AND ITS
ADAPTATION
HOMIEOPATHIC PRACTICE.
WILLIA.M T. HELMUTH, MI. D.
[[luntratdb with Nunmtrous Cngravings on tlUoy.
PHILADELPHIA:
MIOSS & BROTHER.
1855.




Entered according to Act of Congress, in the year 1855, by
MOSS & BROTHER,
In the Clerk's Office of the District Court of the United States in and for
the Eastern District of Pennsylvania.




PREFACE.
THE author of this volumes has a satisfactoryreason for its publication at the present time, in the
desire so urgently and' generally expressed for a
surgical work in connection with Homoeopathy. A
perusal of its contents will satisfy the reader that the
materials have been collected from a tolerably wide
field of research. That much important matter has
been overlooked is unhesitatingly. admitted; the chief
labor, however, has been accomplished, and should
the work be favorably received, in a future edition
more practical matter will be embodied, omissions
supplied, and its defects as a whole remedied.
The descriptions by Homoeopathic practitioners of
some of the unusual varieties of disease, are deficient
in that accuracy and precision of detail, which are
essential to certainty of practice. These imperfections may be attributed often to the obscure nature of
the disorders themselves; in many instances to their
complicated conditions arising from the fact of not
having been submitted to Homnoeopathic treatment in
the earlier periods of their existence; to their comparative infrequency of occurrence, as well as the
limited means yet discovered for their removal.
From the volume there is purposely excluded many
surgical details, together with a large amount of mat



1V                 PREFACE.
ter connected with surgery, but not with its practice;
the chief object of the publication having been the
collection and arrangement of those materials which
are considered as constituting the medical treatment of
surgical diseases. Little as may have been, and much
as remains yet to be accomplished, an impartial scrutiny cannot fail to discover, that Homoeopathy has
already contributed considerably to alleviate and cure
a vast amount of disease previously beyond the reach
of medical treatment. If so much progress has been
made in so short a period of time, it may be confidently
expected that future physiological provings will substitute medicinal for surgical instruments, by which
many diseases now so formidable and fearful will be
successfully combated.
Time, however, and the united efforts of numbers
of properly educated practitioners, will be necessary
before there can be accumulated that amount of rigid
and intelligent experiment, close description and
truthful testimony, all confirmed by practical experience, by which for several of the specific and malignant forms of disease a reliable or certain treatment
will be ascertained.
It would be foreign to the occasion as well as derogatory, to notice in a work devoted to a branch of
medicine so essentially exalted in its nature as surgery, the very illogical objections so often repeated
against everything connected with Homorneopathy. Its
absurdity and impotency in the estimation of some are
proven even in the fact, that Homoeopathic practitioners have recourse to mechanical means for the
treatment of accidents, or the removal of mutilated or




PREFACE.                     V
diseased parts; in other words, because medicines have
not physical power to supply the place of cutting instruments, bandages, fracture boxes and pulleys, it is
unworthy the attention of an intelligent mind. As
this objection, however, applies equally to alloeopathy,
the two conflicting doctrines are thereby placed in the
same position, and there the  olomoeopathic physician
may be quite satisfied in allowing them to remain.
An outward abuse, however, of Homoeopathy, with
a clandestine use of several of its medicines, and often
in minute doses-for example of arnica, ipecacuanha,
aconite, pulsatilla, bryonia, belladonna and others, certainly does not comport with that moral dignity,
which should be one of the attributes of the physician;
nor is it in accordance with those rules of ethics by
which the medical profession profess to be governed.
A posterity, however, and that not very remote, will
render the tribute to whom it justly belongs.
In a few instances only, throughout the work, have
the strength and frequency of repetition of dose been
mentioned; to have done so frequently would have
increased unnecessarily the bulk of the volume; the
presumption being entertained, that such knowledge
is already possessed by those who venture upon surgical practice. Full instructions as to the mode of
preparation of the medicines, the potency usually employed, and the circumstances regulating repetition,
are conltained in the Homoeopathic Pharmacopoeia and
nuineroues practical works.  As a general rule it may
be observed that most success will be obtained from
dynamizations not lower than the third, and in a large
proportion of cases, especially in those of a chronic or




vi                 PREFACE.
sub-acute character, as likewise in those of a specific
nature, the twelfth, eighteenth and thirtieth dilutions will be found to be possessed of most curative
action, and that more certain and positive effect will
be obtained from their exhibition at long rather than
at short intervals.
It will be observed during the perusal of this work,
that portions of it, and more particularly those that
relate to the mechanical treatment of injuries and surgical diseases, have been selected from standard authorities. The chapter on "the Means and Instruments
for arresting Hemorrhage" is taken from " the Practical Surgery" of Mr. Fergusson;* that upon Amputation from the modern work of Mr. Druitt;t and with
the necessary substitution and addition of Homoeopathic treatment, those upon Fractures and Dislocations
from  Dr. HIastings' "Practice of Surgery."$  The
various other authors who have been consulted, and
the medical periodicals that have contributed to the
formation of the present publication, are mentioned in
the foot notes throughout the volume.
PHILADELPHIA, July 11, 1855.
* Pp. 34-37.  t Druitt's Modern Surgery, pp. 534-546.
$ Pp. 164-238.




C O NTEN T S.
CHAPTER I.-Inflammation; Symptoms of, Analogy between Fever and Inflammation, Treatment of, Resolution, Local Treatment, Poultice in,.......   1
CHAPTER II.-Suppuration; Pus Globule, Properties of Pus, Medicines
for Suppuration,........................................ 19
CHAPTER III.-Ulceration and Sloughing; Fallacy of Hunterian Theory,
Granulation, Cicatrization,.............................. 24
CHAPTER IV.-Gangrene, Mortification; Phlyctenae in Mortification, Sphacelus, Crepitation in Sphacelus, Line of Demarcation, Line of Separation,.
Dry and Traumatic Gangrene,......................................... 29
CHAPTER V.-Varieties of Inflammation.  1. Erysipelas.  2. Furunculus.
3. Anthrax. 4. Pernio. 5. Burns and Scalds............................ 38
CHAPTER VI.-Wounds. 1. Incised. 2. Punctured. 3. Contused. 4.
Lacerated. 5. Poisoned-Hydrophobia. 6. Gun-shot Wounds. 7. Tetanus, 56
CHAPTER VII.-Means and Instruments for Suppressing Hemorrhage...... 120
CHAPTER VIII.-Ligation of Arteries. 1. Topography of Neck. 2. Ligation of the Radial Artery.  3. Of Ulnar. 4. Of the Brachial. 5. Of the
Subelavian. 6. Common Carotid. 7. Lingual. 8. Facial. 9. Anterior
Tibial. 10. Posterior Tibial. 11. Femoral.  12. Iliacs,................. 137
CHAPTER IX.-Abscess.  1. Of Antrum.  2. Of Manmae.  3. Hepatic. 4.
Lumbar.  5. Paronychia,.............................................. 146
CHAPTER X.-Ulcers. 1. Simple Ulcer. 2. Irritable. 3. Indolent. 4.
Index to Treatment of Ulcers,.......................................... 174
CHAPTER XI.-Venereal Disease.  1. History of Syphilis. 2. Gonorrhoea.
3. Syphilis. 4. Primary Syphilis.  5. Bubo.  6. Constitutional Syphilis,.. 190
CHAPTER  XII.-Cancer.  1. Of Face.  2. Of Mammee. 3. Uterus. 4.
Fungus Haematodes.  5. Chimney Sweepers' Cancer...................... 226
CHAPTER XIII.-Scrofula; Scrofulous Diathesis, Scrofulous Ulcers........ 273
CHAPTER XIV.-Splints and Bandages,................................. 279
CHAPTER XV.-Fractures.  1. Definition and Mode of Union. 2. Fracture
of the Cranium. 3. Of the Nose. 4. Lower Jaw. 5. Scapula. 6. Clavicle.
7. Sternum. 8. Ribs. 9. Spine. 10. Pelvis,.......................... 288
CHAPTER XVI.-Fracture of Upper Extremities.  1. Fracture of Fingers.
2. Fore-arm.  3. Humerus,......................................... 310
CHAPTER XVII.-Fracture of Lower Extremities. 1. Of Foot. 2. Leg.
3. Patella............................................................. 321
CHAPTER XVIII..-Compound Fractures. 1. Pseudo Arthrosis. 2. Cracked
Bones,...................................................                 334
CHAPTER XIX.-Dislocations.  1. Of Jaw. 2. Of Clavicle,............... 341
CHAPTER XX.-Dislocation of Upper Extremities.  1. Fingers. 2. Forearm. 3. Humerus........................................................... 352
CHAPTER XXI.-Dislocation of Lower Extremities.  1. Pelvis. 2. Toes. 3.
Knee-joint. 4. Leg,....................................           363




Viii                           CONTENTS.
CHAPTER XXII.-Subluxations and Sprains. 1. Rupture.of Muscles and
Tendons,............................................................... 376
CHAPTER XXIIT.-Diseases of the Periosteum  and Bones. 1. Periostitis.
2. Caries. 3. Necrosis. 4. Exostosis. 5. Spina Ventosa. 6. Osteo Sarcoma.  7. Mollities Ossium and Rachitis.  8. Fragilitas Ossium,........... 379
CHAPTER XXIV.-Diseases of the Joints. 1. Synovitis. 2. Morbus Coxarius.
3. Fungus Articulorum.  4. Anchylosis.  5. Ecphyma Cartilagineum.  6.
Diseases of the Bursae.  7. Deformity of Joints.  8. Talipes,.............. 414
CHAPTER XXV.-Diseases of the Blood Vessels. 1. Diseases of Arteries,
Degeneration of Tissue, Calcareous Deposit. 2. Aneurism. 3. Diseases of
the Veins, Phlebitis, Consecutive Abscess, Varix,......................... 435
CHAPTER XXVI.-Injuries and Diseases of the Head.  1. Wounds of the
Scalp. 2. Concussion.of the Brain.  3. Compression of the Brain,........ 445
CHAPTER XXVII.-Diseases of the Eye.  1. Ophthalmitis and Catarrhal
Ophthalmia, 2. Ophthalmia Purulent. 3. Gonorrhoeal. 4. Syphilitic. 5.
Rheumatic.  6. Arthritic.  7. Erysipelatous.  S. Variolous. 9. Scrofulous.
10. Iritis-Iritic Ophthalmia.  11. Psorophthalmia,  12. Hydrophthalmia.
13. Pterygium.  14 Diseases of the Cornea.  15. Hypopion.  16. Staphyloma. 17. Cataract. 18. Glaucoma. 19. Amaurosis. 20. Fistula Lachrymalis. 21. Tumors of the Eyelids. 22. Strabismus. 23. Ectropium. 24.
Entropium. 25. Hordeolum.  26. Ptosis,............................... 452
CHAPTER XXVIII.-Injuries and Diseases of the Ear.  1. Otitis. 2. Otorrhoea. 3. Otalgia. 4. Deafness. 5. Congenital Occlusion of the Meatus,
and other Affections.  6. Perforation of the Membrana Tympani.......... 522
CHAPTER XXIX.-Diseases of the Nose.  1. Ozoena. 2. Polypus Nasi,... 531
CHAPTER XXX.-Diseases of the Mouth.  1. Hare-Lip.  2. Malformation
of the Fraenum Linguae.  3. Ranula. 4. Cynanche Tonsillaris........... 534
CHAPTER XXXI.-Diseases of the Neck, 1. Stricture of the (Esophagus.
2. Foreign Bodies in the (Esophagus. 2. Extraneous Bodies in the Larynx
and Trachea. 4. Bronchocele,.............................. 542
CHAPTER XXXII.-Injuries and Diseases of the Thorax. 1. HydrothoraxEmphysema-Empyema.  2. Injuries of the Chest,........................ 547
CHAPTER XXXIII.-Injuries and Diseases of the Abdomen.  1. Wounds
of the Abdominal Viscera. 2. Tumors of the Abdomen.  3. Ascites,...... 552
CHAPTER XXXIV.-Hernia. 1. Varieties of Hernia. Operations for Hernia, 558
CHAPTER XXXV.-Diseases of the Rectum. 1. Prolapsus Ani.  2. Hemorrhoids.  3. Fistula in Ano. 4. Tumors of the Rectum-Stricture of the
Rectum-Fissure in the Anus-Pruritus Ani,............................. 578
CHAPTER XXXVI.-Diseases of the Testicle and Penis.  1. Hydrocele.  2.
HIematocele. 3. Sarcocele.  4. Varicocele. 5. Phymosis.  6. Paraphymosis. 7. Cancer of the Penis. 8. Castration,............................. 588
CHAPTER XXXVII.-Diseases of the Urethra and Bladder. 1. Stricture of
the Urethra.  2. Fistula in Perineo. 3. Retention of Urine. 4. Urinary
Calculi. 5. Lithotomy. 6. Lithotripsy,................................. 605
CHAPTER XXXVIII.-Question of Amputation.  1. Compound Fractures.
2. Contused and Lacerated Wounds. 3. Gangrene and Mortification. 4.
Diseases of Joints. 5. Exostosis and Necrosis............................ 619
CHAPTER XXXIX.-Amputation.  1. Amputation of Lower Extremities.
2. Amputation of Upper Extremities.....................................   627




SURGERY,
AND ITS ADAPTATION TO
HOM(EOPATHIC PRACTICE.
CHAPTER I.
INFLAMMATION.
PERHAPS there is no subject, to which the attention of those
interested in the investigation of medical questions has been
directed, that has caused such diversity of opinion; and to
account satisfactorily for which, more hypotheses have been
advanced, than that of Inflammation.
However, after much laborious and patient investigation, and
many protracted discussions, the majority of the profession of
the present day, coincide in the opinion that Inflammationproperly so called, or when fully established-consists in an
engorgement of the capillary vessels, dependent on their* diminished action, and the relaxed condition of their coats, together
with more or less accelerated motion of the heart and arteries;
and that from such an abnormal condition arise the well known
characteristic symptoms-pain, heat, swelling and redness.
(Dolor, calor, tumor, rubor.)
In all organic textures, the transmission of the blood from
the minute branches of the arteries to the minute veins is
effected through a net-work of microscopic vessels (the capil* Dr. Fletcher's Elements of General Pathology, p. 161. Miller's Principles of Surgery, p. 108.




2                  INFLAMMATION.
laries), in the meshes of which the proper substance of the tissue
lies. The diameter of these vessels varies somewhat in the
different textures of the body, the most common size, however,
being about -S]on of an inch.*  It must be obvious, therefore,
that if the action of these radicles be diminished, by any
cause whatsoever, that the blood will not pass with sufficient
acceleration through them; and that in a short period, the
heart still continuing its action, they would become enlarged
by the unusual accumulation of blood.
This engorgement, this agglomeration of blood disks in the
capillary tubes; dependent on their diminished action and
increased power of the heart and arteries, is Inflammation.
The whole process may be clearly demonstrated by a common
surgical example, frequently encountered in routine practicethe application of some corrosive substance to the skin. The
period of incubation might be designated, as the time that
elapses between the application of the irritant and the establishment of the inflammatory process.
In the first stage there is not only an increased flow of blood
to the affected part, but the circulation is carried on with increased velocity, which may result from the contraction of the
capillaries, which, as has been before stated, are the essential
seat of the disease.
As the coats of these tubes appear to be analogous to the
involuntary muscular tissue of the human body, this contraction has been termed by some physiologists " spasm," while
the subsequent relaxation and distention that occurs when Inflammation is fairly established has been designated "paralysis."
As this dilatation proceeds, those radicles, that in the normal
condition were only capable of transmitting the liquor sanguinis,
now, by their extension, admit of the introduction of the red
globules; and those that previously circulated but a single file
of the colored corpuscles, are now filled with them in agglomerated masses, and the augmentation of such a condition
necessarily tends more and more to retard the circulation.
* Kirkes and Paget, Manual of Physiology, p. 105.




INFLAMMATION.                        3
The capillaries being overburdened with blood, there is consequently more transudation than in a non-affected part, and
this consists generally of serum, which may be found in the interstitial spaces or upon open surfaces. The natural function of
the part is exalted, if the normal action be secretion, the product is in increased quantity; nutrition is enhanced, and the
surrounding tissues somewhat increased in bulk.
This stage is not wholly inconsistent with health, and has
been termed by recent physiologists " vital turgescence;" indeed it may be reasonable to suppose, that at certain periods
of existence such a condition, when caused by a vital stimulus, is necessary to certain organs, in order that they may perform their destined functions, and thus fulfilling the office
assigned them by the Creator, complete in perfectness the
wonderful mechanism of the human economy. The blush upon
the maiden's cheek, and the increased vascular action that
takes place during the secretion of milk in the mammea, are not
diseases; but it is probable that nature, when she has performed the duty incumbent upon her, checks the normal stimulus she has brought to her aid, and this being withdrawn, the
part having accomplished its mission, returns to the quiescent
condition from which it has been aroused.
As the inflammatory process progresses, the arterial trunks
partake in the excitement, and in endeavoring to overcome the
resistance, enlarge, pulsate, and throw an increased quantity of
blood to the part; the already distended capillaries become
more enlarged, the little contractility they possess becomes
weaker, and the blood disks within them more agglomerated;
exudation is increased in quantity and deviates from the healthy
standard; the tissues around become enlarged and softened,
because the exuded plastic material is too great for the normal
appropriation of the textures, and if still the unhealthy action
continues, the attenuated walls of the capillaries, unable to
withstand greater distention, give way, and extravasation
results; the surrounding tissues become filled with liquor
sanguinis, pus commences to be formed, and the destroyed
tissue of the part is mingled with the contents of the vessels.




4         SYMPTOMS OF INFLAMMATION.
Such are the pathological changes that are manifested from
the commencement to the completion of the inflammatory process; and if these occur with rapidity, and decline in the same
ratio, the inflammation may be termed acute; if, on the contrary, the action be sluggish, and weeks and months elapse
before the climax is established, the decline be of long duration,
and the termination imperfect, the disease becomes chronic in
its character; and it is such a condition that frequently baffles
and disheartens the practitioner with unsatisfactory results, and
unlooked-for complications.
The acute form may assume a chronic character, from
improper treatment, the habits of the patient, the condition of
the affected part, &c., &c., &c.
The most prominent symptoms that denote the presence of
inflammation, are, as has been above stated, the pain, heat,
swelling, and redness.
Pain is the most characteristic symptom of inflammation,
and is caused by the compression of nervous filaments, from
the encroachment of the swelling upon them, which acts as a
mechanical force; consequently, the pain increases as the
tumefaction advances, particularly if the surrounding textures
are firm and unyielding. The function also of the sentient
nerves is perverted, and they become, themselves, one of the
seats of inflammatory action. Moreover, at each throbbing
impulse of the heart and arteries, the nervi vasorum of the
distended and elongated vessels add something to the general
amount of pain. But such causes, as well as their results, are
liable to vary. The pain present in inflammation is not uniform. It is, as has been before mentioned, in a great measure
influenced by the elasticity of the textures in which inflammation occurs. Thus, when a bone is affected with the disease, it is more painful than when the skin is attacked. The
intensity of the inflammatory action, and the sensitiveness of
the affected part, also, to a great extent, influence the amount
of pain.
Heat.-" The symptoms and consequences of inflammation,"




SYMPTOMS OF INFLAMMATION.                     5
writes Mr. Liston,*-" and amongst others, heat —are modified
by the distance of the affected part from the centre of the
circulation. All actions, healthy as well as morbid, proceed
with more vigor in the superior extremities —the head, the
neck, and the trunk-than in the more remote parts of the
body; for in the former the blood is transmitted more speedily,
if not in greater quantity, and is not so liable to be impeded in
its return."  This is evidently true, as ascertained by the
thermometer. The normal temperature of the body, at the
heart and upper parts of the trunk, varies from 980 to 100~, at
the extremities about 92~,t but there is very little rise of the
mercury from the heat of an inflamed part, and though the
patient complains of extreme heat, burning and throbbings, the
thermometer only indicates a rise of four or five degrees.This, however, can be readily accounted for. During the
inflammatory process the nerves of sensation, partaking in the
general abnormal action, become perverted, indeed, increased
sensibility is one of the signs of inflammatory action; this
accounts for the sensation of heat so frequently noticed and
complained of by the patient; and if we also remember that a
very fruitful source of animal heat is referred to the changes
that take place in the blood circulating in the capillaries; and
as these changes are carried on with great rapidity in inflammation, we can readily imagine that the heat of the part which is
the seat of the abnormal action, may be somewhat elevated.
Heat must also be connected with other symptoms, to assist
in the diagnosis of inflammation, for we all know, and are
every day told of burnings in different portions of the body,
when there is not the faintest trace of any inflammatory
action.
Swelling.-This effect arises from several causes; first, the
effusion of coagulable lymph and serum; secondly, the
increased quantity of blood in the vessels; thirdly, the depo* Liston's Elements of Surgery.
t Cyclopedia of Practical Medicine, p. 738.
f Loc. cit.




6          FEVER AND INFLAMMATION.
sition of new matter; fourthly, the interruption of absorption,
particularly noticed by Soemmering.
The swelling is, for the most part, confined to the cellular
texture, and is commonly the greatest where the inflammation
commences; but this symptom, when viewed alone, cannot by
any means indicate the disease, others must be conjoined with
it. In the simplest form of cedema, is there inflammation
present?
The redness is evidently caused by the increased quantity of
blood contained in the capillaries, and of the introduction of
the red globules into those radicles, which previously would
not permit their admission. The color of the blood, also, in
inflammation assumes a deeper tint, but there are some instances
in which the inflammatory process may have been present to a
certain extent, and the parts be paler.* This, however, is not
generally the case. The enlargement and engorgement of the
capillaries, was made plainly distinguishable by Mr. Hunter:
he says, " I froze the ear of a rabbit and thawed it again; this
occasioned considerable inflammation, an increased heat and
thickening of the part. This rabbit was killed when the ear
was in the height of inflammation, and the head being injected
the two ears were removed and dried. The uninflamed ear
dried clear and transparent, the vessels were distinctly seen
ramifying through its substance, but the inflamed ear dried
thicker and more opaque, and its arteries were considerably
larger.
It may not be uninteresting to insert here a few remarks
concerning the analogy between fever and inflammation. The
theory appears to be very plausible, and supported with well
founded arguments; however, the object of referring to the
subject, is merely to give the student an insight into the matter, hoping that the inquiring mind, anxious for further elucidation, will be led to other investigations, that may prove
conclusive, either for or against the theory.  "It must be
* Liston's Elements of Surgery.




FEVER AND INFLAMMATION.                         7
abundantly obvious," writes the late John Fletcher,* " that it
is the first stage of fever which is (as in inflammation) that
of increased action, at least with regard to the extreme vessels
of the surface of the body (the essential seat of the morbid
change), and the second that of diminished action with respect
to these vessels; and this, whether the exciting cause be stimulant or sedative.  It is true-the increased excitement of these
vessels being always attended by a diminished excitement of
the rest of the body, and the diminished excitement of these
vessels by an increased excitement of the rest of the body-it
is difficult to divest one's self of the notion, that the cold stage
of fever is one of deficiency of action, and the hot stage of increase of it; and it was this which gave occasion to Dr. Armstrong to call the three stages of continued fever (corresponding
to the cold, the hot, and the sweating stage of an intermittent)
by the names of the stage of oppression, that of excitement,
and that of collapse-names which, it must be remembered,
apply only to the state of the body in general, and not of the
capillary vessels of the surface, which, during the stage of
oppression, are in a state of preternatural excitement; during
that of excitement, in a state of corresponding collapse; and
during that of collapse, in a state of reaction.'Whenever,'
says Dr. W. Phillip,'increased temperature, swelling and redness appear, the capillary vessels are debilitated, and preternaturally distended.' Now, in the hot stage, the whole surface
is affected with increased temperature, redness, and swelling.
The deduction is obvious, and the analogy of fever, in every
respect, with inflammation, is too manifest to require further
comment. In fact, inflammation and fever differ only in their
seat and in their degree: the seat of inflammation being anywhere, and more or less circumscribed, and its degree commonly considerable; whereas, the seat of fever is in the whole
surface of the body, and its degree commonly slight. It is
here, however, meant, that the degree of inflammation, in any
* Elements of General Pathology, p. 176. —ed. J. J. Drysdale, M, D.,
and J. R. Russell, M. D. Edinburgh, 1842.




8    TREATMENT OF INFLAMMATION.
given number of capillary vessels, is commonly slight in fever,
compared to that of inflammation, properly so called; but the
number of them much more than compensates for the slightness
of the inflammation of each, and the constitutional affection is,
of course, great in proportion."
The symptoms as above stated-pain, heat, swelling, and
redness-are those that are most frequently manifested in inflammation, and are in themselves, generally, sufficient to the
allopathic practitioner, not only to designate the disease, but
also to suggest the system* of treatment that must be employed; but, to the homceopathic physician, though the pain,
heat, swelling, and redness proclaim the pathological action
that is being established, they are of but little utility with regard to the treatment. The medicines exhibited according to
the law of simile are not to be prescribed for the name inflammation, but for the character and kind of the symptoms that
present themselves in such an unhealthy condition; the study
becomes more arduous, the investigation more thorough, and
the examination more minute; the character of the pain must
be ascertained, whether it be boring, sticking, tearing, lancinating, &c.; the conditions that aggravate or relieve the sufferings
must be investigated; the time of occurrence, and the causes
that produced the disease, must be understood; the temperament, age, sex, and habits of the patient must be noticed, and
the supervening constitutional symptoms also receive their due
share of attention, before the appropriate medicines may be selected and administered.
There are many instances, however, when some of the local
* Concerning the theories of inflammation adopted by allopathic writers
and the fallacy of their treatment, we may refer the reader to a number of
articles, entitled " Phenomena and Theory of Inflammation connected with
Homeeopathic Statistics," written by Dr. Ozanne, and which appeared in
the Homoeopathic Times (London), during the year 1852; and also to a
paper, " On the usual Antiphlogostic Treatment of the Old School," by
Dr. J. W. Arnold, of Heidelberg. The latter essay was reprinted in this
country, in the Quarterly Homeeopathic Journal. Boston, 1849, pp.
24-35,




TREATMENT OF INFLA M  ATION.                   9
manifestations of inflammation cannot be appreciated, but the
constitutional symptoms-quick, full pulse, dry, furred tongue,
high-colored urine, thirst, &c.-may, perhaps, lead to the detectection of the disease; " but," says Mr. Fergusson,* " some of
these, even, are not entirely to be depended on, seeing that they
may be present without the existence of inflammation; whilst,
again, that disease may be in full vigor, and yet the symptoms
may be such, that the most experienced may be deceived."
Again, he says, referring to the same subject, "exceptions to
these observations must be familiar to every one who has seen
even a little practice."
Here, then, in the treatment of this disease, the homceopathic
practitioner has a most decided advantage, and one that may be
instrumental in rescuing his patient from the grave.
Let us suppose that one of the "most experienced" physicians of the old school be sumnmoned to attend a case, where
"' the disease may be in full vigor," and the presenting symptoms not such as would indicate to his mind, the high state of
inflammatory action that is taking place in the system. What
would be the course pursued? Either to treat the name of some
other affection, that the symptoms may somewhat resemble,
and which may be entirely at variance with the true state
of the disease; or, perhaps, to prescribe for the invalid some
"'neutral mixture," without the most remote idea of the
dangerous' condition of the patient, who, under such treatment, in a short period may terminate his sufferings in death.
But, on the other hand, the Homceopathic physician-although to his mind the pathological condition of the part
may be equally obscure-has the light of a law of nature,
universal, and coextensive with disease, to guide him in the
selection of his remedy.
That there must be some presenting symptoms is obvious,
for, says Hahnemann, "There is no curable malady, nor any
invisible morbid change in the interior of man, which admits
of cure, that is not made known by symptoms, or morbid
* Practical Surgery, p. 70.




10                INFLAMM ATION.
indications, to the physician of accurate observation." Therefore, if the medicine be selected and administered in strict
accordance to the law similia similibus, those symptoms will
be removed, at least if the disease be curable; and if removed,
the affection, with its internal change, whether structural or
functional, will have disappeared also. Hahnemann again
says, " The cure which is effected by the annihilation of the
symptoms of a disease, removes at the same time the internal
change upon which the disease is founded, that is to say,
destroys it in its totality.  It is accordingly clear that the
physician has nothing more to do than to destroy the totality
of the symptoms, in order to effect a simultaneous removal of
the internal change, that is to say, annihilate the disease itself."
He says further, " It is not possible to conceive or prove by
any experience after the cure of the whole of the symptoms
of a disease, together with all. its perceptible changes, that
there remains, or possibly can remain, any other than a healthy
state, or that the morbid alteration which had taken place in
the interior of the economy has not been annihilated."
But let it not here be understood, that a knowledge of
pathology is of no practical avail to the student of Homoeopathy; on the contrary, by understanding the pathological
changes that occur in any organ of the body, a class of medicines is suggested to the mind of the practitioner, and from
this genus, the remedy must be selected, in accordance to the
presenting symptoms.
But when such a case, as the one alluded to, occurs, when
the pathological changes are obscure, the physician who prescribes in accordance to one certain law, is, to say the least, far
more liable to effect a cure, than he who, led astray by a
thousand flickering lights of conjecture and empyricism, knows
not whether to stimulate or deplete, and therefore frames in
his mind an hypothesis, draws a conclusion, whether false or
true, and prescribes accordingly.
In alluding to the subject of inflammation, an eminent
Homceopathic physician of this city writes: "Inflammation
of the cellular, osseous, nervous, and muscular tissues, is cir



RESOLUTION.                        11
cumscribed and the pain throbbing. In morbid growths and in
tubercle the objective symptoms are different, nor is there
much pain nor increase of heat. In other varieties of abnormal
growth the appearances again are dissimilar, and the pains are
acute and lancinating. Inflammation of the lining membrane
of the larynx is admitted to be quite different from inflammation of the lining membrane of the trachea. Inflammation,
seated in the same tissue of the same organ, assumes at different tirmes different characters, as is observed in cutaneous
affections. How are these differences to be understood and
encountered? Can they all be grouped together and treated
as that pathological condition termed inflammation?  If systems of medicine and not the law of simile be true, they ought
to be so understood and treated, and the successful result of
such practice would confirm the truth of the systems. But
they are not treated upon any general principle. In diseases
of the dermoid system, the chief reliance is reposed upon what
are termed specifics. An impartial mind can entertain no other
idea, than that the different subjective symptoms as exhibited,
for example, in different varieties of pain, such as tearing,
burning, darting, lancinating, pressive, piercing, boring, are the
result of essentially different morbid actions; each one, therefore, of necessity requiring its appropriate remedy. To these
differences a critical attention must be given for the most successful application of means. It is unpardonable ignorance at
the present time, when the bright rays of true medicine are
illuminating our pathway with floods of light, to have an
imperfect knowledge only of symptoms, and to confound all
distinctions."
The consequences of inflammation are often more conspicuous
than the disease itself; as, for example, suppuration, ulceration, granulation, and gangrene, in all of which the symptoms
of inflammation are thrown into the shade, as it were, by the
remarkable features peculiar to each, and therefore the treatment of the disease, in all its phases, can only be rightly understood by one who is well acquainted with the nature of these
different conditions. As it is, in general, a most desirable




12        METASTASIS AND  RESOLUTION.
object, however, to prevent any of these consequences occurring,
the chief aim at the commencement of the treatment is to
endeavor to do so, and to bring about what is usually called
the resolution of the disease-that is, to cause the subsidence
of all the symptoms, and to leave the part as if no disease had
ever been present. But inasmuch as it can only be hoped for,
while the action is yet beneath the inflammatory acme, the
treatment must be commenced early, and the remedy nicely
adapted to the disease, for if the abnormal action has reached
its height, true resolution-that is, complete restoration of the
part, as regards both structure and function, to its original and
normal state-is impossible.
"Resolution may be gradual or sudden, spontaneous or artificial, imperfect or complete; the more early and slight the
action, the more likely is the resolution to be rapid, spontaneous
and perfect. When sudden, the term delitescence is commonly
employed; denoting an occurrence favorable in itself, but
invariably associated in the mind of the experienced practitioner,
with a suspicious prognosis. Were the delitescence effected
simply, and there an end, the immediate benefit derived would
be without alloy. But experience tells us, that the abrupt
and sudden disappearance of advancing vascular action in one
part, is often, if not usually, followed by the appearance of
similar disorder. elsewhere. And, as we have no guarantee
that the change may be to an equally harmless locality, such
change must at all times be a matter of suspicion, and often of
danger. The process which effects subsidence of the original
action and the establishment of the new, is termed metastasis.
Resolution being about to occur, increased deposit probably
takes place, of serum, liquor sanguinis, or both. By this means,
among others, the burdened vessels are more or less relieved;
they recover their wonted tone and calibre, and the red corpuscles resume their individual distinctness; the agglomerate
mass, also, of both red and colorless corpuscles, first oscillate
and then move steadily on. Absorption, which has been embarrassed hitherto, or altogether held in abeyance, comes
actively into play; and the extra-vascular deposit is more or




TREATMENT OF INFLAMMATION.                     13
less rapidly removed. Ultimately, an equality of action is
arrived at, between the depositing blood vessels and removal
by absorption; the balance of healthy nutrition in the part is
restored, and normal function is resumed.
Although this, as a result, cannot always be expected, still
it frequently does occur, and when this is the case it is the
most desirable termination of the inflammatory process —at all
events, the first treatment should be directed to the establishment of resolution, which, if it does not prove sufficient for this
end, may mitigate some of the after consequences of inflammation. It frequently happens, however, that by the appropriate
Homceopathic treatment, the tendency of parts to take on
inflammatory action may be removed, and thus the patient
may be relieved of a considerable amount of suffering, and the
probable tedium of a long and debilitating confinement, and
the physician from the harassing and perplexing complications
that so frequently present themselves as the sequelae of inflammation.
The following are the medicines that appear best adapted to
accomplish such a desirable end:
(1.)  Chain., Graph., Hepar, Petrol., Silic., Staphys.,
Sulph. (2.) Baryta-carb., Calc.-c., Lye, Nit.-ac., Rhus.,
Sepia.
Should these not be sufficient, and the inflammatory action
appears to be progressing, the medicines to be relied on, are,
(1.)./con.,.Irs., Bell., Bry., Hepar, JMerc., Phosph.,
Silic., Sulph.  (2.) Asa., Arn., Calc.-c., China, Graph.,
Mang., Nati.-m., Petrol., Puls., Rhus.
These, perhaps, it will be sufficient to name, although there
are many others of minor importance, that are serviceable in
treating the concomitant symptoms of inflammation.
21conite is peculiarly adapted to inflammations occurrring
either in the internal or external parts, when the pains are
lancinating, or when there is much synochal fever. Also, for
acute local congestions with erethysm of the nerves, it appears
to be, according to Noack and Trenks, best adapted to individuals of a plethoric habit, lively character, bilioso-nervous or




14       TREATMENT  OF INFLAMMATION.
sanguineous constitution, with dark hair and light complexion.
This medicine is certainly one of the greatest so termed antiphlogistic remedies, and is highly recommended by some practitioners of the old school. In one of the best surgical works
of the present day, we read, "Aconite is a powerful antiphlogistic. It tends to relieve by cutaneous and other secretions,
but its most important effect is, to lower the heart's action
and general circulation. In this respect, indeed, it is the most
simple and yet the most powerful of sedatives.  Small doses,
such as a drop or half a drop of the strong tincture in aqueous
solution, repeated every hour, every half hour, or every two
hours, are quite safe and truly antiphlogistic; often under their
use, the pulse will be found to come down even rapidly, the
other febrile symptoms at the same time giving way."  Again,
from another modern surgery, we quote the following: "./conite and Belladonna are useful antiphlogistics in certain cases,
as in the inflammatory stage of erysipelas, inflammation, rheumatism, &c. They should be employed with care, however,
and given in small doses."  Aconite is, indeed, serviceable in
the first stage of almost every variety of inflammation where
the pains appear particularly aggravated at night. In active
congestion also, this powerful medicine displays a remarkable
degree of action, particularly in persons with bright redness of
the cheeks, especially in young girls of a plethoric habit, disposed to congestions, nervous or irritable, and leading sedentary lives.,Jrnica.-We find it recorded that this panacea lapsorum is
suitable for those stages of inflammation, where the vital
powers begin to become extinct, and where there is a tendency
to low grades of fever. Under such circumstances, it is the
contrary of Aconite, which, as has been before mentioned, corresponds to the more acute variety; but the effects of Arnica
are most fully developed in those inflammations that are consequent upon blows and injuries of all kinds, but particularly
in those that are contused, when there is hot, hard, and shining
swelling of the affected part; when there is dry heat over the
whole body, with general sinking of strength.  The use of




TREATMENT  OF  INFLAMMATION.                   15
Arnica, and other medicines adapted to the treatment of
wounds, will be mentioned in a subsequent portion of this
work..Jrsenicum is suitable to inflammatory conditions, involving
to a very high degree the sensitive sphere; threatening gangrene, or paralysis of the nerves of the parts. It is peculiarly
suitable to individuals of impoverished, exhausted, and nervous
constitutions; also, to the leucophlegmatic temperament, and to
both acute and chronic inflammation.
Belladonna is especially adapted to persons of a plethoric
habit of body, with tendency to congestion of blood to the
head. As indicated by its pathogenesis, the various symptoms
attending upon vertigo, with the heaviness of the head, glowing redness of the face, dilated pupils, dimness of vision, &c.
It is also suitable to scrofulous, irritable individuals. What
A.con. is to inflammatory fevers, Bell. is to the inflammation
itself, or the inflammatory action of the capillaries. If, after
the inflammatory action has been subdued by sqcon., other
symptoms remain, (chiefly nervous,) Bell. is of infinite value;
the more delicate the inflamed organ or tissue, the more
suitable is this medicine; it is also very useful in alternation
with JMerc. for inflammations of the lymphatics and glands.
Under this medicine we also find erysipelatous inflammations,
with swelling, or even mortification of the parts-redness,
inflammation, and swelling of the whole skin-red, not swelling, of the affected parts.
Bryonia. —This is a medicine of great value in inflammations
of many organs and tissues of the body, when there are flying,
darting pains, with chilliness, or when the inflammatory swellings are tense, hot, and rather pale, with stinging during
motion. In the dermoid tissues also, its action is powerfully
displayed, and it is suitable to very many inflammations that
occur in those structures. The temperament indicating Bry. is
the choleric or bilious-persons with brown complexions, brown
or black hair, and irritable disposition. The pains are aggravated at night and by movement or contact.




