the palm of the hand, the ends of the radius and ulna bearing
with great force against the annular ligament, while unprotected
by the carpal bones, they being bent backwards.  On the contrary, the displacement
- at the BACK OF THE WRIST takes place when a person falls
on the back of the hand, so that the arm bones may be similarly
thrust over the carpus, while the carpal bones are thrown forward
and upward under the flexor tendons, in front of the fore-arm.
The distinctive SYMPTOMS are indicated in this account of the
nature of the accidents. In the former case there will be a manifest protuberance on the front of the wrist, with a somewhat similar
FIG. 37.
but smaller one at the back of the wrist, produced by the carpel
bones.  The hand is bent back out of the line of the fore-arm.
In the latter case, -the luxation backwards or to the back of the
wrist (represented by Fig. 37),-the symptoms are exactly reversed. There being projections both behind and before in either
case, can never occasion their being confounded. The direction
of the edges or ends of the projections, as well as of the hand,
will immediately show the nature of the case.
Strains of the wrist, produced by falls and other violence, may
occasionally simulate dislocation.  They may be distinguished by
the fact of the questionable symptoms coming on gradually, and
not showing themselves immediately after the accident, as in actual dislocation. There will also be more flexibility of the hand;
nor will the swellings be likely to imitate accurately the separated
extremities of the arm and carpal bones.
The REDUCTION is similar in both cases. The surgeon takes
hold of the patient's hand in one of his, while the fore-arm is supported by his other hand. An assistant meanwhile holds the arm
at the elbow, keeping that joint slightly flexed. As soon as suf



OF THE HAND, FINGERS, AND TOES.             63
the position of its styloid process, which is thrown out of its proper
line with the metacarpal bone of the little finger,
To accomplish the REDUCTION, all that is required to be done.is simply to place the ulna down in its proper cavity at the side
of the radius, and retain it there by suitable compresses and
splints. The latter should extend along the fore-arm in a line
with the back of the hand. They should be well padded and then
secured by a roller.
OF THE CARPEL AND METACARPEL BONES.
Luxations between these bones are accidents of very rare occurrence. They are easily ascertained when there is no tumefaction, by the bones rising on one side or the other. Any bone so
rising can be easily pressed down again and secured, the hand being extended when the pressure is applied. Proper compresses
and bandages are then to be kept on until all danger of recurrence has disappeared.
DISLOCATION OF THE FINGERS AND TOES.
FIG. 38.
This accident may be brought about by various causes, - at
any of the phalangeal joints, —and in either direction; the
smaller bone being pushed over or under the larger, constituting
what are distinguished as the posterior (Fig. 38) and the anterior
(Fig. 39) dislocations.
FIG. 39.



64             DISLOCATION-OF THE FINGERS.
The SYMPTOMS need not be described. The nature of the case
will be plain at the very first sight.  There will sometimes be very
great rupture of the ligaments, while at others very slight injury
may be done.
In REDUCING a dislocated finger or toe, let the operator place his
thumb at one of the divided extremities, and his finger at the other,
then make extension (as he is represented doing, without the former
expedient in the cut, Fig. 40), while the joint is gently flexed;
and the parts will very easily regain their proper place, unless
FIG. 40.
considerable time has elapsed since the occurrence of the accident.
In such a case, extension has to be kept up for some time, and
should be perseveringly attempted
FIG. 41.           before the case is abandoned. For
this purpose, where much force
has to be used and kept up for a
II ^ ^    J {           ^long time, a piece of tape should
be fixed to the finger by the
" clove-hitch" (Fig. 41), and the
extending force applied to this.
Toes are more difficult of adjustment than fingers, owing to
their shortness and their joints being less palpable. The dislocation is sometimes brought about by
the contraction of the tendons.
DISLOCATION OF THE THUMB.
This is rather a rare occurrence, but deserves separate mention, from the difficulty of REDUCTION, occasioned by its strong
ligaments and muscles. The deformity and inconvenience result



THUMBS, &C. — OF THE HIP JOINT             65
ing from the accident will be a sufficient diagnosis. To reduce it,
frequently requires very great extending force. This can be best
applied by means of strong tape fixed round the thumb (by the
preceding clove-hitch), this being pulled upon while the divided extremity is pushed towards and into its place, in the same manner
as directed for a finger or toe, though there is often so much tenderness that the main dependence must be upon the extension by
the tape roller. During the operation, the thumb is to be flexed
or bent towards the palm of the hand, so as to relax the flexor
muscles. Care should always be taken to well bandage the thumb
with other wet tape, before fixing on that to which the force is to
be applied.
CHAPTER VI.
DISLOCATIONS OF THE LOWER EXTREMITIES.
OF THE FEMUR AT THE HIP JOINT.
THIS important JOINT, though well secured by cartilage and
FIG. 42.                              FIG. 43.
9                                     (PABT I.)



66             DISLOCATIONS - OF THE FEMUR.
ligament, particularly the cotaloid ligament, which greatly deepens the acetabulum, is subject to too much violence not to be occasionally dislocated. The thigh bone being inserted into it obliquely, requires the more study to understand its mechanism and
derangements.
Four distinct dislocations require to be noticed. The head of
the femur may be thrown, 1st, upwards on the Dorsum of the
Ilium  (Fig. 42); 2d, downwards into the Foramen Ovale (Fig.
43); 3d, backwards into the Ischiatic Notch (Fig. 44); 4th, forwards and upwards upon the pubes (Fig. 45).
FIG. 44.                      FIG. 45.
UPWARD DISLOCATION —on the Dorsum of the Ilium,
- that where the femur rests on the concave side of the pelvis, -is by far the most common, being the necessary result of
sufficient violence in an outward and upward direction.
SYMPTOMS.- The limb is from an inch and a half to two inches
and a half shorter than its fellow, -from which it cannot be separated, the knee being advanced towards the opposite one, though
not reaching it. In plainer language, the knee and foot are both
"turned in," the toes resting on the other foot (as seen in the



UPWARDS -TIME AND MEANS OF REDUCTION.               67
illustrative Fig. 46- compare also Fig. 42).  The thigh can be
bent over the opposite one.  The round head of the bone can be
felt moving upon the ilium, when the knee is rotated, at least if
there is not much swelling, or the patient is not very fleshy. The
affected "hip" or side of the pelvis is much less evenly rounded
than natural, and the trochanter major is nearer the superior anterior spinous process of the ilium.
Fracture of the neck of the thigh bone, which may be confounded with this accident, rarely occurs except in very old persons; and in that case, though the leg
is shortened, it can be easily extended,      FIG. 46.
contracting again  when the force is
withdrawn: the knee also is generally
turned out instead of in.
Previous to REDUCTION, it will generally be necessary to produce some re-',.
laxation of the muscles, in this as in all       
other dislocations of the hip, and in some   )  -  "
cases this must be carried as far as the        ) l. 
patient's safety will permit.  Repeated          b   ~\ 
doses of some nauseant will effect the     \          /  \
object, and as good a one as any is an  
acetous Tr. of Lobelia, c. p., once in ten
minutes. Ether or chloroform may be
used.  The same or even a stronger pre-  i  "'1 )
paration of lobelia may be used as an  U       ll   /
injection. The warm bath may be also
resorted to with advantage.  The most
complete insensibility  and  relaxation  
may be produced by the use of ether or
chloroform.  When the relaxation is
deemed sufficient, wrap the patient up, so as not to allow him to
get chilly, and proceed to the
- OPERATION, by laying the patient on a table, or placing a
board, covered with a quilt or blanket, under him, on the bed.
Pass a strong counter-extending strap between his legs. A sheet
split in two, and folded so as to be about four or five inches wide,
will answer the purpose. This should be so placed as to press up



68            DISLOCATIONS -AT THE HIP JOINT.
wards on the perineum, at the inside of the dislocated limb, passing up before and behind his hip (as represented in the accompanying plate, Fig. 47, and explained by Fig. 42). Fix the two ends
of this strap or bandage to some unyielding point, a post, staple
in the wall, or the like. Then apply round the leg, just above the
knee, a wet bandage.  Give it eight or ten turns, fixing by its
means your straps for extension. These are to be drawn upon by
assistants, or what is generally safer and better, to be attached to
a pulley, so stationed that the force may bear in the direct line of
the limb, with the fastening of the counter-extension. This consideration must be kept in mind when the surgeon or assistant
comes to pull on the straps or cord of the pulleys, so that the
limb be extended in the direction of its longest axis, and the head
of the femur forced directly towards the acetabulum.
FIG. 47.
1;R011" "INA.    100
Steadily increase the extending force, keeping the knee bent at
right angles, until the patient complain, then hold for a few moments, without letting back a hair's breadth, until he gets easier.
Increase the tension again as far as it can be borne, and so continue,
stopping and resuming, until the head of the bone has reached the
edge of its socket. At this point, the surgeon intrusting the extension wholly to his assistants, directs the movement, rotating the limb
a little inwards, and sometimes it is necessary, by means of a towel
passing under the upper portion of the thigh, to elevate the head
of the bone over the edge of the acetabulum, as it sometimes catches
against it. When counter-extension is made by manual force, it
can be heard to snap as it slips in, but with the more gradual



70             DISLOCATIONS- OF THE FEMUR.
extension in the former case, -so that        FIG. 48.
when the two ends are drawn upon,
the force will bear against the inner
and posterior surface of the bone —
that is, from  the foramen and towards
the acetabulum. Pass another strong   \
girth or band transversely around the 
pelvis, above the acetabulum, the front
end passing over the former strap (so as 
to give to it a more upward direction).
This cross or counter-extension is to be 
made as before from  a post, staple, or
other fixed point.  Force is now to be
applied by pulleys (or otherwise) to the
first strap; and, as the head of the 
femur begins to rise, let the surgeon
pass his hand under the opposite leg, 
and, seizing the ankle of the affected 
one, bring it gently but firmly towards
the other.  This movement in connection with the pressure at the other end of the limb, will bring it
into its proper place.
FIG. 49.
i;
BACKWARD DISLOCATION -into the Ischiatic Notch.
In this case, the head of the femur being deeply lodged, can



BACKWARDS AND FORWARDS- REDUCTIONS.             71
rarely be felt.  The position of the trochanter,- though it is not
turned down, flattening the hip, as
FIG. 50.         in the upward dislocation, —being
farther back than natural, will indicate the mal-position of the head-.  ~,\ ~(Figures 50 and 44).  The displacement of the trochanter may be accurately ascertained by measuring, on
I,,.  \  each side, from the spinous processes
of the sacrum.  The foot and knee
i'  u Il  turn inwards, the knee being also a
l~I / I        a. 1  ^little flexed and advanced forwards,
I ~'8T~ ^y  ^^  the heel raised, and the ball of the
great-toe resting on the base of the
I  ~r~, \   \other great-toe.  The limb is shortF1 i\ \'             ened, but not more than from half
an inch to an inch. The limb canI'     not be further flexed or straightened, nor rotated, without much
"\. /                 force and pain.'~  t                  This variety of dislocation is the
~(~'~^~  -..-      most difficult of all to REDUCE. The
patient should be placed upon a table or board, as directed for the
first form of dislocation, but on his sound side instead of his back,
with the affected thigh drawn over the middle of the other. Use
FIG. 51.
the same means for extension and counter-extension as in that
case, with the addition of a towel or strap round the upper part



DISLOCATIONS- AT THE KNEE.                73
as downwards. Use the lifting bandage as the operation proceeds,
the assistant pressing down on the pelvis as he raises the head of
the bone over the pubes and edge of the acetabulum. When the operation is complete, secure every thing as before directed.
[These dislocations of the hip may, any of them, be occasionally reduced by the rotary plan, mentioned under the head of general directions for reduction. A case where the femer had remained two weeks upon the dorsum of the ilium is there alluded
to. Almost every day, during that time, other means had been
tried. The object was effected very easily by raising the heel as
far as possible towards the abdomen, across the other thigh, and
keeping it there for a minute or two; and then, while the patient's attention was directed another way, a sudden circular motion was given to the limb, and the heel brought down again to its
natural position, when the bone snapped into its place and all was
right.]
DISLOCATIONS AT THE KNEE.
THE PATELLA.
— may be displaced outwards, inwards, or upwards.
Of the LATERAL DISLOCATIONS the outward (Fig. 54) is far more common than the     FIG. 54.
inward.  In either case, the knee is partially flexed and the joint immovable, the
patient complaining of a "sickening" pain
in it. In reducing, place the patient in a  
recumbent posture, and raise the limb by the
heel, thus taking off the tension of the ex-  1
tensor muscles. Then press down the edge
of the patella most distant from the joint.
This will raise the ridge on the posterior
surface so as to let it pass over the condyle,
when it will be naturally drawn to its place by 
the action of the vasti and rectus muscles.
The UPWARD DISLOCATION, with RUPTURE
of the ligament, is a very obvious case, and there will be little
10



74              OF THE PATELLA AND TIBIA.
more difficulty in the reduction than in the diagnosis. The difficulty is in keeping it reduced. Special precautions, also, must
be taken against inflammation: give Arnica and Rhus, &c., as
directed in general treatment of dislocations. But among the
best as well as the handiest means for keeping down both the inflammation and (what is the peculiar object of treatment in the
case), the patella, at the same time, is the application of a roller
to the whole leg from the toes to the groin. This will restrain
vascular excitement, and directly keep the loose parts in proper
position, and to a great extent paralyze the muscles of the thigh,
that would otherwise be sufficient to overcome all retaining force
that could be conveniently applied.  The roller should be kept
wet with dilute Tr. Arnica.
A very ingenious recent invention for keeping the patella in
place, after dislocation or fracture, will be described, with a plate
to illustrate, in connection with the subject of FRACTURES.
OF THE TIBIA AT THE KNEE.
This bone may be separated from the femur in four ways, forwards, backwards, or to either side.
The LATERAL displacements are only partial, one condyle resting on the head of the bone where the other should be, and that
FIG. 55.                       FIG. 56.
other projecting to one or other side, external, or internal, as the



DISLOCATIONS-AT THE KNEE.                T5
case may be, -a part of the head of the tibia forming another
tumor on the opposite side (see Figures 55 and 56).
In the FORWARD dislocation (see Figure 57), the head of the
tibia is distinctly seen and felt above the front of the condyles,
while these are perceived in the popliteal space. There is such
pressure on the nerves and the popliteal artery as to stop the pulsations of the anterior tibial artery, and to cause more or less
numbness of the foot.
FIa. 57.                      FIG. 58.
In the BACKWARD luxation (Fig. 58) the limb is slightly bent
and sensibly shortened. The condyles project, causing a depression of the ligamentum patellse; and the bend of the limb is, of
course, backward instead of forward, the foot being drawn forwards.
REDUCTION is mainly accomplished in all these cases by simple extension. The pelvis is fixed and the force applied by means
of a bandage round the ankle. In most cases the patient can sit
in a chair, while you place your own knee under his. Press also
upon the separated head of the bone with your hands, while your
assistant pulls suddenly but forcibly upon the ankle.  Thus the
force of the muscles is counteracted and the limb flexed at the
same time. In this manner we have several times succeeded in a
few seconds. The success of the manoeuvre depends on first raising the heel, as in dislocation of the patella, and then, while the



76        REDUCTION OF TIBIA   THE ANKLE JOINT.
patient's attention is attracted to some other object, quickly extending and flexing the limb into place.
OF THE FOOT.
DISLOCATION AT THE ANKLE
-may occur in various directions, outward, inward, forward,
and (very rarely) backward. There are generally complications.
FIG. 59.                      FIG. 60.
The DISLOCATION INWARDS is the most common. A tumor is
caused by the internal malleolus pressing so firmly against the
skin as almost to burst through (see Fig. 60). The foot is turned
out, but the joint is still movable. The fibula (as here represented - Fig. 59) is almost always fractured about three inches
above the ankle, where a depression may be felt.
To REDUCE, let an assistant take hold of the foot by the heel
" and toes, flexing the leg to a right angle with the thigh, and -
while the thigh is held fast by another assistant just above the



78                 OF THE FOOT, TOES, &C.
tion should be used to prevent stiffness of the joint. The foot
may be regularly flexed and extended several times a day. No
weight must be borne upon the foot until thus prepared for it.
Where this precaution has been neglected, much inconvenience
has often resulted. See remarks on the general directions for the
reduction and treatment.
DISLOCATION OF THE TARSUS AND METATARSUS.
When the os calcis, astragalus or other bones of the foot are
dislocated, the nature of the case needs no description. Reduction can be effected by extension of the foot, in connection with
directly pressing the bones into their proper places. They require compresses and bandages to keep them there, and the proper
treatment to keep down the inflammation.
DISLOCATION OF THE TOES
-was taken up in connection with that of the FINGERS. The
symptoms are very similar in both, and the same principles are
applicable for reduction.



OF FRACTURE TN GENERAL.                 79
CHAPTER VII.
OF FRACTURE IN GENERAL.
BEFORE entering upon the subject of fractures, we would call
attention for a moment to the mechanical means and appliances,
-splints, bandages, &c., that will be needed in the treatment of
these cases.
There has been a good deal of this sort of apparatus invented,
to facilitate the surgeon's object. Some of these inventions, particularly some recent ones, are very convenient. We shall not
describe the use of any of them, as they all explain themselves, or
have the necessary directions accompanying them.  Others still
better are no doubt yet to be invented.
Inasmuch, however, as many of them are too expensive for the
physician, with a limited surgical practice, to be expected to keep;
and as therefore few practitioners, especially in the country, will
have access to them when the occasions for using them occur, -
we deem it our duty to give such directions respecting splints
and all other necessary means, as will enable the country practitioner to furnish himself at the right time with all that is requisite. And we would here remark that, in all cases and all places,
the true surgeon will exercise his own ingenuity and judgment,
and adapt his mechanical appliances, no less than his medical
treatment, to the exigencies of the case before him, regardless of
any particular directions or models presented by his teachers or
authors.  All that the teacher can do, is to communicate such
general principles, with such examples by way of illustration, as
will prepare the student both to think and act aright.  With a
general knowledge of what is necessary, and a particular knowledge of much that has been done, the practitioner is left free to
devise or adopt any plan that may appear to his judgment best,
-whether really an improvement on what others have done, or
only the best that can be under the circumstances. No lecturer
or writer pretends to anticipate all the peculiarities and exigencies
of actual practice.  Among the illustrations, if we ought not



80               OF FRACTURE IN GENERAL.
rather say, among the principles, with which the student should
be familiar, is the proper use of the BANDAGE. Hence some directions on that subject have been given in detail (see chapter on
ulcers).
SPLINTS may always be made of thin pine or poplar boards,
and then wrapped with cotton cloth when the occasion calls for
them, though as manufactured ones are very cheap, the surgeon
should always have some on hand of different sorts and sizes, properly covered and ready for use. Still he may not have such as
will suit every case.  Gutta Percha makes an admirable splint as
it can be moulded to any shape desired by being softened in hot
water, and very soon becomes hard and firm as board. We would
recommend a trial of it.
As a general rule, the simplest apparatus is the most effectual,,
-such as the surgeon's own good sense will suggest, at the moment it is wanted.
The violence which CAUSES fracture must be a force applied to
some point in the body of the bone while its extremities are fixed,
or to the extremities while the fixed point is intermediate. The
fixed as well as the moving force equally concurs in the effect.
Thus the contraction of the muscles acting on the bone often contributes to its fracture, and is sometimes sufficient to produce it
without any extraneous force. When what is considered "the
cause," that is the moving force is applied at or near the extremities, the bone generally breaks near the middle; but in other
cases at the point on which the force is brought to bear.
LIABILITY to this accident depends much on the age, general
health, and constitution of the patient. The imperfectly ossified
frame-work of children will often bend rather than break. In old
persons, on the other hand, the earthy matter predominates and
their bones are quite brittle. Some persons have this brittleness
throughout life, and are constantly getting some bone or other
broken by accidents that would have no effect on others.  In
these cases, also, the mending process is often as difficult as the
breaking is easy.  Some diseased conditions render the bones
very brittle, even in young or middle aged persons.
The mode of union between the broken parts is the following.
Soon after the accident, coagulable lymph and fibrin, as well as



SURGEON'S MEANS AND DISCRETION-LIABILITY          81
blood, are thrown out by the vessels connected with the parts,
and the loose bones become, as it were, slightly glued together, as
they may happen to lie in proximity.  After a while a "provisional cartilage" is formed round the parts, like a capsule, and
firmly supports them.  This gradually hardens into "the provisional callus," —a bone-like ring round the fractured parts, holding them together even more firmly than they were before the accident, -though the proper substance of the bone has not yet
become whole again.  The ossific process goes on, for from five to
twelve months, according to age and constitution, and when it is
complete the supporting ring or provisional callus disappears.
The provisional union, however, by means of the extraneous deposit, may be regarded as the completion of the reparative process, as far as the surgeon is practically concerned.
The PERIOD, after which it will be too late to adjust a fractured
bone with the expectation of having it united with the ordinary
attentions and appliances, varies much in different cases. It will
depend much on the particular bone concerned, as well as on the
age and constitutional habits of the individual patient. The inferior maxillary, for instance, will begin to unite about the sixth or
seventh day, or even earlier in very young subjects, and the provisional union be often completed by the end of three weeks;
while in very old persons it may be much longer before the process begins, and its progress also will then be much slower. The
periods are about the same for the ribs and other bones liberally
supplied with arterial blood. In bones but moderately furnished
with arteries, and more distant from the source of circulation, as
those of the extremities, the provisional union may be regarded as
commencing, in the earlier period of life, some time between the
eighth and tenth day after the accident, and as being completed in
a period of about five or six weeks. In patients past the meridian
of life, the process may be in operation by the twelfth day, but
will go on but feebly at first, and is not to be deemed complete or
secure under from two to four months.
It may therefore be often "too late " to set or re-set a fractured bone a fortnight after the occurrence of the accident, and in
the case of some bones in very young and healthy patients, the
lapse of a single week may render any fresh derangement ques11                                    (PART II.)