1.6     TREATMENT  OF  INFLAMMATION.
Graphites is also usefiA in many varieties of inflammation of
the skin, particularly chronic inflammations.
Camphora is useful in general or local asthenic inflammations, especially when of a rheumatic and erysipelatous character,
with a weak, soft pulse, and shrivelled, flaccid skin.
China.-As this medicine is particularly adapted to a state
of asthenia or exhaustion of the vital powers of the organism,
with relaxation of the solids, and deficiency of animal heat; it
is said to be extremely useful in asthenic, passive inflammation.
Hepar is especially suitable in the second stage of inflammation; it has a powerful influence over the suppurative process,
and hastens it when advancing, and also tends to heal the part
after the evacuation of the pus. MJercunus, however, forwards
the formation of matter more rapidly under certain circumstances, particularly in inflammation of the glands. Sulph.
and Silic. are also important medicines, and particularly in
chronic inflammations.  Rhus Tox. —Inflammatory swelling
and redness, with increased burning and stinging.
Of course, it would be highly improper to administer any of
the above mentioned medicines merely for the few indications
that have been mentioned, the totality of symptoms must be
considered; but it would certainly be a work of supererogation;
indeed, it would be impossible to mention in this chapter the
medicines that are to be exhibited in every case of inflammation, for the disease, as is well known, occupies not only the
attention of the surgeon, but constitutes a large proportion of
those affections that are encountered by the ordinary practitioner
in the daily performance of his duty.
The following medicines may, however, be mentioned:
Inflammation of the Glands.
(1.) Bell., JMerc., Phosph.  (2.) Acon., Baryta-e., Camph.,
Nux Vom., Puls., Sil., Sulph.  (3.) Ars., Bry., Canth.,
Carb-a., Cham., Hep., Lyc., Nitr.-Acid, Rhus., Staph.
Inflammation of the Bones.
(1.) MJerc., Puls., Sil., Staph.  (2.) Acon., Asaf., Bell.,
Calc., Lyc., Nit.-Ac., Phosph., Sulph.  (3.) Ars., Bry.,
Clem., Con., Hep., Mang., Mezer., Rhus., Sep.




TREATMENT OF INFLAMMATION.    17
Inflammation of the Periosteum.
(1.) Jlsaf., dMerc., Jfez., Ph.-ac., Sil.  (2.) Bell., Chin.,
Puls., Staph.
Inflammation of External parts.
(1.)./con.,.Jrs., Bell., Puls., Sil., Staph., Sulph.  (2.)
Bry., Calc.-c., Cham., Euphr., Hepar, Lyc., Merc., Nitr.,
Nitr.-ac., Phosph., Rhus., Spig. (3.) Ant.-c., Am., Asaf.,
Bary.-c., Bor., Cann., Creos., Cupr., Dig., Hyos., Ignat., Led.,
Natr., N.-vom., Petrol., Plumb., Ran.-bulb., Sassap., Sep.
Inflammation of Internal parts.
(1.).Icon., Bell., Bry., Canth., Jferc., J..-Vom., Phosph.,
Puls. (2.) Ars., Cann., Cham., Chin., Hyosc., Kali, Lyc.,
Nitr., Scill., Sulph., Veratr. (3.) Calad., Calc., Camph.,
Colch., Coloc., Con., Dros., Euphorb., Hepar, Iod., Ipecac.,
Mang., Mez., Natr.-m., Nitr.-ac., Par., Ph.-ac., Rhus.,
Sec.-cor., Sep., Spong., Stram.
Inflammation of 3Mucous JMembrane.
(1.)  Acon., oqrs., Bell., JIerc., X.-vom., Sulph.  (2.)
Agar., Bor., Bry., Calc., Canth., Cham., Dros., Ignat., Natr.mur., Par., Phosph., Puls., Scill., Sep., Sil. (3.) Amm.-mur.,
Ant.-crud., Arg., Bar., Carbo-a., Cocc., Con., Euphra., Graph.,
Jod., Lyc., Natr., Nitr.-acid, Ph.-ac., Sab., Spongia, Verat.
Inflammation of the Skin.
(1.) Hep., JMerc., Sil.  (2.) Acon., Ars., Asaf., Cham.,
Nit.-ac., Rhus., Staph., Sulph.  (3.)  Bell., Borax, Bry.,
Calc., Camph., Mezer., Natr.
LOCAL TREATMENT.
In all cases, the first circumstance that must receive attention, is the removal of such exciting causes as may happen
to be present. Of course, we could not expect to treat successfully, any case of disease while the exciting cause is still
operating. A slight inflammation arising from a small splinter,
cannot be cured until the extraneous body is removed.
In wounds it is often found that foreign substances excite an
unnecessary degree of inflammation; these should be taken
away as speedily as possible: splintered pieces of bone often
give rise to the abnormal action, and require removal. The
2




18       TREATMENT  OF INFLAMMATION.
head of a bone being out of its place may cause inflammation
in the part in which it lies; it therefore must be placed in its
natural position before inflammatory action can be subdued.
There are very many other exciting causes that may soon be
detected, and the sooner they are remedied the better.
Rest of the inflamed locality, if possible, should be absolute;
when the muscles are affected, they should be placed in such a
position that they may be entirely relaxed.
Position is all-important in the management of local inflammation; the part should be placed in such posture, that gravitation will act as a sanguineous drain, and at the same time
oppose further injection of the inflamed part.
The efficacy of a poultice in the treatment of inflammation is
a disputed point in our school; some practitioners (and these
generally the most skillful) discard the use of such adjuvants
entirely, while others have recourse to them frequently, and
speak loudly in favor of such means. As a general rule they
should not be used, but in some instances, in certain stages of
inflammation, a poultice may be of service if applied and removed at the proper time. If the inflammatory process is slow,
and the patient is afflicted with some other affection, (a cough
for instance,) that demands attention, or the suppuration is imperfect, an unmedicated warm poultice may be applied; but the
practitioner must be positive that inflammation has undoubtedly
set in, otherwise such treatment would produce aggravation
instead of amelioration of the symptoms. When this question
is settled in the mind of the surgeon, and the inflammatory
process has passed the first stage, the power of heat and moisture cause a relaxation and'distension of the parenchyma and
the engorged vascular trunks causing more copious effusion,
which relieves the overburdened vessels, and the circulation
can be more readily resumed.
But the very moment this end is attained, the poultice must
be removed, or of course, the same agents continuing to act,
inflammation would be set up anew, and fresh trouble, and
increased pain be the consequence. The poultice must then be
withdrawn at the proper time, and the part be kept at perfect
rest, and protected from external injury.




SUPPURATION.                        19
CHAPTER II.
SUPPURATION.
IF resolution has not been accomplished by those means
already referred to, before the acme of the inflammation, suppuration is inevitable. It has been noticed that the walls of
the capillaries were already distended to the utmost, that the
circulation had almost approached a state of stagnation; if
the abnormal action still continues, the walls of the vessels
give way, the entire function of the part is either perverted or
destroyed, the textures are broken up, and pus is generated;
however, though the formation of matter is generally connected with inflammatory action, the student must be prepared
in some instances, under peculiar circumstances and in certain
constitutions, to witness suppuration, when there has been no
previous solution of continuity, and without those symptoms
that have been alluded to as indicative of a high state of
inflammatory action; for, says Mr. Liston,* "pus is frequently
contained in the serous and mucous cavities, when no breach
of continuity can be discovered, at least we find a fluid not
distinguishable from purulent matter; it may be a vitiated
secretion, but still it presents the usual characters of pus. But
it occurs, generally, when there has been a previous lesion of
structure, and in this case its progress is most distinctly marked.
In exposed cellular texture, for example, particles of blood are
effused; the serum is afterward absorbed, and the lymph
remains; this latter gives transmission to minute vessels, which
deposit the purulent matter, whilst others secrete particles of
organized matter to form granulations in order to repair the
loss of substance. This process is often unattended with any
great degree of constitutional disturbance."
The pus globule, according to Gluge,t " consists of a whitish
* Elements of Surgery, p. 28.
t See Fletcher's Elements of General Pathology.




20                    SUPPURA T ION
gray mass, not very resistent and somewhat elastic. In this
mass four or five dark points, seldom more, are observable,
which do not lie only on the surface but penetrate the interior of
the globule. They are easily separated from the white mass,
whose surface, which was in contact with the dark kernel, is
quite smooth. Neither the tissue, the organ, nor the degree of
inflammation, has any effect in changing the character of the
pus globules, which are the same as found in bone, sinew,
muscle, lung and brain, and as taken from gangrenous, syphilitic, or other sores. This last observation is supported by
Valentin." (vol. ii. p. 259, 1837.) The corpuscles are generally spherical, but vary considerably in size, but most frequently  they are about -,I   of an inch in diameter; they
resemble in appearance the white corpuscles of the blood; they
are soluble to a great extent in dilute acids, and when macerated several nuclei are found.
To the eye, pus is a yellowish-white creamy liquid, sometimes of a slight greenish tinge, with scarcely any peculiarity
of odor, and heavier than water according to chemical examination. The pus globule is said to be a protein-compound,
consisting of the binoxide and tritoxide of proteine,* but these
bodies are included in regularly organized cellules, and they
float in a clear liquid called the liquor puris.  This secretion
is closely analagous with the serum of blood, and differs from
it chemically only in the fact that its protein compounds are
oxydized.t
* Gardner's Medical Chemistry, p. 305.
t An analysis of pus gives the following elements,Water,                                          86.1
Fat soluble in hot alcohol,  -    -      -       1.6
Matter soluble in cold alcohol, (fat and ozmazome,)    4.3
Matter soluble in hot and cold alcohol, (pyina,)
albumen, globules, and grains of pus, -  -     7.4
Loss,.6
100
The above is quoted by the Editors of Fletcher's Pathology. Note,
p. 271.




S U P P U R ATION.                 21
Pus, as has already been described, is what has been termed
by many writers laudable or healthy pus, and as such, resists
putrefaction for a length of time; but there are very many
circumstances that may cause the matter to assume different
characters; these are thus described by Mr. Miller: "A chemical action —perhaps the result of atmospheric contact-may be
superadded to the vital action, producing by decomposition of
the albumen of the serum, hydro-sulphate of ammonia, whose
presence is indicated by an offensive odor, and by the blackening of silver probes brought in contact with the pus.
Putrescence may be thus begun in the fluid, while it is yet in
contact with the living part."
"Disintegration of the surrounding textures by ulceration,
is often coexistent with the formation of pus. It is then mixed
with the fluid debris of the part, and in consequence, becomes
more prone to chemical change.
" Or it may be mixed with blood either fluid or solid. It is
reddened thereby, and found to contain blood discs or masses
of coagula. It is then termed sanious or grumous.
"In those of weak systems, it is often deficient in solid
matter, consisting chiefly of a thin serum; it is then termed
serous.
"In the scrofulous and cachectic, besides being serous, it
often contains flakes or masses of a curdy appearance; and to
such pus the term scrofulous is usually applied.
"Sometimes it is impregnated with a subtle virus, as the
venereal or vaccine; it is then said to be specific.
"Or it may be variously mixed with secretions from mucous
and serous membranes, and termed in consequence, sero-purulent and muco-purulent."
Such are the changes that may be noticed in suppuration,
and by understanding them the student and young practitioner
will often be able to trace more minutely the origin of the
disease and render a more perfect diagnosis.
Pus is rarely absorbed, and in the generality of instances if
not assisted in its discharge by the surgeon, finds for itself an




22                  SUPPURATION.
opening, leaving a scar, that ever after denotes that disease has
once been present in the system.
When suppuration is fairly established, the more acute sufferings of the patient subside, the throbbing which was before
frequent, disappears, and the sharp piercing pains become more
dull and constant. Generally about the centre of the tumor
a small conical eminence appears, that is most commonly of a
paler hue than the surrounding textures; when such appearances present themselves the abscess is said to be pointing.
The fluctuation of a fluid can often be perceived beneath the
integuments by careful examination with the fingers, but in
some cases it so happens that the presence of matter may be
so deep seated, that this sensation cannot be appreciated by the
practitioner. The attendant occurrences and the presenting
symptoms cannot be too carefully studied, when such a condition is suspected, for the discovery of the existence of deep
seated matter, is a circumstance of the highest importance, and
one which involves the practitioner's reputation, and frequently
the life of the patient.
Mr. Cooper says, "In no part of the surgeon's employment
is experience in former similar cases of greater use to him, than
in the present; and however simple it may appear, yet nothing,
it is certain, more readily distinguishes a man of observation and
extensive practice, than his being able easily to detect collections of deep seated matter.  On the contrary, nothing so
materially injures the character and professional credit of a
surgeon, as his having in such cases given an inaccurate or
unjust prognosis; for, in diseases of this kind, the nature and
event of the case. are generally at last clearly demonstrated to
all concerned."
The only characteristic constitutional symptom, that is said
to denote the formation of matter, is that of shivering. On
this subject, however, as there is some difference of opinion
among the profession, concerning its usefulness as an indication
of formation of pus, Mr. Fergusson is quoted.  "It is," says
he, "in my opinion, less worthy of estimation than some seem
to imagine: —it frequently happens in instances of disease where




TREATMENT  OF SUPPU RATION.                      23
suppuration never ensues; it often occurs even in a state of
health, and equally often when it does happen, it may be overlooked. Shivering is a symptom which the surgeon is often
deeply interested in, not so much, however, from the dread of
suppuration, as that it denotes some peculiar condition of the
system  fraught with much danger to life,-as, for example, if
within the first ten days after a capital amputation, or after
lithotomy, a patient is seized with shivering, there is much
reason to anticipate a fatal result; and although this may not
occur in all such instances, every practical surgeon must bear
me out in the formidable estimation I have made of this symptom. But whether it has preceded suppuration or not, the
surgeon will seldom be thus satisfied that matter has formed."
Though the treatment of suppuration will be more minutely
enlarged upon, under those diseases in which it occurs, the
following  medicines  will, in the generality  of cases, be
serviceable.*
The principal remedies for suppuration are:
(1.) A.sa., Hep., Lach., JMerc., Puls., Sil., Sulph.  (2.)
Ars., Bell., Calc., Canth., Carb.-v., Caust., Cist., Dulc.,
Kreos., Lyc,. Mang., Nitr.-ac., Phos., Rhus., Staph., Sulph.-ac.
For Bloody Pus: —(1.) aJsa.. Hep.,.Mierc.  (2.) Ars.,
Carb.-v., Caust., Nitr.-ac., Puls., Sil.
For Jelly-like:-Cham., MJerc., Sil.
Ichorous:-(1.) A/rs., AJsa., Carb.-v., Chin., JMerc., J\itr.-ac.,
Rhus., Sil. (2.) Calc., Caust., Kreos., Phos., Sulph.
Watery, thin: —(1.) Visa., Caust.,.Merc., Sil., Sulph.
(2.) Ars. Calc., Carb.-v., Lyc., Nitr.-ac., Ran., Rhus., Staph.
Fetid, cadaverous: —(1.) A1sa., Carb.-v., Chin., Hep., Sil.,
Sulph. (2.) Ars., Calc., Graph., Kreos., Lyc., N.-vom.,
Phos.-ac., Sep.
Viscid:-s-sa., Con., JIXerc., Phos., Sep.
Brown, brownish:-.rs., Bry., Carb.-v., Rhus., Sil.
Yellow: —(1.) Hep., JMerc., Puls., Sil., Sulph. (2.) Ars.,
Calc., Carb.-v., Caust., Phos., Rhus., Sep., Staph.
* See Chapter VII., Sections 1, 2, 3, 4.




24        ULCERATION AND SLOUGHING.
Greenish:-.sa.,./ur., Caust.,.Merc., Puls., Rhus., Sep.,
Sil.
Gray:-.-drs., Caust., JMerc., Sil.
Leaving a black stain:-Chin.
Sour Smelling, or causing an acid taste:-Calc., Hep.,.Merc., Kal., Sulph.
Salt: —JImb.,.irs., Calc., Graph., Lyc., Puls., Sep., Staph.,
Sulph..Acrid, corrosive:-(1.).Ars., Caust.,.Merc., JVitr.-ac.,
Ran., Rhus., Sep., Sil. (2.) Carb.-v., Cham., Clem., Lyc.,
Natr., Petr., Staph., Sulph., Sulph.-ac.
Laudable pus:-(1.) Hep., Lach., Jlierc., Puls., Sil., Sulph.
(2.) Bell., Calc., Mang., Phos., Rhus., Staph..Malignant:-(1.) dJsa., Chin., Hep., JMerc., Phos., Sil.
(2.) Ars., Calc., Carb.-v., Caust., Kreos., Nitr.-ac., Rhus.,
Sulph., Sulph.-ac.
Too profuse:-(1.) Hep.,.Merc., Phos., Puls., Sep., Sulph.
(2.) Ars., Calc., Chin., Lyc., Rhus., Sil.
Suppressed, or prematurely stopping:-Calc., Hep., Lach.,
Merc., Sil.
CHAPTER III.
ULCERATION AND SLOUGHING.
ULCERATION is that process by which a solution of continuity
is effected in a living solid; it is of much more frequent occurrence in the cellular and adipose tissue, than in muscles,
tendons, ligaments, nerves or blood vessels.
Until lately, the Hunterian theory was generally received,
that such breach of continuity was effected by what was
termed ulcerative absorption, or in other words, that the
absorbent vessels were chiefly concerned in the establishment
of the process; modern pathologists, however, appear to
regard ulceration as the molecular death of a part; a gradual
softening and disintegration of tissue, molecule by molecule;
the effete matter being mixed with purulent and other secretions, and thus carried out of the system. This process is gen



ULCERATION AND SLOUGHING.                     25
erally one of true inflammation, or connected in some degree
with inflammatory action.
If the inflammatory process continues, suppuration, softening, disintegration, and detachment of the tissues in minute
portions, follow in succession the abnormal action; the separated
molecules become mixed with the pus and are removed with
the discharge of the matter; it would appear therefore, that
with such a process, absorption would be but little connected.
The more important arguments in support of this doctrine,
are the following:ist.-" Ulceration is an immediate result of inflammation,
or is coexistent with it; and, during inflammation, absorption
in a part inflamed is very much diminished, if not altogether
arrested. Inflammatory action simply subsiding, on having
just touched its true acme, or barely so, is followed almost
immediately by very actively renewed absorption, by which the
inflammatory deposits are speedily cleared away. But when
the action does not so subside, and advances to suppuration with
ulceration, the result is otherwise; absorption is not renewed,
with any energy, if at all, until the action has abated. During
the persistence of such action, inflammatory deposits may, to
a certain extent, disappear; but only by disintegration along
with the original tissues, and admixture with the extruded
purulent discharge.
2d.-" If ulceration consists in mere absorption, why is it
invariably accompanied by discharge?
3d.-" Certain structures resist all excitants of absorption,
long and successfully, yet are remarkably prone to ulceration;
and the inference appears plain, that the two actions-one
opposed, the other embraced by the same part at the same
time-must be dissimilar.
4th. —" In the case of virulent inoculations, whence the system
is to be contaminated by absorption of virus from the part
inoculated, as, for instance, in the primary venereal ulcer —it is
considered that the system is safe during the formation of that
ulcer. The part inflames and ulcerates; in no long time after
the first blush of inflammation, the ulcer is fully established;




26        ULCERATION  AND SLOUGIHING.
and during the first few days, according to the Hunterian
theory, there should have been great and constant activity of
the absorbents pouring virus into the circulation, together with
the debris of texture. But the experience of the practitioner
tells an opposite tale; there seems to be little or no absorption
during that period, for if the ulcer be cured in this its earliest
stage, the disease is arrested, and there is no absorption of virus
into the system.
5th. —" Ulceration is most rapid, when absorption is generally
supposed to be least active; that is, during the persistence of
acute inflammation.
6th. —" Absorption is proved to be feeble during acute
inflammation."*
There are several other circumstances, which are opposed to
the theory of ulcerative absorption, and indeed form conclusive
evidence that the absorbents do not perform that action in
ulceration, that was attributed to them by Mr. Hunter.
Ulceration is a step beyond suppuration. The inflammatory
process having reached its climax, in infiltration, and partial
softening of the textures, if ulceration supervenes, the molecules become further softened, and carried away with the discharge from the part; this is effected easily from open surfaces,
but when ulceration is progressing in an unbroken part, a small
abscess or pustule is formed, and after their contents is evacuated the ulcerated surface is revealed.
The terms acute, inflamed, chronic, phagedenic, sloughing
ulcer, &c., are all modifications of the process of ulceration;
the severity of which is in proportion to the grade of the
inflammation, and the vitality of the part.
If the inflammatory process is moderate, and the ulceration
is established steadily, it may be termed acute; if, however, the
degree of abnormal action is greater, the ulcer is said to be
inflamed, on account of the unusual amount of pain, heat,
swelling and redness, that surround the part; if the inflammation is of a still higher grade, the destruction of the tissues is
* See Miller's Principles of Surgery.




ULCERATION AND SLOUGHING.                     27
still more rapid, and a phagedenic sore is produced; and if still
the inflammatory action progresses, partial death of the part is
effected, and a sloughing ulcer is the result.
However, after ulceration has been established by inflammation, the latter may subside, and the ulcerated surface be
repaired in a short period; but if the inflammation is sluggish,
the ulceration proceeds slowly and becomes chronic in character.
The process by which an ulcerated surface is repaired is
termed granulation, and the covering of these granulations
with cuticular formation, or the absolute healing of the part, is
designated cicatrization; these two actions, when united, constitute healing by the second intention.
Healing by the first intention, or adhesion, cannot occur
after inflammation has reached its acme, on account of the
breaking up of the textures, &c., that are consequent upon
that unhealthy action; indeed, when healing by adhesion does
take place, there must be a sufficiency of normal circulation
through the part, which, as has been before mentioned, cannot
be the case in true inflammation. The process is simply this:
the cut surfaces being nicely adapted, liquor sanguinis exudes,
the serum is carried off, and the fibrin remains; this in time
becomes fully organized, adheres to the surfaces of the wound,
and continuity is restored.
Healing by the second intention (granulation and cicatrization,) is the process by which ulcerated surfaces are repaired,
and is also the usual mode by which wounds, in which there is
much loss of substance, are healed.
The granulations are formed in layers, and by liquor sanguinis, that, while the ulceration is progressing, mingles with
the abnormal secretions and is carried away; but as the
inflammatory action ceases, a portion of the fibrin remains,
and becomes incorporated with the original tissue, forming
granulations-small, red, irregularly raised points, vascular
and fleshy.
The liquor sanguinis continues to be secreted, and new layers
of granulations are formed upon the old, while the pus that is
still poured out to a certain extent, serves as a covering to




28       ULCERATION  AND  SLOUGHING.
protect the whole. As the new layers are forming, the old
ones become organized,* and as the process continues, the
cavity becomes filled.
The means by which the new integument is, as it were,
engrafted upon the granulations, from the thin outspreading of
cuticle to the formation of true skin, is cicatrization.
When the healthy action appears to be arrested the granulations become larger and paler, and become flabby and gelatinous; when such appearances are present, the granulations
are termed unhealthy.
The same causes that create inflammation are productive of
ulceration. These actions are portions of the same process, commencing with vital turgescence, and terminating in gangrene.
Ulceration is the medium between suppuration and gangrene;
in the former the action does not proceed far enough to disintegrate the textures; and in the latter the death of the part is
effected in mass, and not molecule by molecule.
Sloughing.-Death of a part, an undoubted termination of
inflammation, as well as of all other vital change, may be
reached at once, from intensity of action, deficiency of power,
or a combination of both.
The broken up texture caused by ulceration, softened, and
infiltrated by liquor sanguinis, pus, and extravasated blood, has
its circulation wholly arrested and it dies; not slowly and
imperceptibly by particles, but plainly, at once, and in mass.
Vital action has ceased, and chemical change advances unopposed, and the part is decomposed by putrescence."t
The term slough is used to denote the death of the soft
parts, and exfoliation or sequestrumn is applied to a dead piece
of bone.
The medicine for different forms of ulceration, will be found
in the chapter upon ulcers.t
* For a very interesting account of the formation of the different tissues
of the animal body, from the development of the nucleolus to the perfection of a part, see Quekett's Lectures on Histology, London, 1852.
t Miller's Principles of Surgery.
* See Chapter VIII., Sections 1, 2, 3, 4.




MOR TIFIC ATION.                      29
CHAPTER IV.
MORTIFICATION.
"THE word Gangrene," says Mr. Guthrie, " is often used
synonymously with mortification. By the public it is presumed
to mean the same thing. Technically, it is more correctly
confined to the inflammatory state in which mortification commences, and with which it proceeds unto the destruction of the
life of the part or sphacelus."  Mortification includes the
whole process of dying, from its commencement to its completion.
The symptoms that are present in inflammation become
modified when gangrene is about to commence.t The redness
passes into a dark and livid hue; for circulation has ceased,
and the blood is becoming decomposed. Circulation having
been arrested, so is exudation, and the swelling is less tense.
On the surface, however, effusions may take place, and that
profusely. All vital action decaying, pain and heat remarkably abate, and often cease suddenly.  Sensation  gradually
leaves the part. Just before, even a moderate degree of pressure aggravated the pain, now, even rude handling is borne
with impunity.  Nutrition, the source of animal heat, having
ceased, temperature necessarily decreases, and usually with
rapidity; rapid putrescence takes place; and, as the result of
chemical change, an offensive odor is more or less freely exhaled. The surface is frequently studded with phlyctena;
that is, elevations of the scarf-skin by putrid serum; readily
distinguished from the dark vesicles filled with bloody serum,
which not unfrequently attend on simple bruise; by observing
that the epidermis is detached from the cutis, not only at the
elevated spot, but all around, and that, consequently, the
* Lectures on the more Important Points in Surgery.-London Lancet,
Sept., 1850, p. 251.
t See Miller's Principles of Surgery, p. 267.




30           LINE  OF  DEMARCATION.
phlyctena may be made to slide from place to place, by slight
pressure. Besides the phlyctena is not attended with heat, pain
and swelling, as in the mere vesicle, but is associated with all
the other symptoms of advancing gangrene. When this is
limited to the part originally inflamed, the discoloration is circumscribed, and may have its border even abrupt; but when
the action and injury which led to it have both been severewhen the power of both part and system have been brought
low-and when, in consequence, gangrene is to spread-discoloration is gradually lost in the surrounding skin, and dark
streaks are seen shooting diffusedly upwards in the limb.
Sphacelus, or completion of the gangrene, is indicated by
the part having become completely cold and insensible. It is
shrunk in its dimensions, soft and flaccid, almost pulpy to the
touch; and it crepitates distinctly, containing not only liquid,
but gaseous contents-the result of putrescence.  All vital
action has ceased, and the chemical reigns paramount. The
color is usually dark, when the part is exposed to atmospheric
influence; but when removed from this, as in sloughing of the
areolar tissue, or of the fascia, or in necrosis-the integuments
remaining yet entire-the dead portions retain their normal hue
but little changed.
When a part dies to a limited extent —as a portion of skin,
areolar tissue, artery or tendon-the sphacelated part is termed
a slough; and the process of death sloughing.
Sphacelus being complete, and gangrene not extending,
nature instantly adopts means whereby she may free herself
from a part which is of no further use, and whose continued
presence may prove seriously injurious. Its recovery is impossible; and if it be allowed to remain in close contact with the
living textures, these cannot fail to absorb more or less of the
noxious results of putrescence, both gaseous and fluid; whereby
a poisonous effect will be produced on the system, already
brought low by constitutional disorder attendant on the gangrene. The living part in immediate contact with the dead,
inflames; and, in consequence, the abrupt livid line is bordered
by a diffuse, red and painful swelling-the line of demarcation.




LINE  OF  DEMARCATION.                     31
This vesicates; the vesicle bursts; puriform matter is discharged; and an inflamed and ulcerating surface is disclosedthe line of separation. The furrow, so begun, gradually
deepens; at first advancing with considerable rapidity, through
the skin, and areolar tissue, which are prone to ulcerate; but
receiving a check, when fascia, tendon, and other fibrous tissue
is reached. The advance is seldom perpendicular, but in a
sloping direction; and the inclination is usually toward, and as
it were, beneath the (lead part; gangrene being generally most
extensive superficially. In time, even the most resisting of
the soft textures are got through by ulceration, nothing but
bone remaining undivided.  No hemorrhage occurs during this
gradual division of parts; for the inflammatory process has
passed leisurely through its ordinary grades; exudation and
organization of fibrin precede the suppuration and ulceration,
protecting the otherwise loose tissues from purulent infiltration, and sealing up the otherwise open orifices of arteries
and veins.
Nature's amputation, so conducted, is unfortunately a reverse of the ordinary operation, producing a stump which is
conical, and otherwise but ill-fashioned for useful purposes.
The surgeon is, therefore, called upon to interfere in most
cases; modifying the arrangement, and securing division of the
bone at a higher point.
When gangrene does not involve the whole thickness of a
limb, the line of demarcation is formed around the sphacelated
portion, and the part sloughs away, leaving an ulcerated
surface beneath, in which the process still continues until the
unhealthy structure is cast off.
The constitutional symptoms in mortification generally
assume the typhoid character. The pulse is quick and tremulous, the skin hot, tongue dry and of a brownish tinge, and
the patient restless and uneasy. Delirium, subsultus tendinum,
nausea and hiccup are frequently present. With regard to
the causes of mortification Dr. Gibson writes,*  "In general
* Late Professor of Surgery in the University of Pennsylvania.




32            LINE  OF DEMARCATION.
the disease results from inflammation. Gun-shot wounds,
fractures, dislocations, simple punctures, concentrated acids,
poisons, stimulating applications, infiltration of acrid fluids
into the cellular membrane, lightning, burns, long-continued
pressure, intense cold, must all operate, more or less, through
the medium  of inflammation,in producing their several effects."
There are also some specific causes of gangrene, which will
afterwards be noticed.
Mortification has been divided into acute and chronic, the
former comprising the humid inflammatory or traumatic, the
latter the dry and idiopathic. Generally speaking, the acute
is humid and the chronic dry-the fluids being retained in the
former, and gradually parted with in the latter-however, this
is not invariably the case.
For the purpose of illustrating the acute form of gangrene,
the following, may serve as an example.-When there exists a
compound fracture of the lower ends of the bones of the leg,
with great contusion and laceration, a high degree of inflammation is the certain result, in consequence of the severity of
the injury; here all the symptoms of the disease will be well
marked; pain, heat, swelling and redness, will all be conspicuous. If gangrene threatens, the swelling will probably attract
most attention; perhaps the pain and feeling of heat may then
be less, and instead of a bright red, the part may assume a
bluish tinge; it may also appear colder, and the cuticle will be
elevated by the phlyctena, or vesicles. At such a time, if the
part is touched by the fingers, it will feel tense and crepitating,
for there will be air in the soft textures. In such a case the
constitutional symptoms are probably of less moment than the
local, as denoting the extent of the mischief. At first there will
be the usual constitutional indications of severe local inflammation, latterly the pulse will sink and become irregular; the
skin will be pale, cold and clammy; the countenance will assume
an anxious, haggard appearance, and there may be vomiting,
hiccup, and delirium. Under these circumstances there need
scarcely be a doubt that gangrene is present, and to such a




DRY  GANGRENE.                            33
case the terms-acute, humid and traumatic gangrene are
applied.*
Of course there may be acute, humid gangrene, without the
traumatic. The example above cited was selected because it
represented the three characteristics.t
Dry gangrene-or as it has been termed, senile gangrene-is
generally seen in advanced years, and in many cases is the
result of deficient circulation.
This variety of gangrene may commence with a burning
sensation, which continues for a time, and ceases suddenly; or
without any well marked symptoms of inflammation, the toes
and feet may become cold, discolored and shriveled, and
finally converted into a hard, dry mass, insensible and of a purple hue. Frequently there is no sloughing, and each part
retains its original form, the skin remains entire, the nails
adhere to the toes, and the part becomes hard and cold, and is
perfectly free from fetor. Sometimes, however, the fetid odor
and sloughing are considerable, and attended by severe constitutional symptoms, although these are of rather rare occurrence.
It is frequently very difficult to assign any cause to this
variety of the disease. In some instances, however, it can be
traced to the diseased rye.  During very moist seasons, secalecornutum, ergot, cockspur, (a medicine whose excellent qualities, in many diseases, is fully appreciated by the Homceopathic
practitioner,) is generated in considerable quantities, constituting
a disease, in which the grains of rye become larger, firmer,
* Fergusson's System of Practical Surg., p. 100.
t Mr. Guthrie, also, makes another division, and one which he considers
more important than any other, viz:-constitutional and local. He says,
"Surgeons have, I am aware, spoken and written of chronic and idiopathic mortification, or certain states depending on internal causes, which
have occupied a considerable time before they gave rise to any great development of evil; whereas the difference between local and constitutional
mortification may depend on a few hours-a time so short, and yet so precious, that it becomes a matter of life and death in many instances."
3




34          TREATMENT OF GANGRENE.
and of a much darker color than natural; the diseased being
mixed with the sound grain, is often eaten by whole families,
and for a time without producing any detrimental effect, but
finally the dry gangrene make its appearance, and the population of whole districts become afflicted with the disease.
But such aggravated form of gangrene, arising from the continued use of secale cornutum, is of much more frequent occurrence in European countries, particularly France, than in North
America.
" The patients who have suffered from it, have experienced
pain and heat with swelling, generally in the lower limbs,
though occasionally in the upper. These symptoms abating,
the parts became cold, insensible and discolored, and were
gradually separated from the body. The disease attacked
patients of both sexes and every age, did not appear to be
infectious, and was frequently fatal."*
Canstatt, however, gives a much fuller description of gangrene caused by the internal use of secale; for this we may
refer the student to Hartmann's Chronic Diseases, volume ii.,
pp. 152-153.
Treatment.-The medicines that are best adapted to the
treatment of gangrene are —.rs., Chin., Crot., Lach., Sec.cor., Silic., Acon., Bell., Carbo.-veg., Euphorb., Hell., Hyos.,
Sabina, Squill., Sulph..rsenicum  has very many symptoms that belong to gangrene, and under its use in alternation with carbo.-veg., we have
seen senile gangrene subdued.  This medicine corresponds to
very many of the constitutional symptoms, and has the following local manifestations.
Numbness, stiffness and insensibility of the feet, with swelling and pain.
Coldness of the feet, with contracted pulse.
Swelling of the feet, with hot shining and burning red spots,
and bluish blisters.
Hard —red-blue painful swelling, itching swelling, colorless
* Liston's Elements of Surgery, p. 40.