82                OF FRACTURE IN GENERAL.
tionable. Simple adjustment and the ordinary dressings will be
insufficient in any case that has been neglected till after the period for provisional union to begin.
Hence it is always best, when practicable, to ADJUST a fracture immediately after the accident, and to examine it again about
the sixth or seventh day, to see that all is right, - after which
nothing more is necessary than to keep it so. For this purpose
great care must be exercised till after the tenth or twelfth day, or
for two or three weeks, in old persons. From that time forward
there is not so much danger from slight motion.
The evidence that this provisional ossification has actually commenced, is an extraordinary sensation of itching and prickling in
the part, -which, however, is not necessarily attended with any
great or preternatural determination of blood to the part. Any
sensible degree of inflammation, it should be remembered, is not
essential to the reparative process.
In very young persons, and in some particular bones, the provisional union has commenced in two or three days. In very old
persons, and those of feeble and faulty constitutions, it is sometimes a difficult matter to bring about any union. In these cases
what is called a FALSE or UNNATURAL JOINT often occurs.  The
cause of this, however, is generally the want of proper coaptation.
When union does not take place after the parts are properly
brought together, we are directed to rub the fractured ends
against each other, so as to produce irritation and the supposed
necessary inflammation, keeping them afterwards at rest and in
contact, that the inflammatory action may become adhesive. If
it be a leg or thigh, the part may be supported by strong splints
and the patient allowed to walk a little, or rest the weight of his
body on it, so as to produce the desired amount of irritation by
pressure.  When the uniting process commences, however, perfect
rest of the part must-be enjoined. It may even be necessary to
cut down and saw off the fractured ends that refuse to unite, and
bring the fresh surfaces into contact.
If, however, you give proper attention to the case in the early
stage, no trouble of this kind need be apprehended, -unless in
very old and unhealthy persons.  Even in these "hard cases," it
is probable that the bones would unite, if they were rightly ad



TIME FOR SETTING- PROMOTING UNION - DEFINITIONS.  83
justed and kept together, and the patient properly treated and
nourished. The old and absurd practice of starving patients under the mistaken and most mischievous notion that a reasonable
quantity of good palatable food favored the development of inflammation -and that "spare diet," i. e., starvation would prevent that "bugbear of the profession,"-has done incalculable
mischief.  The case under consideration is but a single example.
This starving and blood-letting,  this letting out and stopping off
life, to ward off the chance of death, -belong to the same category of ancient absurdities, or one-sided views and exaggerations,
still practiced by the great mass of the profession from mere force
of habit, - the vis inertia of mind, - though at the manifest expense of life and limbs.
A FRACTURE is said to be "transverse" when the bone is
broken directly across, "longitudinal" when split lengthwise, and
" oblique " when in neither of these directions.
CASES of Fracture are DIVIDED into simple and compound,
complicated and comminuted.
A SIMPLE FRACTURE is when a bone is broken at one point (or
it may even be at more than one place, but-) without extensive
laceration of the soft parts, or at all events, without any connected external wound.
A COMPOUND FRACTURE implies, -not only a laceration of
the soft parts by the fractured ends of bone, or by the instrument
with which the force was communicated, so that there must be always more or less "solution of the continuity" of the surrounding parts, but that some portion of the broken bone protrudes
through the integuments.
A  COMPLICATED FRACTURE is distinguished from  a "compound" as occurring in connection with the dislocation of a joint,
the rupture of some large vessels or ligaments, with a gun-shot
wound, or with some condition of the system which impedes the
ordinary process of ossification, or renders the ordinary appliances
insufficient.
A COMMINUTED FRACTURE is, in more idiomatic phrase, when
the bone is "broken to pieces," or very much shattered, -when
there are several fractures so near together that the bone is much
divided or splintered.



SPECIFIC TREATMENT.                    85
the fractured bone, and retaining it in its natural position by the
application of splints and bandages. This with an abstemious
diet and keeping the limb at rest and wet with cool water would
be all that is absolutely necessary for simple fracture upon a healthy
person. But very few are truly healthy - many are scrofulous -
the vital powers of a host are impaired by the use of spirituous or
malt liquors, age, long subjection to the impure air of cities, improper sensual gratification and a multitude of other causes.
Many have an irritable temperament in whom the slightest local
injury is followed by very great constitutional irritation. Hence
even in simple fracture (much more in compound, complicated, or
comminuted) there is danger of irritative secondary, or symptomatic fever (any fever from a local injury), rising and preventing a
favorable termination of the case.
To prevent the rise, or to control it after it has arisen, becomes
therefore an important duty of the surgeon.
All classes of allopathists employ the same means to control
this, the result of mechanical injury, that they use in other fevers
and inflammation, ignorant that any remedy possesses a specific
adaptation to this form of fever. It would be reasonable to suppose that they who claim to be the " scientifics" and to pay such
attention to the causes of disease, would see the inconsistency of
such a course of treatment. Blood-letting, topical remedies, purgatives, and sudorifics are the usual means relied upon. Some
discard blood-letting and rely upon the others - we, however, reject all, with the exception of topical applications, and employ
those remedies that have a specific relation to the cause.  Our
medical treatment is therefore simple, and efficacious as simple,
because in accordance with God's law.  We are thus enabled not
only to prevent the rise of much irritative fever, or control it after
it has arisen, but to hasten the reunion of the fractured bone which
is not attempted to be done by others.
We would therefore recommend in all cases that after carefully
adjusting the fracture, splints and bandages should be applied,
and occasional doses of Arnica, 3d dil., should be given for a day
or two, and to facilitate the coaptation of the fractured bone and
prevent the rise of irritative fever, the limb should be kept constantly wet with cool arnicated water-after which the arnica



86                OF FRACTURE IN GENERAL.
should be alternated with Symphytum Offic., except the fracture
implicates the ankle or wrists, when Ruta should be alternated
instead. Advantage may be derived from occasionally adding the
Tr. of Symphytum or Ruta in place of the Tr. of Arnica to the
water applied to the limb. This treatment will not only enable
you to discharge your patients sooner than those treated by other
surgeons, but will enable you to succeed in many cases of fracture
which, under other treatment, would result in the formation of a
false joint. For the first day or two we prefer to repeat the remedies at intervals of from three to five hours. In those cases
where the surgeon is not called until there is a high degree of inflammation, repeated doses of Aconite, either alone or in alternation with Arnica, should be given until the inflammation is partially subdued, and at the same time the limb should be frequently
subjected to the influence of hot vapor from a decoction of arnica
flowers, Hops, Hypericum perforatum, or Cynoglossum offic., and
in the intervals a fomentation of the same should be applied. But
as soon as the irritative fever is subdued, treat as first directed.
In some cases it is impossible to adjust the fracture before the reduction of the inflammation.
COMPOUND FRACTURES,
-says a distinguished author, "demand all the art of the
highest class of surgery, whether relating to their local or to their
constitutional management —in compound fractures the present
symptoms are severe, and are yet more so in prospect. Local inflammation, extensive suppuration, and possibly gangrene are accompanied by the various forms of severe traumatic fever, assuming the characters of hectic and typhus. In severe cases the constitutional forces are reduced to the lowest ebb, the powers of life
are exhausted, and under circumstances of peculiar difficulty the
question of amputation is often raised." Such a gloomy picture
or so sad a result is not often presented under judicious Homeopathic surgery.
They are to be treated the same as simple ones, so far as regards the " setting" and " fixing" of the divided bones; but the
bandages and other apparatus must be so arranged as to enable
you to dress the wound, without the risk of subsequent displace



COMMINUTED FRACTURES.                   87
ment.  If called early, adjust the fracture as soon as possible,
and bring the edges of the wound together and retain them if possible in complete juxtaposition by strips of adhesive plaster. Keep
the wound constantly moist and completely shielded from the atmosphere by cloths wet in cold arnicated water. In other respects
treat as directed for simple fracture. If the wound heals by the
first intention no other treatment is required. But if not treat as
for lacerated wounds.
If an artery is wounded and the bleeding cannot be arrested
by means of cold or styptics, it should be tied before setting the
limb.
COMMINUTED FRACTURES
— have to be treated in a similar manner to "compound."
If there be spicule of bone, already separate or loosened, as often
happens, remove them with your fingers or forceps, but use no
force. Unless they come away easily let them remain. If matter form and there be no rupture of the surface, puncture and let
it off.
When bones are separated from their connections with other
bones, as well as broken, -constituting one variety of " COMPLICATED FRACTURE,- or it may be also, a
COMPOUND DISLOCATION,
- in which event as in the simple laceration, strictly so called,
- the luxation if it is possible is to be first reduced, and the case
then treated as one of "Compound Fracture," —with this difference, that Rhus. Tox. should be occasionally used, and special care
should be taken to prevent suppuration. Use cooling lotions, but
not emollients. If, however, the inflammation has already gone
so far, that suppuration or worse is inevitable, then resort to fomentations and poultices.
SUPPURATION must be encouraged as a means of avoiding
tetanus and gangrene.  The sad consequences of suppuration,
described in the books, are by no means inevitable.  With the
proper local and general treatment, no particular danger to life
need be incurred.  When the activity of the inflammation has
subsided, should the discharge of pus continue profuse, it may be



88             OF DISLOCATIONS- ANCHYLOSIS.
checked and adhesion favored by a few applications of some strong
vegetable astringent, such as the Oak-bark, the Geranium, the
Rock brake (Pteris atropurpurea), or the Epiphegus virginianus
or Marsh rosemary.  A wash of some of these articles, with the
aid of judicious. compression, will soon remove all danger from
suppuration. When it is not possible to reduce the dislocation first,
which is indeed generally the case, reduce the fracture as though
unaccompanied With dislocation; and when the bone is united, attempt the reduction of the dislocation. In five or six weeks union of the fractured bone will probably be so that the dislocation
may be reduced.  (For other treatment, see WOUNDS and Gene.
ral Directions for Dislocations.)
AMPUTATION may have to be resorted to in these cases, though
it will be rarely necessary under judicious and efficient medication.
When, however, the suppuration is extensive, though the limb as
well as life may be saved,
ANCHYLOSIS
- is very apt to follow. This subject might be properly taken
up in this place, as it is a result of mechanical injury to a joint,
as well as of spontaneous disease.  The subject has, however,
been anticipated in both these aspects.  We mentioned the precautions necessary to be used to prevent this accident, in connection with Scrofulous Diseases of the Joints. Any injury of the
joint likely to involve this result will, of course, have to be treated
accordingly, bearing in mind the peculiar liabilities and future
uses of the part.
The age, habits, and general state of health of the patient with
fracture must be carefully considered, in prescribing his diet. If
he is robust and of full habit it should be low and unstimulating,
but if the vital powers are enfeebled it should be more nutritious.
A full supply of pure air is very important - also frequent sponge
baths- should the patient be compelled to use the limb before the
union of the fractured bones is perfectly firm, the application of
a starched bandage will afford great support. It should be applied
when wet and the limb not moved until it has become dry and
firm.



PSEIDARTHROSIS.                     89
If a fractured bone fails to unite by ossification or callus, and
remains loose, a "false joint,"
PSEUDARTHROSIS,
- is formed, the limb being nearly useless. It may occur from
a fracture of any of the bones, but is most frequent in the arm
and thigh. It may be occasioned by a too early use of the bone,
by some fault in the constitution preventing the formation of callus or the deposit of ossific matter, or from a neglect of bringing
the fractured ends properly in contact. Whatever may have prevented the union, the result is the same.
The extremities of the bones become smooth and round, and are
covered with a kind of ligamentous capsule.  In some cases a
regular ball and socket joint is formed, so that the ends turn upon
each other.
If the patient be old and feeble, little hope of effecting union
can be entertained after the lapse of twelve months. In such persons the greatest care should be exercised in keeping the fractured
ends in contact, and perfectly free from motion for at least one
year after the fracture, unless union takes place sooner. If, however, union is not effected in that time, the patient may be allowed
to use the limb.  This experiment of using the limb after the
lapse of three or four months, or rubbing the fragments together
for the purpose of promoting callosity, has proved successful.
The safer plan in all cases is to keep the parts in juxtaposition
by splints and bandages, and give the remedies as before directed
from eight to twelve months, at least, before any motion is allowed
to be made.  Cold bathing over the whole body, with pure air and
nourishing diet, and freedom from mental anxiety, will do much
to aid in the cure.
But if you are called to a case after the unnatural joint has
become established, some more direct measures will be requisite.
There are two modes of remedy in use among surgeons.  One is,
to cut down to the bone, saw off the fractured ends and place
them together firmly, closing the wound and allowing it to heal by
the first intention- the limb to be supported by splints, &c., until
union is effected. This is successful in some cases, but it is a
12                                      (PART I1.)



90              FRACTURES    OF THE CRANIUM.
formidable as well as difficult operation, and has been followed by
violent symptoms, and even the death of the patient.
It is said that the seaton has been quite successful, though it,
like other means, occasionally fails. In performing this operation,
the surgeon uses a long seaton needle armed with a skein of silk.
The limb is extended by assistants or machinery so as to separate
the extremities as much as possible.  The surgeon passes the
armed needle directly through the limb, from side to side, between
the ends of the bones, being careful to avoid large arteries, veins,
and nerves. Lint and small compresses are placed over the holes,
and the splints and roller applied to support the limb in a proper
position. The seaton should be allowed to remain until union is
complete. This may take five or six months, and even in some
cases twelve months. It is directed to be continued for the latter
period, unless union occurs sooner; since cases are recorded in
which consolidation of the parts took place after remaining disunited, in spite of the seaton, for a year or more. It might be
questioned whether the seaton was of any benefit? The general
health of the patient should be attended to: if impaired, every
possible means for its perfect restoration should be employed, and
all causes calculated to impair it, scrupulously avoided. The accident rarely occurs where there is not some general debilitating
cause in operation.
CHAPTER VIII.
PARTICULAR FRACTURES OF THE HEAD AND TRUNK.
FRACTURES OF THE CRANIUM
- seldom occur without injury to the brain or its appendages.
The danger, therefore, depends not upon the fracture of the bone
itself, but the degree of injury to the brain.
The skull-bone may be merely cracked in a straight line through
one or both plates; or it may be crushed, the fractures extending
in different directions from a central point. When the outer table
only is crushed, it may be depressed into the diploe, or porous
space between the two plates.



COMPRESSION - CONCUSSION.                 91
The SYMPTOMS are generally of easy detection.  When the
skull is crushed, crepitus can be felt through the skin. There are
more or less marks of violence on the surface. If the scalp be
torn, as is most frequently the case, the wound should be explored
with that best of probes, the finger. If much time has elapsed,
there will be a considerable tumor, which may prevent the proper
examination until it has subsided.
It must not be forgotten that the skull-bone may be bent in
without being fractured.  If there be evident symptoms of COMPRESSION upon the brain, and these do not subside by the use of
proper constitutional and local treatment; and it is ascertained,
moreever, that the blow upon the head was made by such an instrument as would be likely to produce fracture, without lacerating
the surface,- there will be strong reason to suspect its existence.
In such a case, if examination through the scalp be not decisive, or
be prevented by the swelling, a portion may be removed, sufficient
to permit the proper examination, and to trephine, if necessary.
A severe blow on the head, by a fall or otherwise, may occasion
fracture of the skull at some other point than that where the foreign force was received. Thus the base of the skull may be fractured, when the top of the head is struck.  When the temporal
bone is broken in this way, blood will flow out of the ears.
SYMPTOMS of compression will always be present soon after
infliction of the injury if the bone is depressed, but though an
effect they are not an evidence of depressed bone, as they may
result from extravasated blood where there is only a slight fissure
without any depression.
SYMPTOMS of concussion must be distinguished from those of
compression.  The former will be present for a short time in
nearly all cases of fracture, as well as after other blows on the
head, when the bone is uninjured. (See for symptoms and treatment of concussion and compression under WOUNDS OF THE
HEAD.)
If there is concussion and there be no symptom of compression, all that is necessary is to DRESS as in any other case, -first
removing the hair for some distance round. Then wash out with
warm water, and bring the lips together with adhesive straps and
bandaging.  Sutures may be necessary, but should be avoided, if
possible.



92          FRACTURES-OF THE NOSE AND JAW.
But if SYMPTOMS of COMPRESSION come on, or already exist and
are not relieved by treatment, it may be necessary to trephine and
elevate the depressed bone or remove the extravasated blood. But
the symptoms of
- both concussion and compression may appear together, and
the exact state of the case not be easily ascertained. In such circumstances, the safest plan is to wait, and use means calculated to
relieve both states, until they subside or those of compression
more clearly develop themselves.
Trephining is always attended, even in the most skillful hands,
with much danger to the patient. Hence it should never be done
prophylactically, as is recommended by some surgeons, but only in
those cases when there is unequivocal evidence of pressure on the
brain, which has not yielded to a faithful exhibition of our remedial means, and where we are tolerably certain as to the exact location of that pressure. If you have resolved on using the instrument, place it on such a part of the head as will, if possible, avoid
the grooves for the middle meningeal arteries in the parietal and
temporal bones, as well as the sutures, and have one edge of the
trephine on the sound and one on the fractured bone. (For the
mode of proceeding with the operation, see TREPHINING.)
FRACTURE OF THE NOSE.
A violent blow upon the nose may not only break in the nasal
bones, but the processes of the ethmoidal bone, and do great if
not fatal injury by rupturing the membranes of the brain. Commonly, however, a nasal fracture is of trifling importance. It is
readily distinguished by the deformity resulting, and almost as
easily adjusted by applying some instrument (as a silver catheter
or the smaller end of a gunshot probe) on the inside of the nose
to push out the depressed bones, while the fingers on the outside
support and keep them  in their place.  Treat as for simple
fracture.
FRACTURE OF THE LOWER JAW.
This bone may be broken at any part.  The accident most
commonly occurs near the chin.  The case is easily ascertained by
the pain and crepitus on moving the bone, by the depression to be



SETTING, &C.                       98
felt on tracing along the edge of the jaw with the fingers, -which
depression is apt to be greater          FIG  62.
on one side than on the other,
— and is also manifested by
irregularity in the line of the 
teeth.
In ADJUSTING, elevate or
depress until all the teeth are
arranged in their proper place    jl
with respect to each other and  I'
those of the upper jaw. If, as
often happens, the case is complicated with dislocation of one of
the condyles, that must be first reduced, and the fracture then set.
There is also almost always a good deal of contusion or laceration
of the soft parts. For this reason, after the proper dressings, the
parts require to be constantly wet with cold arnicated water. (See
next illustration.)
Secure the jaw after adjustment, by shutting the mouth closely
and keeping it shut. Take a piece of stout calf-skin leather, about
two and a half inches wide, and long enough to pass nearly or
quite from ear to ear and over the chin. Spread upon this some
good adhesive plaster, or collodion, and stick it smoothly on. The
Gum Shellac cloth or Gutta Percha would do still better than the
leather, and need less bandaging over it.
If no teeth are wanting in the fore part of the mouth, and
there is not sufficient space between them, one or two will have
to be extracted previously to closing the mouth, in order that there
may be a space through which the patient, by means of a tube,
may take drink and food in a liquid form. As the patient may
not like to lose a front tooth, one of the cuspids or the first of the
bicuspids may be chosen.
The BANDAGE for securing the jaw may be of strong muslin or
drilling, about two and a half inches wide and two yards long. It
is to be split from each end to within six inches of the middle,
where a small hole is made for the chin. The two lower ends are
brought up over the top of the head, while the upper ones are carried horizontally round to the back of the neck.  Several turns
should then be made with each pair, some round the head horizon



FOUR-TAILED AND GIBSON'S BANDAGES.            9b
the horizontal ones above the ear over the occiput and forehead next follow; and then several others below the ear and lip.
Pins or stitches should be applied wherever the roller changes its
direction or the turns cross each other. The median strip over
the top of the head, from the neck to the forehead, should be also
fastened to each layer as it crosses. Its object is to keep the other
turns from slipping.
Dr. Hill was called while engaged in the Eclectic practice in
Cincinnati, to a lad who was kicked by a horse in such a way as
to occasion three distinct fractures of the inferior maxillary (as
represented in Fig. 62), besides other complications. Several of
the molars and one of the incisor teeth were knocked out; blood
flowed freely from one ear; and there were signs of much cerebral
implication.  The face and head were very much bruised; the
mouth could not be closed; the lower jaw being drawn back as
well as down.  Each condyle was broken, besides a fracture
through the front of the bone. Dr. Hill was called about an hour
after the accident, and with the patient's father (Dr. Carter) adjusted the parts, he pressing down and forwards upon the fractured condyles, and then, when the mouth could be closed, arranging the front fracture and the teeth, bringing these on a plane
with each other and parallel with those of the upper jaw. This
done, an adhesive plaster was placed over the chin, and the whole
secured by the four-tailed bandage (that first described, before giving Gibson's plan). The parts were kept constantly wet with a
preparation, composed of equal parts of common whisky and water,
saturated with common salt, to which strong tincture of camphor was
added in the proportion of a pint to two quarts of the first mixture;
and an active cathartic given on account of the cerebral symptoms.
These, with the bleeding from the ear, gradually ceased; the patient continued comfortable; and on the seventh day the dressings
were removed for the sake of examination and readjustment. In
about a month the cure was complete, leaving scarcely any perceptible deformity, and allowing the complete use of the joints
and jaw.  He was then unacquainted with the efficacy of Homeopathic remedies in surgery.