TREATMENT OF GANGRENE.                     35
swelling of the malleoli, with tearing pains, which are relieved
by external warmth.
The skin of the bottom of the feet is insensible, thick as
leather, with rhagades.
The toes are stiff and do not allow him to tread.
Titillation and creeping, itching of the great toe.
Ulcerated and spreading blisters on the tips of the feet.
Parchment-like dryness, coldness and blueness of the skin.
Black blisters, with burning pain.
Discoloration of the nails.
Crotaluts.Swelling of the feet with coldness.
Painful numbness of the toes, as after a cramp.
Swelling of the bitten leg, burning like fire.
Heat and intolerable gnawing of the feet.
Livid spots with frequent fainting fits and imperceptible
pulse.
The swollen part is cold and painful to pressure.
Hot swellings, with cold skin and sickly appearance.
Insensibility of the swollen part.
Gangrene over the whole body.
The spot where the bite was inflicted looks black, with red
dark circle, blackish redness of the sub-adjacent muscles and
cellular tissue, and inflammation extending from the place of
the bite to the pectoral muscle, where gangrenous spots are
exhibited.
The skin where the bite has been inflicted becomes gangrenous and is separated from the muscles by a fetid fluid.
Lachesis.Gangrenous blisters.
Black-blue blisters, vesicles the size of a hazle nut, with
violent itching and burning, as if the flesh would be torn from
the bones,
Swelling and inflammation of the bitten limb, with violent
pains, dry mouth, constant fever, dry skin, and constant thirst.




36          TREATMENT OF GANGRENE.
The lightly brown areola becomes bluish-black.
Gangrene of the bitten part, and gangrenous blisters.
Tingling in the toes, with heat and numbness.
Cracked skin between the toes, also deep rhagades.
Blue-red, large swelling of the leg and foot; prickings
around the malleoli and calf, and aggravation of the swelling
in the warmth.
Coldness of the feet also, as from ice.
Itching places on the tibia, with pain as if burnt, changing
to painful spots after rubbing, with blue-red dark borders, and
dry scurfs.
Tingling in the right tibia, from the knee to the dorsum
of the foot and into the toes, with cold feet, and icy cold
malleoli.
Secale-cor.The skin is dry and brittle, withering dry.
The skin all over the body looks lead-colored, the parts
becoming shriveled and insensible, and not emitting a drop of
blood on being cut into.
Burning in the skin as if a spark of fire had fallen on it.
Bloody blisters on the extremities, becoming gangrenous.
Black suppurating blisters.
Formication of the hands and feet.
Numbness, insensibility and coldness of the limbs.
The limbs become cold, pale and shriveled, as if they had
been lying in warm water for a long time.
Gangrene of the limbs, the limbs becoming suddenly cold
and lead-colored, and losing all their sensibility.
Gangrene, deadness and falling off of the limbs.
Pain, accompanied with slight swelling without inflammation, followed by coldness, blue color, gangrene and deadness
of the limbs.
Numbness of the fingers and tips of the fingers.
Tingling sensation in the anterior portion of the thighs and
calves, as if gone to sleep.
Gangrene of the feet up to the knees.




TREATMENT OF GANGRENE.                     37
Gangrene of the lower limb, and spontaneous dropping off
of the same.
In threatened traumatic gangrene, when there is violent
synochal fever, of course aconite should be prescribed, and calendula in solution may be applied to the wounded part, or
arnica diluted may be employed locally if there be but little
solution of continuity. The former medicine has been highly
recommended as a vulnerary, and it has been used with great
success in Europe in all kinds of lacerated wounds; it has a
powerful action over suppuration and its consequences, indeed
its beneficial influence in wounds of all descriptions is remarkable. This subject, however, will be again alluded to, when
treating of wounds.
Belladonna is also a very important remedy, and must be
exhibited when the constitutional symptoms demand its exhibition, particularly when the patient complains of burning heat
and unquenchable thirst, and especially if there be that characteristic trembling of the extremities, clouds and spots before
the eyes, with dilated pupils. This medicine is useful in dry
and humid gangrene.
China must be used when there has been profuse hemorrhage, which has greatly debilitated the patient. When there
is coldness of the whole body, particularly of the extremities,
with pale and clammy face, the parts around the wound beComing blue, swollen and soft. If there be gangrenous spots, with
inability to swallow, hiccup, vomiting, hyos. may be administered; if typhoid symptoms present excessive prostration,
rhus-tox. or phosph. should be exhibited.
Carbo.-veg. is indicated in some cases of humid gangrene,
but from the general sphere of its action, it is especially serviceable in gangrena senilis. It has in its pathogenesis several
symptoms that present themselves in the disease, and has been
of much service practically in the treatment. Euphorbium is
also useful in the gangrene of old persons.
Silic. and Sulph. are also important medicines in both forms
of gangrene, and perhaps with./rsen., Crotalus, Lachesis,
Secale-cor., and also Carbo.-veg., and Solanam  nigrum, are




38                   ERYSIPELAS.
the most useful medicines for the treatment of gangrene as
occurring in oldl persons.
It may be useful also, in this affection, to wrap the feet or
other parts affected in carded wool. This practice is recommended by Sir B. Brodie in his Lectures on Mortification, and is
mentioned by Mr. S. Cooper in his "First Lines." There have
been several cases treated successfully by this method,* and no
doubt these means may assist in maintaining the warmth of the
part, while by the proper administration of medicine the cause
upon which the disease depends may be removed.
The following medicines have also been recommendedChinin., JMerc.,.Mur.-ac., Plumb., Sabin, Scill., Sulph.-ac.,
Tart.
CHAPTER V.
VARIETIES OF INFLAMMATION.
Section 1.-Erysipelas.
ERYsIPELAS is an inflammatory affection, accompanied with
fever, which, together with drowsiness, is generally present a
few days before the attack; the latter symptom disappearing
when the disease is fully established.
The inflammation is generally confined to the epidermis,
which becomes hot, red and swollen, and sometimes covered
with blisters, (erysipelas bullosum,) but in very violent cases,
the deeper seated tissues are affected, and the disease is termed
phlegmonous erysipelas. Every part of the body is liable to be
attacked, although the face, legs and feet are most frequently
affected.
Erysipelas does not often attack persons before the age of
puberty; it is a disease of advanced life, and is more frequently encountered among females than males, particularly
those of a sanguine, irritable temperament.
* See a paper " On the Treatment of Gangrena Senilis," by HeInry S.
Taylor, Esq., Surgeon, Guildford.-London Lancet, Nov. 1845, p. 443.




ERYSIPELAS.                        39
In some individuals, there appears to exist a predisposition to
the disease.  In other instances it returns periodically, attacking
the patient once or twice a year, and sometimes oftener, thereby
greatly exhausting strength.
Erysipelas is occasioned by the several causes that are liable
to excite inflammation; such as injuries of all kinds, the external
application of acrid substances to the skin, exposure to cold,
obstructed perspiration, suppressed evacuations, &c., &c. The
disease also appears to be under certain circumstances epidemic,
caused by a peculiar state of the atmosphere, and this is frequently
the case in crowded ships or in hospitals.
In slight cases, when the extremities are attacked, this
disease makes its appearance with roughness, pain, heat and
redness of the skin, which becomes pale when the finger is
pressed upon it, but immediately returns to its former color
when the pressure is removed. There also prevails a slight
febrile disposition, and the patient is rather hot and thirsty.  If
the attack is mild, these symptoms will continue for a day or
two, when the surface of the affected part assumes a yellowish
tinge, the cuticle may separate in small scales, and the patient
experience no further inconvenience; but if the attack is severe,
and the symptoms of high inflammation are present, there will
be intense throbbing pain in the head, pain in the back, great
heat, thirst and restlessness; the affected part will swell, the
pulse become frequent, and either hard and tense, or it may be
small and rebounding; and about the fourth day, a number of
small vesicles make their appearance, containing a limpid, or
in some cases a yellowish fluid. In unfavorable cases, these
blisters have sometimes degenerated into obstinate ulcers, which
have assumed a gangrenous character. This, however, does
not happen frequently, for though the surface of the skin and
the bullke may assume a bluish, or even a blackish tinge, yet
such appearances generally disappear, together with the other
symptoms of the complaint.
The appearance of these vesicles is not always present in an
attack of erysipelas, and when they do show themselves, the
period of their eruption is very uncertain.




40         TREATMENT OF ERYSIPELAS.
The trunk is also attacked with erysipelas, but less frequently
than the extremities; but infants a few days after birth, may
be affected in this manner, the genital organs being generally
involved.
When erysipelas attacks the face, the premonitory manifestations are chilliness, succeeded by heat, thirst, restlessness, glistening eyes, coated tongue, redness of the cheeks and other febrile
symptoms; and when the disease attacks this portion of the
body, there is drowsiness, or a tendency to coma or delirium,
and the pulse is very frequent and full. At the end of two or
three days a scarlet redness appears on some parts of the face,
which may extend to the scalp, and then gradually down the
neck, leaving tumefaction in every part occupied by the redness.
When the swelling and redness have continued for a time,
blisters varying in size, and containing a thin, colorless and
sometimes acrid liquor, arise on the face, which becomes turgid
and swollen, and the eyelids are sometimes swelled to such a
degree, that the patient for the time is deprived of sight. The
fever sometimes becomes less when the inflammation is established, but in the majority of cases it increases as the latter
extends, and unless checked by the appropriate means, may
continue for the space of eight or ten days. If such is the case,
the coma and delirium increase greatly, and the patient may be
destroyed between the seventh and eleventh day. If the attack
be mild the inflammatory symptoms subside gradually, and the
disease terminates in a few days.
Erysipelas of the face is more dangerous than when other
portions of the body are attacked, because there is a tendency
of the inflammation to attack the brain. The prognosis is
unfavorable if the fever assume a malignant type, or when
there is theatenened metastasis to internal noble organs.
Treatment.-The medicines that are most serviceable in
erysipelas, are.con., Bell., Bry., Euphorb., Puls., Rhus-t.,
Sulph,.Acon.-In simple erysipelas, with the ordinary fever and other
accompanying symptoms, this remedy will frequently be sufficient
to arrest the disease, without the administration of any other




TREATMENT OF ERYSIPELAS.                      41
medicine; it is also of great service when in violent cases there
is intense synochal fever, but belladonna is more preferable in
many cases, where there is coma, delirium, flushed cheeks,
throbbing carotids, where the swelling is tense, and there is
present a stinging or shooting pain, increased by contact or at
night, when the erysipelas extends in rays, and there appears to
be a disposition of the inflammation to attack the deeper seated
tissues, (erysipelas phlegmonodes.) In a majority of cases, acon.
in the commencement of the disease, and bella. exhibited when
the affection has fairly set in, will be sufficient to complete the
cure.
Bryonia may be employed, in cases in which the affection
attacks the joints, when there are drawing, tearing pains,
increased by motion.
Euphorb. —This is suited to erysipelas of the head and face,
with digging, boring and gnawing pains, followed when ameliorated by creeping and itching of the part. When there is considerable swelling and the vesicles are small, the fluid rather
yellowish than white, and a considerable amount of heat, this
medicine is also indicated.
Pulsatilla is indicated when the erysipelas shifts from  one
place to another, (erysipelas erraticum,) and when the hue of the
skin is less intense, and there are shooting pains. This medicine
should also be recollected when the disease affects the ear.
Hartmann remarks, "pulsatilla is never indicated in pure erysipelas of the face, except when accompanied with stitches, in which
case the disease is apt to go to the brain; this can be more
effectually prevented by belladonna than by pulsatilla."
Rhus-tox. —This is the principal medicine for vesicular erysipelas, it is also indicated in erysipelas where there is extensive
oedema, or where there is a tendency to metastasis of the disease
to the brain; thus radicans has been very highly extolled for
facial erysipelas, as has been also graphites and hepar, but of
course there must be corresponding symptoms to indicate their
use.
According to Reissig, nux vom. is well adapted to this disease




42                 BOIL-FURUNCULUS.
when it attacks the knees or feet, when there is intense pain and
bright red swelling.*
If there be a tendeney to metastasis to the brain, cuprum acet.
is an extremely valuable medicine, as the author has had
opportunity of witnessing. Dr. Schmid of Vienna, also corroborates this statement.
Belladonna and rhus-tox. are adapted to that form of this
disease which is found in hospitals. The erysipelas partakes of
the phlegmonous character, and therefore the former remedy
would perhaps be the preferable. If the disease assume a gangrenous form, the vesicles become dark and blackish, with prostration, dry skin, frequent but easily quenchable thirst, arsen.
should be administered, or perhaps carbo-veg. may also be
indicated in erysipelas gangrenosa, particularly if there be
night and morning sweats, excessive prostration and disposition
to typhoid symptoms.
Rhus should also be remembered, and administered if suitable  for such a condition.   If there  be  a disposition  to
ulceration, sulph., hepar, graph., silic., are important medicines.t
Section 2.- Boil-Furunculus.
A boil is a prominent, hard, red and circumscribed tumor,
very often extremely painful, and though terminating in suppu" I had a case of Erysipelas where the disease re-appeared frequently,
always on one side of the face only, and where every attack was preceded
for several days by a violent cardialgia. A single dose of nux vom. 15,
effected a permanent cure, showing that accompanying symptoms often
indicate a different remedy, from what are generally considered specifics for
Erysipelas. In such cases Sulphur might likewise be resorted to, particularly when a throbbing, stinging pain is experienced in the swelling."
Hartmann'slAcute Diseases, vol. ii., p. 39.
t There have been many interesting cases of erysipelas reported in
the Homeeopathic Periodicals of the day. One of the best can be found in
the British Journal of Itomceopathy, vol. vi., p 532.




B O I L -- F U R U N C U L U S.       43
ration, the process by which the pus is formed is frequently of
long duration. The inflammation is of the sthenic type, affecting the skin and areolar tissue; the latter becoming disorganized,
constitutes what is termed the core of a boil.
A common furuncle differs from a carbuncle, because the
latter is asthenic, not only constitutionally but locally, the life
of the patient being often endangered by the disease, while a
boil is sthenic in itself, is generally indicated by a robust and
plethoric temperament, and is in most instances free from fever
or any constitutional disturbance. The cases in which fever, &c.,
may be expected, are those in which the tumor is large and
situated on a sensitive part, or when a number of these swellings
appear at the same time in different places. A carbuncle contains no core, and has several openings for the exit of sloughs.
As suppuration progresses in the tumor, the apex of the cone
becomes yellowish, and surrounding this, the hardness of the
swelling disappears, though still the base is firm and unyielding.
The pus is superficial, the slough or core being at the base.
According to Richerand, the origin of boils depends upon a
disordered state of the gastric organs; this is frequently the
predisposing, while the exciting cause may be a prick, a scratch,
or some other slight irritation.  Constitutional irregularity,
however, is, in very many instances, sufficient in itself to produce this variety of inflammation.
Boils may appear in any part of the cellular tissue, and are
mostly found among young plethoric individuals, or in those
persons who are given to high living and suffer from dyspepsia.
Some individuals appear to be particularly liable to the formation
offuruncle, and the hips and buttocks are frequently the seat of
the disease; it is in this locality that they are extremely
vexatious, as the afflicted mortal can neither sit with comfort,
or walk without pain, which is occassioned when the muscles
are rendered tense, and, moreover, the individual is constantly
kept in a ferment of anxiety and suffering, consequent upon the
frequent blows that are invariably, unaccountably and inadvertently inflicted upon the tender and painful tumor.




44              TREATMENT OF BOIL.
A boil, after suppuration is complete, bursts at its apex, and
the purulent secretion is discharged, after which, the pain, heat
and swelling subside, but unless the slough is also extracted,
the part may remain in a sub-acute inflammatory condition, the
disorganized tissue acting as any other mechanical irritation.
Treatment.-The Homceopathic treatment of boils is very
efficacious; indeed the careful practitioner can frequently administer prophylactic medicines to those in whom there is a
tendency to this variety of inflammation, thereby saving the
patient from great inconvenience and a considerable amount of
pain.
In the treatment of furuncle a poultice is never required;
well selected and properly administered medicines, being sufficient to accomplish the cure. There is naturally existing in
the minds of the older portion of the community, whether physicians or laymen, a favorable predisposition in regard to the
application of a poultice. Those who have been born, bred
and habituated to the application of such means for almost
every variety of local inflammation, cannot without some hesitation resign the adjuvants; but experience teaches, that patients
are cured as speedily, and in most instances more radically, of
such inflammation, by Homeopathic medicines, than by purging
the patient with drastics, " touching the liver " by means of
mercury, and enveloping the tumor with a poultice of mush, oatmeal, flaxseed or slippery elm.
The medicines that are mostly applicable in the treatment of
boils, are qrn., Bell., Calc., Hep., Lyc., Phos., Sulph., or ASlum,
/Jnt.-c., Led., Jlerc., Jur.-ac., Jit.-ac., JVux-vom., Sep., Thuj.
To eradicate the disposition to boils, the medicines are Calc.,
Lyc., Jaux-vom., Phos. and Sulph.
If the boils are large, Hepar, Lyc., Xit-ac., Sil. or Hyos.,
Phosph., Tart.-e.
If small, mrn., Bell., Sulph., Zinc.
If suppuration progress slowly, IMerc. will hasten the formation of matter.
When there are stinging pains in the boil the medicine is
JVux-vom.




A N T H R A X - C A RB UNCLE.            45
When there is troublesome itching, Carb-veg. or Thuja,
the latter particularly when the redness extends to some distance
around.
If the pain is lancinating, Calc.-carb. If the pain is stinging,
when the boil is touched, Lyc. If this be present during motion,
JMur.-ac.
If burning, Colocynth.
If there is burning pain extending to some distance around,
sJntim.-crud.
There are also many other remedies mentioned for boils, appearing on the different parts of the body, but it is probable that if
the above symptoms are present, the medicines will relieve,
without regard to locality.  However, the student is referred to
the symptomen codex, to ascertain the particular situation of the
boil, if the treatment above recommended has been unsuccessful.
Section 3.-  nthrax-Carbuncle.
A carbuncle is, in some respects, analagous to a furuncle,
though the former is much more dangerous, the inflammation
being more extensive and gangrenous in character.
The tumor is deep seated, hard and circumscribed, and
rapidly advances, becoming livid and attended with severe
burning or lancinating pain. The inflammation, as has been
before stated, is of the asthenic type, and attacks the skin and
sub-adjacent areolar tissue.
As the inflammatory process progresses, the tumor becomes soft, of a purple hue, and spongy; suppuration, ulceration and sloughing of the cellular tissue supervenes, and
numerous small apertures form in the skin, through which a
thin saneous pus is discharged, together with the disintegrated
areolar tissue.  This condition is one of the most important
diagnostic signs between anthrax and common boil, for in the
latter, however large, there is but a single opening.
The usual situation of carbuncle is the back, from the nape
of the neck to the pelvis, though any portion of the body may




46           TREATMENT  OF ANTHRAX.
be attacked. The size varies from that of a chestnut to that
of the palm of the hand, the constitutional symptoms, when
the tumor is large, being dangerous in the extreme.
The fever, primarily, is simple, or may be bilious in its character; but as the disease progresses, typhoid symptoms make
their appearance and increase, and as the occult gangrene
extends, prostration becomes more extreme, and hiccup, delirium, coma, and even death may ensue.
The swelling is generally flat, bluish and spongy, only
slightly elevated above the surrounding skin, and in most
instances circular, and circumscribed by a distinct line of
demarcation, which, as in other sloughs, indicates the separation of the dead from the living tissues.
Carbuncles are most common in advanced life, although they
may be seen in young persons, especially among those who
have been accustomed to hardships or severe privations. It is
also encountered in adults who indulge in the excesses of the
table, or who have debilitated their constitutions by a life of
debauchery.
The medicines for carbuncle are, lArsen., Bell., Chin., Hyos.,
J.cid.-m~ur., AJcid.-nit., Rhus, Secal.-cor., Silic.
A.rsenicum is indicated, when the burning in the seat of the
carbuncle is intense, and when this symptom is present for some
distance around the tumor, or when there is a sensation in the
swelling as though boiling water was running beneath the
integument, when the pulse is small, irregular and frequent,
and there is cold perspirations. It is also adapted to individuals of a nervous, choleric temperament, who have been reduced
by long sufferings; when there is emaciation, vomiting of fluids,
burning thirst, or bilious diarrhcea.
Belladonna.-When the cerebral symptoms are well developed, red face, shining eyes, severe heat-when the parts
around the carbuncle have a tendency to erysipelatous inflammation. Dr. Pardo thinks bell. is best adapted in the transition from gangrene to sphacelus.
China is recommended by Dr. Pardo, " when the asthenic
character of the disease is particularly well marked, with symp



TREATMENT OF ANTHRAX.                       47
toms of a febris putrida, the more so when the patient is leucophlegmatic and much reduced by loss of blood, or if the carbuncle develop itself under the influence of swamp miasms."
Hyos. is particularly serviceable when the disease is present
in nervous or hysterical individuals; when there is coma-vigil
or great restlessness, caused by excessive nervous excitement,
shaking of the head in all directions, optical illusions, constriction of pharynx, when there is itching around the part.
JMur.-ac. is said to be the main remedy, when the carbuncle
appears in scorbutic individuals, with ulcers on the gums, and
if in addition to the local symptoms, there be a feeling of emptiness in the stomach and abdomen; frequent desire to urinate
with profuse emission of clear urine.
Rhus-tox.-When there is burning itching around the carbuncle, with vertigo as if one were about to fall, stupor, pale
face, disfigured and convulsed; pointed nose, sanguineous or
serous frothy diarrhcea.
Lachesis or Kreosote may also prove serviceable in this
disease.
Calcarea MJuriatica has also been employed by Rademacher
with great success.
Dr. Pardo * and Dr. Victor de Iturraldet mention several
cases of carbuncle, that were cured by Homceopathic treatment;
the medicines employed were ars., bell. and silic. The latter
named gentleman used chiefly bell., and after relating his success, he remarks: "The irritability under the usual treatment
was great; by Homceopathic treatment, however, nine-tenths
less."
Incisions are requisite, and must be employed in those cases
of carbuncle, in which ulceration has advanced and sloughs have
formed. In many instances, however, by the proper administration of the Homceopathic medicines, the inflammation is dispersed, and suppuration and ulceration either limited or prevented.
But when there are many openings and large sloughs, the bis* Bulletin Official de la Soc. Hlahnemnann, vol. ii., No. 12, 1848.
t Loc. cit., vol. ii., No. 1, 1847.




48              PERNIO- CHI L BLAIN.
toury must be freely used. The apertures should all be made to
connect by the requisite division of the parts, or the whole
tumor may be opened by a crucial incision. Such means must
be resorted to, together with the exhibition of the proper
Horncepathic remedy, if we wish to succeed in the treatment of
disease.  The use of incision is obvious; it evacuates purulent
formation, affords exit to the tenacious slough, and prevents
infiltration, from which the most serious results have ensued.
Section 4.-Pernio-Chilblain.
Pernio is an inflammatory affection, usually the secondary
effect of cold, caused by heat and circulation being prematurely
restored. It is commonly met with in the extreme parts of
the body, as the fingers, toes, heels, ears and nose; as these
are not only habitually exposed to cold, but also are of comparatively weak circulation, and consequently of low power.
The skin is at first pale and presents a somewhat shriveled
appearance, but this is in a short time succeeded by tumefaction and (lark redness,' with a sensation of heat and intense
itching. The swelling also, sometimes cracks, and bleeds, and
there is a tendency to ulceration.
These are usually the presenting symptoms in ordinary chilblain; however, if the disease advances, the skin assumes a
purplish cast, the tingling, burning and itching become intolerable, and vesicles form, which contain a serous fluid; these do
not desquamate in the ordinary manner, but burst, and disclose
beneath a painful and ill-conditioned sore, that discharges a
thin watery fluid; this ulcer is often slow to heal, and may
assume the character of an irritable or indolent sore, which is
generally superficial, but may become gangrenous, or may penetrate to a considerable depth, involving tendons or bone.
The milder form of the complaint-that unattended with
ulceration-is of frequent occurrence in this climate during the
winter season.  It particularly appears on the feet of those
who have been compelled to stand or labor in the snow, which




TREATMENT  OF  CHILBLAINS.                    49
melting, penetrates through the leather of the shoe or boot,
thus wetting the feet, which are often imprudently held near
a warm fire, and allowed to dry; this premature restoration of
heat engenders the affection.
Chilblains often disappear spontaneously in the summer, but
return again in the winter season, generally attacking those
parts that have previously suffered.
This affection is also very liable to occur in those individuals
afflicted with dyspepsia or other disease which renders extreme
circulation imperfect.
The medicines for chilblains are-agar., arnm., ars., bry.,
bell., carbo-a., kali-c., lyc., nit.-ac, nux-vom., petr., phosph.,
puls., sulph., zinc.-met../garicus is of great service, when the itching is very intense,
and accompanied with burning. This medicine is frequently
sufficient to cure the affection, and allays the itching in a short
time.
Arnica " is a certain remedy when the inflammation of the
chilblain is caused by pressure, friction," &c.*.lrsen. should be used if the vesicles appear or become blackish, and there is tendency to gangrene, or china may be prescribed under such circumstances if other symptoms correspond;
it is particularly indicated if humid gangrene should have set
in; opium also, may sometimes be indicated.
Kali-carb, for inflamed chilblains with aching, or with cutting plains.
JVit.-ac. when there is much itching with swelling and pain.
Petrol. and phosph. are also very serviceable when the suffering
is intense.
JVTux-vom. is indicated when the inflammation is superficial,
with bright red swelling, with burning itching, or when the
tumefied part cracks and bleeds readily.
Puls. must be administered if the swelling is bluish, hot and
attended with throbbing pains, particularly if the patient is of
a gentle or phlegmatic disposition. Bell. may also be indi* See Hartman's Acute Diseases, vol. ii., p. 41.
4




50             3BURNS AND  SCALDS.
cated in this form of chilblain, if the disposition of the
individual is sad and indifferent, though at times vehement.
Rhus-tox., " when there is burning itching in the afternoon
and evening; when not scratching there is a pricking in the
chilblain, obliging him to scratch; blotches after scratching."
Sulph. is suitable when there is redness and swelling with a
tendency to suppuration, and also " for thick red chilblain on
the finger, itching during warmth, also painful."
Zinc.-met.-" Chilblains on the hand, itching and swelling
violently."*
JVit.-acid and petroleum have been recommended when the
inflammation sets in with very cold weather.
For " chilblains on the feet, with pain and redness during the
summer season," antim. crud.
Section 5.-Burns and Scalds.
The practitioner is frequently called upon to treat injuries
that have resulted from the application of heated solids or fluids
to the skin. Sometimes the danger to the system is slight, but at
others, when the heated matter has come in contact with a large
surface, the prognosis is very unfavorable. By the term scald
is understood the effect of heated fluids, when applied to any
portion of the body, while the consequences of hot solids or
ignited combustibles, are termed burns. The latter class is in
the generality of instances the most serious, although the former,
though not injuring the skin deeply, gives rise to very alarming:symptoms, when a large extent of surface is involved.
A slight degree of heat, is only productive of a sharp hot
pain, with redness of the surface, and these may both subside
without any other unpleasant symptoms, but in very many in-stances effusion of serum immediately takes place beneath the
-cuticle. In other cases the cutis may be destroyed by the
* See Mat. Med., vol. ii., pp. 690, 924, 1033. Ibid. vol. i., p. 121.




BURNS.                          51
intensity of the heat. Parts also that at first do not present
appearances of any very serious injury, may afterwards be
involved, perish, and be cast off as a slough. The surrounding
textures also have their vitality diminished, and when they
come to be the seat of the inflammatory process, are unable to
sustain the increased action, and from the want of corresponding power sloughing very often ensues.
Burns on the trunk and genital organs are very serious and
productive of the most disastrous results, and extensive injuries
of this kind, no matter in what portion of the body, are much
to be dreaded. The constitutional symptoms are often well
marked; they are, great sinking of the vital powers, (which
generally is present immediately after the reception of the
injury,) shivering, weakness, cold extremities, anxiety, vomiting.
And these may be readily accounted for, when it is remembered what an important office is fulfilled by the texture that is
in almost every instance the first to be implicated.
The classification of burns has been differently proposed by
various authors Dr. Thompson* arranges them,
Ist. Into such as produce an inflammation of the cutaneous
texture; but an inflammation, which, if it be not improperly
treated, almost always manifests a tendency to resolution.
2d. Into burns, which injure the vital powers of the cutis,
occasion the separation of the cuticle, and produce suppuration
on the surface of the cutaneous texture.
3d. Into burns, in which the vitality and organization of a
greater or less portion of the cutis, is either immediately or
subsequently destroyed, and a soft slough or hard eschar
produced.
Pearson also names three varieties, and his arrangement is
approved and followed by Dr. Gibson, viz:
1st, superficial; 2d, ulcerated; 3d, carbunculous.
The best classification, however, is that of Dupuytren, which
is recommended by Dr. Henriques.t He divides burns into six
degrees.
t Lectures on Inflammation.
t See British Journal, vol. xi., p. 97.




V52                       B U R N S.
The first occurs when a small quantity of caloric has been
applied for a short space of time, which determines simply a
greater or less degree of inflammation of the skin, and resembling much, simple erysipelas.
In the second degree, there is not only cutaneous irritation
or augmented organic action, but there is also vesication or the
formation of bladders more or less considerable, which resemble
strikingly the blisters of very acute vesicular erysipelas.
The third degree is characterized by disorganization of the
dermoid tissue, and its conversion into a hard, black and dry
slough.
In the fourth degree, both the dermoid and sub-cutaneous
tissues are completely disorganized.
The fifth degree comprises those only in which there is disorganization of the skin and all the subjacent tissues, except the
osseous; and in the sixth, there is carbonization of the osseous
tissue, as well as of the surrounding soft parts.
From the fact, says Dr. Henriques,* that caloric does not
act with the same degreee of intensity upon the whole burnt
surface, it will readily be understood that only the first degree
can occur alone, and that two or more degrees will be found in
all other cases of burns. This is admirably illustrated in the
application of the moxa; where it will be found, at the part
where the heat is immediately applied, the skin diseased and
gangrenous; whilst simple inflammation will be present around
the edges of the slough, which gradually diminishes, the inflammation assuming the figures of concentric circles.
The dangers of this form of injury are various, says Mr. Miller, even to a greater extent than wounds, they are not mere
causalities happening to a part. 1. The system receives a shock,
which, when the injury is extensive and severe, or when it
involves an important part, may terminate the patient's life by
syncop6. 2. Imperfect or nervous reaction may result to an
excessive and uncontrollable degree, the patient sinking exhausted under febrile tumult of the asthenic kind at an early
* Loc. cit.




B   R N S.                     53
period. Sometimes a deceptive lull precedes this form of reaction.  An elderly patient, badly burned, may walk to the
hospital, and yet die in forty-eight hours afterward. 3. Or
reaction of the sthenic type proves excessive, and under
the violence of inflanmmatory fever, life may be endangered.
4. During the progress of inflammatory fever, the internal
organs, more especially the lungs, are apt to suffer, seriously
complicating the case. At a more advanced period, fatal
diseases of the intestinal mucous coat, may occur. 5. More
remotely tedious cicatrization, confinement, and discharge are
prone to peril the system by hectic. Death escaped, life may
be rendered miserable, by the deformity and impairment of
function often inseparable from the healing of the burn.
It will be clearly evident from the above, that an extensive
burn is an extremely dangerous accident, and one, froin which,
though the patient may ultimately recover, may leave deformity,
perhaps remaining for life, or only capable of removal by painful
and extensive operation.
The indications for the treatment of burns are1st. To allay the intensity of the pain.
2d. To arrest the internal reactionary effects.
3d. To prevent deformity.
The above indications are fulfilled in Homceopathic Therapeutics, by external appliances, and internal remedial agents.
The most appropriate external applications are, arnica,
canth., urtica-urens. The injured parts should be washed, first,
with a lotion of ten drops of the mother tincture of either of
the above mentioned remedies, and half a pint of French pale
brandy;* after which the whole affected surface must be enveloped by thick layers of carded cotton, which not only totally
protect the part from atmospheric air, but also appear to
possess a specific action on injuries of this class. The value of
this application was discovered accidentally by a lady living in
* This treatment is taken from a paper by Dr. Henriques, on the
"Homeopathic Treatment of Burns." British Journal of Homoeopathy,
vol. xi., p. 100.




54            TREATMENT  OF BURNS
Harford County, Maryland, whose child was scalded by boiling
water, over nearly its whole body. The mother was carding
cotton in an adjoining room at the time of the accident, and
having no medical assistance within reach, undressed the chil4d
as quickly as possible, and covered the whole burnt surface
with masses of cotton. The effect was wonderful; for the
child soon became perfectly quiet, fell asleep, and upon removing the cotton a few hours afterwards, no inflammation whatever could be perceived.*
When the epidermis is destroyed, as in burns of the third
degree, the best mode of preventing suppuration, and of promoting the reproduction of the cutis, is by penciling the injured
parts with arnicated collodion; and protecting the parts from
the external air with thick layers of carded cotton, as in former instances. In burns of the fourth, fifth and sixth degree,
when there is considerable loss of substance, a solution of calendula or crocus is the best application.
In order to remedy constitutional disturbances, which always
occur with more or less intensity and gravity, the best remedies
are, in the first instances, opium, arnica, coffea, carbo-veg.
Opium is indicated principally in children, who frequently
show a disposition to convulsions and other spasmodic affections
from the feelings of fright, which this accident produces in the
extreme nervous susceptibility natural to this age.
/Jrnica is useful in all cases and ages to allay the extreme
sensibility of the whole body, the general restlessness and intense
pain in the seat of injury.
Coffea is necessary to promote sleep and allay nervous
excitement.
Carbo-veg. is peculiarly adapted to those extreme cases formerly alluded to, in which the pain is so excessive as to threaten
the complete extinction of life.
When excessive reaction takes place, and there is dry, burning heat of the skin, with thirst, head hot and painful, face red,
pulse hard, frequent and contracted, aconite is the medicine
* See Gibson's Institutes and Practice of Surgery, vol. i., p. 72.




TREATMENT OF BURNS.                      55
indicated. Should suppuration take place, and the discharge
be so great as to impair the constitution, it will be necessary to
administer hepar sulphuris, and china, to combat its morbid
effects. Causticum and calcerea carbonica may sometimes be
indicated in such cases.
To favor the sloughing of eschars, and to promote healthy
granulation and cicatrization in the most severe cases of burns,
either arsenicum, nit.-ac., lachesis, rhus-tox. or secale cor.,
may be required, according to the totality of symptoms present
in any given case.
In explaining the variety of lesions which caloric produces,
it has been stated, that the second degree was characterized by
the separation of the epidermis and the formation of blisters.
It is important to bear in mind that, in removing the clothes
from the injured parts, we must be careful not to tear away the
epidermis, because it would greatly increase the sufferings of
the patient, from the exposure of the raw surface to the irritating influence of the atmospheric air; if the blisters are intact
it will be advisable to prick them with a fine needle, and allow
the serum to escape; after which recourse must be had to the
remedies.
The third and last indication of which it is necessary to speak,
relates to the formation of abnormal adherences, which burns
frequently produce; this is a most important point in the treatment of these injuries, because they not only produce deformity,
but also impede the free motion of parts where they occur; and
sometimes prevent the exercise of an important function.
In some instances, no matter how judicious the treatment, this
most disagreeable and unfortunate result cannot be prevented.
It is a natural consequence of the contractive force of the inodulary or cicatrizing tissue. In order to avoid it, however, the
process of cicatrization must be carefully and constantly watched, and so regulated that the cicatrix may have the same extent
of surface as the original skin that has been destroyed; and in
preventing it from being formed by the drawing together of the
edges of the surrounding skin; this can be effected, first, by the
administration of appropriate medicines, when the granulations




56                       o UNDS.
are unhealthy; second, by the proper position of the injured
part; third, by the method of dressing the wound; fourth, by
the use of fitting mechanical apparatus; fifth, by specific
dynamic agents internally administered.  Notwithstanding all
these means, should we fail in preventing deformity, there is still
a resource in operative surgery, which will certainly relieve the
patient.
When the process of cicatrization is accompanied by excessive inflammatory action of the surrounding edges, either ars.,
hepar, merc., nit.-ac., phosph., ruta. or silicea will be found
useful, according to the particular indications of the special case.
When the granulations appear luxuriant or excessive, alum,
sep., thuja, are indicated. When cicatrization is interrupted
by excessive suppuration, the most appropriate remedies are
asaf., caust., hepar, merc., puls., rhus., silic. or sepia. When
the ulcerated surface bleeds, the remedies most indicated are
arn., ars., creos., crocus, phos.-ac. or secale-cor.
The external application of soap (not the Emplastrum Saponis of the Allopathic Pharmacopzeia) is recommended by
Homceopathic physicians. A thick lather should be made of
Castile soap with water, several coatings of which should be
applied, the first being allowed to dry before others are laid on.
The application of cotton, however, is preferable.
CHAPTER VI.
r O U N D.S.
WOUNDS are solutions of continuity in any texture of the body,
occasioned by violence.  This definition includes not only the
most extensive laceration or incision, but also the slightest contusion'or abrasion.
Surgeons have arranged these injuries under the following
heads: Incised, punctured, contused, lacerated, poison-ed and
gun-shot, and these have been subdivided into wounds of the
head, face, neck, thorax, abdomen and extremities.