96              FRACTURES-OF THE SCAPULA.
FRACTURES OF THE SCAPULA.
These are very rare, except that which separates the acromion
process.
When the BODY of the bone is fractured across, the parts remain so nearly in place as to cause no deformity. There is pain,
however, and crepitus can be perceived on pressing the hand upon
it.  The TREATMENT in such a case consists in applying bandages
around the thorax and over the shoulder, so as to prevent all motion of the parts, keeping their surface wet and cool, placing the
hand and fore-arm in a sling and keeping them very quiet.
FRACTURE OF THE ACROMION PROCESS is easily caused by a
blow on the point of the shoulder. A depression at that point is
very manifest, and the natural fullness of the deltoid muscle is
wanting.  The separated portion of the bone is, with the clavicle,
drawn downwards and forwards by the sub-clavius and pectoralis
major.  When the arm is pressed upwards crepitus may be noticed, but not when it is simply rotated.
To REMEDY this accident, press the head of the humerus up, so
as to carry the fragment to its proper place, and fix the arm in
that position by the " clavicle bandage,"- omitting, however, in
this case, to place anything under the arm, as is done in fracture
of the clavicle.* The parts must be kept at rest and steadily
fixed.  (See under FRACTURE OF THE CLAVICLE.)
The NECK of the scapula may be so fractured as to involve
only the glenoid cavity and the coracoid process, leaving the acromion entire. This case is apt to be confounded with a dislocation.
As the long heads of the biceps and triceps originate from this
portion of the scapula, those muscles retain it in contact with the
head of the humerus, which is drawn down with it into the axilla,
both by the weight of the arm and the contractions of the pectoralis major, latissimus dorsi and subscapularius. The head of the
humerus can be felt in the axilla, as when it is luxated. The
acromion process is very conspicuous, from a depression beneath.
The deltoid is flattened and the arm elongated. Crepitus can be
* Dr. Hill recently had an otherwise extraordinary case brought to him from
the country, in which both the acromion and end of the clavicle were severed. It
was an infant, the damage having been done by the accoucheur in bringing down
the arm after "turning."



FRACTURE-OF THE CLAVICLE.                  97
discovered and the nature of the case readily ascertained, by placing the thumb on the coracoid process and the fingers in the axilla,
while the arm is pushed outwards and upwards.
The treatment in this case consists merely of putting the parts
properly in apposition, and keeping them there, by the " clavicle
bandage" with a wedge-shaped pad under the arm, so as to keep
arm and shoulder both perfectly fixed and immovable until union
takes place. (See treatment for SIMPLE FRACTURE.)
FRACTURE OF THE CLAVICLE.
This is a very common accident, and easily distinguished. The
" collar bone " usually gives way near the middle with an " oblique
fracture" (as in Fig. 64). Passing the finger along the edge of
FIG. 64.
the bone from the sternum, will readily show the point and direction of the split. A considerable tumor often forms at the place.
Not unfrequently a spicula of bone will be found protruding
through the skin, constituting the case one of " compound fracture." Crepitus occurs in moving the shoulder, which is drawn
forwards and inwards by the contraction of the pectoral muscles.
In ADJUSTING this case, the surgeon stands behind the patient
and puts his knee between the shoulders, drawing them both back
until the parts of the broken clavicle have necessarily assumed
their proper position. The shoulders are to be kept back, and the
arms down by suitable apparatus. Before applying the " clavicle
bandage," which we will presently describe, we are in the habit
of applying a piece of leather tolerably stiff and spread with ad13                                      (PART II.)



CLAVICLE BANDAGE - PRECISE DIRECTIONS FOR.         99
to, or nearly to, the coracoid process of the sound side. Thus
make six or eight folds round the body, including the arm in each.
Then lay the roller again over the sound shoulder, across the back
and round the body, over and below the elbow on the breast, and
up in front over the sound shoulder.  Make five or six of these
oblique turns, and fasten your bandage. Also, stitch the successive folds of the roller, as they overlap each other from the
shoulder down below the elbow and up along the fore-arm, so that
they may not possibly slip up             FIG 66
or down.  Next, having covered the affected clavicle with a
compress laid over the plaster,
confine it with your bandage,
brought round from under the
sound arm, and obliquely across
the breast over the affected clavicle and the shoulder above.
Six or eight of these turns com- 
plete the operation, so as to keep
everything smooth and firm.
The modes of applying the     
bandage laid  down in  most 
works, does not seem to us as
efficient as this, which we can   
recommend from experience. It   
has always fully realized our 
expectations. Several severe cases, in some of which the fractured
clavicle protruded through the skin, were adjusted in the way described; and so perfect was the union that, after the lapse of a year
or two, not a trace of the accident could be discovered except a
slight scar where the surface was broken through. The surface
of the united bones was smooth as on the opposite side.
The advantage of applying the bandage in the way recommended, is, that if there be any external wound, it can be dressed,
- or the part can be examined, if there be occasion for it, -without so far removing the bandages as to cause any derangement, or
indeed allow of the least motion. The clavicle itself, though secured by plaster, position, &c., was the last part bandaged (which



100       CLAVICLE BANDAGE -STERNUM AND RIBS.
the front view of Figure 66 was intended to represent). This precaution should never be lost sight of. Treat as directed for simple fracture.
Rest for a few days should be enjoined, though with the
straight-waistcoat-like protection of the properly adjusted bandage
little risk is incurred.  Union of bone will take place much quicker at this central part of the body, than in the extremities. Two
or three weeks will generally be long enough to keep on the apparatus. Of this, however, the practitioner must judge for himself, in every case guided by the constitutional vigor of every
patient.
FRACTURE OF THE STERNUM.
This accident never happens, except from very great force applied directly to the part. It is important on account of the great
liability of inflammation/extending to the pleura and thoracic viscera.  It may always be considered a dangerous case, requiring
careful management.
Its SYMPTOMS are a depression at the point of fracture, with
pain and crepitus accompanying the movements of respiration.
Spread strips of leather, Gutta Percha, or Shellac cloth an inch
in width with adhesive plaster. Have the patient take a moderately full inspiration and then hold his breath for a few moments.
And while the chest is thus expanded apply the strips spread with
adhesive plaster diagonally across the chest from each side crossing each other over the sternum. Next apply a roller round the
chest, so as to stop all motion, causing respiration to be carried on
by the abdominal instead of the intercostal muscles. Inspiration
should be natural while the roller is applied. Keep the patient
very quiet. Be very thorough in the application of the cold arnicated lotion to the injured part and in the other treatment as directed for simple fracture.
As an adjuvant the feet should be occasionally immersed in
hot water and
Should much inflammation threaten, moderately tight bandages should be occasionally placed around the arms and thighs to
prevent an undue determination of the blood to the chest. (See
IJHMASTASIS.)



104                     FRACTURES.
and TREATMENT, is to place the patient, as gently as possible, in a
horizontal position. We are then directed to observe, with as
little handling as we can, whether the legs, the spinous processes
of the ilia, and other prominent points on each side compare. If
there is deformity discovered, making a fracture probable, before
going any further with the examination,-introduce a catheter, to ascertain whether the urethra or
bladder be involved in the injury. Should there be bloody urine,
or any obstruction to the advance of the instrument, let it remain
in the bladder, or as far towards it as it has gone, and proceed at
once to
-apply a roller round the pelvis in such a manner as to keep
all the bones in proper juxtaposition. Then have a strap passed
under the nates, and attached to a pulley suspended over the bed,
so that the pelvis may be raised without any muscular effort on
the part of the patient.
All possible precautions, topical and general, must be taken
against inflammation. (See treatment of FRACTURE.) In addition to the local treatment there recommended, the use of frequent enemas of cold arnicated water may do much good.
If, however, the injury be severe, there is but little hope of
saving the patient.
CHAPTER IX.
PARTICULAR FRACTURES, CONTINUED —THOSE OF THE UPPER
EXTREMITIES.
OF THE HUMERUS.
THIS bone is generally broken near the middle; it may, however, give way near the condyles, or just under the head, in the part
called (in surgery) the neck -(see Figures 68 and 69).
A fracture in any part of the SHAFT of the bone (as in Figure 67) is easily detected. There will be obvious deformity, the
parts of the bone being drawn out of a line by the different mus



VARIETIES OF ARM-FRACTURE.              105
cles. The patient feels more or less pain at the fractured point,
and is unable to use the limb. By rotating the
lower portion of the arm, while the upper is    FI. 7.
fixed, crepitus can generally be noticed; and the
direction and extent of the fracture can easily
be ascertained by the touch, on tracing with the
finger from the condyles upwards.
Fracture of the NECK (Figure 68) is not always easily distinguished from a dislocation.  It
may be borne in mind, however, that it is an accident which seldom occurs, except in old persons. In the fracture, the roundness of the shoulder is not lessened, as when the head of the bone
is out of its place.  Crepitus will always decide
the point. By taking hold of the arm  below
and rotating, the grating of the fractured portions on each other may be felt, if not heard.
Fracture at or near the CONDYLES (one form    i
of which is also represented in Figure 67 and   q
another in Figure 69) may be mistaken for luxation from the fore-arm. The use of the elbow joint will aid in
the discrimination. Let the elbow be fixed, and rotation of the
hand will seldom be much impeded in mere fracture, even when
the condyles are broken off, or have a fissure between them. If
the fracture be just above the condyles (Fig. 69), as usually happens in the case of children, the arm will be shortened. Crepitus
will be decisive.
The TREATMENT, when the shaft of the bone is broken, is simple. The proper extension has first to be made, by drawing upon
the wrist or elbow the fore-arm being about half bent; and the
adjustment then accomplished, by comparing the length and appearance of the limb with its fellow. If it be an oblique fracture,
great care must be taken not to let the ends of the bones slip by
each other, and thus render the arm permanently shorter. The
muscles naturally tend to bring about this result.
Have the parts held, when once in proper juxtaposition, by an
assistant, while a roller is applied, rather loosely, from the elbow
to the shoulder. Then place on four splints about a quarter of
14                                     (PART II.)



106              FRACTURES -OF THE ARM.
an inch thick, and of a convenient width, so as to cover nearly
the whole surface of the arm. Let them be nearFIG. 68.   ly as long as the humerus itself, the inner one be{    ing a little the shortest, so as to allow the elbow
to be bent.  Then continue your roller, bringing
it down again over the splints from one end to the
other a sufficient number of times to fix them
firmly to the arm, and prevent any motion or contraction of the muscles.
The fore-arm and hand must be suspended in
a sling from the neck. It is best to have one of
the splints extend from the shoulder to the back
of the hand, it being bent to a right angle at the
elbow, and secured by the roller being brought
down to the hand.  This will more effectually
protect the arm, by preventing rotation and all
/2 II    other motion of the fore-arm. This splint, and
all the others, may be of Gutta Percha or Gum
Shellac cloth, two or three thicknesses being stuck'1aml  ~together.
Some recommend the roller in the first instance to be carried
from the fingers up to the shoulder, so as to allow of its being
rolled very tight, preventing all motion below, and paralyzing
the muscles above. This, however, is not necessary in ordinary
cases.
When the neck of the humerus is fractured (as in Figure 68),
the parts are to be kept in their place, after adjustment, by a
wedge-shaped pad in the axilla.  The Gutta Percha or Shellac
Splint should then be applied on the outside and over the top of
the shoulder and the whole firmly fixed by the clavicle bandage.
The Gutta Percha or Gum Shellac cloth is to be spread with
adhesive plaster and extend from  the neck down near to the
elbow, and be wide enough to envelop the whole shoulder and
two-thirds of the surface of the arm. Those not yet acquainted
with these excellent moldable splints have to trust wholly to their'" clavicle bandage."
FRACTURE just above the condyles (Figure 69) can be easily
distinguished from dislocation of the radius and ulna backwards,



VARIOUS MEANS-  GUM SHfELAC, &c.            107
for which it is sometimes mistaken, by extending the arm when
all the marks of dislocation are removed, but return on discontinuing the extension, also by crepitus just above the elbow-joint
upon rotating the fore-arm upon the humerus. After the proper
FIG. 69.
extension and juxtaposition, apply a roller loosely around the arm
and fore-arm while bent, and afterwards fix on with it two angular
splints, one in front and the other to the back of the arm, reaching nearly from the shoulder to the wrist. Prevent all motion
both of the arm and fore-arm, and suspend the latter in a sling.
Here again the Gutta Percha or the Shellac cloth makes the best
possible splint. Passive motion, for the prevention of anchylosis,
may be gently commenced in two weeks, if the patient is young;
but if an adult, at the expiration of three.
In true "fracture of the condyles" (as in Figure 67), one or
the other of the moldable splints should by all means be used.
The divided parts are to be pressed together and the splint or
cloth cap smoothly stuck on. Let it reach to the wrist. In about
eighteen or twenty days remove the first splint, and substitute
another, bent about half as much, and take the opportunity of
making a little passive motion of the arm backwards and forwards.
Keep this on for two or three weeks, and then apply a still
straighter one. After this, remove the dressings every two or
three days, and move the joint a little. (See treatment of FRACTURES, DISLOCATIONS, and WOUNDS OF THE JOINT.)
"More or less deformity is liable to occur in this case, as well
as in the preceding, in spite of the best management.  This
should always be made known to the patient or friends, in order
that censure for bad surgery may not be incurred."



108           FRACTURES -ABOUT THE ELBOW.
So say the best authorities. Our success, however, has been
such, in the treatment of those cases that have fallen into our
hands, that there has been no deformity or loss of motion. That
they were not all mild cases may be learned from the following
case of Dr. Hunt's:  In July, 1851, a son (aet. 11) of Mr. B.
Boffinger, of Cincinnati, fell from a shed, upon his right elbow,
which entered the ground for several inches.  Dr. Hunt was
called, and found the humerus fractured, as in Fig. 69, with the
upper part protruding nearly an inch through the skin. There
was also a fracture of the internal condyle.  Reduction was
effected by pressing with the thumb upwards and backwards upon
the protruding bone.  At the same time, extension was made
upon the fore-arm, flexed. A loose bandage being applied from
the hand to the shoulder, a strip of Gutta Percha, of the length
of the limb, and sufficiently wide to encase the back part of the
arm and extend over the condyles, was, after being softened in
hot water, fitted to the back part of the limb and permitted to
cool.
Another strip of Gutta Percha was fitted over the front part
of the arm, and extending down over the fore-arm.  After this
had become cool and firm, an aperture was made in it over the
wound. These splints were then applied and made secure by means
of a second roller. By this arrangement, each part was kept in
its proper position, and the wound could be dressed without removing the splints and bandages.  The medical treatment was
the same as that before recommended for fractures, under which
there was but little secondary fever; the wound healed with but
little suppuration, the bones speedily united, and no permanent
anchylosis occurred. At the expiration of a couple of weeks, the
splints were taken off, slightly straightened-gentle motion commenced.  The patient entirely recovered the use of the arm.
FRACTURES OF THE ULNA PROCESSES.
The Oleeranon Process
— is sometimes broken off and drawn up on the back of the
arm, leaving a depression between it and the joint (see Fig. 70).
If, however, the ligaments be not ruptured, little or no retraction



110            FRACTURES - O  THE FORE-ARM.
very rare. It occasions a difficulty of bending the elbow, as the
action of the brachialis upon the fore-arm is lost. There is also,
almost of necessity, a backward dislocation, the coronoid process
FIG. 71    being nearly all that prevents the triceps extensor
drawing the ulna backwards and upwards.
All the necessary TREATMENT is to flex the
fore-arm and retain it in that position by splints
and bandages. (See treatment of FRACTURE.)
This fracture also unites only by ligamentous
connection.
W l tFRACTURES OF THE FORE-ARM.
The radius and ulna may both be broken
through, or either of them alone (see Figures 71,
72, and 73).  These common accidents may be
Il      ascertained by tracing the bones from the wrist
up, until when the finger comes to the divided
part a depression is felt; by the crepitus, on fixing the elbow and rotating the wrist; and by the
pain, and more or less loss of motion in the hand.
The only point of TREATMENT that is not obvious, is the precaution of keeping the bones
apart, so as to prevent their being drawn into the
interosseous space (by the pronator and supinator muscles, and
particularly the quadratus, which having a special direct tendency
to this result, from its fibres running perpendicularly across the
bones, is represented in Fig. 71, near the wrist). The bones thus
uniting, would for ever prevent the circular movement of the
radius round the ulna, and the full use of the hand. After adjusting the fracture by extension from the wrist, bend the arm at
a right angle, having the thumb directly above the little finger,
that is, mid-way between pronation and supination. Then apply
a roller loosely, and over it two splints, one from the internal
condyle to the palm of the hand; another on the outer side, from
the external condyle to the back of the wrist.  These splints
should be convex on the side next the arm, and padded with cotton, or have a cotton compress laid beneath them, between the
bones, so as to press into the interosseous space. After this mat



FRACTURES- 0  THE FORE-ARM.                111
ter is attended to, secure the splints by a roller, extending from
the hand to the elbow.
If the radius alone is fractured (Fig. 72), it is best to leave
FrG. 72.
the hand loose, so as to let it drop down, and thus exert some
force of extension on the bone. But in fracture of both bones
(Fig. 71), or of the ulna alone (Fig. 73), let the splint and bandFIG. 73.
age extend to the ends of the fingers, keeping the hand and forearm in the same line.
After ten or twelve days the splints may, in ordinary cases,
be removed, land a starched bandage applied; but care must still
be taken that the bones be not forced together. To prevent this,
a compress had better be put along the interosseous space, at least
along the front of the fore-arm. (See treatment of FRACTURES.)
The Lower End of the Radius
— may be fractured at about half an inch, or still less, from
the joint. As the hand is distorted, it is apt to be mistaken for
FIG. 74.
__ul l!Beliz  



114              FRACTURES   OF THE THIGH.
A fracture within the capsular ligament (Fig. 76) very rarely
unites by bony connection.  Either a strong ligamentous subFIG. 76.
stance has to bind the parts together and serve instead of bone,
or there is no fixed union at all. In the latter case a sort of
"double joint" is formed, the fractured surface of the head becoming hollowed into a socket, and that of the neck rounded so
as to play into it. The ligaments of the joint become greatly
thickened and strengthened, as is also the case with the obturator
externus muscle. The limb in this case is permanently shortened,
causing halting in the step.
Treatment.
Sir Astley Cooper, after giving some half dozen different
modes of management, thus concludes:" Baffled in our various attempts at curing these cases, and
finding the life of the patient occasionally sacrificed under the
trials made to unite them, I should, if I sustained this accident
in my own person, direct that a pillow should be placed under the
limb throughout its length; that another should be rolled up under the knee, and that the limb should be thus extended until the
inflammation and pain had subsided. I should then daily rise and
sit in a high chair, in order to prevent a degree of flexion which
would be painful; and, walking with crutches, bear gently on the



116              FRACTURES -OF THE THIGH.
pens in persons under the age of fifty. Crepitus in the case of
external fracture is much more easily distinguished, while the limb
itself is not so much shortened or everted. The pain and swelling
are greater and often become excessive, with attendant constitutional symptoms.  In the intra-capsular fracture, there is but
little symptomatic fever after the first few days.
Union by ossification will in this case take place in healthy
young or middle aged persons, and even in those of a more advanced age whose constitutions are very robust.
The TREATMENT therefore should be such as will keep the
parts properly in contact. The length of the limb must be preserved, and the trochanter pressed inwards.  Jarvis's apparatus
is well adapted to this purpose. We would simply recommend it
as the best we have seen, and say nothing about any other means,
if it were not too expensive for all practitioners to keep.
Of the various methods devised for fulfilling the proper indications, and described in detail by surgical writers, we may remark that no two of them agree in recommending any one as the
best.  As we consider the two plans of the great —and great
because practical -English surgeon to be as effectual as any, and
better than most, inasmuch as they are simple and cheap, we shall
here also take the liberty of repeating his directions in his own
language.*
" In the TREATMENT of this injury the principles are to keep
the bones in approximation, by pressing the trochanter towards
the acetabulum, and to preserve the length of the limb.  The
foot and ankle of the injured side should be firmly bound with a
roller to the foot and ankle of the other leg, and thus the uninjured side will serve as a splint to that which is fractured, giving
it a continued- support, and keeping it extended to the proper
length."  (That is, of course, on the presumption that the sound
limb itself is kept straight, though nothing is said by our author,
or others, of preventing both limbs being drawn up together.)
"A broad leathern strap should also be buckled around the pelvis, including the trochanter major, to press the fractured portions
of the bone firmly together; and the best position for the limb is,
to keep it in a straight line with the body.
* Sir A. Cooper's Dislocations and Fractures, p. 151-2.



118               FRACTURES-  OF THE THIGH.
As these are cases of great importance, and frequently occasion much trouble, we will give another plan, which is simple, and
will answer the purpose very well. Mr. Listen, in describing his
favorite mode and means of adjustment, thus speaks:-" Whether
the fracture is suspected to be within or without the joint, either
entirely or partially, the broken surfaces are to be brought in
contact and retained immovably in apposition for a time sufficient
to admit of union. The limb is put up in apparatus not requiring
removal and but little adjustment.  This can be effected only in
the extended position.  Many splints, with foot-boards, straps
and screws, are intended for this purpose, some to be attached to
the injured limb, others to the sound one; but the apparatus
which is most simple and easily to be procured at all times and in
all circumstances, is at once the best and most efficient. This is
a straight wooden board, not so thick as to feel cumbrous, and
not so thin as to be pliable or easily broken; in breadth, corresponding to the dimensions of the limb; in length, sufficient to
extend from two, three or four inches beyond the heel, to near
the axilla; deeply notched at two places at its lower end, and
perforated by two holes at the upper.  The splint, well padded,
is applied to the extended limb, the ankles being protected by
proper adjustment of the pads.  The apparatus is retained by
bandaging (see Fig. 78). A common roller is applied round the
FIG. 78.
limb, from the toes to near the knee, sb as to prevent infiltration,
which would otherwise follow pressure above by the rest of the
apparatus.  The splint is then attached to the rest of the limb
screwed on the lower end. A square stick is fastened by another hinge to the
thigh-piece, and has a groove and holes in its lower end to fit over a projection at
the back of the leg-piece. In this are several corresponding holes, by which the
two are pinned together, thus flexing the limb as little or as much as is desired.



LISTON'S SPLINT AND DIRECTIONS.           119
by involving both in a roller from the foot to above the knee;
and, in doing this, the bandage, after having been turned round
the ankle, should be passed through the notches, so as to be firmly
attached to the end of the splint, thereby preventing the foot
from shifting.  A broad bandage is applied around the pelvis,
over the groin and down the thigh, investing all that part of the
limb left uncovered by the previous bandaging. A broad band,
like a riding belt, is fastened round the pelvis, so as to bind the
splint to the trunk, and thereby keep the broken surfaces of the
bone in contact. A large handkerchief or shawl is brought under the perineum, and its ends secured through the openings at
the top of the board. It is evident that the splint being thus securely fixed, and made as part of the limb, tightening of the perineal band will extend the member and preserve it of its proper
length. By care and attention in applying the apparatus, and in
adjusting the cushions about the ankle and perineum, there is little or no risk of the skin giving way. The bandages will require
to be reapplied once or twice during the cure; and the perineal
band should be tightened frequently. The apparatus is retained
for six or eight weeks, the time necessary for union varying according to circumstances. After its removal, great care must be
taken at first in moving the limb and putting weight upon it: it
should be accustomed to its former functions very gradually."
(Medical treatment as directed for SIMPLE FRACTURE.)
FRACTURES ABOUT THE TROCHANTERS.
OBLIQUE FRACTURE THROUGH THE TROCHANTER MAJOR.When this rare accident occurs, the limb is everted and slightly
shortened. A fissure can be felt between the shaft of the bone
and the trochanter. The TREATMENT of this case does not differ
from the last. The limb is to be extended by the proper apparatus, and a strap applied around the hip, with a pad over the
trochanter, to keep the fractured portions together. Bony union
will readily take place.
The Shaft just below or about THE TROCHANTERS may be broken. This accident will be followed by great pain and deformity,
from the psoas and iliacus internus muscles drawing the upper
fragment of the bone upwards and forwards to a considerable



OF THE SHAFT —-SPLINTS AND BANDAGING.          121
which by combining three or four thicknesses, may be as stiff as
wood half an inch thick, yet exactly and easily fitted.
All the splints must be firmly fixed with a roller, and then
the limb placed on the inclined splint (see Fig. 77), and there
fastened by bands or buckles, the foot also being attached to the
foot-piece.
The first BANDAGE that is rolled from the foot upwards should
be so applied to the knee as to allow it to be bent. It is best to
have three separate strips, one terminating just below the joint,
another covering it and there fastened, and a third commencing
just above and enclosing the thigh.  Thus, if a change in the
position of the joint should be required, the bandage may be
loosened around it for a moment. At the first bandaging the limb
should be partially flexed,
The patient should not be permitted to lie down for ten or
twelve days, as, in that posture, the action of the muscles might
disturb the adjustment of the limb in spite of all your dressings.
The muscles must not be put upon the stretch before union has
taken place. (Medical treatment as directed for SIMPLE FRACTURE.)
FRACTURES ABOUT THE KNEE.
THE CONDYLES OF THE FEMUR
- are oftenest broken in old persons. It is always a serious
accident, sometimes a fatal one. It not unfrequently necessitate
amputation.
In the TREATMENT much ceare is required to keep down inflammation, and to prevent irritation of the nervous system, which
may easily produce tetanus.  To adjust the fracture, have the
limb straightened, so that the head of the tibia will press upon
the condyles, and keep the fractured portions together. Secure
by roller and splints. If it be a compound fracture, the parts
must be so fixed that the wound can be dressed without unsetting
again, or allowing of any motion. (See treatment for FRACTURES.)
FRACTURE OF THE PATELLA
-is generally transverse. The upper part is drawn high up
16                                    (PART II.)



122            FRACTURES -ABOUT THE KNEE.
by the rectus femoris. The fissure between the divided portions
FIG. 79.         is very distinct.  The patient has
not the power of straightening his
leg.
In TREATING this accident, lay
the limb perfectly straight, and se\I~    cure it in that position with a stiff
splint placed on the back of the
thigh, extending down the calf of
the leg. Apply a roller from the
-^   toes to the knee, and affix the splint
firmly to the thigh.  The divided
Hi       1    parts may be brought together in
this way: Straps are buckled round
below the lower part and above the
upper, and drawn together by means of other straps attached to
them, and meeting longitudinally at the sides of the knee. Pull
the circular straps up and down, until the fractured parts come
together, and -then secure them firmly. Unless perfect coaptation
be preserved, the union will be only ligamentous.
Longitudinal Fracture of the Patella is easily treated. After
subduing inflammation, extend the leg, bring the parts together
and secure them  by bandage, with compresses and paste-board
or Gutta Percha splints.
For the difficult object of fixing the patella in its place after
dislocation, or keeping its segments together after fracture, an ingenious apparatus has been quite recently invented (represented
in Fig. 80). This consists of a ring or case exactly fitting the
FIG. 80.
A



124                FRACTURES - OF THE LEG.
fracture be simple or comminuted, you can generally use with advantage such apparatus as has been recommended for fractures of
the neck or shaft of the femur.  The most convenient of them
for the present purpose will be the double inclined-splints.
The bandage, that is the first thing to be applied in these cases,
need not begin over the ends of the toes,
nor be so firmly rolled, as was directed for      FIG. 81.
the treatment of ulcers (and there illustrated,
Fig. 1).  It will be well enough in this case 
to leave out the toes and heel, and run on 
with fewer turns and less over-lapping, as is   Jil
usually done in other cases where such looseness is not so safe or effectual.  (Figure 81 
shows this common bandaging.)  This first
roller is not to be so tight as to prevent further extension, and exact adjustment being
made after it is on; for it will be best in
most cases, especially
-in OBLIQUE FRACTURES, to place the
limb (after provisional rectification with the
roller as above) on the inclined-splints, and
there extend it so as to compare exactly with
the other, and then fix the foot firmly to the
board provided for the purpose, by straps 
that will not stretch or get loose. Remember that the great toe
is always to be kept in a line with the inner edge of the patella.
After having the bones thus symmetrically adjusted and securely
fixed, two or three splints should be still applied to the sides and
front of the leg, and kept on by a roller, which also includes the
large supporting splint or " inclined-plane," fastening the whole
firmly together.  By this plan you not only make " assurance
doubly sure," but can at any time remove the splints, for the purpose of examining or dressing, without the risk of disturbance.
Dr. Hill once, on the spur of the occasion, in a bad case of
comminuted fracture, got up the following apparatus, which we
shall describe, because, while we believe it as good as any other, it
can be readily made wherever there can be found wood, with an axe,
a hand-saw, an inch or an inch and a half auger, and a jack-knife.



BANDAGING AND ADJUSTING -APPARATUS.            125
Get two pieces of board, five or six inches wide and half an
inch thick (common siding will do), and long enough to reach several inches above the knee and below the foot. Bore a hole near
the lower end of each, and also two holes through each at the
upper ends. Protect the thigh from the ends of the boards by a
roller, to which two pads of cotton cloth are attached.  To these
pads you fasten your boards by strips of drilling or strong muslin, run through the holes and round the limb. This done, wrap
the foot and ankle moderately tight with a roller, and fix, by its
means; a strong band to each side of the ankle, and another behind and above the heel. Pass through the lower holes a smooth
stick, ten or twelve inches long, and large enough to nearly fill
them.  Then make extension on the leg by the straps attached to
the ankle, or by taking hold of the foot and heel, until the fracture can be properly adjusted, and fix the straps to the cross-piece
below, so as to prevent any relaxation. To be certain that the
proper extension has been made, you should always measure from
some fixed point on the knee or pelvis to the malleolus, and see
how the length compares with that of the sound leg., When thus
secured in position, roll the leg with the bandage, and apply
splints in front, behind and at each side, all fastened on by the
bandage.  To make this last part of the operation more convenient, the lower ends of the boards may be separated five or six
inches further, with but little alteration in the distance of the
cross-piece, to which the extending force is fastened, and which
may be turned, so as to roll up and proportionally to shorten the
extending straps, and fixed as long as necessary by a pin, nail, or
wedge. This will be safer than to trust to an assistant for holding
the foot, until the apparatus can be replaced.
As, however, the patient will get tired of having the limb kept
straight, the apparatus may be so contrived as to let him have it
bent.  There may be circular joints at the knee, which will bend
without allowing the distance between the knee and the foot to
vary; and a pad may be fixed at the foot, like a sole, extending
an inch or more behind the heel, to which the extending straps
may be made fast. This contrivance becomes then an equivalent
for the inclined-splint, before recommended.
If it is deemed necessary to keep up -the extending force, a



CASES OF FRACTURED FOOT OR HAND.                127
first to be reduced, and the fracture then ADJUSTED, and kept in
place by a splint at the back of the leg, and a foot-board, fixing
the foot so that the great toe is in a line with the inner edge of
the patella. Another splint along the course of the fibula will be
necessary, and bandages, as in other cases. Keep both leg and
FIG. 82.*                       FIG. 83*.
l(il
foot quite still, and in the easiest position for the patient, as was
stated in the treatment of fractures. Ruta should be used in these
injuries about the ankle.
The TIBIA may be fractured near its lower end,- generally
obliquely, with the internal malleolus broken off (see Fig. 84), —
by twisting the foot inwards with sufficient force.  The fracture
may be transverse, extending through the fibula. The symptoms,
in either case, are the same and obvious:-the foot is seen turned
inwards, instead of outwards, as when the fibula alone is involved,
the external malleolus projecting (as seen in the figure), if not
also broken off. The crepitus is to be felt on the inside. The
* Fig. 83 represents the position of the foot and external appearance, Fig. 82
the condition of the bones or surgical anatomy of the case.



128              FRACTURES- OF THE FOOT.
treatment is in all respects the same as directed for the former
FIG. 84.       case, except that the one splint is to be applied on the side of the tibia, instead of the
fibula (unless the latter be also broken and:
require another).
FRACTURES OF THE FOOT
I I ^~- are in nearly all cases connected with
severe contusions, and more or less laceration. Treat them in all respects, aside from
the fracture, as you would any other contused or lacerated wound.  The bones are
to be confined to their proper places with
pasteboard, Gutta Percha, or Shellac splints,
compresses and bandages, In all cases the
foot has to be kept very still, and other precautions used to keep down inflammation.
A faithful application of our remedial
means, and a just reliance on the restorative powers of nature,
would restore to usefulness many a foot consigned by allopathic
surgeons to amputation. We are knowing to several cases, where
distinguished old school surgeons have deemed amputation the
only safe resort, which have been cured by remedial measures,
and a useful foot preserved.
CHAPTER XI.
AMPUTATIONS.
SHALL a limb or part of the human body be removed by the
knife, and the individual be incapacitated to fulfill many of the
duties of life, or to participate in many of its pleasures? nay
more, is it necessary to mutilate that the life of the patient may
be saved? are questions the surgeon must often decide; and the
decision of which should demand great skill in curative surgery,
a mature judgment, and the warmest sympathies in behalf of the



AMPUTATIONS.                      129
patient.  Yet, do surgeons feel their responsibility?  Have they
exhausted all curative resources, and given the patient the benefit
of every doubt as to the necessity of amputation before they operate?
Does not the eclat and emoluments following an important,
successful surgical operation, ministering to their vanity, ambition
and self interest, often mislead many a distinguished surgeon?
Indeed, do not many of them owe their notoriety, as well as dexterity, to the fact that they have so often found it necessary to
resort to amputation? And that it is often a proof of their ignorance, is shown by other surgeons (less distinguished in the eyes
of the world) curing the very cases they had decided must be operated upon. We might instance a number of such. Strange infatuation, that this power to mutilate, which is often the evident result of bad surgery, and always a confession of the poverty of the
surgeon's resources, should be considered a proof of great surgical
skill. We trust, however, that a brighter day for humanity is dawning, and that it will not be long before curative surgery shall have
attained its proper position, and that the test of surgical superiority will be the infrequency and not the frequency of the necessity for a resort to the knife. And however imperfect this work
in other respects, it will not be valueless, if it shall contribute a
mite to the furtherance of this desirable object.
Amputation is considered justifiable whenever it is thought the
constitution will be unable to stand the shock and continued irritation consequent upon severe mechanical injury; or whenever
the disease, upon which any local deterioration is dependant, cannot be removed by medicine.  Hence operations are resorted to
in gangrene of the extremities,supposed incurable, disorganization
of the joints, copious undefinable hemorrhage, necrosis, incurable ulcers and diseases of the skin-in malignant growths-in distortions
(operations of expediency), cases of irreducible dislocation, and in
severe compound or comminuted fracture.  The proper medical
treatment that will render amputation, in nearly all of the above
cases unnecessary, has been before given.  (See GANGRENE,
WHITE SWELLING, ULCERS, CANCERS, &C.)
At the time of operating, the patient should be in as good
health as possible, and should have become accustomed to the in17                                       (PART II.)



PREPARATIONS - INCISIONS - SAWING.            133
is necessary to give room for the operation. The brachial artery
lies near the surface, and may easily be compressed against the
humerus at any part of its course. Near the elbow it lies in front
of the brachialis anticus, but runs up obliquely towards the axilla,
having afterwards, in front of it, the biceps and coraco-brachialis,
and, behind it, the triceps with the insertions of the latissimus
dorsi and teres major.
The patient is seated in a chair, or laid, in a convenient posture, upon a table or bed. One assistant has hold of the fore-arm
to support and steady it, while another grasps the arm with both
his hands above the part to be operated on, and pulls back the
integuments as tight as possible. If the
CIRCULAR OPERATION
-is the one to be performed, the surgeon, knife in hand, passes
his hand under the patient's arm, bringing the knife completely
over it towards himself, with the point downwards (see the position
of the hands in Fig. 86, representing the commencement of the
FIG. 86.
operation on the left arm); and proceeds with his first incision,
drawing the blade backwards from hilt to point, completely round
the limb, merely cutting through the skin and superficial fasciae.
The instrument is then laid aside or handed to an assistant, and
the integument loosened from the muscles beneath by detaching
the cellular membrane with scalpel or bistoury. The skin is now
forcibly retracted further up, and another incision made, in the



134      AMPUTATION IN GENERAL AND OF THE ARM.
same manner as the first, as far up as the skin will permit, dividing all the flesh down to the bone. It is perhaps better to make
both incisions somewhat eliptical —or rather twice varied from
the circular direction —leaving the muscles longer both before
and behind than at the sides.
The next step is to separate the muscles from the bone for an
inch or two, with the point of the knife (if a pointed one is used)
or a scalpel; and apply a two-tailed retractor (which is made
by slitting to its middle a common bandage or strip of muslin,
about a yard long and three inches wide). The broader end is to
be placed on the under side of the arm, passing the two tails up
on each side of the naked bone and crossing them at the top. The
flesh is pulled up as far as possible on the bone by an assistant,
who retains it there by holding the ends of the retractor. A cut
is then to be made all round the bone, close up to the retracted
muscles, for the purpose of separating the periosteum. In commencing with the saw, place the heel on the bone where the periosteum has been thus separated, and draw it back so as to have a
slight groove for the forward motion. Then saw away steadily, but
lightly. Let there be no roughness or hurry in this part of the
business.  The operator should have hold of the arm above the
saw, while an assistant steadies the fore-arm, till the bone is divided and the severed limb quickly put out of sight by the latter.
The last few strokes of the saw should be short and gentle, to
avoid splintering the bone.  Should any splinters nevertheless
occur, they are to be carefully removed by the bone-forceps or
nippers, and the end of the bone made smooth.
The retractor is now to be removed and the brachial artery
taken up and tied. This is done by seizing the end of it with the
forceps, and holding it while the ligature is applied. Before that
is done, however, the nerve or nerves (according to the part of the
arm divided) should be separated from the artery with the fingers
or the handle of the scalpel; or the cellular membrane which connects them may be cut off. This separation should go no further
than is absolutely necessary to make room for the ligature. Pulling at the artery for this purpose should be gently done, as it is
the most painful part of the operation; but it may save the patient many an after pang of the most intense neuralgia, to which



DRESSING AND AFTER-TREATMENT.               135
he will be forever liable (as well as the immediate risk of tetanus),
if the nerve is bound up with the coats of the vessel. Should
there be any difficulty in finding the artery, in consequence of its
retraction after division, the tourniquet is to be loosened a little,
when a jet of blood will betray the spout. Seize it immediately
and renew the pressure above, till the ligature is applied. Then
unscrew the tourniquet, and if there are any arterial branches
necessary to be secured, the flow of blood through them will determine the fact as well as their location.
As soon as the veins have ceased bleeding, let the stump be
cleansed from all coagula, and dressed in the following manner.
The flesh must be drawn down in mass over the end of the bone,
and the edges brought together in a horizontal line across the
middle of the stump.  There will be no necessity in this case for
any sewing.  The common adhesive plaster of the shops is sufficient, the straps to be about three-fourths of an inch in width,
and long enough to turn over for four or five inches on each side.
Place the first across the middle of the seam, taking care to have
the edges of the wound exactly adjusted. Another is then fixed
on each side of the first, at about a quarter of an inch distance,
and more, if necessary, to keep the edges together in the horizontal line. One end of the ligature should be left long enough to
hang out between the straps; between which some little space
should be allowed for the exit of any matter that may form.
Ligatures should always be brought out of the wound in the most
direct line from the ligatured artery. Two straps should be laid
obliquely across the others, covering and pressing down the cor,
ners, so as to make a round, smooth surface.  Narrower straps
may be applied, if necessary, to close any part of the lips that,
having been left free, seem inclined to gape. Lastly, have one
strap to go round the arm, binding down the ends of all the others;
but not so tightly as in the least to retard the circulation.
Over the straps, the end of the stump should be covered with
lint or cotton, kept on by a bandage lightly applied, - but evenly
and so as to prevent the adhesive straps from being loosened by
any'lotions that may be needed, - taking care again, however,
not to obstruct the circulation. Let these dressings be kept constantly wet with some cool lotion, as Arnicated water, aqua Cal



136      AMPUTATION IN GENERAL AND OF THE ARM.
endula or Momordica, as directed for incised wounds. A dose of
Aconite should be given, to prevent the rise of inflammation, and
repeated if necessary.
If no unfavorable symptoms occur, the first dressing may be
left on for four or five days. But if on the second or third day
after the operation, there shall be any discharge from the wound,
and particularly if of an offensive character; if the dressings be
saturated with a bloody or sanious fluid, or the limb be hot and
painful or sensitive to the touch, the stump should be dressed.
These symptoms will not usually appear until the third day,
except in very hot weather, and the less clearly they are then
marked the greater the probability of complete union by the first
intention. When the stump is dressed, the strips of plaster should
be removed with the greatestgentleness, and not all at once; but
commencing from one extremity of the wound, two or three strips
may be removed, the edges of the wound being carefully supported and gently sponged, and fresh pieces of plaster applied
before the other strips are removed; in this way the wound is
supported during the entire dressing, which is very important,
since the adhesion is at this time but feeble. We must be careful
that in removing the plaster we do not move or pull upon the ligatures, as it might cause secondary hemorrhage.
FOR THE FLAP OPERATION,
the patient is placed in the same position, and the fore-arm
bandaged and held by an assistant, as for the circular method.
It is still best to have another assistant to draw back the skin,
just as before directed, as this will obviate the accident of having
muscle protruding between the skin of the flaps, which frequently
occurs when the precaution is neglected. The flaps themselves
had better be taken from before and behind than from the sides.
The point of the knife is entered at one side, with the blade
held horizontally and passed on, penetrating directly to the bone.
It is then turned a little forwards, - the muscles being drawn up
in front, - and pushed over the bone, or rather half round it, the
point being depressed and emerging from the other side, just-opposite to where it entered. By proceeding in this way, the bloodvessels are left behind the knife, to be divided when the second



PUNCTURING AND CUTTING OUT -FITTING FLAPS.    137
flap is cut. When the blade is fairly through, with the edge looking towards the elbow, it is made to cut downwards and outwards
FIG. 87.
to the surface, making the first or front flap about two and a half
or three inches in length. The point is then re-entered in the
wound about three quarters of an inch below the former point of
entrance, passed on to the bone, round it behind, and out through
the former wound a little lower than before.
The edge is then brought downwards and backwards to the
surface, making the posterior flap of equal length to the anterior.
The flaps are now held firmly back by an assistant, and the edge
of the knife made to sweep round the bone, to detach any remaining fibres. It is still better to detach the muscles from the bone,
with a scalpel or bistoury, a little further up, and to hold back
the flaps with a retractor, as in the circular operation, though it
is not here so essential. The periosteum is then to be separated
as before, and the bone sawed off as high up as convenient.
The artery, — which, in cutting according to the directions
above given, will generally be found in the posterior flap, - being
secured, and the tourniquet removed, the wound is cleansed, and
18                                     (PART II.)