TREATMENT OF WOUNDS.                      57
There are certain wounds that are not confined to the soft
parts, but affect even the bones; sabre-wounds are of this variety, as they frequently separate at once, both a part of the
scalp and the subjacent portion of the skull. Many wounds of
the head, thorax and abdomen, injure the organs contained in
those cavities; in short, the degree of danger and variety of
wounds depend on the extent of the injury, the kind of instrument inflicting the wound, the size and importance of the blood
vessels that have been injured, the situation and texture of
the affected part, and the age and constitution of the patient.
Injuries of this kind involving large joints, blood vessels and
nerves, are considered as the most dangerous, although a very
slight wound, under unfavorable circumstances, may be productive of the most violent symptoms, and even death.
The constitutional effects of a wound are in proportion to
its magnitude, but this will also depend greatly upon the
nature of the parts injured. In severe wounds, it generally
happens that the whole system for a time is excessively prostrated, there is more or less insensibility, sickness or vomiting,
quick, small pulse, cold, clammy skin, slow respiration, and if
the patient has any command of speech, the voice is very
feeble.  This condition is termed by surgeons the stage of collapse, and supervenes not only upon injuries, but also upon
many operations which the surgeon is called upon to perform.' The treatment of wounds (writes Croserio) depends on the
nature of the tissue injured, the part wounded, the nature and
form of the lesion, the circumstances which accompanied it,
and the condition and constitution of the patient.
"In studying the pathogenetic effects of arnica montana,
we find nearly all the general and local symptoms of sensation,
and even the physical symptoms, such as ecchymosis, etc.,
which result from mechanical violence to the living body; such
as vertigo, so that one is like to fall; heaviness of the head;
loss of memory; varied pains in the head; ringing in the
ears; dilated pupils; swelling of the nose; epistaxis; the
head is so heavy he cannot support it; coagula of blood Jrom
the vagina; pains like those of a luxation; sundering pains;




58           TREATMENT OF WOUNDS.
shocks and blows in the body like electricity; breaking pains
in all the limbs, etc. It is not surprising, therefore, that
Hahnemann regarded it as the special specific in wounds, and
restored it to the honored and merited title, entirely forgotten
by modern physicians, of panacea lapsorum, which Fehr had
given it two hundred years before, although the symptoms
which are manifested in the wounds of certain tissues and
organs, in certain circumstances, are better represented in the
pathogeny of other remedies, such as thus toxicodendron,
aconite, symphytum oficinale, sulphuric acid, causticum, etc.,
which, consequently, are more appropriate in such cases. I
will review briefly the different conditions of wounds, in order
to point out the most appropriate medicines, and the method of
their administration.
"Wounds of parts, the base of which is the cellular membrane,
the skin, the mucous membranes, the muscles, and the serous
membranes, require arnica. If the wound is small and superficial, requiring but a day or two for its recovery, external
application of the remedy is sufficient; but in more grave cases,
it must be given internally at the same time. If there be a
solution of continuity of the skin, the wound should be covered
with a pledget of lint, dipped in the pure tincture of arnica,
which should be renewed morning and evening, for five or six
days, and then be replaced by a large compress, dipped in a
solution of a single drop of the tincture in an ounce of fresh
water; which has the double advantage of keeping the skin of
the wounded part cool, and maintaining the specific action of
the remedy. The compress should be dipped in the solution as
often as it becomes dry. If the skin remains undivided, the
pledget may give place to simple frictions of the part, with the
same tincture. It is necessary to give careful attention to
subjects with a fine, sensitive skin; that the external application be not continued too long; for. it may produce irritations
or eruptions on the part, which are removed with difficulty.
The Count de V., an old man, of nervous temperament, fair
complexion, and fine skin, after a fall by which he received a
severe blow on the patella, followed by an extremely painful




TREATMENT O F WOUNDS.                    59
swelling, made application of the pure tincture of arnica to the
parts, and the desire of a rapid recovery induced him to renew the
dressing several times a day, with an excessive quantity of the
tincture. After the fifth day of its use, red and painful pimples, like the eruption of variola, appeared on the knee, and
the hand employed in the friction; and although the remedy
was discontinued, the eruption soon covered the whole hand,
and extended to all the parts which had been touched with the
tincture. In a few days, the pimples overran the whole lower
extremities, even to the soles of the feet, and then extended to
the abdomen, back, arms, scalp, in a word, the whole surface
of the body was covered with a copious eruption like distinct
small-pox. It was not accompanied by fever, or any symptoms which would warrant the suspicion of eruptive fever;
although the patient was of a gouty diathesis, and had many
chronic symptoms, which revealed a psoric taint, still the order
of its appearance left no room for doubt as to the origin of this
phenomenon, viz,, the dynamic action of arnica. His cure
was long and difficult. Antidotes to arnica were of no avail.
Sulphur and other antipsorics were alone of service. This
case has made me cautious in the application of the tincture of
arnica. After four or five days, I dilute it with a quantity of
water; more or less, according to the sensibility of the skin.
If the wound be deep or extensive, or if there be reason to suspect a dynamic action on the tissue of the part wounded, or on
other parts, arnica should be immediately administered internally, and repeated as often as may be necessary, for an interval of
two or three days. If the injury has been attended with circumstances calculated to excite terror, as a fall, and if it be
recent, it will be well to administer first a dose of aconite, and
an hour after, arnica.
" Wounds in tissues of great sensibility, as of the nerves, or
in tissues very susceptible of inflammation, require aconite, and
when they are very painful, and accompanied with inflammation, even without fever; and especially, if there be fever,
they should always be combated with aconite before the use
of arnica, if indeed this last be at all necessary.




60            TREATMENT  OF WOUNDS.
"Wounds which are not kept open by accidental causes, such
as the movement of the parts, foreign bodies, or a great alteration of tissue, and which are not healed in the time which their
extent would seem to require, suggest the presence of psoric
taint in the constitution. In such cases, if, after one or two
doses of arnica, there is no amendment, I give sulphur 30,
every five days, till I perceive some effect from it; I then leave
it to exhaust its action, and ordinarily the cure is effected
without any other remedy, or arnica may then prove efficacious.
"Fibrous tissues, as the tendons and ligaments, require thus
toxicodendron, 30, internally administered, especially if the
wounded parts have suffered violent tension, as in sprains, luxations, or muscular efforts; and at the same time, the remedy
may be externally employed. Rhus vi., 9th, in three ounces
of water. This remedy is often of surprising efficacy in injuries of ancient date. The lady of a superior officer of the 66th
regiment of the line, in garrison at Metz, was confined to her
pallet by a sprain received three months ago. All allopathic
means employed for her relief had proved fruitless. I sent her
trhus 30, to be dissolved in eight tablespoonfuls of water, a
spoonful to be taken every morning. She immediately experienced the best results; was able to walk about her room the
first day, and the fifth, through the city.
"Glandular tissues, cellular in their texture, when recently
wounded, require arnica; but if the injury has been neglected,
and indurations have formed in the organ, conium 30, in eight
spoonfuls of water, a spoonful every morning, is to be prescribed. Injuries of the bones are healed most promptly by
symphytum  of/icinale 30, internally, once  a day.  This
remedy accelerates the consolidation of fractures surprisingly.
I have seen a transverse fracture of the femur so united in
three weeks, as to dispense with the bandage, and permit all
necessary freedom of movement of the limb, though, as a precaution, the patient was kept in bed two weeks longer. A
fractured radius, near its carpal extremity, of an aged lady,
was perfectly healed in three weeks, without deformity of




TREATMENT OF WOUNDS.                        61
the wrist-joint.  In these cases I used arnica internally and
externally, the first five days, to prevent local inflammation
and traumatic fever, afterwards the symphytum, as above described.
" Of the parts wounded, I have little to add to what has just
been said of the tissues. I will only remark that the pathogenetic effects of arnica on the head are so numerous and characteristic, that it is not surprising its curative effects on this part
of the body have been so frequent and important. The observation of Dr. Crepu, of Grenoble, in the Bibliothique Homceopathique, is remarkable for the numerous cures of these lesions.
In all cases of wounds of the head, arnica, both internally and
externally, is to be employed, but with the exercise of caution
as to the dose, because of the great affinity of this remedy
with the head, that we may avoid dangerous medicinal symptoms. If not called to the patient till the injury has developed
violent inflammatory fever, with redness of the face, aconite
should be first administered, and if this be not sufficient,
belladonna, especially if there is delirium, before having recourse
to arnica internally, although this complication need not hinder
the immediate local application of this remedy, as already
directed.
"'The eye is so sensitive, vascular, and ready to take on
inflammation, that, when wounded, we must immediately have
recourse to aconite, 30, in three tablespoonfuls of water, a
teaspoonful every two hours, and even every hour, if the
inflammation is severe. Hahnemann recommended this remedy
in cases of foreign bodies lodged in the eye, and experience
has many times confirmed the utility of the prescription.  In
wounds of the organ, it is indispensable.  In severe cases, I
apply, locally, a solution of aconite 6, in a glass of water.
This remedy suffices for the whole cure. It is to be continued
in all cases till the inflammation and pain are entirely dissipated. The wounds of the lids class with those of the skin; and
if the globe is not affected, arnica will suffice for their cure.
"Wounds of the chest, whether penetrating or otherwise,
as well as severe contusions of this cavity, require arnica,




62           TREATMENT OF WOUNDS.
whether there be hemorrhage or not. If the heart or its
pericardium be involved, perhaps aconite may be serviceable
in the first instance.
" Wounds of the mammary glands fall under the observations
already presented in relation to glands; but their sensibility
renders aconite necessary when acute inflammation is developed,
and phosphorus 30, when there are indications of suppuration.
A young lady received a blow on the breast. She had neither
pain nor indurations in it before the third day. On the fifth,
an allopath ordered fifteen leeches. The pain and inflammation increased from this time. I was called the eighth day.
The breast was a deep red, with shooting pains extending to
the axilla. Fluctuation was perceived in the centre of the
tumor. I gave phosphorus 30, in four tablespoonfuls of water,
to take a spoonful immediately, and evening and morning, with
the removal of all topical applications. The next morning, she
reported a better night. The breast had nearly regained its natural size and color; the abscess appeared reduced to a fourth
of its previous extent; and the third day the cure was complete.
"Penetrating wounds of the abdomen, with lesions of the
peritoneum, or contained organs-as the liver, intestines, or
bladder-also involve organs very susceptible of inflammation,
and of that, too, which is exceedingly dangerous. The old
school are accustomed to exhaust or destroy their patients to
prevent this inflammation, (as happened to Canel, late editor
of the French National,) by abstractions of blood, which is
ever insufficient for the attainment of the object. Hahnemann
has given to the art of healing more efficacious and more rational
means, with which to meet these serious injuries..Aconite,
administered immediately as directed for wounds of the eyes, at
once calms the nervous excitement and anxiety of the patient,
and at the same time prevents the vascular excitement, which
ends in the inflammation of the parts. If visceral inflammation
be already developed, with symptoms of peritonitis, after a
dose of aconite, recourse must be had  to belladonna 30,
repeated till the inflammation be resolved. J.rnica will complete the cure.




TREATMENT OF WOUNDS.                      63
"The treatment of wounds is modified somewhat by the
nature and form of the lesions. Those produced by a direct
percussion, whether simple contusions or solutions of continuity,
or by a cutting or pointed instrument, require arnica; thus,
gun-shot and bayonet wounds, falls, &c., demand this remedy.
Superficial contusions, and those of long duration and those
from riding on horseback, yield most speedily to a local application of sulph.-ac. Mechanical lesions, produced by a simple
distention of tissue, such as sprains and luxations, often yield
only to rhus-tox., administered as above directed.  Jrnica is
often followed by prompt success in injuries of this description.
" The treatment of burns should be varied according to the
extent and depth of the organic lesion, and the attending circumstances. Burns which do not penetrate beyond the epidermis, are
resolved with great promptness by the application of arnica,
but I have had no experience with it in more profound injuries
of this sort. Carb.-veg. 30, internally, has been recommended,
by which great advantage is said to have been obtained. It
soothes the frightful pain with great promptness. In deep
burns, in which it is to be feared the viscera have been involved,
as the danger consists in consecutive inflammation, aconite
should be of great value. When inflammation has been prevented or subdued by aconite, the sloughing of the eschars will
be promoted by arsenic 30, repeated according to the necessity
of the case. If the suppuration be very abundant, china 12,
may be preferred. If the acute pains of the burn do not yield
to carbo-veg., recourse should be had to coffea 3.
Dr. Goullon, of Weimar, has employed causticum for a long
time with great success, given internally, every three or four
hours, and externally, in solution, especially when the injury
has been of long continuance, and has been buried in ointments. The pathogenetic symptoms which attend the phlyctnoidal eruptions of this antipsoric led him to the choice of the
remedy.
" The accompanying circumstances which may present especial
indications of treatment are terror, and other moral emotions,
which the cause of the injury may have produced. If the




64           TR EATMENT OF WOUNDS.
patient has been affected with terror, the remedy is aconite; if
he has had anger or rage, chamomilla or bryonia; if he is addicted to excesses of alcoholic drinks, or if intoxicated at the
time of the injury, he should immediately have a dose of nuxvore., and afterwards, the remedy specific for the injury received. If he has lost much blood, he should have china 12, and
arnica seven or eight hours after.
" Of course, the dynamic treatment which homceopathy brings
to the cure of wounds should be aided by the mechanical
appliances of surgery, when they are required. Parts should
be retained in the most complete repose; wounds should be
cleansed, and the junction of divided tissues maintained by appropriate means. Parts displaced are to be restored.  Divided
vessels are to be tied or compressed; and foreign bodies
removed by the necessary operations.
" The regimen to be observed is that appropriate to convalescents, and neither the severe diet nor the sanguineous depletions resorted to by the old school, to prevent inflammation.
The proper administration of homeopathic remedies, internally
and externally, attains this object much more successfully, and
by sustaining the vital forces by appropriate nutrition, they
repair with greater facility the losses occasioned by the wound.
"When inflammation supervenes in a wounded part, after
removing its cause, give aconite as directed; and if the part be
threatened with or attacked by erysipelas, belladonna.  When
profuse suppuration is produced by the presence of a foreign
body in the wound, or by lesion of the bones, as in the case of
gun-shot wounds, with considerable comminution of the fragments, china 12, every day, is indicated. It is also serviceable
in the diarrhoea produced by the absorption of pus, and in colliquative sweats. If these symptoms are obstinate, recourse
must be had to sulphur. Silicea, mercury and phosphorus may
be useful in some such casts.
"The gangrene which occurs in wounds should be treated
according to the supposed causes. I have, however, found
china 12, morning and evening, very serviceable. If it be extensive, with ichorus suppuration, arsenic 30, in three table



TREATMENT OF WOUNDS.                       65
spoonfuls of water, a teaspoonful every three hours, and lotions
of the same attenuation, are preferable.
"In surgical operations, homeopathy possesses many precious
resources with which to ensure success. It is well known that,
of the operations the best performed, death often follows after
a longer or shorter period, in consequence of traumatic or suppurative fever, secondary abscess, of absorption or excessive
secretion of pus; so that the operation the most plainly indicated, and best performed, is often the cause of the more sudden
destruction of the patient.   Surgery is painfully impotent to
prevent or cure these accidents. Bleeding, and only bleeding
and diet, with opiates, its sole resources, ought to be, and are,
followed by unfavorable results, for the debility consequent on
blood-letting increases greatly the moral and physical sensibility of the patient to the pains and emotions of operations, and
consequently can never prevent the evils developed by these
causes. Just as a feeble valetudinarian or convalescent will be
more readily made ill by external causes of disease, than the
strong and robust, as is proved by daily observation.  For the
same reason, an individual enfeebled by blood-letting or severe
diet is less likely to sustain a severe operation than in his natural state. This truth, so simple in itself, is the reason why so
great care is taken to avoid exposures to cold and other causes
of disease, while fasting in the morning. It required the flippancy of the schools to set at naught observations of so long
standing, and so oft repeated. Homceopathy, having removed
these prejudices, provides means more in accordance with
natural laws, the superior efficacy of which, experience has
ever confirmed. The late Dr. Gueyrard employed them in a
case of amputation of the thigh, by Professor Berard, with the
greatest success: cicatrization followed, without either traumatic fever or suppuration. September 20th, 1841, I assisted
the same professor in the excision of cervix uteri, invaded by
a cancerous fungus. The patient, forty-five years of age, of a
nervous temperament, had for two years been subject to considerable uterine discharges, which she supposed indicated that
the catamenia were about to cease, and gave them no particu5




66           TREATMENT OF WOUNDS.
lar attention, till at last she was seized with severe pains in the
loins, abdomen and thighs, when I apprized her of the necessity of ascertaining the cause of her distress.   MM. Marjolin
and Lisfranc confirmed the diagnosis of disorganization of the
cervix, and declared its immediate removal indispensable.
Professor Berard would only undertake the operation on the
condition that I should continue my attendance on the patient.
I forbade the potions he directed to calm her nervous excitement, arising from the necessity of submitting to such an operation. In order to attain this object, she was only directed to
inhale ignatia the day preceding that of the operation, and
aconite an hour before its commencement, and at the moment
of her being placed on the table. The operation was performed
with the greatest exactness, and lasted twenty minutes; yet
this female, so nervous and timid, had no fainting. After the
operation she had an injection of the solution of the tincture of
arnica, in water, and inhaled very lightly, aconite; and as
soon as the patient was removed to her bed, I dissolved
arnica 12, in a glass of water, of which she took a teaspoonful every four hours, while the local application of the remedy
was continued. The excised portion was of the size of a hen's
egg, and embraced the whole cervix.   The division was
through the healthy tissue of the uterus. The hemorrhage
during and immediately after the operation was trifling; but
two hours after it became frightful. It was arrested by the
two assistants who had been left with the patient, in anticipation of this accident, by compression of the abdominal
aorta.   After this there was not the slightest unfavorable occurrence; the patient had positively no fever, and the
wound cicatrized the twelfth day. The symptoms of abdominal irritation or congestion, which sometimes exhibited themselves, were combated with belladonna and nux vomica.  The
catamenia have never returned, and her health has been good
during the year which has elapsed since the operation. Will
it continue? Time will show.
"In the meantime it must be acknowledged, that homceopathy was here of great service, since the operator has declar



TREATMENT OF WOUNDS.                      67
ed, that it was the only case in which he had known a similar
result.
"The report of this case shows the manner of employing
homceopathic medicaments, in grave operations, where large
wounds are inflicted, as in amputations, extirpation of tumors,
etc. Pledgets of charpie, and compresses dipped in solution
of tincture of arnica, and the dressings to be wet several times
a day with this solution, till the cure is effected, as directed in
the case of wounds.
"Dr. Wurtzler, of Bernbourg, in a memoir presented to the
Central Homceopathic Society, in 1841, recommends aconite
immediately after the operation, and says its effects are astonishing.  The pains were entirely dissipated at the end of three
hours, at the latest, and the patients slept immediately after
the operation very quietly, as in some instances they had not
done for years. Sometimes the terror produced by the shock
of the operation required opium. One patient also slept very
calmly under the influence of arnica. The pathogenetic symptom  of jerkings of the limbs renders it immensely valuable in
amputations and fractures, where patients are so tormented by
jerking of the muscles of the affected limb during sleep.
"' Operations on the eyes require the same management as has
been directed for wounds of these organs. Dr. Wurtzler, in
the memoir just cited, makes some very interesting observations
on these operations.
" The chief remedy of the operations on the eyes," says he,
C appears to be aconite. Before I ascertained this application
of the remedy, I had tried several medicaments without success, and particularly arnica proved powerless. In many
cases, aconite alone is sufficient for the entire cure; at times,
as exceptions, I have been compelled to have recourse to some
other remedy.
"In patients of very gentle disposition, aconite is not always
appropriate. Then the violent lancinating pains in the temples and eyes are removed by ignatia.
"If there follow violent pains, with vomiting, bryonia will
be useful.




68           TREATMENT OF WOUNDS.
"If the pains were by shocks, with vomiting and lientery,
asarum relieved.
"If the pains were burning, with diarrhcea, arsenic gave
relief.
"Crocus removed pulsation and beating pains in the eyes.
If there be lancinating pains through the temples, with complete loss of appetite, thuja is the appropriate remedy.
"After depression of a cataract, when the crystalline lens
was broken in small fragments, senega produced their absorption.
" When, after the cure, vision was affected by various
colors, particularly when objects appeared covered with blood,
strontiana gave perfect relief.
"In operations in the cavity of the abdomen, and on the
organs of generation, the same treatment should be had recourse to as in wounds of these parts../conite, and sometimes
belladonna, should be continued after the operation, so long as
inflammation threatens, before passing to the use of arnica,
after which, the wounds belong to the class of ordinary injuries,
and should have the same treatment. I have not spoken of the
preparatory treatment to which surgeons have thought proper
to subject their patients previous to their operations, and which
always has an effect contrary to that desired, because this
belongs to the medical treatment of the disease requiring the
operation, when this has proved insufficient for its cure.  This
treatment is of the greatest value if it has been properly
directed, for it will have destroyed, in a great degree, the
psoric taint of the constitution, which so frequently reproduces
the disease where this precaution has been neglected.
" The subjects of operations are in a pathological condition
which renders them extremely susceptible of impressions from
external objects, and surgery rightly recommends the greatest
caution in preserving them from such influences; but if accidents from this source have already occurred, the resources
of homeopathy are powerful to arrest and remove them, by
administering, the soonest possible, the specific against the
presumed cause, and the symptoms it has developed. Care




INCISED  WOUNDS.                     69
must be exercised to arrest these complications in their outset,
for they soon attain a gravity which compromise the success
of the operation.
"The prompt and salutary effects of homceopathic remedies,
so often experienced, as I have already shown, in all sorts of
wounds and surgical operations, are so easily proved, that it is
shameful, and even criminal, on the part of the Army Board
of Health, (Conseil de Salubriti des AJrmees,) that they have
not taken the necessary measures to prove the reality of these
advantages. What a difference in the fate of the unhappy
man struck by a shot on the field of battle, if there were a
small supply of arnica to mingle with a little water, with
which the surgeons could bathe his wound. Those acute
pains which so torment him during the first few days, the
traumatic and suppurative fevers, the copious suppurations,
which so often exhaust and carry down to the grave, and the
more terrible gangrene and tetanus, so frequent in warm climates-all these sufferings and dangers can be avoided by it,
and the wounded will only endure the sufferings inseparable
from the destruction of the tissues affected by the wounding
body; their recovery will be more prompt, and never followed
by those protracted and painful convalesences so expensive to
government, by the wounded being left the subjects of interminable pains through all their subsequent lives. We hope,
when these facts come to the knowledge of that great mind
who has the direction of the department of war, his love for
the soldier will induce him to order the necessary measures for
the investigation of a truth so important to the welfare of the
troops and the economy of public treasure."
Section 1.-Incised Wounds.
Incised wounds are inflicted with a sharp, cutting instrument,
and are generally considered the simplest of all the varieties
previously mentioned, but the latter feature must depend to a
certain extent on the parts that are injured. The most trouble



70      TREATMENT  OF INCISED WOUNDS.
some symptom is hemorrhage, and this aside, there is but
slight danger connected with them-fibres have been simply
divided, they have suffered no contusion or laceration, and consequently they are less likely to inflame severely, or to suppurate or slough.
Simple incised wounds pour out more blood than the contused or lacerated, although in the latter much more important
blood vessels may be injured, but their coats not being divided
entirely or fairly, they recede, owing to the size of the instrument by which the wound is produced, or to their inherent
elasticity or contractility.
If the hemorrhage be arterial, the blood has a florid, bright
red color, and if vessels of any magnitude are severed it spouts
in jets; if the blood be venous, it is a dark red or purplish, and
flows gradually.
Treatment.-In the treatment of incised wounds, the surgeon
should endeavor to accomplish three objects, viz: 1st. Arrest
the hemorrhage. 2d. Remove all extraneous matter from the
wound. 3d. Coaptate the edges in the manner most favorable
for their union.
Arterial hemorrhage is most effectually checked by the application of a ligature to the ends of the vessels, (it is frequently
necessary in the treatment of incised wounds to ligate both
extremities,) when the bleeding is slight, it may be arrested
either by compression or twisting the divided ends of the
artery.*
After the first and most important object has been effected,
attention must be directed to the second consideration-" removal of all extraneous matter." The wound should be carefully
examined, and all such substances, which, by their presence
would prove a source of irritation, (glass, dirt, clots, &c., &c.,)
should be gently removed, as it is impossible for the wound to
heal by the first intention, if such be allowed to remain.
Hemorrhage having been staunched, and the wound cleansed,
the third consideration, coaptation, is to be thought of. In former
days it was deemed advisable to effect the union immediately
* See chap. on arresting hemorrhage.




TREATMENT OF INCISED WOUNDS.                    71
and completely, but the experience of modern surgery teaches
the expediency of moderate delay and incompleteness.
If the external wound be put together while oozing blood
continues, even though slightly, especially if the part be covered
with lint, bandages, &c., adhesion is necessarily thwarted, on
account of the oozing blood, which, being unable to escape,
accumulating, forms a coagulum between the lips of the wound,
and this, acting as any other extraneous body, prevents the
union.
All attempts at closure should, therefore, be delayed for a
time, in wounds of moderate extent; and in those of large
dimensions, the approximation of the edges should be incomplete. In cases where the wound is not extensive, a few
moment's delay suffices, and when the cut surfaces present a
glazed appearance, they should be nicely adapted and retained,
either by straps or sutures.
If the oozing from the lips of the wound continue for some
time, and if a considerable amount of blood is thus discharged, the
internal administration of arnica, crocus, diadema, creosote or
phosphorus, should be internally administered. If the patient's
strength appears to be failing very rapidly, the countenance
becomes deadly pale, or assumes a livid appearance, china-off.,
should be prescribed, and the dose repeated every ten or fifteen
minutes, until the symptoms commence to disappear.
After the bleeding has entirely ceased, adhesive plaster and
position are frequently sufficient to complete the cure; this
method, if practicable, is much preferable to any other for promoting union; but there are cases in which the wound is so
situated, or so extensive, as not to admit of the application of
adhesive straps, and when such is the case, recourse must be
had to sutures. Those most commonly employed are the interrupted or twisted.
In wounds that are slight, a French surgeon, M. Vidal, employs small spring forceps, which at their extremities are provided with hooks, sufficiently sharp to hold the integument,
without transfixing or laceration: when they have been
allowed to remain, from ten to fourteen hours, the wound may




72     TREATMENT OF INCISED  WOUNDS..
have sufficiently healed to permit their removal, after which all
other means required for retention, are said to be unnecessary.
When strapping is deemed sufficient to produce adhesion,
the part should be placed in the position that relaxes the
fibres of those muscles, which if remaining tense, would tend
to retard union. The surrounding skin should then be perfectly
freed from moisture; and if there be any hair upon the part,
it should be carefully shaved. The plaster that is now most
in vogue, and is regarded by experienced surgeons as preferable
to any other, is that composed of a strong solution of isinglass,
in spirit, spread evenly upon oiled silk, fine animal membrane,
or upon silk gauze; the latter is recommended by Mr. Miller,
as the best, when prepared in the following manner: The
gauze should first be rendered water-proof by a coating of
boiled oil, and then laid over with layers of the dissolved isinglass. The advantages of this plaster are, that though it adheres with much tenacity, it does not encourage inflammation,
that its frequent removal is not necessary, and that, being
translucent, the whole track of the wound may be examined,
as though no dressings were present. The straps should be
long, and extend some distance from the wound, in order
that they may supply the place of the bandage, in supporting
the surrounding parts. Interstices should be left between the
straps, to allow the escape of the serous discharge, that passes
off during the process of adhesion.
If sutures have been employed together with the plaster,
they should be allowed to remain uncovered, in order that they
may be easily removed, when their aid is no longer essential. The sooner they can be dispensed with, the more rapid
will be the adhesion.
After the wound has been dressed, the patient should be
placed in bed, all stimulating diet should be prohibited, and
all causes of excitation be, if possible, removed; arnica should
then be administered internally. If the patient be robust,
and there is a tendency to fever, delirium, &c., acon. or bell.
may be employed. Staphys has been recommended for incised
wounds.




PUNCTURED WOUNDS.                      73
After surgical operations, &c., acon. has been very highly
recommended. Dr. Wurtzler writes, "After amputations, extirpations and other surgical operations, I have invariably derived
the most important service from the employment of aconitum.
In most instances a complete cessation of pain took place, three
hours after its administration; traumatic fever never supervened, and the patients almost always fell into a placid and
refreshing slumber; but rarely was it found necessary to have
recourse to opium, and that only when startings from sleep
took place from local or general convulsive jerkings or
twitchings."
Section 2.-Punctured Wounds.
Punctured wounds are inflicted by sharp and narrow instruments, as needles, pins, thorns, nails, splinters, &c., which
bruise and tear as well as cut. They are, when slight,
attended with little danger, but when of any considerable
extent, the injury is always serious. Much also depends upon
the constitution of the patient, and the situation of the
wounded part. A superficial wound along the integument,
and not involving the textures beneath, is of trivial importance;
but when the direction is from the surface internally, there is
always some danger to be apprehended, either from the injury
inflicted upon some internal organ, or from inflammation
occurring in the deep part of the wound, inducing the formation of matter, which  being  confined, infiltration of the
surrounding textures is likely to supervene, giving rise to
much constitutional and local disturbance.  Large collections
of matter have formed beneath the fasciae, giving rise to
excessive pain, and even permanent contraction or extension
of the limbs, by uniting the muscles or their cellular texture
together.
Dr. Gibson mentions a case of a young man, whose forearm
was covered with sinuses, from which matter could be pressed




74   TREATMENT OF PUNCTURED WOUNDS.
in every direction. The fingers were permanently contracted,
and consequently useless. The disease arose from a very
trivial wound inflicted by a needle, fixed in the end of an
arrow.
The lymphatics often swell from punctured wounds. A
wound in the foot may produce a sympathetic bubo, or a
wound in the hand may give rise to inflammation and swelling
of the axillary glands.
Treatment. It was formerly the custom among surgeons to
endeavor, by immediately dilating punctured wounds, to convert
them into incised, and treat them as that variety of injury; but
this cruel practice is fast becoming exploded, although dilatation
may be necessary under peculiar circumstances-viz: If a
portion of the weapon that inflicted the wound be imbedded in
the injured textures, its removal requires that incisions be
made to permit the introduction of instruments used in extraction. If an artery be punctured, it must be ligated; and this
requires a certain degree of dilatation. Or, again, when by the
formation of matter, infiltration of the surrounding tissues is
threatened, free incisions must be employed.
But in many cases of punctured wounds, after ascertaining
that there is no extraneous substance present, by the use of the
isinglass plaster, and by placing the part at rest and in the
proper position, union by the first intention takes place, and
the wound in a short time heals. If, however, inflammation
appear and suppuration  threaten,  hepar,  mercurius,  or
silicea, should be administered.  If the local inflammation is
excessive, cham., bell., or rhus, will prove serviceable; but by
the judicious and early exhibition of arnica or aconite, the
above symptoms may be prevented. JNit.-acid and cicuta-vir.
have been recommended in the treatment of this variety of
wounds.
Ledum is said to be one of the most serviceable medicines
in punctured wounds and affections attendant upon them.
The characteristic symptom for its exhibition is coldness during
the fever. M. Teste remarks —"Ledum is for wounds inflicted
with sharp instruments, what arnica is for contusions."




CONTUSED WOUNDS.                      75
The above writer mentions instances in which this medicine
was productive of most beneficial results.
" 1st. In several whitlows, caused by the pricks of a needle.
" 2d. Violent bite of a water rat.
"3d. In a serious wound inflicted upon a young lady, who
fell, with an embroidery needle in her hand, which pierced
through and through. No hemorrhage occurred, but I observed
the intense cold, which accompanies and characterizes ledum
fever."*
If there be any laceration present, calendula officinalis
should be used internally, and also as an external application.
Indeed, this remedy has been highly extolled by Dr. Thorer,
as exercising great control over the processes of granulation
and cicatrization. The directions for preparing the aqua calendula officinalis, are as follows: —
"Fill one-third of a clean bottle with petals, or leaves of
the flowers; the remaining two-thirds with fresh pure spring
water. Cork the vial well, and expose it for two or three
days to the rays of the sun. The water is by this process
rendered slightly aromatic; it is then poured off from the
leaves into a bottle, which must be sealed and placed in a
lower temperature. While the liquid is being exposed to the
rays of the sun, it must be narrowly watched, and as soon as
there are signs of incipient fermentation, measures must be
taken to arrest it."
If, as a consequence of punctured wounds, tetanus supervene, acon., am., angust., cicuta, may be employed.t
Section 3.-Contused Wounds.
In every contusion there must be a certain degree of injury
inflicted upon the parts beneath, though the integument from its
elasticity may remain unbroken.
Ecchymosis in the generality of instances, occurs from the
*Teste-Mat. Med., p. 77.
t See chapter on Tetanus.




76     TREATMENT OF CONTUSED WOUNDS.
rupture of smaller blood-vessels, their contents being poured
into the surrounding cellular tissue.  If larger vessels have
been torn, danger is to be apprehended from the extensive
infiltration of blood, giving rise to inflammation, suppuration
and gangrene.
If, together with the contusion, the intergument is broken,
the injury is then termed a lacerated wound. Such wounds,
when first inflicted, give rise to little pain, because the nerves
of the part have suffered from the concussion; but after a time,
when the part has to a certain extent recovered its nervous
power, the pain increases in proportion to the inflammation
that is established.
The degree of violence of contused wounds, is in proportion
to the velocity with which the contusing weapon is carried
against the parts, and the resistance of the textures to which it
is applied. If the parts yield, the shock is diminished, and
consequently the injury is less considerable.
Treatment. —In simple bruises, or in the most violent contusions, provided there is no abrasion of the integument, the
remedy is arnica, administered internally, applied as a lotion
externally, or both.
The extraordinary virtues of this "panacea lapsorum," is
not only appreciated by the whole medical profession, but as a
domestic medicine its excellent qualities are fully understood,
and the frequency with which it is employed with success,
bears testimony to its usefulness in all manner of bruises.
As an external application, the tincture should be diluted,
according to the sensitiveness of the skin of the patient, but in
the generality of cases, one part of the pure tincture to ten or
twelve parts of water will be sufficient.  If ecchymosis be
present to any extent, the internal administration of arnica or
sulph-ac., will generally suffice.
If, however, by the use of the diluted arnica, there be any
aggravation of pain, or if any of the pathogenetic effects of the
drug are manifested, calendula-oficinalis must be employed.
Helianthus and symphytumn have also been recommended.
If contused wounds be slight, and the vitality of the affected




TREATMENT OF CONTUSED WOUNDS.    77
part not much impaired, union by the first intention should, at
least, be attempted, inasmuch as partial agglutination may prevent deformity and other ill consequences; but if the injury be
of any considerable extent, adhesion is impossible, for the
bruising is such, that the texture is immediately deprived of
life, or its vitality is so much diminished that death is inevitable.
In all cases, sutures should be dispensed with, and isinglass
adhesive straps employed, to retain the edges of the wound as
nearly in situ as possible. Rest andl perfect relaxation of the
muscles of the part are indispensable.
When ligaments or tendons are implicated, thus tox., as
adapted particularly to extension of such tissues, is preferable
to arnica as an external application, and should also be administered internally.
If gangrene threaten, china-off. should be immediately prescribed(l; but if the wounded part assume a bluish tinge, and
the patient's strength sink rapidly, arsen., or carb.-veg., must
be administered.
When there has been considerable loss of substance from
contused wounds, the parts can only heal by granulation, and
if there be present any dead or (lying tissue, it must first slough
away. When such is the case, the patient must be kept at
rest and hepar or mercurius-sol., be administered to aid nature
in her efforts to cast off the slough, and when this has been
effected, calendula, silicea or sulphur may be administered to
forward the granulations, and complete the cure. If the bones
or periosteum has been affected by the injury, mez., phos.-ac.
and ruta., should be employed; the latter is especially serviceable, when the wound has involved the tarsal or metacarpal
joints.
In all injuries when there is great contusion, arnica should
be immediately administered internally, and if high fever delirium supervenes, it may be alternated with acon., bell., hyos. or
stram., according to the indications for each medicine. If the
fever assume a lower grade and typhoid symptoms are present,
thus, ars. or carb.-veg., must be employed agreeably to the
presenting symptoms.