OF FORE-ARM BY EACH METHOD.               139
part of the limb necessarily tends in some degree towards plethora in the smaller system left, supposing the stomach, heart anl
lungs to produce and elaborate as before. This has been noticed
in some cases to occasion a complete and not unfavorable change
in the person's constitution. Generally, however, the whole physiological system appears to accommodate itself to the new state of
things with surprising facility; though it is long before the individual's mind is so reconciled as to acquire a familiar consciousness of his new bodily condition.  He is often caught in the
attempt to walk on the leg or strike with the hand - that is in
the grave!
CHAPTER XII.
AMPUTATION OF THE FORE-ARM, HAND AND FINGERS.
OF THE FORE-ARM.
THE CIRCULAR AMPUTATION is performed in the same manner
as described for the arm above the elbow, except that the interosseous ligament must be separately cut with the point of the
knife, and that a three-tailed retractor has to be used, one strip
passing between the two bones.  The operation is, in respect to
ligating and dressing, the same as in
THE FLAP METHOD,
of which a plate is given.  The patient being in a convenient position, and the brachial artery secured by tourniquet as
directed for operating on the arm, the fore-arm is steadily supported by an assistant in a position between pronate and supine,
that is, with the thumb upwards; -or the surgeon may so hold
the wrist in his left hand while operating with the right; — while
the assistant, or another assistant, draws up the integument.
Make your posterior or external flap first. Having previously
had the integument stretched back as far as possible by an assistant, enter the knife, with the edge towards the hand, at the
radial side of the arm. When the point reaches the bone, gently
rotate the hand a little inwards, and push the point on close over