78             LACERATED WOUNDS.
Section 4.-Lacerated Wounds.
A wound is said to be lacerated, when its edges present a
torn and ragged appearance.
In this variety of injury, there is generally but little hemorrhage, and it is this circumstance that frequently leads
inexperienced practitioners to establish a false prognosis regarding the termination of the case, but the experienced surgeon does not allow himself to be deceived by the absence of
hemorrhage; on the contrary, in proportion as there is little
bleeding, the violence that the fibres and vessels have received
is estimated. Whole limbs have frequently been torn from the
body, without the occurrence of profuse hemorrhage.
In La Motte's TraitW  des.Sccouchernens, can be found an
interesting account of an injury of this kind, that happened to
a lad, who, while playing near the wheel of a mill, entangled
his arm and forearm in the machinery. The limb was violently
torn away from the shoulder joint, but the hemorrhage was
so trivial that it was stopped with a little lint, and the boy very
soon recovered.
The indisposition to hemorrhage manifested by lacerated
wounds is owing to the following circumstances. The orifices
of the bleeding vessels, from the laceration, become drawn together or as it were puckered, consequently, the stream of
blood is diminished in volume; they also retract to a greater
degree than when they have been evenly divided; the sheathes
of the vessels are drawn, at the lacerated extremity, to a point,
which also tends to retard the flow of blood, and the arterial
coats being divided at different times contract separately, the
internal and middle being the first that are separated. These
circumstances, as will be perceived, tend greatly to arrest the
hemorrhage, which otherwise would necessarily occur.
Any irregular body, driven with violence, may produce a lacerated wound. They may also be caused by falling from a height
upon uneven surfaces; but machinery, when in full motion,
produces, perhaps, the most fearful and disastrous lacerations.




TREATMENT OF LACERATED  WOUNDS.   79
There are cases of this description recorded by Carmichael,
Morandl, Chesselden, and also in many of the medical and surgical journals, that are highly interesting, as denoting from what
frightful laceration the system may ultimately recover.
Complete union by the first intention is impossible in lacerated wounds; inflammation and suppuration are certain, and the
dead tissues must be thrown off in the form of a slough, and if
this be large, severe constitutional symptoms are likely to supervene; but this is not the only difficulty which has to be encountered, gangrene often spreads rapidly in the surrounding
textures, thus increasing the danger to both life and limb; or
tetanus may threaten with its alarming symptoms.
Treatment.-The first attention of the surgeon when called
upon to treat a lacerated wound, must be directed to the
removal of all extraneous bodies, and if it be present, arresting
hemorrhage. It sometimes happens that dirt, sand, &c., are
begrimed in the wound, and this is particularly the case when
the injury has been occasioned by the patient falling from a
height upon uneven ground and loose stones. After all such
foreign matter has been extracted, and the wound cleansed
carefully, the most important blood-vessels that have been
implicated must be searched for and ligated, and a dose of
arnica administered internally.
It is advisable never immediately to cut away any of the
lacerated soft parts, because it frequently happens that some
portion of them may heal by adhesion, thus leaving a less
amount of surface to be repaired by the reproductive process,
(granulation and cicatrization.)
Adhesive straps should then be loosely applied, and in such
a manner that a free exit be allowed for the matter to escape.
Calendula officinalis, prepared as before directed, should be
applied to the part, and also administered internally in the
usual form, as it is known to prevent, in many instances, that
prolonged suppuration that so frequently occurs in extensive
lacerations, and also exercises a powerful influence over granulation and cicatrization. If, however, the expectation of the




SO               POISONED  WOUNDS.
practitioner be disappointed, and suppuration is excessive,
hepar, silic., or sulph., should be substituted.
If the patient is restless, uneasy, and excited by the least
emotion, and the local pain severe, chainm. will prove serviceable; or if, together with the pain, there is high fever and
delirium, acon. or bell. should be resorted to, the latter particularly if the patient is of a robust habit of body. Either of the
above may be alternated with arnica or calendula.
If the patient becomes extremely weak, with thirst, &c., hot
dry skin, and gangrene threaten, ars. must be substituted; or
if the symptoms correspond, carbo-veg., china, or lach., are to
be employed.
While the ulceration and sloughing are progressing, the
wound must be narrowly watched, as there is danger of
hemorrhage ensuing. Tetanus may also be present, the proper
medicines for which will be found in another portion of this
work. (See Tetanus.)
In some cases, however, notwithstanding the best directed
efforts in both constitutional and local treatment, gangrene
appears to be spreading rapidly; in such the question of
amputation must be seriously considered.  (See Question of
Amputation.)
Section 5.-Poisoned IWounds.
A poisoned wound is characterized by the presence of some
poisonous material, which is itself the principal source of danger, the wound being generally a mere puncture or scratch.
The prognosis in such injuries must depend upon the extent of
the wound and the virulence of the poison introduced into the
system.
The virus* pervades the body through the blood, and
thence reacting deleteriously on the nervous system, interferes
to a greater or less extent with all the animal functions. The
effects are never instantaneous. A certain number of seconds,
* Miller's Principles.




POISONED WOUNDS.                      81
(not less than nine,) are requisite for absorption, even of the
most deadly poisons. Some of the more intense, as that of
the most venomous serpents, would seem to have a direct
influence on the nervous centres; probably by contact of the
poison with the nerves of the part injured.  Certain it is, that
the nearer the wounded part is to the brain, the more
speedily are the untoward symptoms developed. But even
admitting that this direct nervous implication be true, it can
only obtain to a comparatively slight extent; and we are still
forced to hold that the main agent of diffusion through the
system is the circulating blood. For it seems established, at
least in the majority of cases, that the contact of poison with
the surface of the body is not sufficient to give rise to general
symptoms, so long as its diffusion throughout the body, by the
circulation, is prevented.
When virus has been introduced into the system, and is
not speedily thereafter extruded by elimination, it is supposed
that a process takes place in the blood, somewhat analogous to
fermentation, and hence the term Zymosis; whereby the whole
circulating fluid is deteriorated, and the poison at the same
time multiplied, perhaps to a great extent; and, according to
the poison, this process varies much as to the time which is
requisite for its completion.
Some poisons, of much virulence, produce their deleterious
and perhaps fatal effects very speedily —so soon as introduced
by the blood into the system; as happens in the bites of the
most venomous snakes.  Others, again, do not exhibit their
results until the process of zymosis has been tardily completed,
as in hydrophobia. A third class appear to have a doubly
zymotic character.  At first, the part is inoculated; and there
the poison accumulates by zymosis, forming the characteristic
pustule and sore. Thence the system becomes contaminated
through absorption; and in the blood a second or general
zymotic process is effected, whence the secondary symptoms
are produced.
Among insects, the bee, wasp, hornet, and yellow jacket,
inflict a slight wound, and infuse into it poison contained in a
6




82                 POISONED WOUNDS.
bladder situated at the base of the sting. The virus flows
from the vesicle through the sting at the instant this passes
into the flesh. Such wounds are, in this country,* generally
trivial, and  their effects  pass off in  a  short  time;  but
sometimes they are productive of intense pain and violent
inflammation. The virus of the hornet, or of the yellow
jacket, is more highly acrimonious than that of the common
bee, and there are instances on record in which both human
beings and inferior animals have lost their lives from wounds
inflicted by these insects. Dr. Gibson records a case of a
female, who died in fifteen minutes after having been stung by
a yellow wasp. Another case is also mentioned by the same
author, of a young woman who lost her life from swallowing
a bee inclosed in a piece of honeycomb.
The mosquito, certain varieties of spider, and some species
of fly, inflict severe and oftentimes dangerous wounds. In
unhealthy constitutions, or in individuals whose skin is very
susceptible to inflammation, the sting of the mosquito will
degenerate into a troublesome sore. Dr. Dorsey (Elements of
* Insects are the curse of tropical climates. The bete rouge lays the
foundation of a tremendous ulcer. In a moment you are covered with
ticks. Chigoes bury themselves in your flesh, and hatch a large colony
of young chigoes in a few hours.-(p. 404.) They will not live together,
but every chigo sets up a separate ulcer, and has his own private portion
of pus. Flies get entry into your mouth, into your eyes, into your nose;
you eat flies, drink flies, and breathe flies, Lizards, cockroaches, and
snakes, get into the bed; ants eat up the books; scorpions sting you on
the foot. Everything bites, stings, or bruises. Every second of your
existence you are wounded by some piece of animal life that nobody has
ever seen before, except Swammerdam  and Meriam. An insect, with
eleven legs, is swimming in your tea-cup; a nondescript, with nine wings,
is struggling in the small beer; or a caterpillar, with several dozen eyes in
his belly, is hastening over bread and butter! All nature is alive, and
seems to be getting all her entomological hosts to eat you up as you are
standing, out of your coat, waistcoat, and breeches. Such are the tropics!
All this reconciles us to our dews, fogs, vapors, and drizzle; to our
apothecaries rushing about with gargles and tinctures; to our old British
constitutional coughs and swelled faces. —Sid. Smith's Works, vol, ii., p.
147.




POISONED  WOUNDS.                      83
Surgery, vol. i., p. 68) mentions a case where gangrene and
death supervened from a bite of this insect. The patient was
previously enjoying good health. There is also recorded-by
Dr. Mease, in the Domestic Encyclopaedia-an instance in
which the sting inflicted by a spider was productive of fatal
results.
The tarantula-a species of spider, that is found in South
America, Mexico, and in Europe, particularly in the neighborhood of Naples —whose bite has been pronounced by some
authors to be exceedingly severe, while others deny that ill
consequences of any severity result from the virus injected into
the system.
The scorpion is an insect whose sting in warm climates is
so severe that death frequently ensues. It attains its largest
growth in Persia, India, and Afirica, where it is termed the
scorpio afer. The reservoir that contains the poison is situated
near its tail, and is ejected from two small orifices on each side
of the tip of the sting. The symptoms produced in animals
after they had been bitten, were-swelling, convulsions, retching, vomiting, and death soon supervened.
The appearances presented when individuals have been
bitten by the scorpion, are related by Mr. Allan to be similar
to those produced by the stings of bees, but much more
aggravated.*
The two species of American serpents that are the most
venomous, are the copperhead and the rattlesnake. Of the
latter there are ten species. The older naturalists mention but
eight; but the two others-crotalus cumanesis and the crotalus
laeflingii-were discovered by Humboldt and Bonpland. All
are poisonous; but those whose virus is most malignant are
the crotalus horridus, miliarius, and durissus. The poison of
the rattlesnake is of a yellow color, tinged slightly with green;
during the extreme heat, particularly in the procreating season,
it becomes of a much darker hue.t
" Allan's System of Pathological and Operative Surgery, vol. i., p. 370.
t Gibson's Practice of Surgery, vol. i., p. 108.




84              POISONED WOUNDS.
Mr. Catesby* informs us that the Indians, who, in their constant wanderings in the woods are liable to be bitten by snakes,
know immediately if. the wound will prove fatal. If it be on
any part at a distance from the large blood vessels, or where
circulation is not vigorous, they at once apply their remedies;
but if any artery or vein of considerable magnitude is involved,
they quietly resign themselves to their fate.
Sir Everard Home, in some observations on the poisons of
the black spotted snake of St. Lucia, the cobra di capella, and
the rattlesnake, remarks:"T'he effects of the bite of a snake vary according to the
intensity of the poison. When the poison is very active, the
local irritation is so sudden and so violent, and its effects on
the general system are so great, that death soon takes place.
When the body is afterward inspected, the only alteration of
structure met with, is in the parts close to the bite, where the
cellular membrane is completely destroyed, and the neighboring
muscles very considerably inflamed. When the poison is less
intense, the shock to the general system does not prove fatal.
It brings on a slight degree of delirium, and the pain in the
part bitten is very severe. In about half an hour, swelling
takes place from an effusion of serum in the cellular membrane,
which continues to increase, with greater or less rapidity, for
about twelve hours, extending, during that period, into the
neighborhood of the bite. The blood ceases to flow in the
small vessels of the swollen parts; the skin over them becomes
quite cold; the action of the heart is so weak that the pulse
is scarcely perceptible, and the stomach is so irritable that
nothing is retained by it. In about sixty hours these symptoms
go off; inflammation and suppuration take place in the injured
parts; and when the abscess formed is very great, it proves
fatal. When the bite has been in the finger, that part has
immediately mortified. When death has taken place, under
such circumstances, the absorbent vessels and their glands have
undergone no change similar to the effects of morbid poisons,
* Preface to Natural History of Carolina.




POISONED  WOUNDS-HYDROPHOBIA.                    85
nor has any part lost its natural appearance, except those
immediately connected with the abscess. In those patients who
recover with difficulty from the bite, the symptoms produced
by it go off more readily and more completely than those produced by a morbid poison, which has been received into the
system."*
The viper is a serpent, whose bite is exceedingly venomous.
It is the virus of the lance-headed viper, (trigonocephalus lachesis,) with which the members of our school are so familiar, by
the labor of research and the self-sacrificing investigations of
Dr. Hering.
This poison has somewhat the appearance of saliva, but it is
less tenacious. It readily forms into drops, and falls without
threading. It is slightly greenish in color, and when exposed
to the air, concretes into a dry yellow mass.t
The bite of rabid animals produces, in many instances, that
disease termed rabies canina, or hydrophobia, although this
affection does not necessarily follow; for it has certainly been
ascertained, that, out of numerous persons bitten by dogs
undoubtedly mad, few have sustained material injury.
The first symptoms of hydrophobia generally manifest themselves between the seventh and fortieth day; but there are
cases recorded of the virus remaining latent in the system for
months and years. The wound is often slight, and heals
readily until the precursory symptoms of the disease begin to
manifest themselves-when it inflames, becomes painful, breaks
open afresh, assuming a livid and spongy appearance, and
secreting an ichorous humor. The patient complains of pain,
extending from the wound, or cicatrix, along the nerves. The
part bitten feels numb, becomes stiff and immovable, or it may
be convulsively moved.
The patient is troubled with excessive apprehension, the
countenance indicates great anxiety, or the features may
assume a melancholy expression. The sleep is restless and
* Case of a man who died in consequence of the bite of a rattlesnake.
t Jahr's Pharmacopoeia and Posology, p. 221.




86      POISONED WOUNDS- HYDROPHOBIA.
uneasy, interrupted by frequent startings, or there is complete
sleeplessness. There are also present drawing pains in the
nape of the neck, burning in the fauces and stomach, sensitiveness to draughts of air, with vertigo, nausea, and vomiting of
green bile.  Constant urging to urinate, the urine passing in
drops, or an irresistible desire for copulation, are symptoms
that are not unfrequently encountered.
When the convulsive stage sets in, there is that frightful
aversion to liquids which characterized this disease, and from
which it derives its name.* Although the patient is tormented
with violent thirst, even the thought of fluid at once excites
most painful and distressing symptoms. If the attempt be made
to swallow a few drops of water, the throat and chest become
constricted, and the most violent, suffocative convulsions of the
facial, thoracic, and abdominal muscles ensue.  The convulsions
are excited by the most trivial incidents. The movement of
a curtain, contact, &c., give rise to spasm. There is also often
present another very distressing symptom-the collection of
thick, ropy, viscid phlegm, adhering with such tenacity to the
throat that it is extremely difficult, and often impossible to
eject. Dr. Marcet, in the Medico-Chirurgical Transactions,
records a case of this disease in which the phlegm was thrown
off with such extreme torture that the patient exclaimed"O! do something for me!  I would suffer myself to be cut
to pieces!  I cannot raise the phlegm; it sticks to me like
bird-lime!"
Finally, tetanic or epileptic convulsions take place, and
the appearance presented by the sufferer during these spasms
is most horrible and appalling. The face expresses intense
* In a letter published in the Lancet, of September, 1829, the following
remarks occur: —"Drinking water is now no criterion by which we can
judge of the existence or not of rabies. The name of hydrophobia is now
universally allowed to be incorrect, there being no dread of water itself,
but of the horrible spasms which the attempt to swallow liquids induces.
Even this is not so constant an attendant on the disease as it was formerly
supposed to be. There are many well marked cases of rabies without
either a horror of fluids or difficulty of swallowing."




POISONED  WOUNDS —-HYDROPHOBIA.    87
anguish and despair; the eyes are protruded, bloodshot, and
roll wildly in their sockets; the delirium is furious, during
which muscular strength increases to such a degree that the
patient is with difficulty controlled. He howls, bites, and
spits, or endeavors to tear himself to pieces. This attack
continues about fifteen minutes, and subsides for a short period,
leaving a state of complete exhaustion. It is during such
intervals that consciousness is sometimes present, and often
it happens when a slight gleam of reason returns, that the
patient warns his attendants to what danger his rage may
expose them, or prays them in earnest tones to terminate his
sufferings.
Sometimes vomiting occurs. Men may be attacked with
priapism, and women with furor uterinus. The beats of the
pulse are small, irregular, and very frequent-about 130 to
150 per minute.
As the disease progresses, the paroxysms increase in frequency and violence, and death ensues in two to eight days,
generally from exhaustion, (apoplexia nervosa,) or the patient
may die, suffocated, in convulsions. These are the symptoms
that occur in most cases of Hydrophobia; but there are modifications in this, as well as in other diseases. In some instances,
the patient may be able to swallow some liquids, and not
water; or the symptoms may only appear during a paroxysm;
or they may be purely nervous.
This disease is said to originate and develop itself spontaneously among the canine or feline race. The virus can be
transmitted to men and to all warm-blooded animals.
Rabies, in the dog, is said to be of two varieties.  "The
first is characterized by augmented activity of the sensorial
and locomotive functions, continued and peculiar barking, and
a strong disposition to bite. The affection commences with
some alteration in the peculiar habits and disposition of the
animal, who, as the case may be, is more irritable, more
tractable, more lively, or more sluggish than usual; or these
several conditions may alternate in one and the same animal.
An early symptom consists in an inclination to lick, or carry in




88    POISONED WOUNDS- HYDROPHOBIA.
the mouth, various inedible substances, especially such as are
cold. The animal after a time gets restless; snaps in the air,
as if at flies; frequently leaves the house, but soon returns;
and is obedient and seems attached to its master. According to
Blaine, constipation constantly exists. There is usually complete loss of appetite; but the animal seems to suffer from thirst,
drinking eagerly, until, as indeed usually occurs, the mouth
and tongue become swollen. The eyes are red, and become
dull, haggard, and half-closed, the skin of the forehead being
also wrinkled, which gives the animal a peculiar aspect. The
nose, tongue, and throat now usually become swollen, and the
coat becomes rough and staring. According to Hertwig, the
mouth is generally very dry; but Blaine has constantly
observed a flow of thin saliva. After some time, the gait
becomes unsteady and staggering, and finally the extremities
are paralyzed. The tail, in this form of the disease, is not
drawn between the legs; and the head is carried erect, the
nose being pointed upwards. A disposition to bite, sooner or
later, invariably occurs. It is not, however, permanent, but
recurs periodically. It is directed against both inanimate and
animate  objects-most especially against the cat-less so
towards other animals, and least of all towards man. When
the animal bites, he does not previously bark, or fly at the
object of his attack, but approaches in a quiet or even friendly
manner, and makes a sudden snap.
" The second form of the disease is distinguished by inactivity
and depression. There is no disposition to bite-probably
from the lower jaw being paralyzed-nor is there any indication for change of place manifested. The first symptoms are
unusual quietness, and apparent depression of spirits. The
voice is peculiarly altered, as it is in the foregoing variety; but
there is much less disposition to bark. The mouth is open,
the lower jaw hangs as if paralyzed, and is raised only under
the influence of strong excitement. There is a constant flow
of slaver from the mouth. The animal either does not drink
at all, or does so with difficulty; but manifests no fear of
water; and, on the contrary, willingly immerses the nose in that




TREATMENT  OF POISONED WOUNDS.    89
fluid. The tongue is almost constantly protruded from the
mouth."*
The anatomical changes that are noticed in the bodies of
those persons who have died from hydrophobia, are as follows:
The subject decays rapidly; the blood is dark fluid, and quickly
imbibed by the system. 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 is very dry; all the muscles are dark red, and,
like the tendons, they are rigid and tight.
The introduction of morbific matter into the system  is
sometimes productive of the worst results. One of the most
deleterious poisons seems to be engendered in the body during
the puerperal disease, and when by any accident there has
been inoculation with this virus, results the most fatal have
followed. Anatomists, or those engaged in macerating, or
making preparations, have suffered severely from accidental
wounds inflicted by the instruments they are using. Violent
inflammation frequently follows such causalities; the axillary
glands inflame and suppurate; the whole limb is painful;
abscesses form, and gangrene and death may result. Many
examples of such cases are on record.
Treatment of Poisoned Wounds.-The bites of the mosquito
and other insects, which are common in our climate, are often
quite painful, and cause considerable annoyance. However, a
lotion composed of a weak solution of arnica tincture, if
applied to the bitten part, eases almost immediately the pain
and itching. Camphora and lemon-juice,t as external applications, are also highly recommended for this purpose. Dr. Gibson writest-" The aqua ammonice applied to a part stung by
bees, I have known to act like a charm." The internal
administration of ledum is also recommended by M. Teste.~
He says-" Against mosquito bites, a single teaspoonful of a
* British and Foreign Medical Review, No. XXV., p. 50.
t Laurie's Homoeopathic Practice of Physic, p. 541.
f Institutes and Practice of Surgery, p. 119.
~ Mat. Med., p. 77.




90    TREATMENT OF POISONED  WOUNDS.
tumblerful of water, in which a few globules of the 15th dilution of ledum had been dissolved, quieted completely, in a few
minutes-I might even say a few seconds-the itching caused
by the bite, without any application being necessary. Also,
the stings of bees and wasps have been treated with ledum in
a most satisfactory manner."
If, after the sting of any insect, the part becomes swollen,
tense, hot, with erysipelatous blush, bella. should be administered, and if fever supervene, acon. may be used in alternation.
Jlrnica is also an important remedy, and should be used, both
internally and as an outward application, when the swelling
assumes a bluish cast, and there is a bruised sensation around
the part. If the pain is stinging, and there is itching, and
a thin discharge from the wound, creos. should be administered.
This medicine has also been recommended as a lotion, of about
ten drops of the tincture to a pint of water.
The following medicines have also been found very serviceable; the indications for their use will generally be found in the
constitutional symptoms that present themselves:.Int.-crud.,
calad., lach., merc., seneg., sep.
In Morocco, where the scorpion is very common, most families keep a bottle of olive oil, in which the bodies of several
of these reptiles have been infused, and when bitten, apply it
to the wound, and with reputed success. A ligature is also
generally placed above the wounded part, to interrupt the
progress of the poison, and the wound is afterward scarified.
"In Tunis, when any person is stung by a scorpion," says Mr.
Jackson,* "or bit by any venomous reptile, they immediately
scarify the part with a knife, and rub in olive oil as quick as
possible, which arrests the progress of the venom. If oil is
not applied in a few minutes, death is inevitable, particularly
from the sting of a scorpion. Those in the kingdom of Tunls
are the most venomous in the world." According to the
same author, the coolies, or porters, who work in the oil
stores, have their bodies constantly saturated with oil, and on
* Jackson's Reflections on the Commerce of the Mediterranean.




TREATMENT OF POISONED  WOUNDS.    91
this account, not only never suffer in the slightest degree from
the bites of scorpions, and other reptiles which creep over them
at night, as they sleep on the ground, but there is not a single
instance known of one of these people ever having taken the
plague, although the disease frequently rages in Tunis in the
most frightful manner.
The use of olive oil has been highly extolled by many writers,
as a remedy for the bites of poisonous serpents. Dr. Miller,*
of South Carolina, relates the case of a man who was bitten in
the sole of the foot by a very large rattlesnake. Although very
little time elapsed before he reached the patient, his head and
face were prodigiously swelled, and the latter black.  "His
tongue was enlarged and out of his mouth; his eyes as if starting from their sockets; his senses gone, and every appearance
of immediate suffocation." Two table-spoonfuls of olive oil
were immediately got down, but with great difficulty. The
effect was almost instantaneous; in thirty minutes it operated
freely by the mouth and bowels, and in two hours the patient
could articulate, and soon after recovered. The quantity of oil
taken internally and applied to the wound, did not exceed
eight spoonfuls. In the course of twelve years Dr. Miller has
met with several similar cases, in which the oil has proved
equally successful.t
The application of dry heat has also been highly lauded for
the neutralization of the'virus inflicted by serpents, &c.
In the western parts of our country, where rattlesnakes
abound, and persons frequently are bitten, the treatment consists in forcing the patient to swallow from a pint to a quart of
some alcoholic stimulant-generally  common whisky.   Although this method of treatment may appear novel and strange,
still the effects produced are recorded as most wonderful. In
the iron regions of Missouri, among the mountains, the rattlesnake is frequently found, and the inhabitants although they
fear the reptile, are destitute of that dread which generally
connects itself to our minds regarding the crotalus; this proba* New York Medical Repository, vol. ii., p. 242.
t The above is taken from Gibson's Surgery.




92     TREATMENT OF POISONED WOUNDS.
blv arises from the belief that their remedy is infallible. A
year or two since, a boy was chasing a squirrel in the locality
above mentioned, when the animal, as the child supposed, ran
into a hollow tree. The boy immediately thrust his arm into
the opening, and was bitten by a large rattlesnake. The hand
and arm soon after commenced swelling, and the glands in
the axilla had become somewhat enlarged, when medical
assistance was procured.   Common whisky was immediately
administered by the half-tumblerful, until the child must have
swallowed nearly a pint and a half.  The stimulus did not
appear to produce any exhilirating effect, but drowsiness came
on and the patient slept for some time; on awaking, though
the arm was still considerably swollen and painful, it was more
natural in color. From this time improvement continued, and
the patient ultimately recovered.*
The best method of practice, however, if the surgeon is present when the bite is inflicted, or is called immediately after,
is the free excision of the part. The indications for treatment
are to prevent absorption of the virus, and obtain its expulsion
from the part. Therefore a ligature must be thrown immediately around the limb, in order to obstruct return of venous
blood, and if the part be favorably situated, free excision be
instantly practised-if the latter is impracticable, incision should
be made, and the flow of blood encouraged by every means.
Suction by the mouth is also exceedingly beneficial after either
operation, and should never be neglected. The suction must
be continued long and repeated often. It is of the greatest
importance to ascertain whether the snake that has inflicted
the wound is venomous or not. Dr. Hering writes, " All venomous snakes have in the upper jaw  but two teeth, very long
and large. All snakes that have two rows of teeth above and
below are not venomous. After the bite of a venomous snake,
a cutting and sometimes a burning pain is experienced. Immediately after sucking the wound, rub into it fine kitchen
salt until the part is saturated with it; or, if that cannot be
* The above was told to the author, during a short stay in the regions
referred to. The authority is undoubtable.




TREATMENT OF POISONED WOUNDS.  93
obtained, gunpowder, ashes of tobacco, or wood ashes may
be used as a substitute. The patient should be kept as quiet
as possible; the greater the motion or the anxiety, the worse
will be the consequences."
If there is vomiting, giddiness or fainting, and blue spots
make their appearance, ars. or carbo-veg. should be administered. The former of these medicines has been used with considerable success by the old school physicians. Dr. Gibson*
writes, " As an internal medicine, arsenic has been lately found
more decidedly beneficial than any other."
Mr. Ireland t has recorded five cases, in all of which the
most violent symptoms produced by the bite of the coluber
carinatus, a poisonous serpent very common at the island of
St, Lucia, were speedily arrested, and cures finally effected, by
the use of this medicine. The supposed efficacy of the Tanjore
pill, a medicine very commonly employed in India against the
bites of serpents, the chief ingredient of which is arsenic, first
led Mr. Ireland to employ Fowler's mineral solution. He gave
it to the extent of two drachms every half hour, and repeated
for four hours, with the best effects.  Severe vomiting and
purging followed the exhibition of the medicine, and the patients
were soon after relieved.
The administration of the above mentioned medicine, in
smaller doses, would prove more serviceable, and save the
patient an immense amount of additional suffering.
A person bitten by a dog, under suspicious circumstances,
writes Mr. Miller, is usually much alarmed, and applies for
relief without delay. The first business of the surgeon is to
inquire into the history of the accident; the disposition of the
dog; its apparent condition at the time; whether loose or
chained; whether provoked or not. For it may happen that
the animal was not to blame, having either been provoked to
assault, or having inflicted the bite with the idea of discharging a supposed duty on an aggressor. Such a wound is not
supposed to contain any virus.
* Loc. cit., vol. i., p 123.
t Medico-Chirurgical Transactions, vol. ii., p. 394.




94        TREATMENT  OF HYDROPHOBIA.
If there be any reasonable grounds for doubt concerning the
state of the animal at the time when the bite was inflicted, the
treatment should be conducted as though the person had been inoculated by the virus. The best method is immediate and free
excision of the parts, and at the same time if there be any presenting symptoms, those medicines best adapted to them should
be administered. If there was unquestionable and undeniable
authority concerning the efficacy of homceopathic treatment of
hydrophobia, it would undoubtedly be wrong to subject the
patient to an operation, and although the cases recorded, particularly those by Mr. Leadam and Mr. Ramsbotham, have the
appearance of genuine hydrophobia, and are evidences of the
powerful action of homceopathic drugs in this affection; still
the disease is so terrible in its nature, that the surgeon has
indeed necessity for being doubly armed against it, for if
excision fail, he has medicines at his command, the symptoms
of which are very nearly allied to those manifested by hydrophobic patients, as will be hereafter shown. Moreover, the
poison is an extraneous matter introduced into the system, and
surely the homceopathic surgeon may be justified in using mechanical means for its removal. But let it be remembered, that
if some time has elapsed between the infliction of the bite, and
the application of the patient for relief, this method of treatment will prove of no avail, and immediate recourse must be
had to medicines, the chief of which are belladonna, hyoscyamus, lachesis, stramonium, cantharides.
The following indications for the first three of these medicines are quoted from  Mr. Leadam, M. R. C. S. L.,* whose
valuable paper on a " Case of supposed Hydrophobia," every
student should peruse.
" Belladonna.-Hydrophobic symptoms, Hahnemann, 65 to
105. The symptoms are descriptive of various forms of headache.
* British Journal of IIomceopathy, vol. vii., p. 145. This paper was
also reprinted in this country in the Quarterly Homoeopathic Journal, vol.
i., p. 308, Boston 1849. See also Mr. Ramsbotham's Case of Hydrophobia,
B. J. H., vol. viii.




TREATMENT OF HYDROPHOBIA.                    95
105. Violent throbbing in the brain, from before, backward
and towards both sides; externally this throbbing terminates
in the shape of painful stitches.
107. Stitching ache in the temples from within outwards.
108. Cutting ache in the temples, from within outwards;
this pain becomes more and more violent, and spreads through
the brain, where it is felt as a violent throbbing.
121. The whole of the head is affected with a stitching ache,
especially the forehead.
124. Sharp stitches through both frontal eminences, from
within outwards.
125. Excessive headache; dull stitches dart through the
brain in all directions.
129-30. Stabbings in the brain.
131. A few lancinations traverse the occiput, immediately
behind the ear, as fast as lightning; they almost made him
scream; in the evening.
152. Pain externally over the whole head, such as is felt in
the integuments, after violently pulling the hair.
170. Distracted features.
172. Paleness of face with thirst.
175. An extreme paleness of the face, is instantaneously changed to redness of the face, with cold cheeks and hot forehead.
185. Sweat only in the face.
339. Increased sensitiveness of the meatus auditorius.
379. Spasmodic movements of the lips; the right corner of
the mouth drawn outwards.
380. Risus sardonicus; spasmodic distortion of the mouth.
382. Bloody foam at the mouth; vacillation and gnashing
of the teeth.
404. The head is drawn backwards; burying of the head into
the pillow.
415. Grinding of the teeth, with copious saliva running from
the mouth.
509. Impeded deglutition.
510. Painless inability to swallow.
511. Short-lasting, but frequently-recurring contraction of




96       TREATMENT  OF HYDROPHOBIA.
the cesophagus, the more during than between the acts of
deglutition.
516. Painful contraction of the fauces; when preparing the
parts for the act of deglutition, a tension and stretching is experienced by them, although deglutition is not accomplished.
521. He has the greatest trouble in swallowing water, and
can only get down very little of it.
522. Aversion to every kind of liquid; she demeans herself
frightfully when seeing it.
523. Pouring drinks down her throat makes her mad.
524. Inability to swallow.
570. Desire for drinks without caring about drinking; he
approached the cup to his lips, and then set it down again immediately.
830. Difficult respiration.
831. Violent, small, frequent, anxious respirations.
832. Pressure in the praocordeal region; this arrests the
breathing and causes a feeling of anguish.
920. Convulsive concussion of the upper limbs, as if caused
by an excess of shuddering.
1067. Convulsive movements of the limbs.
1069. Twitching of the limbs.
1070. The most violent spasm after a slight vexation.
1072. Lassitude and anxiousness accompany the spasms of
the limbs.
1073. Convulsions.
1074. Convulsive momentary extension of the limbs when
waking from sleep.
1089. Spasmodic extension of the limbs, with distortion of
the eyes.
1094. Trembling, with convulsive concussions of the body.
1134. Frightful dreams, which one recollects very vividly.
1142. Anguish prevents one from falling asleep.
1144. Starting in a dream; this wakes him up, his forehead
and the scrobiculus cordis being covered with sweat.
1189. He is tormented by a burning thirst and by heat, and
desires to drink from time to time; but when offered a drink
he repels it.




TREATMENT OF HYDROPHOBIA.                   97
1212. Extreme sensibility to the cold air.
1219. A convulsive shuddering lifts him up in his bed; in
two hours heat and general sweat come on, without thirst
either during the shuddering or heat.
1314. Great anguish about the heart.
1315. Anxious and fearful.
1325. Complains about an intolerable anguish in the moments which are free from rage; this makes her feel desirous
of dying.
1339. He talks about wolves; full pulse.
1340. Delirious prattle about dogs that swarm about him.
1341. He is beside himself; rages; talks much about dogs.
134.5. Paroxysms of delirium.
1374. Violent shaking of the head, foam at the mouth, and
loss of consciousness.
1377. Horrible contortions of the muscles of the face.
1400. Great irritability and sensibility of the senses; taste,
smell, tact, sight and hearing are more refined and keener than
usual; his feelings are more easily stirred up.
1403. He becomes angry easily, even at trifles.
1410. Rage; the boy did not know his parents.
1412. He tosses about in his bed in a perfect rage.
1413. He tears his shirt and clothes.
1415. Frenzy, with attempts at violence.
1417. Instead of eating that which he had called for, he bit
the wooden spoon in two, gnawed at the dish, and grumbled
and barked like a dog.
1418. Rage, the patient being sometimes very cunning, and
alternately singing and screaming or spitting and biting.
142t. He wants to bite those around him.
1425. He bites everything in his way.
1426-27. Inclination to bite and tear everything around
him.
1428. Bites and spits.
1429. Attempts to jump out of bed.
1430. Apprehends death.
1433. Is afraid of an imaginary black dog, &c.
7




98    TREATMENT OF HYDROPHOBIA.
Lachesis offers the following symptoms. Jahr.
1. Dartings in the head.
2. Deep stinging throughout the whole head.
3. Sticking with pressure in the right side of the head.
4. Tearing lancinations in the forehead, above the eyebrows.
5. Distortion of the face.
6. Distortion of the mouth to the left side during a fit.
7. Hurried talking, with headache and redness of the face,
or with mental derangement and constrictive sensation in the
throat.
8. Difficulty of swallowing food, or drink, or saliva.
9. Dryness of the pharynx and csophagus, preventing deglutition.
10. Jerking and twitching of the hands.
11. Twitching of the left lower limb while sitting.
12. Tingling in the toes, also with heat and numbness or
prickling.
13. Constant sopor after cessation of pains.
14. Convulsions and other spasms, with violent shrieks, &c.
15. Sensation of internal trembling, as from anguish.
16. Violent convulsions of the limbs and face, with rigid
stretching of the body.
Hahnemann gives among the symptoms of hyoscyamus:
113. Impeded deglutition.
114. The posterior part of the throat is affected.
115. Frequent hawking up of mucus.
116. Burning heat in the throat.
117. Dryness and subsequent fine stinging in the region of
the larynx.
118. Parching dryness of the fauces.
119. Great dryness in the throat and thirst.
122. Dryness in the throat.
123. Thirst and dryness in the throat.
124. Thirst occasioned by stinging dryness in the throat.
125. His throat feels so dry and constricted, that a little tea
came near choking him.
128. Constriction of the throat.