OF FINGERS AT OR BETWEEN THE JOINTS.          141
branches seem to bleed too freely and do not stop on the application of cold water, take up and tie them also in the same manner
as the main trunks.
Diess the stump in the same manner as directed for the
upper arm.
OF THE FINGERS.
The necessity for removing a finger, or part of it, most commonly arises from its getting crushed in machinery or burnt with
gunpowder.  The operation is frequently resorted to without necessity. If you use proper means and care in curing the wound,
you will very rarely have to amputate.  When this cannot be
avoided, it should always be an object with you to preserve as
much of the finger as possible.  The stump of one joint, or even
part of a joint, may be of considerable use. Not a joint can be lost
from the hand, without injury to its power as well as appearance.
An assistant grasps the wrist, and the surgeon, if about to
amputate at a joint, and by the flap method, seizes the finger (it
having been previously wrapped with a bandage, and the others
separated from it), and bends the joint at a right angle. A semilunar cut is made on the back of the finger, from side to side, a
quarter of an inch below the joint. The joint is opened at its
lowest point with a scalpel or bistoury. The knife is passed up
to the joint and completely through it, so as to divide the lateral
ligaments, - when, of course, the bone is dislocated. The knife
is still carried behind it, and as the finger is straightened, made
to cut outward and toward the end of the finger, so as to leave a
flap on the inner or palmar side long enough to cover the stump
(see Fig. 89).
FIG. 89.
~~~P~~~~I1~~~~N



142             AMPUTATION OF THE FINGERS.
The digital arteries may bleed considerably, but can generally
be stopped, without a ligature, by cold water. If not, you can
close them by twisting with a pair of forceps, though we prefer
tying to this torsion.  When all bleeding has ceased, the wound
is washed clean and the surface of the finger made quite dry, the
flap thrown over the end, its edge brought up exactly to where
the other side was first cut, and the whole secured with straps.
A little lint is then placed over the stump, a bandage applied
round the finger and hand, and the hand supported in a sling. The
stump generally requires to be kept wet with the usual cool lotion.
It may not always be convenient to cut the flap from  the
palmar side of the finger, in which case the hand should be reversed and the operation commenced from the palmar side, enough
of the integument being left on the back to cover the stump.
In the circular amputation an incision is made round the finger, at the distance of a half or three-quarters of an inch below
the joint, and the integuments dissected up to it, having previously
drawn the skin up as far as it would go. The joint is then separated and the operation completed as before directed.
Amputation BETWEEN THE JOINTS is performed by either
method.  The difference is not great.  The skin should be retracted as far as possible in either case, and the incision made at
a proper distance below the point where the bone is to be divided.
Another way is, after making the circular cut, to make also a
longitudinal one on each side, towards the base of the finger, and
then dissecting up sufficient flaps from before and behind to fold
over and meet across the center. The bone can be divided by the
bone-forceps, or the finger-saw may be used.
Amputation at the BASE of the fingers, or at the phalangeoFIG. 90.             metacarpal articulation, is
effected by making an incision upon the knuckle in
an elliptical form  around
the finger, terminating at
N a  a \  the point of commencement.
-,'-    Make it extend down upon
the palmar surface of the
finger for an inch, or far



METACARPAL BONES.                   143
enough to make a flap that will cover the joint. The tendons and
ligaments can then be cut through, the bone dislocated and removed by passing the knife through the joint (Fig. 90), and the
operation completed as in the case of any of the lower joints.
The METACARPAL BONES are amputated by making an incision
through the integuments directly over the bone, commencing above
the point where it is necessary to amputate, and carrying the incision down, diverging as you go to one side of the articulation,
and then along between the fingers and to the requisite distance
FIG. 91.       on the palmar surface, where
FIG. 91.
it is met by another incision
passing by the other side of
the articulation.  These lines
are somewhat curved so as to
meet when the bone is taken
out. Then divide the tendons
12f Hi" ^II^a- and fasciae at the point of amputation, and lay bare the
bone as much as possible for
its whole circumference, keeping the knife always in contact with it.  After having
bared the bone for nearly its whole surface, it should be cut off
with Liston's bone-forceps (represented in the act of nipping, Fig.
91), and then completely dissected out.
This operation is very severe, and rarely, if ever, necessary.
The diseases or accidents for which it is enjoined may be remedied or cured under almost all circumstances. We: have never
been obliged to perform it, having been hitherto so fortunate as to
cure those cases commonly supposed to require amputation.
The arteries must be taken up and tied -the bleeding cannot
be otherwise arrested.  The lips of the wound are brought together by adhesive straps, lint and bandage applied, the part kept
constantly wet, as in other amputations, and the hand supported
in a sling. It is best in such cases to keep the fingers forcibly
straightened by a splint under the palm of the hand, as they are
inclined to cross each other.



144             AMPUTATION OF THE THUMB.
THE THUMB
— is amputated between the joints, or at either of the two
FIG. 92.
philangeal joints, in the same manner as the fingers. (See Fig.
92, and directions for AMPUTATION OF THE FINGERS.)
For the carpo-metacarpal AMPUTATION OF THE THUMB, begin
an incision on the back of the hand a little above the upper extremity of the metacarpal bone of the thumb, continuing it down
between the thumb and fore-finger.  Introduce the point of a
narrow bistoury or scalpel at the lower extremity of this incision,
passing it up under the metacarpal bone, so as to bring the point
out where the first incision began (see Fig. 93), with the edge
looking towards the end of the thumb. Then cut outward and
downward, so as to make a good flap from the palmar surface to
FIG. 93.
cover the part after the bone is removed. The bone can be readily



PREPARATION AND MODE OF PROCEDURE.             145
separated from the trapezium and wholly removed. To arrest the
hemorrhage, it will generally be necessary to take up one or more
small arteries. Secure the flap in place by adhesive straps, apply
your lint and bandage, and support the hand in a sling. (See
AMPUTATION OF THE ARM.)
CHAPTER XIII.
AMPUTATIONS OF THE LOWER EXTREMITY.
OF THE THIGH.
ALL necessary arrangements being made, your instruments at
hand, and your assistants ready with proper instructions, the patient is placed in a convenient position on his bed, or a table
covered with folded blankets. If you conclude not to remove him
from his bed, he must be on a mattress, or boards suitably covered.
The limb to be operated on should project over the edge of the
bed or table, while the other is fastened by bandages to some fixed
point, or firmly held by a strong assistant.* After everything
else is ready, the patient is rendered insensible by some anaesthetic agent,  if that measure is deemed advisable, — and the
operation immediately begins:
-The tourniquet is applied with the pad over the femoral
artery, just below Poupart's ligament, and screwed down so as to
arrest the circulation at the moment when the surgeon commences
his incision. If the circular operation is preferred, it is proceeded
with in a similar manner to that described for the arm. As, however, the flap operation is now more common, we will describe it
more minutely.
The operator stands on the outside of the limb to be amputated, if it is the left leg; and on the inside, if the right. He
grasps the flesh of the anterior part of the thigh, raising it from
the bone; and passes his knife horizontally through it, the point
* This and other precautions will be unnecessary, if the patient is properly
under the influence of ether or chloroform.
19                                      (PART II.)



146              AMPUTATION OF THE THIGH.
directed towards the bone till it touches, then inclined over it and
down again on the other side as far as possible. After the instrument is through, the edge is brought out, upwards and forwards
toward the knee, so as to leave the anterior flap of the required
length, according to the thickness of the limb. The knife is now
entered again a little below the top of the former incision, passed
behind the bone as close to it as possible, and brought out on the
other side just below the former point of emergence. The posterior flap is then cut (in the direction represented by the dotted
line, Fig. 94) a little longer than the anterior, as the flexor musFIG. 94.
cles are more liable to retract than the anterior, —being larger
and stronger, and less firmly attached to the shaft of the bone.
The flaps being now drawn back, and held by an assistant, the
remaining muscular fibres are severed by a sweep of the knife
round the bone; and the bone sawed off close up to the base of
the flaps (see Fig. 95), the surgeon steadying the lower portion
of the bone with his left hand.
Some surgeons prefer to make the flaps from the inner and
outer, instead of the posterior and anterior sides of the bone.
This may be done with ease in so fleshy a part; and is perhaps a
safeguard against the flaps being so directly separated by muscular contraction.



WHERE AND HOW TO CUT BELOW THE KNEE.            147
The femoral artery will be found, - when the operation is performed, as here described, -in the posterior flap, unless the opFIG. 95.
eration is very high up indeed. About the middle of the thigh,
it may not be necessary to take up more than the femoral artery.
Frequently, however, several branches have to be also secured.
To ascertain this and find these branches, loosen the tourniquet
for a moment.
It is safer, - and this is the only difference between this operation and that for the arm, - to use sutures in securing the flaps.
Apply one about the middle of the line of union, and one or two
on each side, should they appear necessary. The flaps may gape
notwithstanding, and require other means. After adhesive straps
have been also applied, with lint and bandage, the stump is to be
placed upon a pillow a little elevated, and kept wet with some cold
lotion.  (See treatment of AMPUTATION OF THE ARM.)
As a precaution against secondary hemorrhage, the tourniquet
may be left on the thigh, and tightened as soon as any bleeding
is discovered. It is sometimes necessary to re-open the wound
and secure any vessels that may have been overlooked, but such
necessity should be carefully guarded against.
OF THE LEG.
The rule for deciding where to amputate for injuries below the
knee, is different in the case of a rich patient and a poor one.



148               AMPUTATION OF THE LEG.
Amputate, say the authorities, as near the knee as possible, unless your patient be a rich man and able to procure an artificial
limb.  For the common wooden leg, the knee is the best support,
and all the limb left below that joint would not only be useless,
but very much in the way, liable to injuries and to suffer from
cold. The rule, however, is rather a European than an American
one, few patients, in this country, not being able, and not preferring, to procure what is called a cork leg. A medium length of
stump below the knee (say six or seven inches from the lower
edge of the patella) will be enough to secure a firm socket, and
thus be convenient either for using the knee joint, or turning the
stump back and resting the weight of the body on it. On such
a point the patient's choice should of course be consulted.
The patient being in a convenient position, the femoral artery
under the tourniquet, and everything ready, one assistant has
hold of the ankle and another of the knee, the latter drawing up
the skin while he steadies the limb. The operator (standing as
before directed for amputation of the thigh) cuts round the limb,
just dividing the skin and cellular tissue down to the muscles,if it is the circular operation that is intended, -at least two
inches below the point determined on for dividing the bones,
(The manner of making this first sweep of the knife is described
in Amputation of the Arm.)  The integument is now to be dissected up for two inches in front and one inch behind. This being
turned up and firmly held by the assistant, the muscles are separated down to the bone by one second circular sweep of the knife,
cutting as closely to the retracted skin as possible, and turning
the edge a little upward as it passes through the muscles of the
calf. A long double-edged scalpel or catlin is then passed between
the bones, to divide the interosseous ligament and muscles which
have not been touched by the eirular cut. Every fibre is then to
be dissected from the bones for a little distance higher up, and
the three-tailed retractor applied, one end passing between the two
bones and having the wide unslit part below. The muscles being
drawn up by the retractor, the bones are sawed off together, as in
the case of the fore-arm; any splinters that may (but ought not
to) be left, removed, and the end smoothed with the bone forceps.
In directing the saw, take care to leave the bones of equal length,



150      HIGH AND LOW OPERATIONS   ON THE FOOT.
made, otherwise it will be left projecting when the integuments
contract. More care will have to be used to get the flap of sufficient size at this part, and it will also require to be secured by
sutures. A stitch or two, indeed, had better be used, whether the
operation be high or low. In other respects the flaps are to be
adjusted in a horizontal line, secured by straps, &c., and the
wound kept cool as in other cases.  (See AMPUTATION OF THE
ARM.)  The stump should rest on a soft pillow, and be raised
above the level of the body.
AMPUTATIONS OF THE FOOT.
Tarso-metatarsal amputation, - or that of all the metatarsal
bones together, requires a semicircular incision across the instep,
with the convexity forwards, beginning at a point just in front of
the articulation of the metatarsal bone of the great toe with the
internal cuneiform, and terminating on the outside, at the tuberosity of the metatarsal bone of the little toe. The flap of skin is
then to be dissected up and thrown as far back as the tarso-metaFIG. 97.
tarsal articulations; and the point of the bistoury is passed behind the protrusion of the metatarsal bone of the great toe, so as
to divide the external ligament which connects it with the cuboides. The dorsal ligaments are then to be cut through in succession and the foot depressed. The other articulations are severed
in a similar manner, dividing their ligaments with the point of the
knife, taking care that your bistoury is not locked between the
bones.  The most convenient order for taking the joints is, after
beginning with the fifth, to separate the third and fourth, then the



AMPUTATIONS OF THE FOOT AND TOES.            151
first, and lastly the second, -the extremity of the bone being
locked between the three cuneiform bones would not be easily dislodged before the others; and it may be sometimes better, for
this bone, to use a Hays' saw. When the bones are all disarticulated, the operation is completed by the division of the plantar
ligaments, with the point of the knife, and the separation of the
extremities of the bones which adhere to their under surface.
The blade is then put under the five bones, and carried forwards
so as to make a flap from the sole of the foot, sufficient to cover
the end of all the' tarsal bones (see Fig. 97). The flap should be
from an inch to two inches wider on the inner than the outer side.
All the arteries being tied, the wound is adjusted and dressed in'
the usual manner.
PHALANGEO-METATARSAL amputation, or that of all the toes
from their junction with the foot, is the most common. A transverse incision is made across the dorsal surface of the metatarsal
bones, and the tendons and lateral ligaments of each joint are divided separately in succession. The first phalangeal bones are
then dislocated upwards, and the knife passed beneath their metatarsal extremities, cutting out flaps from their inferior or plantar
surfaces sufficient to cover the ends of the metatarsal bones. Arteries have to be tied and the flaps secured as usual. The foot
must be laid in an easy position on the outer side, so that whatever matter is formed may readily escape. As in the case of single toes and fingers, however, it is better to divide the bone than
disarticulate, - taking precaution, by means of the bone forceps,
not to leave sharp or prominent edges to the bones. This direction for dividing between the joints applies particularly to the
great and little toes, as they both aid very much in walking.
Amputation of separate toes is performed precisely as that of
the fingers. Occasions oftener occur, however, for removing several at once. Badly managed frost-bites may require this.  Hospital Gangrene is another too frequent cause.



152             EXCISION OF THE WHOLE ARM.
CHAPTER XIV.
AMPUTATION AT THE LARGER JOINTS.
THE ARM is removed entire or " excised" from the body at the
SHOULDER JOINT
- in several different ways, by different surgeons; but the one
represented in the cut is now the most generally performed, and
is as safe and convenient as any. Place the patient in a sitting
posture, supported by assistants, who also sustain the arm in a
horizontal, or a little above the horizontal position. A transverse
incision is made, down to the bone, about four and a half inches
below the acromion process.  Two other incisions are made, one
posterior and the other anterior, commencing high up on the
shoulder, and following the margins of the deltoid down to the
extremities of the first or transverse incision. The flap is then
dissected up from  the bone,
turned over the shoulder, and            FIG. 96.
held fast by an assistant,-who
had better have a dry cloth in  ll               \
his hand, as he may not other-,i"",   A.       v
wise be well able to hold the 
bleeding part.  The surgeon                   \
next opens the capsule of the
joint, and directs the assistant 
to make a preconcerted leverlike motion, luxating and rais-         1
ing the head of the bone up- 
wards. The axillary artery is \''                "
then sought for (at the inner 
margin  of the wound), the                           -
nerves  completely  separated
from  it, the vessel raised, by
passing the aneurism  needle 
(see Fig. 20) or blunt end of the probe under it, and tied.  This
done, the knife is passed between the head of the bone and the



AMPUTATION AT THE LARGER JOINTS.             153
glenoid cavity, with the edge kept close to the bone, and brought
outwards and downwards (of course below the ligature), below or
beyond the level of the arm-pit (see Fig. 98). All smaller arteries are then tied, cold water applied to stop the venous hemorrhage, and, as soon as that is effected, the deltoid muscles brought
down and secured by adhesive straps.
Compression of the sub-clavian artery, - which is very necessary, if the axillary artery is cut before being tied, — is a very
difficult matter.  If, however, circumstances absolutely require
the operation to be performed differently, in this respect, from
what has been described, the sub-clavian may be commanded by
the thumb of a skillful assistant where it passes over the first rib,
in the space between that bone and the clavicle.  There is no
safety in attempting to control it by a key or any mere mechanical
compress there; the assistant can feel when he has hold of the
artery or when he has lost it.
AT THE HIP JOINT.
This is the most formidable operation in the whole list of amputations, -not only on account of the large extent of surface
to be divided, and the large number of nerves and blood-vessels,
but the fact that the latter cannot all be secured before cutting.
Happily the occasions for a resort to this operation are very rare.
The femoral artery being compressed by the thumb of an asFIG. 99.
sistant, -the point of the knife is to be entered about half way
between the anterior superior spinous process of the ilium and the
20                                       (PART II.)



154       AT THE HIP    ELBOW AND OTHER JOINTS?
trochanter major, and then directed through across the front of
the articulation, until it emerges on the inside of the thigh. The
assistant rotates the limb a little inwards, and the knife cutting
downwards is brought out in front, so as to form a suitable anterior flap. The assistant then abducts the thigh and presses it
backwards, another holding up the anterior flap, when the capsular ligament is divided in front; and the head of the bone being
dislocated by a lever-like motion, the round ligament is severed,
and the blade of the knife brought behind the neck of the bone,
passing through the posterior part of the capsule (see Fig. 99.)
The posterior flap is then formed by cutting downwards, and outwards. The vessels upon the posterior flap are to be tied before
any others, as these are large, and bleed most profusely. They
must be secured as soon as possible, and those of the front flap
also attended to.
Another mode of performing the operation is, to make lateral
flaps, by first passing the knife completely through the limb, on
the inner side of the joint, and then carrying it forward, so as to
form a flap of the adductor muscles. The joint is then cut into,
and the ligaments severed, together with the muscles attached to
the digital fossa. The surgeon here makes use of a strong curved
knife, which is brought downwards and outwards, so as to make
the external flap.
The vessels are then to be secured, venous as well as arterial
hemorrhage suppressed, and the flaps brought together and secured by sutures, adhesive straps, compress and bandage.
AT THE ELBOW, WRIST, KNEE AND ANKLE
Excision, -as the operation is called, to distinguish it from
ordinary amputation, — has been performed at each of these
joints; though at all of them (except the wrist) it is liable to so
much objection, that it is difficult to imagine cases where it ought
to be preferred. The rule laid down by Druitt, from the first volume of Guy's Hospital Reports is, that excision is "advisable in
the shoulder and elbow [?];-admissible, though of doubtful
utility, in the ankle; — inadmissible, except under very peculiar
circumstances, in the wrist [?], hip or knee." From this conclusion, we differ, as you will see, in two point



AMPUTATION AT THE LARGER JOINTS.            155
The ELBOW JOINT ought never to be chosen for the point of
division on account of disease of the fore-arm, when the smallest
portion of the latter, if only an inch, can be preserved. That
much of stump, with the use of the joint, will for many purposes
be as good as a finger to the patient. Disease of the joint itself
would be only an additional reason for cutting above, even if the
humerus and integument enough to cover it were sound and preservable. The broad condyles of the humerus, with a thin covering, - a mere skin and bone extremity, - could be no advantage
over the round section of bone, well protected, like the natural
fingers' ends, with flesh as well as sensitive cutis. Besides, the
flap over the uneven end of the bone cannot possibly be secured
as smoothly and heal as kindly as in ordinary cases.
When performed, the surgeon passes his knife through the
muscles in front of the joint, and cuts downwards and out to the
surface, so as to make a flap of them. He then makes a transverse incision behind the joint, through the external lateral ligament; and brings the instrument into the joint, between the head
FIG. 100.             of the radius and the exFIG. 100.
ternal condyle, to divide
the internal and other ligaments. The olecranon process is then sawed through,
-- ~-  lS=-.^ bthe head of it being left on
the stump.  The vessels
are secured and the stump
dressed as inother cases.
AMPUTATING AT  THE
WRIST may be preferred,
because more covering can
there be sometimes secured
from the thumb and palm
than from off the bones above; and because it leaves
a stump terminating in two
firmly connected ends of
bone. After describing the
usual mode of operating,



156      AT THE WRIST - CASE- KNEE AND ANKLE?
we will relate a case where Dr. Hill resorted to this method not
"under very peculiar"- at least not favorably "peculiar circumstances."
For this operation, the brachial artery should be secured as
for amputations of the arm above.  An assistant supports the
fore-arm, and draws back the skin from over and under the wrist.
A semi-lunar incision is then made, with the convexity downwards,
on the back of the hand; the flap dissected and turned up past
the joint, and the joint opened from that side. The ligaments
and tendons are freely cut through, and disarticulation effected,
the knife being carried through the joint (see plate, Fig. 100), and
downwards and forwards on the inside. The palmar flap should
be the longer, as it is thicker and better than the other. Arteries
have to be secured and everything completed as in other cases.
David Howell had his hand and wrist terribly mangled in the
planing machine, at Holmes's factory in Cincinnati. Not only
were the carpal, as well as metacarpal and phalangeal bones literally crushed, but the extremities of both radius and ulna severely
bruised and divested of much of their covering. Instead of amputating the arm, Dr. Hill merely took away the hand and wrist
bones, smoothing off the bruised ends of the radius and ulna, as
well as the ragged portions of muscles and tendons hanging to
them, but taking care to leave the ligaments connecting the two
bones untouched. As there was no flap to be got from the hand,
he drew down the skin of the fore-arm by main force, and fastened it over the end of the radius by two sutures and a sufficient
number of adhesive straps. To keep it close in place, he put a
large cotton wad over the end; and, as a security against contraction, applied a bandage firmly over it and up to the elbow.
The stump was kept constantly wet with a solution of common
salt, combined with an equal quantity of spirits of camphor (he
was then unacquainted with the virtues of Arnica, Calendula,
&c.) The healing went on well and rapidly, without ever giving the patient pain after the first two or three hours, almost
the whole surface forming adhesion by the first intention. Only
two spots, not the size of a five cent piece, required granulation.
The limb was entirely well in a few weeks, a smooth and beautiful
stump being formed, - which the patient, by an ingenious con



AMPUTATION AND OTHER OPERATIONS.            157
trivance of a loop and clasp, was able to use among the machinery
almost as efficiently as a good hand.
EXCISION AT THE KNEE would seem, plainly enough, inadmissible, without the experiments relied on in the Hospital Report
before quoted. The patient could never walk on the half knee
as on the whole one, and would find it very difficult to adjust in
any socket for bringing the weight to bear higher up, besides its
preventing an artificial knee being substituted.  Similar objections apply to
AMPUTATION AT THE ANKLE JOINT. The patient cannot walk
on the stump or fix an artificial foot so well as if the leg were divided higher up. The stump is not likely to be so well covered,
or to heal so kindly, and the operation itself is more tedious and
painful for the patient. Therefore when the whole foot must be
lost, amputate the leg.
CHAPTER XV.
OTHER OPERATIONS ON THE EXTREMITIES -TENOTOMY, MYOTOMY.
THE ARTERIAL TRUNKS of the extremities have occasionally to
be tied for wounds as well as disease. [For cases requiring these
to be secured above the limb, see directions for taking up the Axillary and External Iliac Arteries.]
The BRACHIAL ARTERY has occasionally to be tied, or otherwise obliterated, in consequence of a wound in the favorite operation of bleeding at the usual point (see treatment for ANEURISM,
varicose aneurism, &c). Whether this " false " or artificial " aneurism" has followed the occurrence or not, we should, if called to
such a case (for the Homeopath, of course, will never have to mend
such blunders of his making), adopt efficient means of compression, bandaging in addition the whole arm; or cut down to the
artery above and below the wounded part (enlarging the original
wound if it is a fresh case, to the extent of two or three inches),
and tie it, taking care not to operate on nerve or vein, as the
original venesector did on the artery. When to be taken up above



158      ON THE EXTREMITIES-ON THEIR ARTERIES.
this part, the brachial artery is easily found on the inner side, and
a little above the middle of the upper arm. Cut down carefully
along the border of the biceps, or if going still higher, that of
the coraco-brachialis; see that no vein or nerve is included in
your ligature, and that there is no higher branch going off to the
part affected, and tie.
The RADIAL ARTERY is to be found, -on the upper part of the
fore-arm, by cutting on a line from the bend of the elbow to the
thumb, and separating the supinator longus and pronator teres, -
in the lower part, where it is pressed against the bone in " feeling
the pulse" along the margin of the flexor carpi radialis, -and
nearer the middle, by making the incision near the ulnar margin
of the supinator longus.  The ULNAR ARTERY is not so easily
reached in its upper part, and it may be better to tie the brachial
than cut the thick muscles that lie over it. Above the wrist, however, and for more than half its course you have only to divide
the integuments along the outer margin or tendon of the flexor
carpi ulnaris, separate this inwards, and pass your needle from
within to avoid the nerve.
The FEMORAL ARTERY is most conveniently found for ligating
just above where it is crossed by the sartorius, the course of the
vessel running from the middle of Poupart's ligament to the inner
edge of the patella. In cutting, carefully avoid veins and enlarged glands; and after introducing your ligature by passing the
needle (see Fig. 20) from the inside outwards, close to the coat
of the artery, so as to separate it from the great vein and saphenic nerve, ascertain that there are no such branches from above
as would render the operation useless - and then tighten and tie.
We were called to treat a case where a distinguished surgeon had
taken up the femoral artery for aneurism, without arresting the
pulsation in the least. The POPLITEAL ARTERY has been occasionally tied, where it lies under the tendon of the semimembranosus.
The ANTERIOR TIBIAL ARTERY is only to be reached, in the
upper part of the leg, by a long and deep incision down to the
interosseous ligament, the tibialis anticus and the extensor digitorum being separated, -in the lower part, by cutting on the
outer side of the tendon of the extensor pollicis. The POSTERIOR
TIBIAL ARTERY can be easily secured in the lower part of the leg,



CLUB-FOOT - TALIPES.                  161
side of it, the great toe turns inwards and upwards and the heel
is elevated.   he cause of this deformity is the contraction of the
muscles of the calf of the leg and the adductors of the foot.
2d. Talipes equinus (Fig. 102).  The heel is elevated from
half an inch in some cases to four or five inches in others.  The
patient walks on his toes or the ball of his foot. He may press
principally on the side of the little toe, on that of the great toe,
or on all of the toes equally with the ball. This is generally
caused by the contraction of the gastronemii muscles alone, but
the flexors of the toes may also be contracted.
3d. Talipes valgus.  The foot is turned out so that the patient
walks on the inner surface, and the external edge is raised from
the ground, the sole looking outwards. The heel is also drawn
FIG. 102.                     FIG. 101.
upwards in this case. The adductor muscles and those of the calf
are contracted.
4th. Talipes calcaneus (Fig. 103).  The toes and foot are elevated, so as to form an acute angle with the leg, while the heel
rests upon the ground.  Here the tibialus anticus and the extensor muscles of the toes are contracted.
Any of these deformities may be caused by disease or accident, but are most frequently congenital.
21                                       (PART II.)



162  VARIETIES OF MAL-FORMATION AND REMEDIAL MEANS.
TREATMENT should  be resorted  to as early as possible.
Whether congenital or accidentFIG. 103.           al, the proper treatment adopted
and carried out at the first dis\,'j  covery of the  deformity will
SI^=   IfJ~       ~ stand a very great chance of
success. But a few years' delay may effect such changes in
the bony structure as to render
any attempt, by operation or
other means, abortive.
Although in many cases the
~~r  /operation of TENOTOMY may be
absolutely requisite, it does not
follow that other means might
not have succeeded in the same
cases, had  they been applied
early.