TREATMENT OF HYDROPHOBIA.                   99
129. Inability to swallow.
131. He twice spat out a liquid, which had been introduced
into his mouth.
132. Hydrophobia.
133. Intolerable thirst.
134. Unquenchable thirst.
135. Dread of drinks.
136. Violent sweat after thirst.
137. After drinking he was now attacked with convulsions,
now he did not recognize those present. ~
138. He asks for drink, and is, nevertheless, unable to
swallow.
139. Frequent spitting of saliva.
414. Mental derangement with occasional muttering.
451. Alternations of ease and rage.
452. Mania, he can scarce be governed.
453. He is extremely strong in his rage.
465. Peevish, sad.
467-72. Went from place to place. Anguish. Fits of anxiety. Horrid anguish.
473. Concussive startings, alternating with trembling and
convulsions.
475. Strange fear that he will be bit by animals.
585. Excessive sweat.
Stramonium.-The following symptoms are recorded in Jahr's
new manual.
1. Endeavors to escape, imagines he is all alone all the time
and is afraid.
2. He endeavors to beat those around him, with a terrible
cry and rage.
3. He bites a person's hand.
4. Great desire to bite and to tear himself with his teeth,
even his own limbs.
5. Alternations of convulsions and rage.
6. Hydrophobia.
7. Delirious, he had no memory or consciousness.
8. With his eyes staring and his pupils dilated, he saw noth



100      TREATMENT  OF HYDROPHOBIA.
ing, did not recognize any of his family, carried his hands about
as if he would grasp at something, and stamped with his feet.
9. Frightful fancies; his features show fright and terror.
10. Convulsions of the head.
11. Swollen face, turgid with blood.
12. Dilation of pupils; staring eyes.
13. His tongue is paralyzed, it trembles when he attempts to
put it out.
1.4. Bloody froth at the mouth.
15. Hydrophobia;' restlessness, violent convulsions, the
patient being so violent that he had to be tied; he rolled
about in his bed sleepless, and uttering crowing screams; he
was delirious, without memory or consciousness; his pupils
were extremely dilated; violent desire to bite and to tear everything with his teeth; extreme dryness of the inner mouth and
fauces; the sight of a light, a mirror, or water, excited horrible
convulsions, irresistible aversion to water, with constrictions
and convulsions of the cesophagus; froth at the mouth and
frequent spitting.
16. Dread of, or aversion to water or any other liquid, with
spasmodic motion.
17. Aversion to watery liquids; he became enraged when his
lips were moistened.
18. Frequent spitting; slaver hanging out of the mouth.
19. Tenacious mucus in the mouth.
20. Stiffness of the whole body.
The following symptoms of Hydrophobia are taken from the
proving of the virus, by J. Redman Coxe, Jr.,* M. D., assisted
by other members of the profession.
1. Slight dizziness and nausea.
2. Violent pressing outward in the forehead, the patient put
the head to the wall.
3. A very intolerable, snappish, irritable headache, with
stiffness of the jaws and numb hands.
(Nearly all the symptoms relating to the head, are such as
might be present in the incipient stage of hydrophobia.)
* See Philadelphia Journal of Homoeopathy, vol. iii., p. 262.




TREATMENT OF HYDROPHOBIA.                     1.01
4. Twitchings of the face and hands.
5. Rending and tearing pain in the malar bones.
6. Face pale, yellow, nearly brown.
7. Both jaws feel stiff, with tingling in the cheek bones.
8. Jaws stiff and sore.
9. Jaws feel stiff and a disposition to gape.
10. Rending pain in right upper jaw, towards the ear.
11. Mouth full of saliva and total disinclination to drink.
12. Saliva more viscid, constant spitting; feeling of general
malaise all over, without pain.
13. Increase of saliva.
14. A large quantity of viscid saliva in the mouth.
15. Saliva more plentiful, but thin and of a yellow color.
16. A desire to swallow, and spittle more viscid than usual.
17. Difficulty in swallowing liquids.
18. Sensation as of inability to swallow, but can do so when
trying.
19. Difficulty in swallowing liquids; epiglottis appeared partially paralyzed.
20. Burning down the (esophagus.
21. Constant desire to swallow.
22. Violent spasm of the throat with sense of suffocation.
22. Strange constrictive sensation, with inability to swallow
without great pain.
23. Constrictive sensation in the throat, much worse when
swallowing liquids.
Drs. Hartlaub and Trinks recommend cantharides as a preventive of hydrophobia. It should be prescribed for the following symptoms:* Alternate paroxysms of rage and convulsions, which may be excited by touching the larynx, by
making pressure on the abdomen, and by the sight of water;
the eyes look fiery 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.
There is an excessive desire for sexual intercourse, with constant painful erections, and continual itching and burning of
* Hartmann's Chronic Diseases, vol. ii., p. 164.




102              GUNSHOT WOUNDS.
the internal sexual parts. The oppression of breathing and
anguish are less striking, than in cases for which bella. and hyos.
are indicated; the convulsions, however, sometimes being
frightful. In general, cantharides appears to be more indicated
when the inflammatory symptoms are the most prominent, and
when the impeded deglutition does not proceed from a spasmodic constriction of the fauces, but from the inflammation of
those parts, or from pains caused by swallowing.
There is a species of hydrophobia, not arising from the inoculation of virus, but proceeding from some violent mental emotion; the disease is termed symptomatic hydrophobia. Fear
and imagination, after a bite from a perfectly healthy animal,
may give rise to symptoms that very nearly resemble those of
the genuine affection. Sometimes very serious trouble is occasioned by large doses of bella., canth. or mercury, the drug
disease assuming as it were the form of a medicinal hydrophobia.
The treatment of these affections is generally simple, when
their cause is correctly ascertained.
When putrid animal matter has been received into the system
by means of wounds, as in dissection, there should be a ligature
worn for a time, and suction by the mouth be immediately
resorted to, after which, collodion should be applied over the
wounded surface; if the wound after a time present rather a
bluish appearance with swelling, china-off. or arsenicum should
be given; if mortification or abscess ensue, the treatment has
already been mentioned.
Section 6.-Gunshot Wounds.
Gunshot wounds receive their name from  the manner in
which they are produced. They are generally occasioned. by
fire-arms, by the explosion of rockets and shells, and also
comprise many wounds, that, during battle, are inflicted by
splinters of wood on board ship, or by stones from ramparts.
This variety of injury partakes more or less of the nature




GUNSHOT WOUNDS.                        103
of contused and lacerated wounds, and is often accompanied
with extreme danger, the patient being either immediately or
remotely destroyed; or there may exist extensive mutilations,
giving rise to abscesses, sinuses, or diseased bones, which are
frequently extremely tedious and difficult to heal. Indeed,
the after life of the patient may be fraught with such intense
suffering, that the approach of death is hailed with joy as the
only relief. The kind and extent of the injury must depend
upon the form and size of the instrument inflicting the wound,
upon the velocity with which it is carried, and a variety of
other circumstances.
A ball moving with great rapidity, and striking the body,
enters readily, and pursues its course generally in a straight
line, either passing through the part or lodging at a greater or
less depth. On the contrary, a ball which moves slowly,
enters with difficulty, and instead of following a direct line, is
diverted by the slightest obstacle, always taking an angular
course. Owing to this circumstance, it often happens that a
bullet strikes some part of the body, and apparently passes
through, but upon examination, it will be found that it has
taken a circuitous route, or traversed the head between the
bone and the scalp, or passed entirely around the abdomen or
neck. When such is the case, the superficial track is marked
by a discolored line, sometimes slightly emphysematous.
Other instances there are, in which the ball strikes an
extremity, runs beneath the integument, or among the muscles,
and is lodged many inches-or even two or three feet-beyond
the point at which it entered.*
The aperture made by the bullet's entrance is small, and
with margins inverted; often it appears of much less dimen* In one instance, which occurred in a soldier, with his arm extended,
in the act of endeavoring to climb up a scaling ladder, a ball, which
entered about the centre of the humerus, passed along the limb, and over
the posterior part of the thorax, coursed among the abdominal muscles,
dipped deep through the glutei, and presented in the fore part of the
opposite thigh, about midway down.-Hennen's Principles of Military
Surgery, p. 34.




104               GUNSHOT WOUNDS.
sions than the foreign body which has passed through it, and
sometimes it may even simulate the incised character. In
such cases, the ball has come from some distance, and has
struck with considerable force and velocity; the aperture,
consequently, is made with comparatively little bruising or
tearing, and the elastic textures close upon its track.
The aperture of exit, on the contrary, has its margins ragged and everted; and is of larger dimensions than that which
marks the entrance.* When the injury has been inflicted at a
short distance, the aperture of entrance is comparatively large,
has no smoothness in its edges, and is obviously of a lacerated
character; then, too, portions of the wadding are usually
impacted in some part of the track, and the surface may be
marked by the grains of powder.t There are many instances
in which there are not two openings. In such cases, the ball,
after having entered, lodges under the integument, in the muscles, or in a bone.
Extraneous substances may be carried before a bullet-such
as buttons, coins, keys, &c. These always produce irritation
in proportion to the irregular shape of the foreign matter.
In other cases, portions of clothing may be driven before the
ball, and be imbedded deeply in the wound. When such is
the case, it frequently happens that when the cloth is removed, the bullet is discharged with it.
Balls have been buried, and never been found. They become,
in such instances, enclosed in a cyst, or surrounded by bony
formation, the patient experiencing little or no inconvenience
from them; or they may change their position, and traverse the
body, giving rise to pain, long suppuration, hemorrhage, or
convulsions. Again, balls by striking forcibly the edge of a
* There has lately been some discussion concerning the size of the
wound of entrance and that of exit. The French surgeons, and particularly M. Roux,'of Paris, (who has had large experience in such wounds,
behind the barricades in that city,) contend, that, in gunshot wounds, it
frequently happens that the aperture of entrance is larger than the opening
made by the ball as it passes from the body.-London Lancet, 1855.
t See Miller's Principles of Surgery.




GUNSHOT WOUNDS.                       105
sharp bone, may be divided, each portion of the bullet taking
for itself a separate route.
"It is no uncommon thing," writes Mr. Thompson,* "for a
ball in striking against the sharp edge of a bone, to be split
into two pieces, each of which takes a separate direction.
Sometimes it happens that one of the pieces remains in the
place which it struck, while the other continues its course
through the body. Of a ball split by the edge of the patella,
I have known one-half pass through at the moment of the
injury, and the other remain in the joint for months, without
its presence there being suspected. In the same manner, I
have known a ball divided by striking against the spine of the
scapula, and one portion of it pass directly through the chest,
from the point of impulse, while the other moved along the
integuments till it reached the elbow-joint. But the most
frequent examples of the division of bullets, which we had
occasion to see, were those which were produced by balls
striking against the spherical surface of the cranium. It sometimes happens that one portion of the ball enters the cranium,
while the other either remains without, or passes over its
external surface.  Not unfrequently, in injuries of the cranium,
the balls are lodged between its two tables, in some instances
much flattened and altered in their shape, and in other instances,
without their form being changed."
The course which bullets take is at all times uncertain, "for
very slight obstacles cause a retroversion from the rectilinear
direction." A shot may rebound from the water, and a button
or a handkerchief has been the means of preserving life.
"Although," says Mr. Chevalier, "in many cases, a mathematical explication of the course of a ball cannot be given,
this arises entirely from the want of data, the laws of matter
being fixed and immutable. But when the data are known,
as, for instance, the velocity and direction of the shot, the
position of the patient, or of the wounded part at the time of
the accident, and the structure of the parts penetrated, a much
* See Thompson's Reports of Obs. in Military Hospitals in Belgium.




106              GUNSHOT WOUNDS.
more probable conjecture of the course of the ball may generally be formed than if these circumstances had not been
regarded."
The opening by which the ball has made its exit is frequently very near the aperture of its entrance. Indeed, there
are cases on record, in which the aperture of exit and that of
entrance were the same. Dr. Hennen mentions an instance, in
which a ball entered the pomum A.dami, and, after running
completely around the neck, was found in the very orifice at
which it entered.
Gunshot wounds partaking of the nature of contused and
lacerated wounds, seldom bleed profusely externally, and for
the same reason; but often, though the bleeding is not manifest, a fatal hemorrhage may be taking place internally.
Secondary hemorrhage is also of frequent occurrence in this
variety of wound, from the detachment of the slough, &c.
But it must also be remembered, that though immediately after
the injury the bleeding may be but slight, in a short time the
hemorrhage may become profuse, and particularly if the wound
be inflicted in vascular parts, like the face and neck; and this
may occur even though the larger branches of the artery may
not be opened.
When a large artery is only partially divided, the bleeding
is more profuse and dangerous than when the vessel is completely severed; and in such cases, the hemorrhage often
continues until the patient expires.
Mr. Guthrie* mentions three cases in which life was lost
from wounds of carotid, femoral, and humeral arteries, no
means having been adopted to arrest the hemorrhage.
There is a peculiar shock which attends upon gunshot
wounds —an extraordinary perturbation, or agitation, which
the bravest are not able to resist. This, however, is not
invariably present; for, says Dr. Hennen,t "the effects of a
gunshot wound differ so materially in different men, and the
* On Gunshot Wounds, p. 8.
t Principles of Military Surgery, p. 33.




GUNSHOT WOUNDS.                       107
appearances are so various, according to the nature of the
part wounded, and the greater or lesser force with which it
has been struck, that no invariable train of symptoms can be
laid down as its necessary concomitants. If a musket or pistol
ball has struck a fleshy part, without injuring any material
blood vessel, we see a hole about the size of, or smaller, than
the bullet itself, with a more or less discolored lip, forced
inwards; and if it has passed through the parts, we find an
everted edge and a more ragged and larger orifice at the point
of its exit. The hemorrhage is in this case very slight and
the pain inconsiderable, insomuch that, in many instances, the
wounded man is not aware of his having received any injury.
If, however, the ball has torn a large vessel, or nerve, the
hemorrhage will generally be profuse, or the pain of the wound
severe, and the power of the part lost. Some men will have
a limb carried off, or shattered to pieces by a cannon ball, without exhibiting the slightest symptoms of mental or corporeal
agitation; nay, even without being conscious of the occurrence; and when they are, they will coolly argue on the
probable result of the injury; while a deadly paleness, instant
vomiting, profuse perspiration, and universal tremor, will
seize another on the receipt of a slight flesh wound. This
tremor, which has been so much talked of, and which, to an
inexperienced eye, is really terrifying, is soon relieved by a
mouthful of wine, or spirits; but, above all, by the tenderness
and sympathizing manner of the surgeon, and his assurance of
the patient's safety."
Surgeons at the present day, deny the existence of the so
termed wind contusion, or the effects produced by the wind of
a ball; and explain the injuries heretofore attributed to them
as produced by spent balls, which have really struck, yet with
so little quickness of force as to merely bruise, without
inflicting an open wound.
The nerves also suffer, to a great extent, in gunshot wounds,
especially those of the extremities. Even after the wound has
healed, there may be very distressing sensations around and in




108  TREATMENT OF GUNSHOT WOUNDS.
the cicatrix, which pains are generally aggravated in damp,
cloudy weather, or from cool, moist easterly winds.
The progress of cure in gunshot wounds is often extremely
tedious, from the numerous accidents that are likely to ensue.
Excess of inflammation, erysipelas, abscess after abscess,
excessive suppuratlon, sloughing, gangrene, non-union of fracture, caries, necrosis, hectic, and tetanus, are some of the
untoward events that may occur to prevent the healing of a
gunshot wound.
Treatment. —Gunshot wounds, are, to a certain extent,
amenable to the rules of treatment that have been mentioned
as applicable to contused and lacerated wounds.
The suppression of hemorrhage and the removal of the
foreign body, should be attended to immediately. If blood be
poured out copiously, the vessel must be ligated, even though
incisions be necessary. As soon as the hemorrhage has ceased,
it is of much importance to ascertain if foreign substances
have lodged in the wound. If the opening be large enough to
admit the finger, it may be inserted; or if the wound be small,
or if the finger be too short to reach the bottom, a probe must
be used. The best of the kind is the long gunshot probe, which,
from its length, is preferable to the ordinary instrument carried
in the pocket case. It is well, however, before commencing
any operation, to administer to the patient acon. and arnica in
alternation; or if there is excessive prostration, china may be
employed, as such treatment may tend to expedite the disappearance of the shock, and relieve pain.
The patient should then be placed as nearly as possible in
the position that he occupied at the time the wound was received, and the probe passed along the wound, gently, but with determination. If from any circumstances the surgeon has reason to
believe that extraneous matter is imbedded anywhere in the
track of the ball, probing should be instituted as soon as practicable after the infliction of the injury. If this operation be delayed for a time, the lips of the wound close, the whole track
becomes so swollen and painful, that it is not only frequently




TREATMENT OF GUNSHOT WOU NDS.    109
impossible to ascertain the direction the foreign body has taken,
but the operation, slight as it may appear, causes intense suffering. But immediately after the wound has been inflicted, the
probe carried through the recently made passage, glides along
with comparative ease to the bottom of the wound, where it
may encounter the foreign body, which may, if practicable, be
withdrawn by the forceps, or removed by a counter-opening
made just over it. In every case, however, in which the ball is
not easily discoverable, all examinations should be abandoned,
and the extraneous body allowed to remain in its situation until
its locality is better known. Mr. Hunter disapproved of making counter openings, excepting when the integuments under
which the ball was lodged were so contused, that sloughing
was inevitable; in such cases, the parts might be considered as
already dead, and an opening might be made for extraction, but
it is the more modern practice to cut down upon the foreign
body and extract it, if it is not too deeply imbedded.
Guthrie mentions, that he has cut out a number of bullets
that were more than an inch below the surface. However, the
surgeon shodld always be guided by the locality and texture of
the wounded part; if the ball be deep and firmly impacted, it
is preferable to wait for the relaxation of the textures that occurs during suppuration, before attempting its removal, as at
this time the foreign body itself, in obedience to the general law,
has begun to seek the surface. It should always be remembered, as has been before stated, that a ball may be enclosed in
a cyst, or surrounded by bony formation, and remain for years
in such a condition, that the patient experiences little or no
uneasiness from its presence.
The forceps that are the most preferable for extracting balls,
"should be very narrow, longer and more slender than those
contained in the pocket case, with small and very sharp teeth;"
these are recommended by Dr. Gibson, who remarks, "I have
used them for several years past, and found them very greatly
superior to any others I have tried, particularly in those cases
where the ball has not been lodged beyond three or four inches
in depth; and where it has been deeper seated, advantage has




110    TREATMENT OF GUNSHOT WOUNDS.
seldom been gained from attempts to remove it by other
means."
There have been various instruments recommended for the
extraction of balls; perhaps " Percy's Bullet Forceps" have
attained the greatest celebrity.
When a bone has been struck, or even grazed, very careful
examination is necessary-assisted by incision, if need be —in
order to ascertain if splintering has occurred or not.  For
recent experience in Paris seems to have shown, that unless all
bruised and splintered fragments are thoroughly removed at the
time, these portions become necrosed, and serious consequences by inflammation and suppuration are likely to ensue.*
The remainder of the treatment should be conducted on
the same plan as that noticed under contused and lacerated
wounds.
If the wound has been inflicted in a vascular part, and there
is considerable oozing of blood from the smaller vessels, the
medicines that will frequently subdue such hemorrhage, if
arnica has not proved efficacious, are crocus, phosphorus or diadema. The latter being recommended " for hemorrhage from
every orifice of the body, for violent bleeding from wounds;"
or perhaps sabina may prove useful, provided the remaining
symptoms correspond.
If there is merely a contusion caused by a spent ball, arnica
is the specific. After the extraction of the foreign matter, not
only to mitigate suffering, but also to prevent exhausting suppuration, calendula must be prescribed. Or if the patient complain during the suppurative process, of boring pain in the
head, particularly in the forehead, whizzing and throbbing in
the ears, chilliness, particularly of the extremities, hepar will be
the better medicine.
If the fever be high, with delirium, &c., acon. and bell. in
alternation; or one of the above with some other medicine,
may be employed.
If the fever exacerbate at night, and also the other symptoms, and if suppuration proceed slowly, mercurius.
* Miller's Principles of Surgery, p. 677.




TREATMENT OF GUNSHOT WOUNDS.   111
Creos. may be employed if the discharge from the wound is
thin and sanious, or consists of decomposed blood, and the
patient is debilitated. JVit.-acid should also be administered
in somewhat similar cases.
Silicea is also another predominant medicine, and should be
exhibited, if the wound is very difficult to heal, and the suppuration very profuse; if the inflammation has a tendency to
spread, and there is drawing pains in the limbs; also, when the
patient is constantly chilly, with insufferable thirst and frequent
flushes of heat in the head.
Sulph. must be employed when the patient complains of frequent internal chilliness, or there may be spasmodic jerkings
through the limb; when the pains in the wound are aggravated
by change of weather, and the patient sleepless and very
restless; also for profuse suppuration and unhealthy pus.
This medicine is also very well adapted to promote granulation and cicatrization, as is also silicea, or according to Thorer,
calendula-off.
There are also other medicines that may be valuable in the
treatment of gunshot wounds, but the practitioner must in all
cases select the medicine, whose symptoms correspond to the most
of those that are experienced by the patient, always, however,
bearing in mind the pathological condition of the part, as it is
an index, as it were, to the genus of the remedies, from which
the appropriate medicine must be selected.
If gangrene threaten, or to prevent the spreading of such
disease, the best medicines are ars., carb.-veg. or china-off.
Very frequently, the first care of the surgeon is to determine
whether to amputate the limb, or to endeavor to save the part.
Of course, whenever there is a reasonable hope that the wound
may be healed, without the performance of a painful operation,
it is the duty of the surgeon to endeavor to produce such favorable results. There are cases, however, when amputation is
absolutely necessary.  "The question of amputation must
therefore be settled by the probability of gangrene, by regard to
the power of the system, in the prospect of a tedious and suppurative cure, as influenced by age, habits and previous condition;




112    TREATMENT OF GUNSHOT WOUNDS.
by the probability of the limb proving useful or otherwise, if
retained; and by the disposable means of conducting the treatment.  If it be determined to remove the limb, a second
question arises as to the proper time for doing so; whether the
amputation shall be primary, performed before inflammatory
accession; or secondary, after the suppurative stage has been
established, with decadence of the constitutional inflammatory
symptoms. In military practice, there is now little diversity
of opinion on this subject-decided preference, for very obvious
reasons, being given to the primary operation.  The shock
having passed off-as usually happens within a few hours-the
part is taken away during the interval of systemic repose, between depression and excessive reaction; a period whose average range is from six to eighteen hours. The mangled limb is
converted into a simple flesh wound; and the dangers of gangrene, high inflammatory fever and hectic, are removed by
anticipation.
" Certain circumstances are usually understood to render the
performance of amputation either essential or expedient. 1st.
When the limb has been carried away, leaving a shattered and
unseemly stump. To refrain from amputation in such a case,
were willingly to encounter immediate risk by gangrene, subsequent danger by hectic, under a wasting and long protracted
suppuration; and certainty of the stump, even when healed,
proving unserviceable. 2. When a limb has been struck by
shot, and shattered, although not carried away; when bones
are broken, blood-vessels and nerves torn, and muscles bruised
to disorganization, gangrene is inevitable and operation imperative. 3. When a mass of the soft parts has been carried away,
involving the principal vessels, yet without injury to the bone;
or when the main vessels remaining entire the rest of the limb
is hopelessly shattered and bruised, still gangrene is certain and
amputation demanded. 4. When the part is crushed to disorganization, without wound of the integument; as by a spent
ball; a state evidenced by the pulpy, loose feel, coldness and
impaired sensibility of the part. 5. When joints are opened,
and the bones composing them broken. This applies almost




TETANUS.                       113
without reservation to the hip, knee and ankle joints. But the
joints of the upper extremity are in many cases exempt, and
seldom afford unqualified indication for immediate removal;
there being in this part of the body a much greater tolerance
of injury, as well as power of repair. 6. Compound fractures
of the thigh, more especially at its upper part, are usually
found to proceed untowardly; and therefore, the majority of
such cases are held to demand primary amputation.
"However plainly the local injury may indicate amputation,
the operation should not be performed, unless there exist a
reasonable hope of recovery.
" Secondary amputation becomes imperative, when gangrene
occurs and spreads rapidly, uncontrolled by medicine, or when
the constitution appears to sink from unmanageable hectic.
" Sloughing, ulceration, or exfoliation of bone, may, under
certain circumstances, require secondary amputation."*
Section 7.- Tetanus.
This disease is a well known, and but too frequent result of
injuries, and so intractable is the affection under any method of
treatment, that its occurrence is always regarded by the practitioner as unfortunate in the extreme; and although the influence that homeopathy possesses over this, as well as over
many dangerous surgical diseases, modifies in some degree the
danger of the affection, still, until the light of further investigation
be brought to bear upon it, the surgeon cannot otherwise than
regard it with a suspicious prognosis.
Tetanus is characterized by a permanent spasm of the muscles of a portion, or nearly the whole of the body, rendering it
stiff and straight. When the spasm presents itself in the muscles of the neck, throat and jaws, the term trismus or lock-jaw
designates such a condition. When the muscles of the back are
" Miller's Principles of Surgery, p. 677. Edinburgh, 1850.
8




114                     TETANUS.
affected, the word opisthotonos expresses the affection, while
emprosthotonos denotes an exactly opposite condition, the body
being bent forwards. Pleurosthotonos is the term used when
the muscles of the side of the body are affected with tetanic
spasm.
The disease may be either traumatic or idiopathic, the latter
often arises without any assignable cause, and is usually
chronic; the former, being acute, follows upon a wound, or
other injury, is much more dangerous and of more frequent occurrence.  The spinal system is the seat of the disease; there
is an " excitable state of the spinal cord, and medulla oblongata,
not involving the ganglia of special sense. This may be the
result of causes altogether internal, as in the idiopathic form of
the disease; in which the condition exactly resembles that
which may be artificially induced by the administration of
strychnine, or by its application to the cord. Or it may be first
occasioned by some local irritation, as that of a lacerated
wound; the irritation of the injured nerve being propagated to
the nervous centres, and establishing the excitable state in
them.  When the complaint has once established itself, the
removal of the original cause of irritation, (as by the amputation
of the injured limb,) is seldom of any avail; since the slightest
impressions upon almost any part of the body are sufficient to
excite the tetanic spasm."*
The brain only becomes affected in the last stage of the
disease, when the delirium and stupor supervene that are present before death.
Dr. Cullen t writes, " In this disease the head is seldom affected with delirium or even confusion of thought, till the last
stage of it; when, by the repeated shocks of a violent distemper,
every function of the system is greatly disordered."
The spasm in the generality of instances approaches in the
most insidious manner; if trismus is about to commence, there
is slight difficulty in swallowing, and the patient cannot open
* Carpenter's Physiology, p. 517.
t First Lines of the Practice of Physic, vol. iii.




TETANUS.                        115
his mouth to the usual width, there is also hardness of the muscles about the neck and throat; the spasm increases, the mouth
becomes distorted, the pulse quick and irregular, the teeth
clenched, and the temporal and masseter muscles become hard
and bulging; the face is distorted by the spasmodic action; the
corrugator supercilii act upon the eyebrows and draw them into
angles; the forehead is wrinkled, the nostrils dilate, and the
angles of the mouth are drawn backward. The orbicularis
oris binds the lips firmly on the teeth, which, however, are now
always more or less seen, and sometimes wholly disclosed.
The expression is indicative of much suffering, and is quite
peculiar to the disease; it may indeed be said to be pathognomonic.
Hitherto the only muscles that have been affected are the
voluntary, but at this stage of the disease, the involuntary become attacked; the first affected is the diaphragm, and consequently breathing is performed with difficulty; the other
muscles of the system soon participate, until the whole body
becomes fixed and rigid. The arms are the last affected, and
the fingers may retain their motive power to the last. The
bowels are constipated, and there is difficulty in passing urine,
occasioned by the spasm of the muscles of the perineum and
neck of the bladder.
The disease is more common in hot, than in temperate climates, and children and adults are more liable to be attacked,
than youth or aged individuals.  It arises most frequently
from  wounds, etc., inflicted in tendinous parts, that are well
supplied with nerves, but it has been occasioned by mere bruises
or blows.  It also has followed an injury done to the nerves, as
when torn in wounds, or ligated together with an artery.
The size of the wound is of no consequence, in regard to its
influence upon tetanus, as severe incised, lacerated or contused
wounds may heal without its accession, while the disease may
appear from a slight puncture or mere scratch.
The duration of time between the infliction of a wound and
the accession of tetanus varies.  The case which illustrates the
shortest period on record, between infliction and invasion, is




116          TREATMENT OF TETANUS.
that related by Prof. Robison, of Edinburgh, in which a negro
expired in fifteen minutes after having torn his thumb with a
broken china plate.*
If three weeks elapse, the patient may be considered safe.
Treatment.-The remedies that are adapted, and those that
have been most successfully used in tetanus, are acon., ang.,
arn., ars., bella., camph., chainm., cic.-vir., cupr.-mett., hyos.,
ipecac., ignat., lauro., nux-vom., opium, rhus-tox., secal.-cor.,
strat., verat.
ASconite is useful, and has been successfully employed in
" trismus, with frequent alternation of redness and paleness of
the face and distortion of the eyes..' It is also to be administered for opisthotonos, the upper and lower limbs drawn in;
the hand and thumb being clenched; also, when the lower limbs
are constantly drawn close to each other, the eyes turned upwards and the face covered with a cold sweat.
AIrnica may be employed in cases of tetanus arising from
wounds; although the cases in which it has proved most efficacious, are those in which it was employed after the use of some
other medicine. In a case of trismus, with opisthotonos, arising
from a wound in the leg, after the violence of the disease had
been abated by mercurius, the cure was completed by two doses
of arnica 12..Arnica should also be applied to the wounded
surface,' in water, as well as administered internally, or the
treatment may be commenced from the first with this medicine,
if the symptoms correspond; short panting breathing; jerks and
shocks, as if produced by electricity, tremor of the limbs, &c..Angustura.  Trismus with convulsions of the muscles of the
back, twitchings in the top of the shoulder; oppression and
spasms of the chest../rsenicum must be used when the tetanic spasms are accompanied with frightful concussion of the limbs, when the patient
lies as a dead person, extremely pale, but warm, with hands
clenched, which are turned to and fro; when the arms are slowly
drawn up and down, mouth much distorted and breathing
* Rees' Cyclopedia-article Tetanus.




TREAT MENT OF TETANUS.                    117
imperceptible; also when there is stiffness of the limbs, particularly of the knees and feet.
Belladonna is adapted to many of the symptoms of tonic
spasms; to these belong partial spasms; shivering and* trembling of limbs; spasmodic, constrictive sensations in the epigastrium, which are accompanied by shortness of breath, and an
anxious, distressing feeling in the breast; drawing and stiffness
in the neck and spine; spasmodic contractions in the tongue;
yawning and vertigo; painful stiffness of the muscles of mastication, accompanied with convulsions in all the limbs and
chilliness; contortion of the eyes, extension of the extremities,
violent distortion of all the muscles, opisthotonos; pleurosthotonos, especially to the left side; paroxysms of stiffness and
immobility of all the limbs, or of single limbs only, aggravated
by the least contact. Trismus, with painful constriction and
narrowing of the fauces, oppression of the chest, labored irregular breathing, delirium and stupor. When belladonna is adapted to trismus, especially in the cases of infants, the following
symptoms must be present: sudden starting and drawing
together of the body and limbs; slight, twitching motions;
strabismus; inability to swallow, and finally severe spasms;anxious, spasmodic respiration; dilated pupils; motionless
staring eyes; involuntary discharges of freces.
Camphora. For tetanic spasms, loss of consciousness; limbs
extended and fixed, head bent sideways, lower jaw rigid and
wide open, lips drawn inwards, unceasing distortion of the
muscles of the face, coldness all over the body, oppressed,
anxious, panting  breathing-Trismus.  Cicuta virosa  is a
valuable remedy in tetanus, particularly when the disease presents itself in the form of trismus, at the same time there
being general tetanic rigidity. The cases that are on record
in which this medicine has proved serviceable, have all originated in immediate irritation of the brain and spinal marrow,
from injuries inflicted upon the head or along the spinal
column. Cicuta is indicated when there is deadly paleness of
the face, with coldness, grinding of the teeth, foam at the
mouth, and  inability  to  swallow;  opisthotonos.  Tonic




118          TREATMENT  OF TETANUS.
spasms of the cervical muscles, cramps, stiffness of the whole
body, with coldness, or with curvature of the limbs, which cannot be straightened; paleness and yellowness of the face.
Cuprum-met.-Under this medicine, we find the following
symptoms: Paleness of the face, spasmodic contractions of the
jaw, foam at the mouth, vomiting, jerking of the limbs, with
distortion; opisthotonos, with the limbs spread out to the
sides, and the mouth open; rigidity of the limbs and trunk;
jaws closed, with loss of consciousness, redness of the eyes,
ptyalism, and frequent micturition.
Cham. should be used if there are twitchings of the eyes and
eyelids; convulsive jerkings of the facial muscles, the lips
being drawn downward; foam at the mouth, and concussion of
the limbs.
Ignatia, when there is trismus or opisthotonos, occasioned
by fright or chagrin. In a case of opisthotonos, in which
the head was drawn powerfully back by tonic spasms, the
countenance livid, pupils dilated, respiration and deglutition of
fluids difficult; ignatia effected a cure.
Ipecac. must be employed when there is a contractive
sensation in the throat and chest, either in opisthotonos or
emprosthotonos, when there are convulsive twitchings of the
lower limbs and feet, together with chilliness and stiffness of
the body, with spasmodic jerkings of the arms towards each
other; nausea, vomiting, and distorted muscles of the face.
Hyos. is indicated by staring, distorted eyes, spasmodic
closure of the lids, bluish face, clenching of the teeth. In
trismus, when the patient is conscious. Foam at the mouth,
constriction of the throat, twisting of the neck to one side, with
rigidity of the hands, contortions, and spasmodic curvings of
the body.
Lauroceracus has the following symptoms, which indicate its
use in tetanus: Hippocratic countenance, disposition to clench
the jaws, spasmodic constriction of the larynx, staring eyes,
foam at mouth, stiffness of the neck, and twitchings about the
head..Jux-vomica is indicated when there are continued tetanic




TREATMENT OF TETANUS.                    119
convulsions, alternating with violent concussion of the whole
body; violent convulsions of the whole body, with extreme
rigidity of the limbs; when the muscles of the chest are
affected, occasioning dyspncea; frightful spasms of the whole
body every three or six minutes, with opisthotonos, drawing in
of the muscles of the chest, distorted eyes, and redness of the
face; spasmodic attacks, merely from touching the hand;
alternate opisthotonos and trismus; frightful convulsions, particularly opisthotonos, returning and abating several times in
one minute, with full consciousness; violent convulsions,
lasting from one to two minutes; all the muscles becoming
suddenly stiff, jaws clenched, frequent and irregular pulse and
profuse sweat; tetanic spasms excited by the least contact.
Opium may be used when there are jerkings of the facial
muscles, distortion of the mouth; trismus, with irregular,
difficult respiration, spasmodic trembling of the limbs, with
foam at the mouth; tetanic spasms, with opisthotonos and
rigidity of the whole body, the trunk being curved in the form
of an arch.
Rhus-tox. must be exhibited when there is rigidity, as from
contraction of the tendons; tingling and twitching of the
limbs; opisthotonos, with great languor; contraction of the
fingers, oppression of the chest; pale, sickly countenance. It
is also very suitable when the disease arises from injuries
inflicted in ligamentous parts.
Secale-cor. —This medicine is adapted to  the  following
symptoms: Humming and roaring in the ears; Hippocratic
countenance; trismus, the mouth being spasmodically distorted;
trembling and rigidity of the limbs, which cannot be overcome;
opisthotonos and emprosthotonos, with cold sweat during the
paroxysms, subsultus tendinum, rapid sinking of strength; the
thumbs are clenched, with violent contraction of the fingers;
grinding of the teeth, vomiting, oppresssion of chest, &c.
Stramonium should be thought of when, during the interval
between the paroxysms, the eyes of the patient glisten and
sparkle, or when the convulsions appear, there is grinding of
the teeth, muttering; oppression at chest; violent motion of




120        MEANS AND INSTRUMENTS
the limbs, with stretching and trembling of the hands, clenching of the thumbs.
Veratrum.-Pale, Hippocratic countenance; trismus, grinding of the teeth, spasmodic constriction of the esophagus, with
contracted pupils. There is also spasmodic constriction of the
palms of the hands and soles of the feet; twitching of the
eyes; the paroxysms are preceded by anguish or despair, the
patient being beside himself.
CHAPTER VII.
HEMORRHAGE.
JMeans and Instruments for Suppressing Hemorrhage.
THE term hemorrhage implies the escape of blood from a
vessel or vessels in any part of the body; but the following
observations apply more particularly to those bleedings that
occur in the practice of surgery. The loss of blood may be so
trifling that it may continue for years without producing any
marked effect on the constitution, as is often witnessed in the
case of bleeding hemorrhoids; or it may be such as to threaten
immediate dissolution, as happens in surgical operations, and
accidental wounds involving vessels of magnitude; the escape
may be from a single vessel or from many at the same time; an
artery or a vein singly may be the source of hemorrhage, or both
may pour out their blood; the occurrence may be the result of
spontaneous rupture; the vessels may be torn, cut, or bruised;
they may be partially wounded, or completely divided. The
bleeding may be the immediate result of an injury, in which
case it is termed "primary," or it may happen as the result of
sloughing or ulceration succeeding a wound, when it is said to
be "secondary." When all primary bleeding' has ceased, or
been arrested by the surgeon, in the course of a few hours a
copious flow may again take place, to which the term "intermediate" has been appropriately applied.




FOR SUPPRESSING HEMORRHAGE.   121
Hemorrhage, under each of the circumstances here alluded
to, is of frequent occurrence, and there is no single department
of the surgeon's duties, which requires more skill, decision and
promptitude than that in question.
The means and                    Fig. 1.
instruments for temporary suppression
of bleeding  from
wounded arteries,
(the most troublesome and also the
most formidable occurrence in all cutting operations in
the living body,) are few and simple in the hands of the
experienced surgeon. In amputations of large portions of the
extremities, a slight degree of pressure with the fingers or
thumbs will, if judiciously applied over the main artery, be
sufficient.
On the upper extremity the             Fig. 2.
circulation may be readily arrested with the fingers, (Fig. 1.)
If their points are properly,  
placed over the artery, a very
slight force suffices, and any
part of the arm may be selected.
In all amputations of the lower
extremity, when such pressure
is required, it had better be    I
made on the brim of the pelvis, (Fig. 2;) if exerted lower
down, much additional force
is necessary; and even then,
especially if the thigh be fat  l
and muscular, it is not always
effectual.  Occcasionally  the
circulation is stopped in the




122         MEANS AND INSTRUMENTS
leg by thrusting the fingers into the ham; but unless the
patient be much emaciated, and considerable force be used, the
plan is far from being a certain one. Some consider it advantageous to compress as near the place of operation as possible,
because in the generality of instances less blood will escape.
The principle is a good one, when judiciously acted on; but,
in attempting to put it into effect, care must be taken that no
impediment is cast on the due performance of the operation —as
by preventing a proper retraction of the soft parts-and, also,
that the pressure is not applied in a situation where it will
be of little or no avail.
In the generality of instances, it is preferable that the pressure be applied over the brim of the pelvis, considering that
the ease and efficiency with which this method is accomplished,
are fully equivalent to the loss of the small additional quantity
of blood intended to be saved by applying it lower down.
Fig.3.               In either the lower or
upper extremity, compression may be applied in a
variety of places, as will
be afterwards explained.
For the purposes above
alluded to, most surgeons
prefer  the  tourniquet,
(Fig. 3,) as being in
general more trustworthy
than the fingers of assistants, which in protracted
operations become fatigued
and benumbed.
On the upper extremity,  the  tourniquet  is
generally applied  about
the situation indicated in
figure 4; but any other part between the arm-pit and
elbow may, according to circumstances, answer equally as
well.




FOR SUPPRESSING  HEMORRHAGE.    123
On the lower limb, the place          Fig. 4.
usually selected for the application of this instrument is the
upper third of the thigh, as
represented  in sketch 5.  If
amputation in the thigh is to be  7 
performed, the tourniquet should     i
be placed as high as possible;
and it should always be remembered that its presence impedes
the retraction of the soft parts.
In amputations of the leg, some
surgeons place the compress on
the lower third of the thigh; a
large pad, proportioned to the
depth of the popliteal space
being  used on the  occasion.
This method has received the
preference by experienced sur-         Fig. 5.
geons.
If the operation is to be r9
performed on the foot, and a  
tourniquet be thought requi- J 
site, it may be applied with
proper  effect, immediately
above the ankle, one roller
being placed over the anterior
tibial artery, and another over
the posterior.
If the instrument is properly applied at the knee, in
the position represented in
figure 6, amputatiom may be
performed anywhere between
the knee and ankle, without,
in many instances, the loss of
a single ounce of blood.




124          MEANS AND  INSTRUMENTS
Fig.G.              The tourniquet may be applied to either extremity in
the following manner: a pad,
such as is seen in fig. 3, or
what is better a hard roller,
(such as exhibited in the other
cuts,) about two inches in
length and one in thickness,
is to be applied to the integument, over and parallel with
the course of the main artery,
and secured there by one or
two turns of its free end; the
strap  of the instrument is
then to be carried round the
limb, and fastened by means
of the buckle, when the
requisite amount of pressure can be applied by turning the
screw. The latter movement effects the separation of the two
plates with which the strap is connected, and thus diminishes
the circumference of that part which is round the limb, and at
the same time forces the roller against the artery. If care be
not taken in its application, there may be as much danger in trusting to this instrument, as to the fingers; the
strap must be sufficiently strong to resist the application of
any reasonable degree of force.  It appears to be of little consequence on which side of the limb the screw is placed; some
surgeons prefer it over the main artery, others directly on
the opposite surface of the extremity; but in every instance
the roller or pad must be placed directly over the vessel, and
the buckle be a sufficient distance from the plates, to allow the
screw to be turned freely without any interference.
After vessels are cut in an operation, it is sometimes found
necessary to apply additional pressure, which could not possibly be effected if the buckle and plates were in close proximity.
It should also be remembered, that when the strap is fastened
to the buckle, the screw should be immediately turned, for a




FOR SUPPRESSING HEMORRHAGE.   125
very slight pressure round the limb, even that occasioned by
the weight of the tourniquet, will retard the circulation through
the veins, especially in those which are superficial; and thus
whilst the blood still passes with its usual power into the lower
part of the limb, a considerable accumulation occurs in the veins
below the instrument, and a larger quantity is lost during the
operation, than can be deemed in accordance with good surgery.
There are other pieces of apparatus which may be used for
the same purposes as the tourniquet, but the above, since its invention by Petit, has generally been considered the most perfect,
and it is an instrument which every surgeon should have in his
possession. Though he may dispense with its use when surrounded by able assistants, and is himself possessed of great
self-confidence, he may, on some occasions, have reason to regret that such means have not been at hand; or even should
this not be the case, he will, at best, only display a degree of
foolish vanity in his own resources and good fortune, if, in
vaunting his temerity, he attempts to bring into desuetude an
instrument which has the sanction of the highest authorities,
and which has so long been considered indispensable in the practice of surgery.
Various pieces of mechanism have been used and recommended to arrest hemorrhage, but there are none that appear
to supersede the tourniquet.
A very ingenious and simple contrivance, invented by Dr.
Signoroni, of Padua, and improved and patented in this country,
has been successfully used, not only for the suppression of hemorrhage, but also to produce prolonged compression on arteries.
It consists of two elliptical bars, united by a hinge at one extremity; the free ends being supplied with pads; by means of
a screw working at the joint these bars may be opened or closed
at pleasure. The amount of pressure may be regulated by the
screw, which being in the form of a key may be removed, the
patient being prevented thereby from altering the degree of
compression, which, although productive of pain, is often deemed necessary by the surgeon. This contrivance, although ex



126          MEANS AND INSTRUMENTS
hibiting considerable ingenuity, is not equal to the tourniquet
in preventing profuse bleeding during operations.
This instrument (figure 3,) embraces tightly the whole limb,
and prevents all circulation in the part beyond the point of application; on that account its prolonged use might be dangerous or destructive to the member, and it therefore can only be
employed as a temporary means for suppressing hemorrhage.
It may be desirable, in some instances, to impede the flow of
blood through the principal vessels of a limb, at the same time
leaving all other parts so devoid of pressure, that free collateral
circulation may continue; the fingers or hand may be employed
to produce this effect, but it is evident that uniform  pressure
cannot be long maintained by this method. In such cases the
instrument of Dr. Signoroni, before alluded to, may be used;
it is perhaps one of the best that can be employed when compression of a single artery is required; by its continued application external aneurisms are said to have been cured.
For the permanent suppression of hemorrhage, the open extremities of divided vessels must be secured by some local mechanical means, of which the most common is the ligature. It
should be applied in the following manner: An artery that
pours forth a considerable quantity of blood, the flow of which
is not arrested by ordinary means, should be seized with the
C" artery forceps," held in the right or left hand of the surgeon,
and the vessel drawn a short distance out of its sheath, and
after having been carefully separated from the textures with
which it may be in contact, a thread should be cast around it,
a little beyond the point of the instrument; the ligature should
then be drawn together and tied sufficiently tight to prevent
its slipping. Thus each vessel may be closed until nature effects its permanent obliteration.
The thread for a ligature should be a small round cord of
hemp or silk, about twelve inches long, possessed of sufficient
strength to allow moderate force to be applied in forming the
knot, which should be tied in such a manner that it will not loosen.
The surgeon's knot, as it is called, which is made by passing
one end of the thread twice over the other, before turning each




FOR SUPPRESSING HEMORRHAGE.    127
end back again to form the second noose, may be applied, but it
seems little used by surgeons of the present day, perhaps in
consequence of statements made by Boyer, viz: that Chopart,
in the presence of some of the most distinguished professors in
Paris, in operating for popliteal aneurism, could not completely
restrain the flow of blood by tying the surgeon's knot; a second
ligature was applied, and then a third, without success; when,
after some deliberation, it was thought advisable to amputate,
as it was supposed that the artery was so ossified, that it
would not close with a ligature. On examination of the vessel
after the operation, it was fbund in the natural state, and that
the knots had not completely closed the canal.
The sailor's or reef-knot, as exhibited in figure 7, when the
noose and loops are well made and tightly drawn together, is
sufficient in the generality of cases to secure the bleeding vessels;
but there can be no harm, indeed it        Fig. 7.
would be proper to form a third
knot with the ends of the ligature,
when there is the slightest apprehension of its slipping.  One end of
the thread should then be cut off,
and the other allowed to remain
hanging from the wound.
In all instances in which a wound is dressed with a view to
union by the first intention, this plan is preferable to that advised by Dr. Hennen and others, who recommend the division
of both ends of the ligature; indeed it is even better to permit
both portions to remain, than to leave the noose to find its own
way to the surface, a process which is sometimes both tedious
and troublesome, as well as a source of much anxiety and pain
to the patient.  Taking into consideration the injury inflicted,
and the extent of a wound when a ligature is required, the
presence of one or both ends of the thread is a matter of little
additional consequence; but if a wound be expected to heal by
granulation, both extremities of the ligature should be removed,
but even in such cases, much annoyance may be caused by the
noose remaining imbedded in the granulations.




128          MEANS AND  INSTRUMENTS
The ligature that is most highly recommended consists of
small, smooth, and well-spun twine, which, as it comes from the
manufacturer, is sufficiently stiff to permit a noose being cast
without the aid of beeswax.  Silk may be used; but it should
not be supposed that a material of more excellent quality will
be productive of less irritation in the wound.
Whatever the substance employed, it should be of sufficient
bulk to enable the individual who ligates the vessels, to readily
feel in the bustle of an operation, that there is something between his fingers.
Very fine silk ligatures are also objectionable, not only for
the reasons above mentioned, but also because they may entirely
divide all the coats of the vessel instead of the internal tunics.
Mr. Lawrence, in some instances, has recommended fine silk
to be employed in deligating arteries, in order that both extremities of the thread may be cut away, thus allowing the smallest
possible foreign substance (the noose and the knot,) to remain in
the wound; but although the objections stated above regarding thin silken thread as a ligating substance, may be set aside
by great care and careful manipulation, there appears to be no
particular advantage in the plan, particularly when the portions
of ligatures usually allowed to remain, may not weigh more
than one-twentieth of a grain.
Sometimes the thread remains in the cicatrix, but much more
frequently it is carried away in the discharge, either during the
primary healing of the wound, or by subsequent suppuration.
It may happen that a wound will at once close over a thread
left in this condition; but in the course of a few weeks or
months inflammation and swelling appear, suppuration supervenes, and when the abscess is opened, or bursts of its own accord, the noose will make its appearance. This result forms
the principal objection to the practice; if, for example, a patient
who has undergone an operation for scirrhous mamma, be dismissed after the lapse of three weeks or a month, with the
wound healed, and some time after a painful swelling and suppuration occur in the cicatrix, she naturally supposes that
there is a return of the original malady, and will not be con



FOR  SUPPRESSING  HEMORRHAGE.                 129
vinced to the contrary, until the abscess has closed; and as it
may even then be uncertain that all the knots are carried away,
for they cannot always be seen, or may be overlooked in the
discharges,) she may, during the lapse of a considerable period,
still dread a return of her sufferings in the same mamma.
Instead of the ordinary forceps, an instrument with a slide or
catch upon it will be of service, when no competent assistant is
near. When the artery is seized, the blades will remain shut,
and the instrument may be allowed to hang until a ligature can
be applied. The catch may be so adjusted, that it may be
slipped out of the way or turned aside, to allow the instrument
to be used, as the common forceps, at the will of the surgeon.
Various ingenious contrivances have been invented to render
these forceps efficient and of general utility; all of them, however, are modifications of the instruments used by Amussat in
torsion of the arteries, a method of arresting hemorrhage,
which, though it has been much practiced on the continent, has
never yet received the entire sanction of the profession, and
which appears to possess such trifling advantages over the ligature, as to still render the latter preferable.  The points of the
forceps may be finished with hooks, which are admirably adapted
to seize and hold firm any object, such as an artery; indeed
the instrument, either with or withoat the catch, is of invaluable service in removing small tumors from the neck, axilla, and
such other parts, where it is desirable to draw the swelling well
out before using the knife to divide the textures behind.  In
hemorrhage from smaller vessels, these forceps may also be
applied with advantage, and by twisting the artery on itself, the
bleeding may be arrested.
It sometimes happens, that the vessels cannot be readily
seized with the forceps, or cannot be drawn out of their
sheaths, to allow a thread to be applied. A pointed hook, or
tenaculum, will then be of advantage; some even prefer it to the
forceps on all occasions. The sharp point is thrust through
the bleeding vessel, and some of the surrounding parts, (for we
can scarcely avoid including some of the neighboring tissues,
9




130         MEANS AND INSTRUMENTS
where all are thickened and matted together,) and then raised,
so that the thread may be tied beyond the convexity.
In arresting the flow of blood to particular parts, as in
secondary hemorrhage, after amputations, or in the operation for
the cure of aneurism, when the main artery is cut down upon
at a distance from the disease, the common aneurism needle,
(fig. 8,) is used. Various sorts and shapes are recommended
Fig. 8.
by different surgeons; but one like the sketch will be found
most convenient for general purposes. The metal should not
bend nor break with moderate force, and the eye should be
near the point, which should not be so sharp as to endanger
either artery or vein. The handle should resemble that of a
common scalpel.
When a ligature is applied to an artery, the nearer it is placed
to the neighboring textures, so much the better; care should
be taken, however, that none of these are included, particularly
the veins and nerves; and in operation for aneurism, the less an
artery is disturbed in passing the needle and thread under it, so
much the more favorable opportunity is supposed to be given
for its permanent closure.
In some rare and troublesome cases of bleeding, when the
vessel or vessels cannot without much difficulty be seized with
the forceps, it is necessary, in order to arrest the flow of blood,
to pass a needle and thread through the textures on each side,
in order to include some of the surrounding parts within the
noose. Common surgical needles are represented in fig. 9, or
one as seen at fig. 10, set in a handle like that of the aneurism
needle.




FOR SUPPRESSING HEMORRHAGE.    131
Fig. 9.                   Fig. 10.
If the parts be deep-seated and difficult to reach, the latter
instrument will be most convenient, more particularly if some
force is required to push the needle through the resisting textures. For passing threads through small tumors, this instrument will also be found exceedingly convenient.
When these means are resorted to, a little more than the
bleeding vessel must necessarily be included in the ligature;
and though this circumstance is of no great moment, the rule
in surgery, of including the bleeding vessel only, when such
a proceeding is practicable, ought never to be forgotten. The
end of each thread should be cut with scissors, for when a knife,
however keen, is used for the purpose, it will drag out the
parts, causing additional pain, and in some instances may actually separate the ligature.  The common dissecting scissors
will answer; but there may be danger in some cases from
the sharp point, therefore, such as those here exhibited, (fig. 11,)
are preferable; which, for the sake of distinction, may be called
the surgical scissors. Their length should be between four and
five inches, and the curve near the hinge will be found of advantage on many occasions.




132          MEANS AND INSTRUMENTS
Fig. 11.
The foregoing observations have reference chiefly to arterial
hemorrhage, and that, too, occurring during operations, or immediately after the infliction of wounds; but the surgeon has
other kinds of bleeding to deal with, and his assistance is required at other and equally important occasions. Although
hemorrhage from arteries is that which is most to be dreaded,
it cannot be doubted that the wound or rupture of a large vein,
may be equally prejudicial, and therefore the surgeon, in all
cutting operations, should endeavor to avoid such vessels. In
operations for aneurism, or for the removal of tumors, the larger
veins should be carefully protected, for the purpose of preventing hemorrhage, and other unfortunate results which may follow their injury; but such vessels must often be wounded or
cut across; as, for example, in operations about the neck, and
in amputation. It rarely happens that bleeding from veins is
at all troublesome to arrest, unless it be from vessels of the first
magnitude.
Perhaps the most to be dreaded of all venous hemorrhages,
is that which occurs during operations at the root of the neck,
(as on the principal arteries,) and in amputations near the
trunk.  In the former case, unless some very large vessel is
wounded, the blood ceases to flow from the aperture as soon
as the struggles of the patient subside, and the respirations become more natural. A slight degree of pressure with the finger
is all that in the generality of instances is required, but if this
cannot be readily accomplished, a curved copper spatula may
suffice, forceps with a catch may be used, or an instrument
such as represented in figure 12, has been devised for the purpose of temporary compression.




FOR SUPPRESSING  HEMORR HAGE.    133
The blades shut of their own ac-       Fig. 12.
cord, and after being opened and
placed upon the bleeding vessel, 0
they retain their hold on the parts
with sufficient tightness.
Even ligatures may in some cases be applied. In arresting
the bleeding from veins, the threads may be drawn with a tightness sufficient to prevent the blood from flowing; it is deemed
by some the best plan to remove them, as soon as the chief
part of the operation has been accomplished. In some cases,
the surgeon finds it necessary to allow the ligatures to remain,
or to replace them, in the event of the hemorrhage continuing;
but this measure should not be resorted to, unless the bleeding
cannot be restrained otherwise. It must be remembered that,
in the neck, hemorrhage may be equally troublesome, from
either end of the vein; and on the external jugular, for example, a ligature may be required both on the uppe- and lower
side of the wound.
Venous hemorrhage during amputation, is commonly most
conspicuous when the fingers are used instead of the tourniquet,
to arrest the circulation; as the main vessels are then alone
compressed, the smaller arteries, given off above, convey a large
quantity of blood to the part of the limb below the pressure,
and it is apt to run from the corresponding veins into the lower
part of the larger tubes, and so escape through their divided
extremities. The valves in the veins in a great measure prevent this: it often happens, however, but usually ceases as
soon as the fingers are removed. Sometimes it is not desirable
to raise the fingers until the large arteries have been secured
with ligatures; and in such a case, whilst they are being applied, the best manner of proceeding is, for an assistant to place
the point of his finger over the bleeding orifice; or such an instrument as that represented above may be applied. At the
shoulder, in the leg immediately below the knee, and above the
middle of the thigh, the large veins are apt to be troublesome,
during the taking up of the arteries, but the bleeding generally
ceases when pressure is removed from above, the flaps approxi



134         MEANS AND INSTRUMENTS
mated, and the stump placed in a proper position.  In
some instances, as in removing the great toe with its metatarsal bone, it is difficult to secure the bleeding arteries in the
usual manner; and in consequence of the hemorrhage appearing partly venous, the wound may be stuffed with lint, and a
bandage applied over all with good effect; but this course prevents union by the first intention, and should not, therefore, be
resorted to unless the necessity be urgent.
In amputations, and in all other operations involving the
division of veins, it is seldom requisite to apply more than
moderate pressure to arrest the flow of blood from the divided
ends. Formerly it was the custom to secure the vein and
artery in the same ligature, but such a plan is now obsolete,
excepting in rare cases, when the surgeon can scarcely do
otherwise.
In securing the main artery of a limb, especial care must be
taken to exclude the accompanying vein and nerve. This
method is a great improvement upon the plan formerly adopted
by surgeons, who in the generality of instances embraced within
the ligature all the textures that surround the vessel, thus
causing increased suffering to the patient and unnecessary
trouble to the operator. Recent experience proves, that notwithstanding the fatal results of ligating the internal saphena,
(as practiced by Home and others,) the danger of interfering
with veins is comparatively of slight import; and as it is rarely
necessary to apply a ligature to arrest venous hemorrhage,
there is no occasion to inflict that additional wound upon the
vessels, which a thread would inevitably produce.
When there is oozing of blood from veins or arteries, it can
frequently be arrested by the application of dry lint, or of
that substance immersed in cold water; if this, however, fails
to produce the desired effect, the compress should be moistened
with a solution of arnica or calendula, which medicines at the
same time may be internally administered. If considerable
laceration of the soft parts has given rise to the necessity of
operation, the latter will be preferable; if contusion, the former
should be exhibited.




FOR SUPPRESSING HEMORRHAGE.                  135
Sometimes a pad, composed of patent lint, applied and
retained by a roller upon the affected part, will by its presence
form coagula and arrest the hemorrhage.
If these means also fail, the internal administration of
diadenia-aranea, together with the external application of a
solution of the same medicine-composed of one part of the
tincture to ten of water-will probably produce the desired
effect. China may also arrest this form of hemorrhage; as
may also crocus and sabina; provided the symptoms of the
patient correspond to those of the medicine. JIgaricus may
in obstinate cases prove of great value. This medicine was
the chief ingredient in the famous styptic of Broussard, whose
preparation for arresting all manner of bleedings was regarded
with wonder and even superstition.
In all cases, the part from which hemorrhage occurs should,
if possible, be placed in a position rather above the level of the
heart, as this may in some degree lessen the discharge of
blood.
Secondary hemorrhage is often more alarming and more
uncontrollable than that which occurs during the performance
of operations, or as the immediate effect of injuries. This
"secondary" bleeding usually happens after amputations and
operations for aneurism, about the period when the ligature
separates from the principal artery, and it is a well-known
result of gun-shot injuries which involve one or more of the
principal vessels of a part. It may ensue in consequence of
the adhesive process not having taken place at the seat of
ligature or in the other wounded vessel, or it may be the result
of unhealthy inflammation, or of ulceration in the wound,
causing the vessels to open after having been closed by the
proper effusion of lymph. The bleeding which occurs in
ulceration and sloughing, such as occasionally happens at the
ham, groin, and neck, (although it may be for the first time,
i. e. primary,) is somewhat analogous, as there is a similar
unhealthy action-a similar deficiency of adhesion.
When the artery is small, the medicines before mentioned
may relieve, or if these means do not prove successful, the




136     MEANS AND INSTRUMENTS, ETC.
vessels may be seized with the forceps, and twisted upon
themselves (torsion). This method of arresting hemorrhage
from trivial wounds is very successful, and is generally employed with success by the surgeons of the present day.
However, even here the ligature is undoubtedly the safer
preventive.
The pressure should be made directly on the bleeding point,
by graduated compresses and bandages; and it will be of
advantage, too, if the force be applied to the main artery, or
arteries leading to the aperture, as on the humeral, radial, and
ulnar, in wounds deep in the hand. In some parts of the
body, as at the root of the neck, the surgeon cannot do otherwise than trust to pressure, which method must always be
considered as hazardous in the extreme. When, however, this
cannot be avoided, medicines may be administered internally.
When the stream is profuse, on certain occasions —as when the
blood flows from a stump-those means already explained may
be resorted to.
There may in some instances a question arise in the mind of
the surgeon concerning the portion of the vessel to which the
ligature should be applied. When this is the case, this circumstance must be remembered-that the very occurrence of
secondary hemorrhage may be regarded as sufficient proof that
the parts have rather repelled the adhesive process, and that
at all events ulceration and other unhealthy action have been
progressing at the seat of hemorrhage. In such cases it will
be advisable to ligate the principal vessel of the limb at a
considerable distance from the divided end of the artery; for
example-in a stump after amputation of the leg, the femoral
artery should be tied in the middle or upper third of the thigh.
The impetuosity of the current is thus stemmed-indeed the
hemorrhage generally arrested-but if not, a slight degree of
pressure will accomplish the desideratum. In some cases, even
after the reproductive process bas advanced to a considerable
extent, the ligature may slough away, and thus cause another
alarming hemorrhage.




LIGATION  OF ARTERIES.                    137
CHAPTER VIII.
LIGATION OF ARTERIES.
Section 1.-Topography of the neckc.*
THE median line in front, and the two sterno-cleido mastoidei muscles, divide the neck into two anterior lateral triangles,
whilst the spaces between the sterno-cleido mastoidei muscles
and the two trapezei muscles form the two posterior lateral triangles. The omo-hyoid muscles divide each of these triangles,
into two, forming, 1st, the posterior inferior; 2d, the posterior
superior; 3d, the anterior inferior; and 4th, the anterior superior triangles. The posterior inferior triangle contains the subclavian artery and vein, the brachial plexus of nerves, and the
transverse cervical artery.  This is the space for the ligation of
the subclavian artery above the clavicle. The posterior superior
triangle contains the cervical plexus of nerves and lymphatic
glands. The anterior inferior triangle contains the carotid artery,
internal jugular vein, the par vagum, and sympathetic nerves.
The anterior superior triangle is bounded above by the digastric muscle and lingual nerve; it contains the carotid artery,
internal jugular vein, descendens noni, par vagum, and sympathetic nerves.  In this space the carotid artery is quite superficial, and consequently may be tied with greater facility than
in any other. The digastric space is formed by the digastric
muscle below, and the inferior maxillary bone above: it is
divided by the stylo-maxillary ligament into an anterior and
posterior part. The anterior digastric space contains the submaxillary gland, the lingual and facial arteries, the lingual and
gustatory nerves, and the sublingual gland.  The posterior
digastric space contains the parotid gland, external carotid
artery, one branch of the seventh pair of nerves, and the portio
dura; still more deeply, the styloid process, internal carotid
artery, jugular vein, the eighth and ninth pairs, and the sympathetic nerve.
* See Hastings' Practice of Surgery, pp. 132 to 142.




138          LIGATION  OF ARTERIES.
Section 2.-Ligature of the Radial Artery.
A line drawn from the middle of the elbow joint to the styloid process of the radius, marks the course of the artery, which
is quite superficial. Its upper half lies between the supinator
radii longus at the outer, the pronator radii teres at the inner
side: it is between its two venae comites; the radial nerve,
which only touches it about its middle, lies at its outer side,
leaving it at its lower third to pass to the back of the fore-arm
and hand. In the lower part of its course it is in front of the
bone, having the tendon of the flexor carpi radialis within, and
the supinator radii longus without: just as the artery is about to
pass under the tendons of the extensors of the thumb, it gives
off the superficialis volae, which supplies the muscles of the
thumb and anastomoses with the arcus sublimis: the radial
artery, getting to the back of the hand, dips down between the
metacarpal bones of the first finger and thumb, gets to the palm
of the hand, and forms the arcus profunda.
Operation. —The radial artery can be taken up with ease in
any part of its course from the wrist to its origin, by pinching
up a fold of the skin over its course, and passing a scalpel
through, cutting outward, making an incision in the integuments
about an inch in length; the fascia must be carefully divided,
by pinching up a portion of it at one angle of the external incision and nicking it with the knife, then pass the grooved
director underneath and divide it by running the knife along the
groove of the director: this is a general rule for getting down
upon arteries. Another is, not to separate an artery from the
surrounding parts more than is sufficient to pass a ligature
around it. The vessel being exposed, an armed needle or the
director is passed under it, being careful to separate it from
veins and nerves; the ligature is to be tied and one end cut off,
the other left hanging from the wound, which should be brought
together by adhesive plaster.
Section 3.-Ligature of the Ulnar./rtery.
A line drawn from the external border of the tendon of the
biceps flexor cubiti muscle, to the radial edge of the middle of




LIGATION  OF ARTERIES.                   139
the ulna, and then carried to the palmar edge of the pisiforme
bone, will mark the course of the artery, which is much more
deeply situated than the radial: it has the flexor carpi ulnaris
at its inner, and the flexor sublimis digitorum on the outer side:
it lies on the flexor profundus digitorum, beneath the superficial
layer of muscles and the aponeurosis that separates them.  At
the inferior third of the fore-arm it is superficial, and bounded
by the tendons of the above muscles; it passes at the side of
the pisiforme bone, over the annular ligament, and, reaching the
palm of the hand, forms the arcus sublimis; it is attended by
two venae comites. The ulnar nerve, coming from behind the
elbow, joins the artery above the middle of the fore-arm, passing along its ulnar shie.
Operation.-The artery can be ligated at any part of its
course, by making an incision over it, and proceeding in the
same way as in the former case: in taking up the ulnar in its
upper third, the incision in the integuments must be at least
two inches in length.
Section 4.-Ligature of the Brachial dArtery.
This artery lies in the groove between the coraco-brachialis
and biceps flexor cubiti in front, and the triceps extensor and
insertions of the latissimus dorsi, and teres major behind. In
the lower part of the arm it lies in front of the brachialis anticus: the brachial vein is at the inner side; where there are
two venme comites; the artery is between them: the internal
cutaneous nerve runs somewhat in front and to its inner side.
The ulnar nerve is a little within, and behind the artery. The
median nerve, in the upper two-thirds of the arm, lies rather in
front of the artery at its external margin, and about two inches
and a half above the elbow it crosses in front of the artery and
gets to its inner side. The brachial vessels are surrounded
rather by a loose cellular tissue than a complete sheath.
Operation. —The artery is quite superficial, and may be tied
at any part of its course, by pinching up a fold of the integuments over the artery, and dividing them by an incision about
two inches in length, and then proceeding with the knife and




140           LIGATION OF ARTERIES.
grooved director as before directed for the division of fascia;
place the director under the vessel, looking carefully that
nothing but the artery is included within the ligature.
Section 5.-Ligature of the Subclavian artery.
The subclavian artery emerges from the thorax between the
scalenus anticus and medius muscles, and passes under the middle third of the clavicle: it is bounded internally by the tubercle on the first rib and the edge of the scalenus anticus, which
muscle separates the artery from the subclavian vein. Externally is the scalenus medius muscle and the brachial plexus
of nerves, the nearest nerve of this plexus lying about a quarter
of an inch to its outer side and rather behind: this nerve is
about the size of the artery, and should not be mistaken for it.
Below and anterior to the artery lies the subclavian vein, which
receives at the external edge of the scalenus anticus and in contact with the artery, the external jugular, supra-scapular, and
sometimes the anterior jugular and acromial veins. The posterior cervical artery arises mostly from the subclavian, and
crosses the root of the neck above the subclavian, on the outer
face of the scaleni muscles to get to the trapezius, and is often
directly in the course of the incision in cutting down upon the
subclavian artery.
Operation.-The operation is usually performed in the posterior inferior triangle of the neck. Depress the shoulder and
clavicle as much as possible, pinch up a fold of the integuments
and make an incision three inches long, parallel with and about
half an inch above the clavicle; divide the platysma myoides,
and push the omo-hyoideus muscle and external jugular vein
out of the way; divide the fascia upon the director, if it cannot be sufficiently broken away with the finger and the handle of
the scalpel.  If the posterior cervical artery or any other be
cut, it must be tied at once; find the tubercle on the first rib
with the index finger, and in a groove to its outer side will be
felt the artery pulsating; pass an aneurismal needle from below
upwards, and from within outwards, guided under the artery




LIGATION  OF ARTERIES.                   141
by the finger, at the same time pushing the nerves upon its outer
side out of the way; assured that nothing but the artery is
within the loop of the ligature, tie it, and bring the wound
together as in other cases.
Section 6.-Ligature of the Common Carotid.
About the level of the superior margin of the thyroid cartilage the common carotid divides into the external and internal
carotids. The common carotid may be tied at any part of its
course, but the place of election is the anterio4 superior triangle; here the artery is covered merely by the platysma
myoides and superficial fascia. The descendens noni passes
down in front on the outside of the sheath of the vessels; the
vein lies external to the artery; the pneumogastric nerve in
the sulcus between and posterior to the vein and artery; these
three parts are contained within the sheath; immediately
behind it lies the sympathetic nerve. The artery runs beneath
the anterior edge of the sterno-cleido mastoideus muscle.
Operation.-Gather up a fold of the integuments, and make
an incision about an inch in extent along the edge of this
muscle; divide the platysma, fascia, and sheath of the vessels,
upon the grooved director, taking care in the division of this
last to avoid the descendens noni as much as possible; the
sheath being open, pass the director or needle under the artery
from without inwards, guarding particularly against including
the par vagum in the ligature; it requires but little care to
guard against this accident, as the vein, artery, and nerve are
separated one from another in a great measure by thin layers
of fasciae: the vessel having been tied, the wound is brought
together as in former cases.
Section 7.-Ligature of the Lingual Jdrtery.
The lingual artery arises from the external carotid, above
the cornu of the thyroid cartilage; it ascends above the
os hyoides to the base of the tongue, passing between the
hyoglossus and  genio-hyoglossus muscles.  The artery is
unattended by nerve or vein, but is deeply situated.