The strong  probability is,
that a large majority of cases
occurring under the age of three years require no operation, as
the proper apparatus early applied will rectify the deformity.
The great success of Dr. Chase, of Philadelphia, in these cases
proves, at least, that the operation is performed far too often, if,
indeed, it is ever necessary in the early stage of the deformity.
We will not attempt to describe all the forms of apparatus
necessary for every variety of club-foot.  We will simply say that
it should consist of a stiff shoe or sole, fixed to a stiff upright
shaft, made fast above the knee with a joint at the knee. The
shoe is so fixed as to turn easily in the proper direction. The foot
is made fast to the sole, to which springs are attached from the
upright shaft, in such a manner as to make constant but gentle
extension on the contracted muscles, and in a proper direction to
rectify the deformity.
Some of these machines made by Mr. Max. Wocher, of Cincinnati, are most admirably adapted to the purpose.  They can
be fitted to any size and shape, so as to cause no pain or excoriation, while the proper force is exerted on the contracted part. All



CLUB-FOOT - TALIPES.                 163
the information he requires respecting the case in order to adapt
an instrument to it, is the kind and extent of the deformity, and
the length and size of the foot, leg and thigh. We would recommend a trial of this machine or some similar fixture, in all recent
cases, before resorting to the
OPERATION.
This is easily performed. It consists simply in a division of
the contracted tendon or tendons. In a large majority of cases a
division of the tendo Achillis is all that is requisite.  For this
purpose the patient is placed on a bed upon his face, or he may
sit in a chair with his foot elevated. The skin of the ankle is
drawn either backwards or forwards so as to make it tense, and
so that when it contracts it will cover the wound. A long narrow
bladed knife is used (see Figure 104), which is round and smooth
for an inch next the handle. It is passed through the skin fiatways between the tendon and the bone, near the anterior surface
of the former, from one to two inches above the internal malleolus, and carried through to the skin on the opposite side. The
FIG. 104.
edge is then turned upon the tendon, and while an assistant, or
the surgeon, with his left hand, bends the foot in such a manner
as to put the contracted muscle firmly on the stretch, he cuts
steadily through the tendon. It will separate with a crackling
noise.
The space between the divided ends of the tendon will be filled
up with coagulable lymph, which eventually becomes firm and
serves as a tendon.
The tendon of the posterior tibial muscle is most readily divided about two inches behind and above the internal malleolus.
The principles of operation are the same. In this case care must
be taken not to cut the posterior tibial artery and nerve, which
might be wounded if the incision were carried too deeply. The
tendon of the anterior tibial muscle must be cut where it passes



166        DESCRIPTION AND USE OF INSTRUMENTS.
deficiency of power is in the rectus externus, the internal drawing the eye-ball towards the nose. A current of electricity frequently passed through the relaxed muscle, with the mechanical
means before mentioned, will often obviate the necessity of an
operation.  Strabismus is sometimes also caused by a partial
opacity of the cornea; of course, an operation would be useless.
THE OPERATION for the relief of this deformity, - or STRABOTOMY, -- consists in dividing the shortened or permanently contracted muscle.  This being generally the Internal Rectus, we
will describe the process of its division. The patient being seated
and the eye secured by the speculum or otherwise, the sound eye
is to be covered and kept from rolling by gentle but sufficient
pressure.  The lids and ball of the defective' side can be best
fixed with the Wirespring Speculum (Fig. 112), shown upon the
eye preparatory to the operation in Fig. 105. (See also Note at
the beginning of next Chapter.
FIG. 112.
In default of such a means, it is usual to have the upper lid
held up by an assistant's fingers, or by a common wire speculum
or elevator (Fig. 113), another pair of fingers being required to
keep down the under lid (as shown in Fig. 114).  These preliminaries adjusted, a double
hook (represented separately             FIG. 113.
as Fig. 106) is hitched to the
conjunctiva, about half way
between the margin of the
cornea and the internal canthus, the ball then rolled outward by it, and the handle given to
an assistant, by whom it is firmly retained in the same position.



170          OPERATIONS ON OR ABOUT THE EYES.
fore given.  There may, however, be another form of lacrymal
fistula or obstruction in the duct of the LACRYMAL GLAND itself,
producing dryness instead of suffusion of the eye. This part,
however, is rarely the object of surgical or medical attention.
When it is, it has to be treated on general principles, with due
regard to the susceptibility of contiguous parts. -In proceeding
to the more common
- OPERATION for Fistula Lacrymalis, place the patient in a
sitting posture, and stand behind him.  Have a small sharppointed scalpel, bistoury, or cataract knife; and holding it perpendicularly to the eye-brows, direct the point to the inferior
margin of the internal tendon of the eye-lids (tendo oculi), -
which can be clearly seen by drawing both lids outwards.  In
FIG. 115.        this place and direction, press the
point of your instrument directly
downwards (as in Fig. 115), until a
flow.; of mucous and tears indicates
that it has entered the lacrymal sac.
As you then raise it out, make a slight
hi afim    outward cut so as to enlarge the opening.  A probe, slightly curving forx!  1|   wards and inwards, is then to be introduced and pushed through when it
meets with obstruction.  A few drops
\ of blood from  the nostril will show
when it has entered that cavity; sometimes there will be quite a
stream.  Another sign is that, on withdrawing the probe, the patient can blow wind out at the eye. The TUBE (see Fig. 110), or
Style (Fig. 111), according to preference, is then to be inserted;
and the wound healed sooner or later, as the case or operator's
judgment indicates.
OPERATIONS ON THE LIDS AND CONJUNCTIVA.
Wounds dividing the EYE-LIDS may require sutures (the " interrupted," using very small needles).
When Pulsatilla (our most useful remedy), Borax, Belladonna,
Mercurius, Hepar, Euphrasia, are insufficient, EXTRACTION of the



172          OPERATIONS ON OR ABOUT THE EYES.
keep the parts constantly lubricated with olive oil, with the other
usual precautions for preventing any long closure of the lids for
a day or two.  SYMBLEPHARON, or adhesion of the lids to the
ball, cannot be so easily remedied. The tendency to re-union is
obviated with difficulty; and the result of the operation very likely
to be unsuccessful, as far as the sight is concerned, from opacity
of the thickened membrane.  Where a false membrane is the
cause of union, the case is more hopeful.
Simple superfluous folds of the conjunctiva may be removed
by simple excision.
PTERYGIUM and ENCANTHUS have been taken up in the first
part. For their removal, if other treatment is inefficient, raise
them with forceps, cut between the diseased growth and the membrane beneath with a fine scalpel, and finish the operation with
curved scissors - or the scissors and forceps alone may be used
for the whole operation.
OPERATIONS WITHIN THE GLOBE.
Complete EXTIRPATION OF THE EYE may possibly be required
for very bad wounds or malignant disease; though the success of
Homeopathy has been such, that these cases ought to be exceedingly rare.  (See MALIGNANT DISEASES.) When the knife is
used it is usual to first pass a hook into the ball and steady it.
The lids being then raised, the ball is separated close to the bone,
and the lacrymal gland also removed.  The muscles and optic
nerve are severed together by a curved knife.  If the patient
does not intend to wear an artificial eye, we are directed to divide
the levator palpebroe, by a transverse incision through the upper
lid; and remove a slip of the lid itself, that it may not be too
long.  We should prefer cutting the muscle off near the lid from
within.
PARACENTESIS OCULI, or tapping the eye, often so unnecessarily resorted to, is performed by simple puncture of the cornea or
the sclerotica. Sometimes both the vitreous and aqueous humors
are evacuated, and even a section of the ball removed with the
cataract knife. In these cases the lens and vitreous humor are
intentionally removed, leaving room for an artificial or partial
glass-eye.  In what is called " schlerotic or choroid staphyloma,"



FOR DEPRESSION     CHOICE OF NEEDLE.          175
" COUCHING."
The patient should be in every respect as healthy as possible
at the time of being operated on.  For some weeks previous, at
least, he should live temperately, but not " starvingly," avoiding
all stimulants and stimulating condiments. The pupil should be
well dilated for one or two days before, by applying to the lids
the Extract of Belladonna and to the -eye-ball a solution of the
Extract of Stramonium  (15 gr. to the oz. of water).  These
should be repeated every three or four hours, or oftener, if necessary.  When this important preparation is accomplished,
The patient is seated in a low chair, in a well-lighted room,
but not in the sun-shine, nor with the eye in such a position with
respect to the window, that the operator will be liable to see
images on the cornea. The assistant should stand behind the patient so as to steady his head, and at the same time hold the
Speculum Oculi (see Figs. 112 and 105), which not only separates
the lids, but securely fixes the ball itself. Usually, the upper lid
is held by the fingers of the assistant, or a mere hook-speculum
or elevator, and the under lid by those of the surgeon, he having
also to prevent the eye from rolling, while his other hand and
mind are engaged in the delicate operation.  The surgeon had
better seat himself on a high chair before the patient, with a footstool high enough for him to steady his elbow on his knee while
operating. Some, for greater steadiness of the head, prefer the
patient to be recumbent; and unless the operator happen to be
left-handed, or be ambi-dexter enough for the occasion (as it is
desirable that all surgeons should be), he may have to stand behind when a right eye is concerned.
The couching-needle (the curved one, Scarpa's needle, Fig. 119,
FIG. 119.
FIG. 120.
is now generally preferred to Hay's, Fig. 120) is to be introduced



OPERATIONS FOR CATARACT.               177
cornea. The cornea-knife used for this purpose has a triangular
blade to make one straightFIG. 122.            forward motion suffice, instead of both a "cut and
thrust," and to fill up the
section, as it goes, thus preventing the escape of the
aqueous humor.  For this
BBI;ig b        operation the speculum, so
-  ~ ~'.  ~convenient in almost all oth"_-___ — _~        er eye-operations, cannot be
used, as it would compress
the globe too much and force out the aqueous humor. Here,
therefore, the upper lid-must be supported by the Retractor
(Fig. 113), and the lower by the fingers of the surgeon (as shown
in Fig. 114)- or the fingers of an assistant may be applied to
the upper.  The operaFIG. 123.              tor is advised to touch
the cornea once or twice
his _ ltfg otpttce aiwith the flat part of the
blade, in order to take
off the patient's alarm;
gin~~S  and abv  i rand to use his left hand
if about to operate on a
right eye (unless he prefer to stand behind his
patient). He should rest
his little finger on the patient's cheek, as if he were writing and
the knife a pen.  The point enters the transparent cornea, with
the edge downwards (see Fig. 122), a little within its outer margin and above its center, and passes straight across, parallel to
the iris, emerging at the opposite margin, the wedge-shaped edge
advancing in two directions round the cornea, until a complete
semi-circular section is made.  Some operators prefer to cut upwards (as in Fig. 123), though there is an obvious advantage in
having the flap kept naturally in its proper place. The instant
the knife is removed, the lids are closed, the operator giving a
signal to the assistant. After a brief interval the eye is again
23                                     (PART II.)



178           FOR EXTRACTION AND ABSORPTION.
opened, the corneal flap raised (or lowered, as the case may be),
the pointed end of the curette or of a needle inserted, and the
capsule freely lacerated with it. Very slight pressure may then
be applied to the eye-ball, if the lens do not spontaneously pass
through the corneal opening.  The cornea is then adjusted; but,
before being fixed with compress and bandage, it should. be opened
once more to see that everything is right, and particularly that
there is no prolapsus of the iris.  Should this accident have o-e
curred, the protrusion may have to be pressed back, or the eye
exposed to a strong light, to cause the pupil to contract and draw
it back.
THE OPERATION FOR ABSORPTION,
-or SOLUTION, is the easiest method of getting rid of the
lens, or opaque coverings, but liable to the objection of having to
be repeated, and requiring several weeks for the completion of
the cure. It excites little inflammation, and is well adapted for
the congenital and other soft cataracts of young persons, but not
old, hard cases.
In the posterior operation (which is generally preferred) the
couching-needle is introduced in the same manner and place as for
depression.  The capsule is freely broken up by it and the lens
cut with it in two or three directions, but not generally dislocated
in the first operation.  If this is not found sfflcient, the lens is
broken up into smaller fragments on repeating the operation,
which gradually dissolve in the aqueous humor.
In the anterior operation, the needle is entered through the
cornea about a line anterior to its junction with the sclerotica,
and passed forwards through the pupil, breaking up the capsule,
if not the lens also.  This may do for the first operation, but is
liable to cause iritis, even when the pupil is well dilated, as it
should be, before the operation.
CONGENITAL CATARACT
-should be early operated on, -when the patients are not
more than two or three months old. If neglected for a much
longer period, the proper nervous and muscular power of the
organ may never be gained; and in process of time, though the



OPERATMINS ABOUT THE HEAD AND FACE.           179
lens is absorbed, the capsule is thickened to a very unmanageable
degree, and will absolutely require extraction or excision. At an
early age the method of absorption is sufficient, and easily performed.
CHAPTER XVII.
OTHER OPERATIONS ABOUT THE HEAD AND FACE.
TREPHINING.
THE necessary instruments for this operation are a large and
small trephine (or cylindrical saw), a Hay's saw, an elevator and
a scalpel. The other instruments which may be required, such as
needles, forceps, &c., are found in the common Pocket Case, which
every surgeon should always carry with him.
The operation is performed for fracture of the skull, with depression, causing COMPRESSION of the BRAIN;- also for compression from extravasation or suppuration, or tumors of the dura
mater; and sometimes even for irritation, as when disease of the
skull causes epilepsy. (For the use and abuse of the operation,
see CONCUSSION and COMPRESSION.)
In cases of extravasation or suppuration, the trephine used
should be large, so as to allow the fluid to escape freely. On the
other occasions a small one may suffice.
The first thing to be done is to remove a sufficient portion of
the scalp, if that has not been done by the accident. Cut a flap
in the shape of the letter D, raising the circular side. If there
be any loose pieces of bone, remove them with forceps, completing
their separation, where necessary, with Hay's saw. The pericranium is next to be separated from the surface of the bone, to
which the instrument is to be applied;- or a circular incision for
the edge of the instrument will answer the purpose of preventing
laceration by the teeth. (To insure this incision being made accurately, we have never seen any thing so good as Gibson's Trephine, with a removable lancet attached.)
Apply the trephine so that the center-pin will rest on a sound



180    TREPHINING - INCISION - SAWING -ELEVATING.
portion of the skull. Then press gently and saw through, steadily
turning the instrument backwards and forwards, but stopping and
removing it frequently to cleanse the teeth with a brush, and to
examine the groove, which must be at the same time well cleansed
from the saw-dust and blood, by means of a wetted sponge. As
soon as the groove is deep enough to steady the instrument, withdraw the center-pin. When you get nearly through the bone, be
very cautious, and examine your progress very frequently, lest
you cut through the dura mater. As soon as any point of the
circle is through the bone, introduce the small end of the elevator,
and endeavor gently to raise the whole. When nearly cut through
all round, it will break off smoothly and come away with ease.
If it should still be very firm, introduce the trephine again and
saw a little more, taking care not to let the teeth touch at the
point or segment which is already cut through. Continue thus,
cautiously, until the elevator can be used without too much violence.
The trephine should not be applied over the course of the
middle meningeal arteries, nor over a suture, if both can be
avoided; nor low down on the front portion of the head, unless
absolutely necessary.  After having removed the extravasated
blood or pus, or elevated any depressed portion of the skull,- by
"prying" with the elevator as a lever against the opposite firm
edge, as a fulcrum, - replace the scalp and secure it by a compress of lint or cotton. The part must be kept wet with cold
water or some other cooling lotion, before recommended. (See
WOUNDS OF THE HEAD.)
HERNIA AND DROPSY OF THE BRAIN, &C.
Trephining has been resorted to for the removal of circumscribed FUNGUS of the DURA MATER. When a sufficient portion
of the cranium is removed, and there still appear nothing to contra-indicate such a proceeding, the fungus is cut out from or with
the portion of the membrane from which it grows, or the ligature
is used instead of the knife, though that measure as well as the
cautery is here, perhaps, really more dangerous than the more
favorite surgical means.
"Hernia Cerebri," or PROTRUSION of the BRAIN, has been



OPERATIONS ABOUT THE HEAD AND FACE.           181
treated with a variety of experimental " operations." When the
sac of investing membranes becomes strangulated, there is sloughing followed by fungous granulation, which is sooner or later fatal.
The "hernia," so called, composed only of coagulated blood, is
more speedily fatal.  The best treatment is the preventive- a
natural degree of pressure or protection where any part of the
cranium is wanting. Shaving or slicing off the tumor level with
the skull has in some cases appeared necessary before the artificial
cranium could be borne, and in some of these has succeeded. A
careful operation to remove the strangulation, enlarging the bony
opening if necessary, has enabled some surgeons to replace the
brain before it had inflamed or degenerated.  When the tumor
contains serous accumulations, the greater success has followed
simple puncture, as in the operation of
PARACENTESIS HYDROCEPHALI.  This is one of the questionable operations, which, though resorted to from the earliest records of surgery, has been followed with so little success that it is
not generally recommended -even as a last resort.  Could it indeed be justified before the brain were seriously injured by the
accumulation, there is reason to believe that better results would
follow.  Other operations and wounds on the parts show that the
opening of the brain is not necessarily fatal. The congenital and
very advanced cases in which it has generally been tried, were
otherwise quite hopeless ones. The same instruments and modes
of proceeding are adopted as for serous accumulations in other
parts. The place chosen is generally one of the still open fontanelles, avoiding sinuses. One surgeon, who has reported the unexampled result of nineteen operations with but one death, directs
the trochar to be plunged in two inches, if necessary, into the
ventricles. The water must not be allowed to run out too rapidly,
-stopt altogether as soon as any sign of fainting occurs. The
cranium must be compressed during and after the flow, to prevent
a rush of blood, on the withdrawal of the accustomed pressure on
the vessels.  The operation has had to be repeated even in successful cases. The wound itself easily heals.
The FRONTAL SINUSES have been opened for the removal of
polypi and other products of diseased action. A sawing instrument or very small trephine is recommended for the purpose, in



182          ANTRUM, JAW AND EAR OPERATIONS.
preference to a trochar, or anything that would split the bone.
The trochar can be used for opening a second chamber when one
is entered. To prevent the fistula which must follow the operation when the connection with the nose is closed up, it has been
made a question whether one should endeavor to reopen the original orifice, bore out a new one, or destroy the mucous membrane
throughout the sinus by cautery.
The ANTRUM HIGHMORIANUM is sometimes opened for polypi
and the presence of foreign substances (as insects), as well as for
disease of the part. -(See under "MAXILLARY ABSCESS."), The
operation is, in rare cases, required to be performed through other
parts than the alveoli, - the mouth or nose, and even through the
cheek, just under the prominence of the cheek bones (eminentia
malaris). In one case Dr. Hill was obliged to take out half of
the palatine process of the upper maxillary with a saw made for
the purpose.
EXTIRPATION of the upper JAW, or large parts of it, is a formidable operation, far too frequently resorted to for osteo-sarcoma
and other much less serious diseases. -See OSTEO-SARCOMA and
CANCER. The origin of the evil in many of these cases is " bad
teeth," or bad-medication, particularly mercury. Another result
of this much " abused" article, is permanent
-ANCHYLOSIS OF THE JAW. -This state, when it results
from mere superficial ulceration, has been remedied by dividing
the contracted masseter, the knife being used in the mouth.
OPERATIONS CONNECTED WITH THE EAR.
FOREIGN SUBSTANCES in the EAR are more safely removed,
when practicable, by syringing, than the use of forceps. Insects
should be well deluged with olive oil.
PERFORATION of the external MEATUS, for adhesions or false
membranes, may sometimes cause a deafness, supposing no other
cause for it. When the operation required is only superficial, it
is simple and easy; when deep, very difficult and questionable.
In the former case, scissors may be sufficient; in the latter, use a
bistoury, sheathed except at the part required to cut. After penetrating half an inch, the operator should cease, at least for a



184                    ARTIFICIAL NOSE.
BORING THE EAR for ear-rings is a surgical operation that,
simple as it is, has been followed by bad consequences. If to be
done at all, a needle should be pushed through centrally, avoiding
the cartilage, upon a cork - the part having been previously compressed, to lessen its sensibility - and a temporary ring immediately inserted, which, after two or three days, must be moved, to
avoid adhesion and insure cutification.
Otoplastice. - One of Taliacozzi's operations or directions is
for the formation of an entire ear out of the scalp behind. The
lower part of the ear has been successfully restored in this way.
The Hindoos are said to successfully transplant fresh-cropped
ears from other heads!
OTHER OPERATIONS ON OR ABOUT THE NOSE.
FOREIGN SUBSTANCES in the NOSTRILS, which children are apt
to introduce, will sometimes get beyond their reach, and cause
some danger and great alarm.  A  scoop or the polypus forceps
will generally enable any one who knows the shape of the cavities,
to get them out. A flexible catheter pushed up into the posterior
nares by the finger and out at the nose, may often effect the object.  Hard sneezing may sometimes aid.
The NOSTRILS are sometimes more or less completely CLOSED,
so as to obstruct respiration and injure the speech. When the
obstruction is not situated too high, and independent of any malformation of the bones, it may be remedied by obvious means of
dilatation or abscision.
A defect, of an opposite character, where the SEPTUM between
the nostrils is wanting, causing "flat-nose," is easily remedied
by means of a strip from the upper lip- at least this is one of
the easiest of the plastic operations, and a part of the regular
operation of
- " RHINOPLASTICS  PROPER (or of the Nose - see Part First,
where the general subject is spoken of —the word meaning, according to etymology, either plastic operations on the integument
generally, or, as it has been of late more commonly used, nosemoulding, the type of such operations).  As this is a really practical and useful piece of work, we will give fuller directions than
for some of the other "rhinoplastic" operations.  The occasions



186               HARE LIP   OPERATION FOR.
after sufficient exposure to the air. The twisted suture is here
used, both to secure the new septum and to reunite the shortened
lip (just as in the common operation for hare-lip). This operation
is sometimes required alone, as above alluded to, in cases of lost
or low septum, when, as Mr. Liston observes, the appearance of
the tumefied lip, as well as of the nose, is improved by the proceeding.  " The cicatrix, being in the situation of the natural
fossa, is scarcely observable." When the ALAE alone are wanting,
it is recommended to bring them from the forehead, rather than
disfigure the face; the long, narrow sanguiduct then necessary, is
supported for a time by being imbedded in a groove along the
surface of the nose.
Granulations will go on rapidly under simple treatment. The
temperature of the transplanted part has to be watched and regulated, generally by covering it with flannel, and the application
of warm or tepid water.  When it has fairly rooted or become
connected by anastomosis with the vascular system of its new location, the connection at the top may be cut and that point also
moulded into seemly proportions.
HARE LIP —LABIUM LEPORINUM.
This striking deformity consists in a fissure or fissures of the
upper lip.  When there are two (as in the case represented, Fig.
124), they usually extend downwards and outwards from  each
nostril.  When there is only one, it 
FIG. 124.
seldom  runs exactly in the middle.'The division sometimes extends back  
through the palate bone, as well as the
soft palate.  When the teeth project
through the severed lip, they add very
greatly to the deformity. It is a con- 
genital mal-formation  or deficiency,
and only to be remedied by
- THE OPERATION.  This may be easily performed in a child
at any age, though it is preferable to have it two or three years
old. If the patient be an adult, let him sit in a low chair and his
head be steadied by an assistant. The surgeon, raising the edges
of the fissure with his fingers or forceps, places a fiat piece of



HARE LIP —LABIUM LEPORINUM.               187
wood between the lip and the gum. In rare cases the lip will be
found adherent to the gum, when it will require to be dissected
loose.  Sponging with cold water will be sufficient to staunch the
bleeding. The edges of the fissure are to be pared off from both
sides upon the wood with a scalpel or bistoury, so as to leave the
sides straight, in the shape of a letter V. When all bleeding has
ceased, bring the fresh surfaces together. Be sure that you have
the margins even at the lip, and then pass a thin sewing needle
through and across the direction of the fissure near its lower
extremity.  Make it penetrate deep enough to be quite near
the inner surface of the lip, where it crosses the fissure.  This
will keep the inner edges near together, while the outer and all
between must be secured by a ligature (or the "twisted suture ")
over the head and point of the needle in the form of a figure 8.
A common waxed thread will be a suitable material, and should
be drawn tight enough to bring the wounded edges together, but
not so tight as to strangulate the parts and cause sloughing.
After the margin is thus secured, introduce two other needles,
deep enough to nearly reach the mucous lining of the lip, and
apply ligatures as before (see Fig. 125). It is proper to break
off the points of the needles with forceps, as they
IG 1    will be in the way. The parts should then be
covered with lint, and a bandage applied to retain it, both being kept constantly wet, and
treated as ordinary incised wounds.  After six
"~ a  days (or four in the case of a child), you can
remove the needles and substitute adhesive straps
or the collodion. Before attempting to pull them
out, take hold of them with the forceps and turn
them three our four times round. If anything adheres at the margin of the hole, carefully scrape it off, and see that the surfaces
of the needles are smooth. To prevent any rusting, they may be
galvanized previous to use; but if a little sweet oil is applied to
them before entering, and every time before the lint or bandage
is re-wet, there will be no danger of corrosion.
The patient should be confined to a room for several days, and
not one allowed to visit him who will be likely to excite him to
laugh or cry, and even much talking should be avoided. It is



188              ATRESIA ORIS -TONGUE TIE.
well for security's sake, to pass a long strip of adhesive plaster
over the lip, reaching from ear to ear, first pressing the cheeks
forward.  Such a strap will prevent any tension upon the lip, until it is firmly united and smoothly healed.
Various modes of bringing and keeping the divided lip together
are recommended by authors, but the foregoing is the plan we
have always pursued, and we have been successful in every case.
It is simple and convenient, and secures the lip for the time, as
well as any other, and much better than most others. The " silver pin" alone, from not bringing the parts together with sufficient force, is very liable to fail. A majority of the cases we have
bad, had been before operated on in this manner unsuccessfully.
If you have a case of the double hare-lip, operate on both fissures at the same time, and secure them  by the same ligatures
and bandage, the intervening portion of lip being transfixed by
the needles. If the teeth project so as to be in the way, and
cannot be pressed back, let them be extracted.  Sometimes the
jaw itself projects too much, in which case that also may be
trimmed off with the bone forceps, after you have first separated
the gum from it.
OTHER OPERATIONS ABOUT OR WITHIN THE MOUTH.
" Cheilo" and " genio-plastice" are Taliacotian operations for
the restoration of lost parts of the lips and chin, respectively, the
material being procured from any approximable part of the neck.
Stomato-plastics are also sometimes resorted to, in connection with
incisions for opening or widening of the mouth in congenital, -
or other partial cases of
— ATRESIA ORIS.  Skin already formed has to be brought, we
are told, from the cheek, and grafted on to the newly-made or
enlarged lip, in consequence of the difficulty of preventing reunion, particularly at the corners.  The necessity for any such
patch-work may be well doubted: and, fortunately, the necessity
for any operation at all is very rare, — the mouth is a part least
frequently defective in the new-born, or inefficient in the older.
TONGUE TIE. —A child is said to be "tongue-tied," when
there is a preternatural extension of the frwnum lingux, to the
tip of the tongue, fixing it firmly to the floor of the mouth. When



OPERATIONS ABOUT OR WITHIN THE MOUTH.          189
this malformation is so complete as to prevent the child from sucking, the superabundant franum should be cut, so as to free the
tongue from its attachment.  This may be done with blunt scissors, cutting loose about one-eighth of an inch of the anterior
portion of the membrane.  The points of the scissors should be
directed downwards as near the floor of the mouth as. possible, so
as to be sure to avoid cutting the lingual artery, which is situated
on the inferior surface of the tongue. It is preferable to operate
when the child is asleep. Hold the tongue up a little with the
fore-finger of one hand and operate under it with the other. But
a few drops of blood will flow.
In LANCING the GUMS of teething children, the lancet should
be so held and directed as not to injure the sacs of the advancing
teeth.
AMPUTATION or EXTIRPATION of the TONGUE, or a part of it,
is sometimes resorted to, not only in malignant diseases, but for
tumors or hypertrophy, aneurism, &c. The knife and the ligature
have had each their advocates in this case.  The latter is certainly less immediately dangerous, preventing the necessity for
tying the lingual artery, and the risk of other hemorrhage.
For TUMORS of the GUMS, and "gum-boils," for which knife
operations are too frequently relied on, see under Epulis and
Ranula, and in connection with Disease and Extraction of Teeth.
For the operation of introducing the style in salivary obstructions, see Parotid Fistula and Fistula Lachrymalis.
The CLEFT or rather DEFICIENT PALATE, —mentioned under
Hare lip, as connected with that deformity, and a similar bony
deficiency resulting from ulceration, -has been successfully remedied in some instances by a sort of internal " rhino plastic " operation, — notwithstanding the natural indisposition of mucous
surfaces to take on adhesive inflammation, and the great difficulty
in this case of keeping the parts in quiet apposition. In this operation the new roof is brought from the walls of the mouth, or
inside of the cheeks, and secured by a sufficient number of interrupted sutures.  This difficult operation (called " Staphylorrhaphe," and by one learned author "Uraniskoraphia"!) is only
necessary where the palate bones or palatine processes of the superior maxillary, or so great a portion of the soft palate is want



192    OPERATIONS ON THE NECK, THORAX AND ABDOMEN.
that we do not recommend it. The simpler method with the instrument described is sufficient and devoid of danger. It is well
also with it not to cut deep enough to wound any considerable arteries. The little hemorrhage that usually occurs may be readily
stopped by cold water, salt, or the dry powder of slippery elm.
EXCISION OR ABSCISION
- of the ELONGATED UVULA can be conveniently performed
by the same instrument. It is too simple an operation to need
further explanation.
THE STOMACH-PUMP
— is a useful instrument, for the INTRODUCTION of which it
may be proper to say a word in this place. When the special
instrument is not at hand, the elastic tube belonging to an injecting syringe will answer the purpose very well; and the syringe
itself may be used as the pump, - if a large one, one stroke of
the piston may suffice. Wetting this tube or the regular one with
water will be sufficient lubrication. In introducing it, insert the
finger also and press into the pharynx and pass the end down the
orifice of the oesophagus; and in withdrawing it, recollect to stop
the outer end, so that any liquid in it may not fall back into the
stomach.
CHAPTER XVIII.
OPERATIONS ON THE NECK, THORAX AND ABDOMEN.
WRY NECK may be caused by spasmodic or permanent muscular contraction, bad cicatrization, or be connected with disease of
the cervical or even lower vertebrae in general spinal curvature.
In the first case, when other medical and mechanical means fail,
the constricting muscular tendon or fascia is to be ascertained,
and divided by "the sub-cutaneous section," no more external
wound being made than necessary to admit the instrument. The
snapping back of the muscle will tell when it has been completely



LIGATING ARTERIES OF THE NECK.            193
severed; —a compress should be immediately applied to prevent
sub-cutaneous hemorrhage.
In all operations about the neck, as in removing tumors, if
they are not very superficial, special care is required, on account
of the number and variety of nerves and vessels to be avoided.
Even the removal of a common parotid tumor may be followed by
palsy of the face.
[For knife-operations in the THYROID GLAND, see under Bronchocele.]
LIGATING ARTERIES OF THE NECK.
The same general principles apply to the tying of arteries
when wounded, as for aneurism or other morbid cause, except
that the wounded artery should here have a ligature below as well
as above the wounded part. When the vessel cannot be reached
through the dilated wound, it should generally be cut down to, in
the manner now to be directed. First, for the
-COMMON CAROTID, we will mention the particulars of an interesting CASE: - In March, 1848, Mr. Jones, of Washington
city, came to Cincinnati to put himself under the care of Prof.
R. S. Newton, for osteo-sarcoma of the lower jaw, which had
already involved the soft parts with a considerable part of the
neck. He had previously consulted several eminent practitioners
and professors, without benefit or encouragement. During treatment for the medical cure, the facial, the internal maxillary, and
the sublingual arteries all sloughed away together. Fortunately,
though the accident happened in the night, Dr. Newton was at
hand, and with his HAND averted the immediate danger from hemorrhage, and continued doing so until six o'clock in the morning.
Meanwhile, as it was impossible for him to attend to this and operate at the same time, he sent for aid. As soon as it was light
enough, with his assistance and that of Prof. Morrow, who was
called, Dr. Hill proceeded to take up the right common carotid.
It was necessary, on account of the extension of th6 disease, to
operate about two inches above the clavicle (instead of the spot
usually preferred, the middle of a line from the angle of the jaw
to the top of the sternum, where the vessel is crossed obliquely
by the omo-hyoid muscle); and to be guided wholly by the anat25                                            CPART II.J



194    OPERATIONS ON THE NECK, THORAX AND ABDOMEN.
omy of the parts, as from the very great exhaustion of the patient,
hardly any pulsation in the artery was perceptible. Another peculiar difficulty experienced, was from the patient's emphatically
hemorrhagic diathesis.  The amount of blood that flowed out from
the smallest veins, at the very first incision, would have made an
observer suppose we had divided the external jugular. It was the
same with every subsequent cut, thus obliging him to stay proceedings until the venous hemorrhage could be averted by styptics. We afterwards ascertained that the patient had been several
times-in danger of bleeding to death from slight cuts in shaving.)
By proceeding very slowly and carefully, however, he got down
to the vessel sought for and applied the ligature. All serious
hemorrhage immediately ceased; and the patient did not appear
to suffer any additional inconvenience from the loss of the artery.
Dr. Newton proceeded with his regular treatment.
In the usual place of operating (noticed above), make a superficial incision through the platisma myoides, when the neck is
tense, obliquely along the course of the vessel, and along the
inner margin of the sterno mastoid for about three inches, and
terminating at about an inch above the sternum. The deep fascia
and cellular substance are to be divided with the handle of the
scalpel, or with your fingers; or, if too firm for this, it may be
carefully cut, and the vessel reached just below, or, in some cases,
above the omo-hyoideus. Pass the artery needle under the vessel
from the inside, bringing it out between the artery and the pneumogastric nerve, the vein being outside of the nerve.
The EXTERNAL CAROTID may require ligating for wounds, when
that of its branches will not suffice. It can be tied below the digastricus and ninth pair of nerves, at the level of the hyoid bone;
but it would be easier and safer to take up the common carotid.
The ARTERIA INNOMINATA or the RIGHT SUBCLAVIAN (internal
to the scalenus muscle) is reached behind the sternal and clavicular origins of the sterno-cleido-mastoideus. A crucial incision is
first made along the inner edge and across the origin of this muscle. This, the sterno-hyoid and sterno-thyroid muscles being cut
through, the fascia beneath is to be divided by the finger, and the
ligature inserted from without inwards, taking care to avoid the
vena innominata and contiguous large nerves.



LIGATING INNOMINATA, AXILLARY, &C.            195
The STIBCLAVIAN is much more easily reached and safely tied
on either side, exteriorly to the scalenus.  The first incision, just
above and parallel with the clavicle, extends from the sternomastoideus to the trapezius. The external jugular is to be carefully avoided.  The first long incision had better be made on the
clavicle, the skin being first drawn down, and all the deepening
done without any more cutting.  The needle should be passed
from  below upwards round the artery, -which is found in the
angle formed by the edge of the scalenus and the first rib.
The AXILLARY ARTERY may also be reached by incision above
the clavicle, extending in an inward curve from near its sternal
extremity to the anterior margin of the deltoid muscle, and turning back a flap. It is better, when there is a choice, to cut up to
it from  the arm-pit, -the first incision being three inches in
length near the margin of the latissimus dorsi, between it and
that of the pectoralis major.
LARYNGOTOMY AND TRACHEOTOMY.
The former of these is chiefly necessary for the removal of
foreign substances. Make an incision through the integuments
in the median line from the lower side of the Pomum Adami to
the lower margin of the cricoid cartilage. Separate the skin a
little with your fingers, and with the handle of your scalpel rupture the cellular membrane between the sterno-hyoid muscles,
down to the crico-thyroid membrane.  Then pass the point of
your scalpel, with a sudden jerk, through the membrane.  A
quarter of an inch incision will be large enough for the passage
of any instrument or the free ingress and egress of air; and this
can be enlarged laterally if necessary for the extraction of any
foreign substance. Take care that the point of the knife does not
pass through and wound the opposite side of the cricoid-cartilage.
This operation has to be preferred to the following, in very young
children, owing to the shortness of their necks.
TRACHEOTOMY is resorted to in croup and other occurrences
preventing respiration through the larynx. The chin and sternum are well separated, and an incision is made in the median
line, extending from near the upper end of the sternum to the
cricoid cartilage. The cellular tissue at the lower end of the



196    OPERATIONS ON THE NECK, THORAX AND ABDOMEN.
wound is dissected, the operator being very careful to hold aside
any veins he may come to.  Continuing the incision down to the
trachea, the point of the knife is made to enter it at the lowest
part exposed, and the edge carried upwards to the desired extent.
If the object is to make an entrance and exit for air, a tube is inserted for the purpose, and the rest of the wound closed up. The
operation is an easy one, and perfectly safe if the directions are
followed -easier on the living than the dead subject. In very
fleshy or short-necked subjects, there may be difficulties. Keeping the median line is essential to success. Opening the trachea is
almost always to be preferred to the more superficial operation
into the larynx.
CESOPHAGOTOMY
has been resorted to as a means of conveying food into the
stomach, when the pharynx was impervious.  It is sometimes indispensable for the extraction of foreign substances lodged in the
throat (see CHOKING). It being ascertained on which side the obstruction adheres or projects, an incision is there made between
the trachea and the sterno-cleido-mastoideus. To avoid the recurrent nerve and the thyroid as well as carotid arteries, the dissection should be made chiefly with the fingers, the fascia being
cut with the protection of a director. The smallest practicable
incision through the oesophagus is to be made -to be dilated if
necessary. This operation is only a last resource, and in a large
proportion of cases a final or fatal one.
PARACENTESIS THORACIS.
Puncturing of the pleura is a much more serious operation
than that of the (diseased) peritoneum. It may be, however, in
some cases necessary; and some have even attempted to relieve
hydrops pericardi by operation.  The most frequent cause for
which the operation is justifiably practiced is EMPYEMA, or the
accumulation of pus within the pleura. In any doubtful case, a
very small trochar or grooved needle is recommended, with a cup
to cause the fluid to rise through the narrow tube. The same
measure (without the cup?) is applicable in EMPHYSEMA and PNEUMOTHORAX (when there is air, instead of pus, in the cellular tissue



HERNIA - OBLIQUE - COMPLETE - DIRECT.          199
(Fig. 129) we find, immediately under the skin, a strong condensed cellular tissue derived from the superficial fasciae of the
FIG. 129.
I'/
abdomen, in which ramifies the external epigastric artery;  next
there is the fascia spermatica; -then a tendinous layer derived
from the semi-circular bands, which connect the margins of the
external abdominal ring;-lastly, the cremaster muscle lies in
immediate contact with the sac. The internal epigastric artery,
it should be borne in mind, always lies internal to the neck of
the sac.
In COMPLETE INGUINAL or SCROTAL HERNIA (Fig. 129), the
Spermatic Cord lies behind (except the Cremaster muscle, which
was mentioned as being found in front of the sac).
DIRECT or VENTRO-INGUINAL HERNIA has the same covering,
except the Cremaster Muscle, there being no connection in this
with the Spermatic Cord. In this case both the cord and the epigastric artery lie on the outside of the sac.
The OPERATION is thus performed: —The patient being placed
in the position described for the Reduction of Hernia, the parts
being shaved and the skin held tense, the surgeon makes an incision through the skin, three or four inches in length, beginning
above the neck and running along the course of the tumor (as indicated by the dotted lines in the figures). He then cuts through
the successive layers before described, by pinching up a small bit
at a time with the forceps, and cutting horizontally through it



202                  OPERATION FOR HERNIA.
sac, may be another layer of fat, liable to be mistaken for omentum.  The sac itself is usually very small, seldom  containing
omentum  or serum; and must be cautiously opened, as it embraces the bowel very tightly. The stricture will generally be
found at the inner edge of the falciform process. This must be
slightly cut, for a line or two only, in an UPWARD and somewhat
FIG. 134.
INWARD direction.  If carried too far, the incision might penetrate the spermatic cord, or, in females (who are more liable to
this form of hernia from greater breadth of pelvis), the round
ligament of the womb.  If that is not sufficient, a few fibres of
Gimbernat's ligament are directed to be severed, although there
is great danger of wounding the obturator artery, which often encircles this ligament. When the hernia is freed, reduction is to
be effected, as directed in the former case.
FURTHER OPERATIONS ABOUT THE PELVIS.
The ATRESIA ANI of new-born children is often but superficial,
or strictly an IMPERFORATE ANUS.  Though the integument is
closed over it, the end of the rectum can frequently be observed
swelling beneath. In such a case a simple incision is to be made
into it, and kept open with suitable means. In other cases there
is only a narrow adhesion of the walls of the bowel, which may
be carefully treated in the same manner.  When, after sufficient
delay, the rectum cannot be reached, recourse may be had to
-the operation for an ARTIFICIAL ANUS.  This is sometimes



ARTIFICIAL ANUS- LIGATING ARTERIES.          203
necessary in adults after closure of the rectum from disease, or
its opening into some other cavity of the pelvis. The least inconvenient place for this business, when there is a free choice, is
the loins. An incision is made down to the descending colon,
where it is uncovered by the peritoneum, just above the left crista
of the ilium. The bowel is immediately attached to the lips of
the wound by two ligatures, and an incision is then made into it,
and the lips of the intestinal wound more closely united with
those of the superficial one. In this part the patient ultimately
gains control of the new organ, a complete sphincter being
formed. In the left groin, where the operation used to be performed, it is much more dangerous, and the result less satisfactory.
About " the operations for Fistula in Ano, Hemorrhoids and
Prolapsus Ani," enough has been said or implied in giving directions for avoiding them. Nothing but malignant disease would
justify a removal of part of the rectum; and then other means
than the knife should also be used, if not solely relied on.
The GLUTEAL and SCIATIC ARTERIES may be found for the
purpose of ligating in case of wounds, by means of an incision,
beginning for the former, an inch, and for the latter, two inches
and a half, below the posterior spinous process of the ilium, and
cutting towards the trochanter major, severing the gluteus maximus.  These incisions have to be both long and deep, and it is
often preferable to take up the external or even internal iliac.
The EXTERNAL ILIAC ARTERY is reached by an incision about
an inch above Poupart's ligament, and nearly parallel with it, but
slightly curved downwards from the ant. post. spinous process of
the ilium to the upper angle of the ext. abd. ring. After the obliquous externus has been divided, the other muscles separated
from the ligament, and the fascia transversalis as well as cellular
connection of the external iliac vein with the artery torn through,
the needle is passed round the artery, behind the spermatic cord.
The INTERNAL and the COMMON ILIAC, and even the great arterial reservoir, above its first bifurcation, have been ligated. The
incision and mode of proceeding is the same for all three. A
longitudinal cut of several inches, reaching nearly to Poupart's
ligament, is made near the external border of the rectus abdominis, the muscles and transverse fascia beneath, being carefully



LITHOTOMY   OPERATION   MANIPULATION IN    209
dilatation. The finger-nail is lodged in the groove of the director,
just in front of the prostate and behind the triangular ligament.
FIG. 136.
The knife is made to perforate the urethra and enter the groove
behind the finger (as shown in Fig. 136), which simultaneously
follows it, entering the urethra, which the knife divides far enough
for the purpose.  The finger moves freely on the dilatable substance of the prostate. The base of that gland is not divided;
and the ileo-vesical fascia is left entire, to prevent the danger of
urinary infiltration. An incision just large enough for the entrance of the finger can be easily dilated for the exit of ordinary
sized calculi.  The rule in this "lateral operation" is "a free
external wound, and a small internal one."  The wider the former, the shallower need be the latter.  Care must be taken in
withdrawing the knife, not to endanger the pudic artery by bringing it too near the ramus of the ischium.
During the dilatation of the deep wound by the finger, urine
escapes; and commonly, the stone or stones descending with it,
can now be distinctly felt.  The staff is gently withdrawn; and
if the stone is found too large to pass through the opening already
prepared, a straight probe-pointed bistoury can be passed over the
fore-finger still in the wound, dividing the prostatic portion of the
urethra on the right side as well as on the left, and then dilating
as before.  This "bi-lateral" incision can be made in the first
27                                     (PART II.)



210                      LITHOTOMY.
place, when the calculus is known before hand to be so large as to
require it.
The finger is kept in contact with the stone until it is seized
by the forceps (represented by Fig. 137). These should be large
FIG. 187.
enough in the blades to hold the calculus by as many points as
possible, and long enough in the handles to furnish sufficient leverage; while for other obvious reasons, it should be as small as
will meet these conditions. To lessen the chance of the stone's
slipping, the blades of the instrument may be lined with cotton
cloth. If the stone is not immediately clutched, the point of the
forceps should be advanced and depressed to the part where it is
most likely to be found.  The object being seized, it is to be
turned round with the forceps, to be certain that no part of the
bladder is included, and then elevated and taken out, -the finger
being again inserted between the blades of the instrument, to ascertain that the calculus is in the best position, or to put it so if
required. Its longest diameter being adjusted in the axis of the
instrument, and that in the direction of the axis of the pelvis,
obliquely downwards, extractive force is slowly applied, the forceps being at the same time moved to and fro, forwards and backwards, to secure further dilatation. The handles are held together
tightly enough to prevent the stones slipping, but not so strongly
pressed as to risk its being crushed or broken. The finger must
be used to prevent the bladder being pulled out before the stone,
and to separate any fibres of the levator ani or other obstacles in
the external wound.
In rare cases the stone has been found lodged above the pubes,



212                      LITHOTOMY.
requires only simple dressings.  The first urine that passes
through the natural channel causes great pain. If any obstruction or unusual delay occur, the catheter will have to be carefully
used.
The chance of final success will depend much on the after
treatment, though still more, perhaps, on the preparation of the
patient for the operation.  The success of Prof. Dudley has
shown that this elsewhere formidable operation may be rendered
a safe one. A repetition is rarely necessary, the removal of one
calculus being said to change the diathesis. However this may
be, other prophylactic measures are proper, and not likely to be
neglected by the patient if he knows them.  (See note under
LITHONTRIPSY.)
Among the casualties which in hospitals, and in most hands,
make this a too often fatal operation, may be enumerated the
dread or shock itself (generally to be avoided by the anaesthetic.
agents), hemorrhage during the operation, and hectic from the inflammation and too copious suppuration of the wound.  Cystitis
and consequent peritonitis are generally to be avoided by proper
care in the operation.  The wound may continue open after the
urethra has resumed its functions, constituting a peculiar and mild
form of " fistula in perineo," or even fistula in ano may be a consequence of inadvertently wounding the rectum.
Urinary infiltration, when it comes on after the operation,
may be mistaken for peritoneal inflammation, before the local
damage occasioned by it is manifest. When both peritonitis and
infiltration occur together, it is confessed by some to be a " perplexing" choice between the measures of depletion, supposed indispensable for the one condition, and the requisite support of the
patient's strength for the other.  "Antiphlogistics" that are not
debilitating, relieve from all such dilemmas.
OTHER OPERATIONS ABOUT THE PUBES.
PUNCTURE, or paracentesis of the bladder,
— has been resorted to occasionally for the discharge of its
contents, where there remains no other means of effecting that
object and preserving life. A trochar and canula are pushed into
the bladder, as in tapping the peritoneum, either just above the



URETHRAL AFFECTIONS AND OPERATIONS.          213
front of the pubes or through the fore part of the rectum (in
women, of the vagina). By sufficient care a permanent orifice
for urine can be made at either point. There is more danger of
infiltration and fistula in the rectal or vaginal, than in the suprapubic operation.
CATHETERISM OF THE URETHRA
- for the evacuation of the bladder, is so much more frequently performed than that of any other channel, that the instrument for the purpose is called the "catheter."  For its use on
the female, directions are always given in books on Midwifery.
The operation on the male is sometimes less simple.
It is best to have the patient on his back, with the shoulders
somewhat elevated, and the penis held at right angles to the body
till the point of the catheter is at the arch of the pubes, and then
depressed so as to be parallel with the thighs, when the instrument
will slip easily over the triangular ligament and into the bladder.
In old men, owing to enlargement of the third lobe of the prostate, the catheter requires to be more elevated than in ordinary
cases.  The patient should be cautioned not to strain or press
upon the abdominal muscles. Any one acquainted with the anatomy of the parts can insert a straight tube as easily as a curved
one. When the gum elastic catheter is used, it is generally necessary to have the wire in it' to prevent its bending at any obstacle it may meet with.
CAUTERIZATION OF THE URETHRA.- Full directions for this
modern operation were given in Part First (see STRICTURE OF THE
URETHRA, and a representation of the instrument, Fig. 16).
IMPERFORATE URETHRA.
This is an occasional congenital malformation or imperfection.
The remedy is obvious: finish nature's work by pushing in a
round trochar, followed by the canula and then by a catheter, and
keep the latter in place, till the new orifice becomes water-proof.
Connected with this imperfection, and independently of it, there
occur what are called,



214              OPERATIONS ON THE PENIS.
HYPOSPADIAS AND EPISPADIAS,
— openings of the urethra, in the upper or under surface of
the penis. The appearance in most cases is as if the lower part
of the urethra were split up and down. When this is the case
the parts may be pared or cauterized and made to adhere. Partial deformities of this kind are often borne with through life, the
consequence being a scattering stream in urinating, and perhaps
an inefficient projection of semen in coitus.
PHIMOSIS AND PARAPHIMOSIS.
These are analogous conditions, both resulting from a constriction of the prepuce, the former before the glans, the latter
behind it.
Phimosis may be congenital or acquired —the latter manifesting itself either as an acute or chronic disease. The acute
form often occurs from infiltration of the part during gonorrhoea
or syphilis. When the contracted edge of the prepuce has slipped
over the glans, but is too tight to be returned, forming a kind of
ligature behind the corona, from the effects of which the substance
of the glans swells still more, - it constitutes para-phimosis. If,
by compressing the glans and other means, it cannot be got back,
the constricting parts may be divided. The other difficulty may
require for immediate relief a straight incision, and for permanent
comfort or security, more or less of " circumcision."



AMPUTATION OF THE PENIS    CASTRATION.          215
A director should be used in making the longitudinal incision,
and sutures are afterwards necessary to keep together the mucous
membrane and the skin that would otherwise contract beyond it.
After the operation, a catheter should be kept in the part to protect and preserve the urethra.
Directions for the radical cure of HYDROCELE by and after the
operation, also before and without that expedient, were given in
the First Part.  The same may be observed of VARICOCELE, and
some other diseases of the same parts.
AMPUTATION OF THE PENIS.
This is one of the simplest of operations, however terrible it
may be thought. Almost the only occasion for it is improperly
managed cancer, or other malignant disease (see CANCER OF THE
PENIS).  When not performed very close up to the pubes, one cut
of the knife suffices, it not being necessary even to draw back the
skin for a flap, as the corpora cavernosa retract sufficiently as soon
as divided. An assistant holds and compresses the stump until the
ligatures can be applied; the two dorsal arteries, if not two or
three others, have to be tied. Higher up, the operator cuts down
to the arteries and ties them before division,  at least the six
principal ones.
CASTRATION.
This final operation is thus performed: — The scrotum having
been shaved, the surgeon grasps it from behind, and putting the
skin upon the stretch, makes an incision from the External Abdominal Ring to the bottom of the scrotum. If the skin is adherent to the testicle, hard, or otherwise in a diseased condition,
two elliptical incisions may be made, so as to remove all the morbid part.  The cord is next to be dissected out and the artery
separated from the other parts and tied. The cremaster muscle
and vas deferens should be separated from the artery nearly up
to the abdominal ring, in order that their contractions may not
carry the artery beyond your reach.  The whole cord can then
be cut off below the tie, and the testicle and all its covering beneath the scrotum dissected out. The wound must not be closed



222                              INDEX.
PAGE
Dissecting     -     -     -     -    -     --                          14
Dressings                        -        -    -    -                   17
Ear, operations on               - -    -    -                        182
Eyes, operations on                 -    -           -    -           170
Excision of Tumors                    -    -         -    -    -        18
Fistula Lacrymalis       -    -        -                              169
Fractures'                 --    -    -    -    - 79
simple    -    -           -                                   84
compound   -    -    -    -                                    86
"    comminuted    -    -    -    -                                 87
Fracture of the cranium   -    -            -                -    -   90
"'         nose    -    -    -            -                       92
"     "   jaww        --    -    -    -    -    - 92
scapula          -     -...      96
"   "    clavicle   -          -     -     -    -    -    - 97
"     "    sternum       -     --    -    100
"     "    ribs       -    -    -                 -    -    -101
"   "    spine       -    -             -                       102
pelvis         -     -     -    -     -103
"    humerus       -    -    -    -                        104
"   "    ulna       -    -      -     -    -     -              108
"     "    fore-arm      -    -    -    -    -        -    -    110
C    a    wrist                        -.                       112
"     "    hand   -    -       -     -    -112
"  fingers               -    -    -            -          -  112
"     "    femur  -      -     -    -     -     -     -    -    113
"     "   neck of femur  -    -        -    -    -            -113
"   "    shaft of   "        -                                  120
"   "    condyles of femur.^.  121
" C   patella -....    121
C     "    head of tibia   -    -    -                           123
"    leg          -    -    -    -    -                         127
"     "    ankles          -    -    -                           128
"     "    foot          -    -    -    -                        128
Hare lip                                                           - -186
Hernia                -    -    -           -    -                    198
Hypospadis and Epispadias                                          -  214
Imperforate urethra     -    -           -    -    -    -    -    213
Incisions       -    -     -     -    -     -     -..   13
Inoculation  -    -    -    -    -                   -    -            15
Issues    -          - -    -                           -          - 15
Laryngotomy                   -    -    -    -             -          195
Lithontripsy   -     —.-..  -  206
Lithotomy  -    -    -    -                               -    -    207
Ligatures      -     --                                -    -      -   11
Ligating arteries             -    -    -    --    193
Mouth, operations on       -    -    -           -    -            -  188
(Esophagotomy   -    -             -    -    -                  -    196
Operative Surgery   -    -    -          -    -    -    -               3
Phimosis and Paraphimosis  -    -                                     214



WESTERN HOMEOPATHIC COLLEGE.
1rogranmme for tile  etssion  1855-g.
The Session will be divided into two Terms, of two months each; the first term
commencing upon the last Monday in October, and closing upon the twenty-fourth
day of December; the second term commencing upon the second day of January,
and closing upon the first Saturday in March.
Two terms constitute a course; two courses are essential to graduation.
FIRST TERM.                         SECOND TERM.
Matriculation Fee, Five Dollars.      Matriculation Fee, Five Dollars.
FACULTY.                             FACULTY.
H. P. GATCHELL,                       C. D. WILLIAMS,
Professor of General and Special Anatomy.    Prof. of Special Pathology and Therapeutics.
S. R. BECKWITH,                          J. G. HUNT,
Professor of Surgical and Pathological Anatomy.   Professor of Surgery and Surgical Diseases.
J. BRAINERD,                           B. L. HILL,
Professor of Animal Chemistry and Toxicology. Prof. of Obstetrics & Diseases of Women & Children.
H. P. GATCHELL,                        J. S. DOUGLASS,
Prof. of Physiology and Principles of Medicine.  Prof. of Materia Medica and Clinical Practice.
Tuition Fee, Twenty-five Dollars.    Tuition Fee, Twenty-five Dollars.
GRADUATION FEE, THIRTY DOLLARS.
HON. JOHN CROWELL,    PROF. S. R. BECKWITH,
Lecturer on Medical Jurisprudence.       Demonstrator of Anatomy
MRS. E. H. BARRY, M. D.,
Demonstrator of Anatomy for Female Class.
INSTITUTION FOR THE TREATMENT OF
SURGICAL DISEASES,
By the combined agency of Homeopathic Medication and Bath Treatment, at
BERLIN HEIGHTS, ERIE COUNTY, OHIO,
UNDER THE CARE OF PROFS. HILL & GATCHELL.
Hernia, Calculus, Fistula, Piles, &c., successfully treated. This Institution affords superior advantages to cases requiring protracted treatment
after an operation.
Female diseases, and chronic diseases in general, are received.
B. L. HILL & CO.
Berlin Heights, Erie County, O.