142          LIGATION OF ARTERIES.
Operation.-Throw the head back; make an incision two
inches long just above the cornu of the os hyoides; the submaxillary gland is exposed and pushed out of the way; the
digastric muscle is pushed upwards, and immediately under it
lies the hypoglossal or ninth pair of nerves, which must be
pushed up also; about one line below the nerve the pulsations
of the lingual artery can be felt through the hyoglossus
muscle; this having been divided with great care, an armed
aneurismal needle should be passed around the artery, which
should be tiecI, and the wound brought together as in other
cases.
Section 8.-Ligature of the Facial./rtery.
The facial generally comes off from the external carotid, but
sometimes arises in common with the lingual artery. It
mounts over the inferior maxillary bone in a groove at the
anterior border of the masseter muscle. The best place to tie
it is at the edge of this muscle, after it has turned over the
jaw. The facial vein is at its temporal side; it is crossed by
branche~ of the facial nerve: over this spot the integument is
to be raised, and opened to the extent of half an inch or less;
the needle carrying the ligature is passed from without inwards,
to exclude the vein. Dress the wound as usual.
Section 9.-Ligature of the Jinterior Tibial Artery.
On the dorsum of the foot the artery passes under the annular ligament, attended by two venae comites and a nerve. A
line drawn from the ankle joint, midway between the malleoli to
the interosseous space between the first and second metatarsal
bones, will mark out the course of the artery. It rests upon
the tarsal bones between the tendon of the extensor pollicis
pedis on the inside, and the first tendon of the extensor digitorum brevis on the outside.
Operation.-Raise a fold of the skin on the dorsum of the
foot over the course of the artery; divide it by passing a
pointed scalpel through the fold, making an incision about an
inch in length; divide the fascia with the aid of the handle of




LIGATION  OF ARTERIE S.                  143
the knife and the grooved director, until the artery is laid
bare; pass the ligature under it, avoiding the veins and nerve,
tie with the surgeon's knot, and bring the parts together with
adhesive straps.
Ligature of the Artery at its Lower Third.-Here it lies
between the tibialis anticus internally, and the extensor pollicis
proprius externally; it is flanked by its venae comites.  The
anterior tibial nerve is nearer the surface, lying external to the
artery.
Operation.-Feel for the space between the above-named
muscles, and divide the skin over it about two inches in
length; divide or break through the fascia; separate the
muscles with the finger, which may be passed down upon the
artery, which lies moderately deep: its pulsations can be felt;
pass the director or aneurismal needle under it from without
inwards, avoiding the anterior tibial nerve and the veins; tie
the vessel and dress the wound as in previous instances.
Ligature of the Artery at its JMiddle and Upper Third.Here the artery lies between the tibialis anticus internally, and
the extensor communis digitorum externally, preserving the
same relations with the veins and anterior tibial nerve as in
the former position.
Operation. —Feel for the space between the above-named
muscles, which is easily found by putting the muscles in action;
it is generally about an inch from the spine of the tibia; raise a
fold of the skin, making an incision three inches long; separate
the muscles with the finger, which, when passed down pretty
deeply, will feel the pulsations of the artery; pass the needle
from without inwards; tie and dress as in former cases.
Section 10.-Ligature of the Posterior Tibial Artery.
The posterior tibial artery, behind the malleolus internus,
lies midway between the edge of the tendo-achillis and the
malleolus internus. It is attended by two veins and the posterior tibial nerve, which lies a little distance behind it.
Operation.-Divide the integuments over the course of the
artery, which is quite superficial; divide the fascia carefully,




144          LIGATION  OF ARTERIES.
and the artery will be found rather behind the malleolus; pass
the ligature from behind forwards, including nothing but the
artery within its loop; tie, and close the wound as in former
instances.
Ligature of the.Artery at its Upper Third. —At this part
of its course it is rather difficult to ligate; it is situated beneath
the soleus muscle and deep-seated aponeurosis of the leg,
resting upon the tibialis posticus and flexor longus digitorum,
about the middle of the leg. It is attended by two venue
comites and the posterior tibial nerve, which is at its outer
side. The artery is about the middle of the diameter of the
leg, and very deeply situated.
Operation.-Divide the integuments about an inch behind
the inner edge of the tibia, making an incision about four
inches long; place the leg in a position to relax the muscles,
raise the soleus from the tibia, and divide the deep aponeurosis
on the director; then feel the artery with the finger, and direct
the aneurismal needle under it, taking care to exclude everything but the artery within the ligature; tie the vessel, and
bring the wound together with adhesive straps.
Section 11.-Ligature of the Femoral./lrtery.
This artery is quite superficial, lying in the sulcus between
the vastus internus and the adductor muscles. About the
middle of the thigh it is covered by the sartorius. The femoral
vein, in the upper part of its course, is at its inner side; lower
down it gets posterior to it. The crural nerve is about half an
inch outside of the artery, two or three of its branches being
very near it, one crossing it. The saphena major descends
within the sheath of the vessels, passing along the outer and
fore part of the artery, down the middle third of the thigh.
A line drawn from the middle of Poupart's ligament to the
internal condyle of the femur traces the route of the artery.
Operation.-Feel for the depression  between the vastus
internus and the adductors of the thigh; divide the integuments
for about three inches, avoiding the vena saphena; draw the
sartorius muscle to the outside; raise and divide the sheath of




LIGATION  OF ARTERIES.                    145
the vessels on the director; pass the ligature from within outwards, being careful to exclude the saphenous nerve; tie the
vessel, and close the wound as in other cases.
Ligature of the Femoral above the Profunda.-The arteria
profunda is given off about two inches below the crural arch.
Operation.-Make an incision about three inches long, over
the course of the artery, commencing at Poupart's ligament;
clear away the lymphatic glands and fascia; divide the sheath
of the vessels on the director, and pass the ligature between
the vein and artery from within outwards; tie the ligature,
and bring the wound together as before directed.
Section 12. —Ligature of the Iliac A.rteries.
The primitive iliacs divide opposite the sacro-iliac symphysis
into internal and external iliacs. The primitive iliacs are
about two inches and a half long: near their bifurcation they
are crossed by the ureters, spermatic vessels, and nerves.
They lie at the inner side of the psoas muscles. The left iliac,
in addition, is crossed by the branches of the inferior mesenteric
artery. The internal iliac, about an inch and a half long, is
directed downwards and inwards to the sacro-sciatic notch,
where it divides into its various branches: the vein lies at its
outer side. The external is a continuation of the primitive
iliac. A line drawn from the umbilicus to a point half an inch
inside of the centre of Poupart's ligament marks the course of
the artery, which is at the inner side of the psoas muscle, with
the vein upon its inner, and two or three small nerves from the
lumbar plexus at its outer side. The anterior crural nerve lies
at the outer side of the psoas muscle. Near Poupart's ligament the external iliac artery gets in front of the psoas
muscle: about this point it is crossed by the circumflex ilii
vein, spermatic vessels, and vas deferens, which, on turning
down into the pelvis, touch its inner side. Just above
Poupart's ligament it gives off the epigastric and circumflex
ilii arteries.
Operation.-Place the patient on his back, with the thighs
and trunk slightly flexed; make an incision through the
10




146                    ABSCE S.
integuments, half an inch from the external abdominal ring,
passing in the direction of the anterior superior spinous process
of the ilium, about an inch above Poupart's ligament; cut
through the tendon of the external oblique, and get under the
edges of the internal oblique and transversalis muscles; raise
the fascia transversalis on the director with great care, and
divide it; then strip off the peritoneum from the loose cellular
tissue with the fingers, and feel for the artery, which can be
readily reached; pass the aneurismal needle, guided by the
finger, from within outwards, avoiding the vein and other
vessels; the ligature being passed, tie it, and bring the wound
together, dressing as in former instances.
The only difference between tying the external iliac and the
primitive iliac, is the necessity of carrying the incision higher
up towards the crest of the ilium.
It may sometimes be necessary to tie the arteria ad cutem
abdominis, as well as some branches of the epigastric and circumflex ilii arteries, in this operation.
CHAPTER IX.
ABSCESS.
WHEN pUS is fully formed, and collected into the parenchyma of a part, the condition is termed abscess, which, on
account of the frequency of its occurrence and its numerous
complications, is of great interest to the surgeon.
Lining the cavity that contains the pus, especially if the abnormal condition have continued for any length of time, is
found a tissue, having a membranous appearance and a membranous function, and possessing a power of maintaining the formation of pus; hence it is termed the pyogenic membrane. This
tissue is endowed with very considerable capability of secretion,
but as an absorbent surface it is comparatively feeble. In regard to this latter point, however, it may be useful to remember
that the pus globule, when extra-vascular and complete, is of




ABSCESS.                       147
comparatively large size, not soluble in its own serum, and
therefore but little amenable to ordinary absorption; the serous
portion of pus may be taken up readily enough, but the solid part
probably remains but little affected. And thus the feebleness of
absorbent power may depend, not so much on defect of either
structure or function in the pyogenic membrane, as on the
nature of the fluid on which it has to operate.
Sudden suppression of purulent formation, is always to be
regarded as an untoward event. It is more liable to occur in
the case of free and open suppuration, than in an unopened abscess. It may be the result of some accidental occurrence, the
nature of which we may be unable at the time to ascertain, or
it may be caused by injudicious stimulation, designedly applied
to the part; but the suppression, no matter how it may be induced, is always likely to be followed by disastrous consequences.
The process of pointing, and the great necessity of observing
fluctuation, have been alluded to in the chapter upon suppuration; but there remains to be mentioned, one of the most important circumstances connected with abscess, which if neglected
may be attended with fatal results, or at least with great
danger and trouble.
It sometimes happens that an abscess is situated directly in
the course of an artery, and when such is the case, the greatest
care and discrimination should be exhibited in the diagnosis,
between the collection of pus and aneurism; the most experienced have been misled by circumstances, and deceived by appearances. Dupuytren himself, whose ability and surgical skill
have always been regarded by the profession with the greatest
esteem, failed in his diagnosis, and once plunged a lancet into
an aneurism, mistaking it for an abscess.
The diagnostic signs are:
From the earliest stage of abscess the tumor is hot, throbbing,
hard and incompressible; in aneurism the tumor is of natural
temperature, and is soft and fluctuating.
The skin covering an abscess is inflamed and discolored, that
which covers an aneurism is of natural color or perhaps paler.




14S                     ABSCESS.
In abscess the formation of the tumor is much more rapid
than in aneurism.
In aneurism the tumor is pulsating; in abscess it is fluctuating, but has no pulsation.
The enlargement in abscess cannot be diminished by pressure,
in aneurism the contrary is the case. When, however, the
diagnosis is sufficiently established, it may become a question
to the surgeon, whether the pus shall be evacuated by the
lancet, or whether it would be proper to endeavor to produce
absorption.
It is stated on the best authority, that large abscesses have
been in a few instances absorbed. Small quantities of pus frequently disappear, therefore, the practitioner, if the case permit,
should endeavor, by administering the proper medicines, to
bring about such a result; if this, however, cannot be effected,
it is preferable to employ the lancet, rather than wait till nature accomplishes the discharge.  On this subject Mr. Fergusson writes, "It is, I imagine, too much the custom  to allow
matter to be discharged naturally. In most parts of the body,
if the suppuration be deep-seated, the matter may extend widely,
and do much harm by the separation of textures, ere it can
reach the surface; and even when it does so, and is discharged
through some small opening, it rarely happens that the interior
of the abscess closes entirely; a discharge continues long afterwards, and ultimately the interference of the surgeon is required.
From this it may be seen, that I am averse to leaving such
cases entirely to nature; occasionally the surgeon cannot do
otherwise, and sometimes, even with all his care, matter will
burst forth when he does not expect it. If an abscess in the
perineum, for example, be left for a day or two, under the
supposition that the delay will be advantageous, even though
it may be intended to use the knife to open it, the practitioner is
often amazed to find that the matter has, in the lapse of fourand-twenty hours, made an exit through the skin or mucous
membrane in the vicinity of the anus; yet it seldom happens,
in such instances, that the knife is not ultimately required.
"However, except under pressing circumstances, I must




TREATMENT OF ABSCESS.                    149
declare myself an advocate for delay in opening abscesses. I
am of opinion, that in ordinary abscess, a bubo, for instance, if
an opening is not made until the matter has approached near to
the surface, the subsequent progress of the case is much more
rapid and satisfactory, provided that a proper opening be made.
I have seen a good deal of the practice of making early openings, and have invariably observed, that more pain was thereby
induced, and I have often fancied, an additional amount of suppuration, whilst the after treatment has been remarkably tedious."
When it is deemed necessary to open an abscess, the incision
should always be made where the integument is thinnest, or in
other words, where the abscess points, at which place, often a
discoloration is manifest.
In most cases the opening should be made freely, and the
matter liberated at one operation; but when the abscess is
large, and the constitution of the patient feeble, the exposure
of so large a surface and the speedy evacuation of a quantity
of matter, might be dangerous in the extreme; it is then
recommended to ascertain to what degree the sac may be
diminished, by lessening gradually the quantity of fluid,
after the manner recommended  by  Abernethy.  That is,
by making a small oblique opening, and allowing as much
of the contents of the cyst to flow out, as the natural elasticity of the walls will permit; the wound will, perhaps,
afterwards heal by the first intention, the aperture may close
perfectly, the patient not be injured by the operation, and there
will be  much  less                 Fig. 13.
fluid in the abscess;
this  procedure  may          I
be  continued,  until
the sac becomes sufficiently diminished in
size, to allow it to be
laid open in the same
manner as smaller abscesses. When a lancet
is used, it should be held in the position represented in fig. 13.




150           TREATMENT  OF ABSCESS.
Fig. 14.            When  the pus is deepseated, the fore finger of the
left hand, and perhaps the
middle also, being  placed
over the abscess with gentle
pressure, the back  of the
knife should  be caused to
W V                           rest against the side of the
fore finger, (as seen in fig.
14,) the point should then be
thrust through the skin; and
the coverings of the matter
divided  as far as may be
deemed expedient; the blade
may then be turned slightly
jf~~:?~iiii.?'~l  on its long axis, when probably the pus will spring up
along  its  surface.   These
methods are recommended by Mr. Fergusson, who remarks,
" In opening abscesses, whatever be the instrument used, I invariably prefer puncturing first and then cutting from within
outward, to the method pursued by some, of making a sort of
dissection, by successive incisions, through the skin and other
textures."*
But the Homceopathic surgeon, may be able, in many
instances, to overcome the necessity of operating, by the administration of appropriate medicines; by the action of which,
the suppurative process may be hastened, and the abscess
allowed to open spontaneously; this should always be effected
if practicable, and the medicines that have been most efficacious
in producing such a result, are hepar, merc. and silic.
When there is much constitutional disturbance on account of
the violence of the inflammatory action, acon. and bell. are to
be used, either separately, or in complicated cases in alternation; the doses to be repeated proc re nata; the proper antiphlogistic regimen also being observed.
*Practical Surgery, p. 88.




TREATMENT OF ABSCESS.                     151
Lachesis is pronounced an excellent remedy, when there has
been much distension of the skin, which has a bluish tinge, or
where the structure has been destroyed by the magnitude of
the abscess.
The medicines for abscesses, are, (1.) bell., hep., mere., sil.,
sulph. (2.) Calc., lyc., phos., puls., sep.
For acute abscesses: ars., asa., bell., bry., cham. hep., led.,
mezer., phosph., puls., sulph.
For chronic abscesses: asa., aurum., calc., carb.-veg., con.,
hep., iod., laur., lycop., mang., merc., merc.-corr., nitr.-ac.,
phos., sep., sil., sulph.
ARSENICUM: Intolerable burning pains, during the fever;
or when the abscess threatens to become gangrenous, or is
accompanied with great debility. Chills, fever, and consecutive
sweat; secretion of offensive matter during the second period;
muscular prostration.
ASAFCETIDA: Abscesses discharging a colorless, serous pus;
violent pains on contact, and great sensitiveness of the adjoining parts; also when there is intermittent pulsations in the
tumor, with darting, tearing pains, which are somewhat relieved by pressure.
BELLAD'ONNA: Pressure, burning and stinging in the abscess;
cheesy and flocculent pus. It is especially suitable for hepatic
abscesses, and also covers very many of the constitutional
symptoms that present themselves during the suppurative stage.
BRYONIA: The tumor is either very red or very pale, with
tensive pain, with sharp sticking and lancinating pains, throbbings in the part, symptoms being worse towards evening and
at night.
HEPAR: When abscess occurs in lymphatic, phlegmatic
individuals, with white delicate skin, blonde hair; especially
when the pains are pressive, aggravated at night, and by exposure to cold; when maturation is imperfect, although
for this symptom, Dr. Kaspar prefers mercurius.* Baryta* Dr. Rummel is opposed to opening an abscess, until the whole tumefaction is matured, and he prefers cold-water fomentations, and upon them




152          TREATMENT  OF ABSCESS.
carb. and carbo-an., are also powerful medicines for promoting
suppuration, when the tumor appears very hard; the former, by
some authors, is regarded almost a specific.
MEZER: For abscesses of fibrous parts, and of tendons, or
for abscesses arising from abuse of mercury, attended by stinging and throbbing pains.
PULSATILLA: When the abscess bleeds readily, with stinging
or cutting pains; or when an itching, burning and stinging are
experienced in the surrounding parts; especially if varices be
present, or, likewise, if the abscesses arise after violent and
long-enduring inflammations.
RHUS: Especially for abscesses of the axillary or parotid
glands, when the swelling is painful to the touch, or discharges
a bloody-serous pus, with stinging and gnawing pains.
MERCURIUS:  Slowly  suppurating  abscesses.   Continual
thirst, coldness of the hands and feet, with internal chilliness
during the febrile stage, with drawing pains in the abscess, and
all the symptoms excessively aggravated at night.
SILICEA: Abscesses  with stitching  and throbbing pains.
This remedy hastens suppuration, or restores it when it has
become arrested in consequence of the suppression of nervous
influence. The pus may be laudable or ichorous. It is also
serviceable after matter has been discharged, to promote
granulation and cicatrization. Calendula of/icinalis is highly
recommended by Dr. Thorer, when the suppuration is profuse
and exhausting, especially in traumatic abscesses.
SULPHUR is especially suited for chronic abscess, and for a
tendency to suppuration, dependent upon a psoric or scrofulous
diathesis. When the pains are throbbing or stinging; or when,
after the evacuation of pus, there is a tendency to ulceration.
This remedy is frequently indicated to complete the cure of the
disease.
a thick warm covering, (we should prefer oiled-silk to warm poultices.)
Hepar-sulph. 30 has proved very useful, especially in suppuration of the
glands, also in the syphilitic and gonorrhoeal bubo.  Sometimes under
its use, the suppurative process is rapidly followed by absorption, and the
abscess disappears without being opened.  Quarterly Homce. Journal,
vol. i., p. 139.




ABSCESS  OF THE ANTRUM.                    153
The importance of applying pressure in the treatment of
extensive abscesses is strongly recommended by Mr. Solly,*
who writes, " I am not aware how far the plan, which it is
my object in this paper to advocate, is in general use or not,
but I am so convinced of its value, that I shall venture to
bring it forward. I refer to the careful application of pressure
over the surface of extensive abscesses, after their contents
have been discharged, and the early disuse of the poultice and
its congener, warm water dressing. I always prefer cotton
wool to any other kind of pad, as it fits better with all irregularities of surface; and I find that a greater amount of deep
pressure can be kept up by strips of plaster than by a roller.
By these means the surfaces of the abscess are kept well in
contact, they adhere together and the discharge soon ceases."
Section 1. —Abscess of the.Jntrum Highmorianum.
Abscesses of the antrum highmorianum, fortunately for
mankind, are not of very frequent occurrence, as they are in
the majority of instances tedious in their cure, and productive
of much pain. The disease may arise from blows on the face,
chronic inflammation of the pituitary membrane lining the
nostrils, exposure to a cold and damp atmosphere, but more
frequently from decayed teeth, which by the irritation they
occasion in the membrane lining the cavity, produce the
inflammatory process which terminates in the formation of pus.
This affection in its first stages is very difficult to diagnose,
and the first intimation that the patient receives of the disease
is pain, which is most generally referred to a carious tooth,
and laboring under such a mistake, several teeth are often
extracted; this, however, does not relieve the suffering, unless
one of the fangs has penetrated through the floor of the
antrum, and being removed allows free exit to the matter that
has been secreted and accumulated in the cavity. If this is
not the case the pain continues extending farther up, and more
* London Lancet, April, 1855.




154            TREATMENT OF ABSCESS
in the direction of the nose and orbit, than is the case in
ordinary toothache; but even this circumstance does not
lead the patient or the practitioner to suspect, the true nature of the affection; in fact, such pain may often be present
in facial neuralgia, without any disease of the antrumn whatsoever. The sufferings of the patient continue for a length of
time, increasing in violence, until finally a tumor becomes
perceptible below  the malar bone; this enlargement may
extend over the whole cheek, but there is a circumscribed
hardness situated above the back molars. The pus may be
evacuated through the cheek, or the matter may move towards
the palate, forming a swelling there, and rendering the bone
in the vicinity carious, unless the patient be relieved; or a
portion of it may be discharged through the nose, when the
patient is lying with his head low, and on the side opposite to
that which is affected; or, as in many instances is the case, the
matter may trickle down between the fang and the socket of
the tooth. The pus that is thus discharged is often so
extremely fetid that no one can enter the room occupied by
the patient without being disgusted by the odor, and the
patient is rendered disagreeable to himself on account of the
matter flowing into the mouth and throat when lying down.
The pain is severe and generally throbbing; sometimes it
remits, but for a short period, returning again with increased
violence.
The formation of pus in the antrum is often attended with
disease of the superior maxillary bone, and is in all instances
tedious, and in many difficult to cure.
The first step in the treatment must be to evacuate the pus,
after which the surgeon can more readily ascertain the condition
of the cavity-whether there be caries, or if any morbid
growth be present within; the selection of remedial measures
consequently being rendered more certain.
All the grinding teeth of the superior maxillary bone,
excepting the first molar, correspond with the floor of the
antrum. These teeth sometimes extend into it, and the fangs
are only covered by the membrane lining the cavity; therefore




OF THE ANTRUM.                     155
the simplest method of evacuating the pus is by drawing one
of the teeth. A caries, or a continued toothache in one of the
molar, should decide the practitioner which tooth to extract;
but if all appear to be sound, the direction is, to strike gently
each one of them, and that which appears most tender, or
gives rise to most pain, should be selected.
The third or fourth molar most generally is extracted, after
which operation, if the pus is discharged, no further operation
is required; if the matter does not follow the removal of the
tooth, a stilet or small trocar must be pushed into the cavity
to produce the desired effect. After the evacuation of the pus,
a probe may be gently pushed into the antrum, and the condition of the bone, &c., ascertained. After the contents of the
cavity have been discharged, it should be cleansed by means of
an injection, thrown into the part from a small syringe, with a
somewhat curved pipe. A piece of bougie must also be worn,
to allow the matter that collects to be evacuated, and hepar,
ars., lyc. or silic. be administered, or other medicines (mentioned in the chapter upon abscesses,) employed, according to
the presenting symptoms.
" Dr. Gullen, of Weimar, from experience in several cases,
strongly recommends ars. and lyc. in this complaint. Alrsenic
generally removes the dreadful throbbing, divulsive pain,
which assumes the quotidian type for the most part; and lyc.
is useful in arresting the thick yellow discharge, which frequently continues after the pain has ceased.  Dr. Gullen
recommends the higher dilutions of both these remedies, and
the use of silic. after the discharge has abated."*
To obviate the necessity of extracting teeth, La JMorier, of
Montpelier, proposed to perforate the antrum above the alveolar
processes, immediately over the third grinder; but, says Dr.
Gibson, "the disease, however, so seldom  occurs without
being accompanied or caused by carious teeth, that such an
operation, though practicable, can scarcely ever be rendered
necessary.
* British Journal of IIomoeopathy, vol. i., p. 407.




156   TREATMENT OF ABSCESS OF ANTRUM.
After the evacuation of the pus, the cavity must be carefully
examined by means of gentle probing. If the internal lining
membrane be diseased, calc.-c., mez., phosh.-ac. may prove
serviceable, if other symptoms correspond; should, however,
the affection have been produced by the decayed tooth, its
extraction and the discharge of the matter will afford great
relief, and the exciting cause being removed, the medicines
will doubtless exert their beneficial actions. But too frequently
the disease has extended itself, not only to the membrane lining the cavity, but also to the bone itself; in such instances,
the treatment, of course, must be directed to the carious bone.
The medicines that have proved most serviceable for disease
of the osseous structure, are, calc., lyc., merc., phosph.-ac.,
silic., staphys, sulph.-or, ars., asaf., aur., hepar, nit.-ac.
From clinical cases that have been recorded, we learn, that
phosph. is an excellent medicinal agent for diseases of the
bones, particularly caries or necrosis. In the British Journal
of Homceopathy,* there is an interesting account of a child that
became affected with diseased bones from the vapor of phosph.
Such testimony as this should at once lead the practitioners of
our school, to investigate more thoroughly the action of our
medicines, as in these instances especially, the power of drugs
over diseases is distinctly perceptible..Iururm. and nit.-acid are excellent medicines when the
patient has previously been affected with syphilis; mez. will be
found efficacious in mitigating, and often arresting the intolerable burning pains which are present, particularly at night.
This medicine, perhaps, is better adapted to the disease when
the bone itself has not been implicated, but when the whole
lining membrane of the cavity is in an abnormal condition.
JMezereon acts more particularly on periosteum than on bone.
It is adapted to dull, crampy pain, and tearing in the malar
bone, with anguish, paleness of the face, continued chilliness,
sometimes cold sweat, constant thirst, tongue coated white,
want of appetite, pale urine, and frequent, small pulse.
* Vol. vi., p. 284.




ABSCESS OF THE MAMMIE.                    157
Kali-hydrioticum is a medicine that has been frequently overlooked in the treatment of this disease; it is suitable not only to
those cases that have originated from the syphilitic poison, but
is likewise serviceable when there is a violent darting pain extending to the ears, or when there is a constant grumbling
sensation in the tooth and face, when there is excessive
accumulation of saliva, with importunate thirst night and day.
As palliatives for the pain that is often so severe as to be
almost unbearable, spigelia, nux-vom., china or phosph., will
be found of much service. Spigelia must be administered when
there is a pressure experienced in the region of the antrum,
with darting and tearing pains, accompanied with burning.
JVux-vom. is indicated when there are tearing pains in the
malar bones, with continual painful soreness of the teeth,
together with boring and gnawing pains.
China will relieve the pains when they are cutting and burning, or when there is drawing pressure in the molars, with sensation of numbness in the side, or when there is a beating or
throbbing in the malar bone, with fine stitches through it.
Phosph., when there is burning and throbbing in the region
of the antrum, when there is a continual, dull, aching pain
(grumbling) in the molars, with jerking and tearings.
Jlercurius is an important medicine, and is well suited to
the disease after the pus has been evacuated, and when there
is caries of the bone; when the pain extends to the ears, is
darting and tearing, and particularly unbearable at night.
Teucriumr is warmly commended for diseases of the antrum.
Staphysagria will also prove serviceable, not only for the
darting pains in the antrum, but also for any unnatural bony
formation. In addition to the medicines already mentioned,
Sulph., carbo-v., antimonium-crud., may be indicated in this
affection.
Section 2.-JMammary J.bscess, MJastodynia 2.postematosa.
Abscesses of the mammae, although most frequently occurring in females who are nursing, may also be present in women




158         ABSCESS OF THE MAM ME.
who have never been pregnant; indeed, by some writers, we
are informed that men have been affected with the disease.
A patient about to suffer from this variety of abscess, experiences for a day or two before the local inflammation manifests
itself, general lassitude, restlessness, and uneasiness, together
with slight soreness of the gland. Afterwards, there may be
coldness of the body and shiverings; the mamma becomes
enlarged, heavy, painful, and may assume a redness all over its
surface, or the tint may be deeper in some parts than in others.
If the glandular portion be most affected, the breast appears,
when handled, to be lobulated and hard; but if the skin and
cellular tissue are the seat of the disease, the tenseness is
uniform throughout. As inflammatory action proceeds, the
pain becomes throbbing, extends to the axilla, and is often
intense, and the patient is unable to bear the slightest pressure
upon the part, even the contact of clothing aggravating the
suffering. The disease is most common about two or three
months after delivery, or during the weaning period, when a
large quantity of milk, by distending the breasts, gives rise to
the inflammatory process which terminates in the formation of
pus. It is said that when the inflammation is confined to the
integument, suppuration follows more speedily than when the
true glandular substance is affected. After the symptoms have
continued for four or five days, unless the progress of the
inflammation has been arrested, suppuration may be expected;
but there are cases in which the inflammatory process proceeds
so slowly that pus is not formed for a much longer period,
during which time the patient becomes much exhausted by loss
of rest, excessive pain, and the accompanying fever.
The most common causes of this variety of abscess are, suppression of milk from various causes, a current of air upon
the breasts, an accumulation of milk through some fault in suckling the child or from weaning, external injuries, or stimulants
which are too frequently allowed to nurses or mothers suckling
their children.
There is also a somewhat peculiar abscess of the mammary
gland, noticed particularly by Mr. Hey. The inflammation




TREATMENT OF ABSCESS OF THE MAMMAE. 159
is very deep-seated, the process tedious, and when suppuration
has supervened and the matter has extended towards the surface, it is discharged through several openings, which become
fistulous, and when these sinuses are opened, a soft, purple
fungus is discovered beneath them; the surrounding parts of
the gland are hard and lobulated.
This form of mammary abscess is difficult to heal; the
discharge continues for a length of time, hectic is superinduced, and the patient may be placed in a very precarious
position.
Treatment.-The homeopathic treatment of this disease is
very efficacious, and if the medicines are employed in the early
stages of the affection, resolution can be accomplished. Warm
applications, poultices, &c., should never be employed in
abscess of the marnmme, as they not only tend to increase the
afflux of fluids, and create more extensive suppuration, but
they interfere with the action of the remedial agents administered internally,* and are prone to induce indurations.  The
only local treatment that should be used should be a light suspensory bandage, to support the tumor in order to prevent its
weight from causing additional pain, and frequent bathing with
tepid water after the abscess has been opened, that the part
may be kept perfectly clean.
If, after the chilliness, the patient experience a tensive, burning, or darting pain in the breasts, if they are somewhat
swollen and red, bryonia should be prescribed; or if before the
symptoms above mentioned appear, and there is only slight swelling, aconite. These two medicines are often sufficient to produce resolution; the child, however, should be allowed to suck,
even though pain is produced. In some instances the breast
pump is serviceable, when the female is desirous of weaning the
infant, but often its use may be dispensed with, the homceopathic treatment being sufficient to cure the affection. If the
milk continues to be secreted in too great quantity, and
bryonia does not relieve, puls. will be found of great service.
* Croserio's Obstetrics.




160   TREATMENT OF ABSCESS OF THE MAMMiE.
Calc. carb. has also been used with success, and lycop. proved
effectual in an obstinate case of the kind.*
Belladonna must be used when there is, together with the
throbbing pain, a shining erysipelatous redness. And also,
when the inflammation is caused by the suppression of the milk
by violent emotions, if the patient be robust, with tendency to
congestions, &c. If this medicine does not relieve, and the
patient complains of chilliness and shuddering, which at this
stage of disease generally indicate the formation of pus, mercurius should be administered, or if the symptoms require, hepar
may be prescribed. If these are not sufficient and suppuration
is progressing, phosph. has been highly recommended by Dr.
Croserio. He says, " Since I have seen the marvellous effects of
phosph. in abscess of the breasts, I have employed no other
medicine, when there have been evident signs of suppuration.
This medicine, administered upon these circumstances, at the
thirtieth dynamization, one globule in water, a teaspoonful
every six hours, promptly calms the pain, procures the opening
of the abscess and its cure, without leaving any visible trace
of the cicatrix upon the breast.
"I could cite many cases of these prodigious cures.
"The efficacy of phosph. in abscesses, shows itself quite as
remarkably in the cure of the rebellious fistulme of these organs,
resulting from allopathic treatment, as also in the induration
of the mammary glands, remaining after the opening of the
abscess by the knife. The homeopathic physician ought not
to open these abscesses with a cutting instrument, because
occupying a part where there is nothing to fear from the effusion of pus, he can wait its spontaneous opening from the
specific administered, which has the advantage of avoiding the
pain, the emotion, and a disagreeable consecutive cicatrice;
and facilitating the complete resolution of the obstruction of
the mammary gland, and also prevents the serious degenerations which sometimes follow these accidents."
There are some abscesses, however, that are so deep-seated,
* Dr. I. Lembke's General Homoeo. Gaz., Vol. XXVII.




HEPATIC ABSCESS.                       161
that although the pus may be fully formed, the time that it
takes in making a passage for itself to the surface, is considerable. In such cases as these there can be no objection to the
physician using the lancet, and evacuating the pus, as the
operation is trivial and the pain slight, compared to what the
patient must suffer during the time that is occupied, while the
matter is making its way to the surface.
After the pus has been evacuated, silic., in most instances,
is sufficient to complete the cure.  This medicine is also
serviceable when the discharge is serous, and has continued for
a length of time.
If indurations remain, conium, merc., phosph.-ac., silic. or
sulph. must be administered, each according to the symptoms.
If the inflammation be consequent upon bruises, arnica may
be applied externally, in a weak solution, and internally in the
form of globules; and should much pain, fever, &c., be present,
in alternation with it, aconite may be prescribed.
Section 3. —Hepatic./bscess.
The frequency of occurrence of hepatic abscess is less
under homaeopathic than allopathic treatment, because by the
administration of homceopathic medicines, the inflammation existing in the liver is generally subdued before suppuration ensues.
There are, however, cases that, notwithstanding the best
directed efforts to procure resolution, terminate in suppuration,
and among these may be classed those inflammations that are
occasioned by wounds, or other injuries; or when the disease is
present in individuals who are weakened by some constitutional
affection, biliary concretions, or the presence of worms in the
biliary ducts.
Kirkland* relates a remarkable instance of the latter; and
also Dr. Thomas Bond,t and Dr. Gibson,4 of this city. The
* Inquiry into the Present State of Medical Surgery, vol. ii., p. 186.
t Medical Observations and Inquiries, vol. i., p. 68.
$ Gibson's Institutes and Practice of Surgery, vol. i., p. 209.




162    TREATMENT  OF HEPATIC ABSCESS.
latter gentleman writes, " a very beautiful preparation made
by the late Dr. Wesenhall, of Maryland, of a liver, the substance and ducts of which are filled and perforated in every
direction, by numerous and very large lumbrici, which destroyed
the child by irritation and suppuration, is contained in my
surgical cabinet deposited in the University."
In abscess of the liver, or rather before suppuration has been
established, the patient experiences a stinging, burning pain in
the right hypochondrium, below  and around the false ribs,
frequently extending to the epigastric region or sternum, and
in some instances, even to the thorax. This pain may be very
severe, or it may be a continual, dull aching pain, aggravated
by lying on the affected side, or by any external pressure; there
is also more or less pain experienced in the right shoulder.
There are also present gastric symptoms, such as hiccough,
loathing eructations, attended with anguish, or there may be
nausea, vomiting, bitter taste, yellow tongue, &c. Rigors generally precede the immediate formation of pus, and swelling may
appear in the right si(le, and as the disease progresses, fluctuation may be perceived. The pus may burrow in various
directions, in accordance with the situation of the abscess; it
may proceed to the region of the hip, along the dorsal vertebrae,
or it may be discharged into the transverse colon, stomach,
duodenum, or into the lung; the latter is a very unfavorable
situation, as the patient frequently dies of hectic.*
After the abscess has opened, the pus that is discharged
changes its character; at first it is thick and creamy, but after
a short time it becomes greenish, fetid, or of a dark brown
color.  Large cavities are formed in the liver, and in some
instances the whole structure of the organ may be destroyed,
and there are cases on record, where this has been the case, as
has been revealed by post mortern examinations.
Treatment.-The (lesideratuln in treating an inflammation of
the liver, no matter by what cause it is occasioned, is to pro* Sometimes the abscess has discharged itself into the pericardium. See
London Lancet, Aug. 1845, p. 154.




TREA T MENT OF  I E PATIC ABSCES S.   163
cure resolution.  The medicines that are most serviceable in
producing such a result are, chiefly, acon., bell., bry., cham.,
merc., nux-vom., sulph.  The indications for their use, will
be found in any work upon the homoeoyathic practice of
medicine.
The medicines that are best adapted to hepatic abscess are,
ars., bell., hepar, merc., silic., sulph.  If the matter has made
its way towards the surface of the body, the prognosis is more
favorable, than when it is discharged into any of the surrounding tissues or organs.  If the pus has commenced \to fbrm,
hepar should be administeredl, or if the process of formation be
slow, mere. and silic. may hasten the suppuration, and allay
the pain; the latter is the best med(icine, particularly when
there is hardness of the surrounding parts, with distention, or
if there is a continual stitching pain below the floating ribs;
but mercurius is to be preferred, when there is burning in the
region of the liver, with distention from  within outwards,
accompanied with perspiration, that is excited by the slightest
motion.
If a swelling appear to protrude through the intercostal
spaces, the pus should be immediately evacuated, by means of
the lancet or bistoury, if this be not done, the matter may be
discharged in another direction, and give rise to very unfavorable symptoms.
If, after the opening is made, the discharge continue, and
become thin, sanious and unhealthy, ars., carb.-veg. or nit.acid must be administered; the directions for their use have
been already mentioned in a preceding portion of this work.
If the opening have a tendency to become fistulous, calc., silic.,
sulph. or phosph. should be exhibited.
In all cases the patient should be kept at perfect rest, and if
extremely weak, a moderate stimulus should be allowed.
In some instances, when there is a large quantity of pus, it
should be evacuated by openings, made at different times, and
at longer or shorter intervals; to determine this, however, the
general constitutional symptoms of the patient must be taken
into consideration. If he be robust and previously healthy,




164              LUM BAR ABSCESS.
and the inflammation has gone through its stages rapidly
though completely, there need be no fear in allowing free vent
to the purulent secretion.  If, however, the patient has been
long suffering from previous disease, the constitution generally
weak, temperament nervous, and the signs of a chronic
hepatitis have been present, care should be taken, that the
removal of a large quantity of matter, does not produce the
most alarming symptoms of debility and exhaustion; it is then
better to practice the method recommended by Abernethy,
already alluded to, in the chapter upon abscess.
Section 4.-Lumbar.Abscess.
This disease is, in most instances, of a chronic nature; the
collection of pus being very gradual; instances, however,
may occur, in which the affection is acute, the matter making
its appearance in a short time after the premonitory symptoms
have been noticed by the patient.
The first manifestations of the disease do not, in many cases,
receive sufficient attention, and are allowed to pass unnoticed,
until the disorder is far advanced, and the danger too proximate to escape attention.  In the incipient stage, the patients
are unable to walk with their usual facility, there is a degree
of uneasiness experienced about the lumbar region, but there is
little very acute pain; rigors are frequently present, the
patients also being unable to use any violent exercise.  As the
disease advances, the testicle of the affected side is drawn up,
and there is more or less pain extending along the course of
the spermatic cord.  Glandular enlargement takes place in the
groin, and there is slight protrusion noticed at that part; the
swelling then appears on the inner side of the femoral vessels,
beneath the pubal portion of the facia lata.  The precursory
symptoms may continue for several months, before rigors, loss of
appetite, hectic and other symptoms which denote profuse
suppuration, are  developed.  Mr. Cooper remalrks, " the
abscess sometimes forms a swelling above Poupart's ligament,




LUMBAR  ABSCESS.                      165
sometimes below it, and frequently the matter glides under the
fascia of the thigh;'ccasionally it makes its way through the
sacro-ischiatic foramen, and assumes rather the appearance of a
fistula in ano. When the matter gravitates into the thigh,
beneath the fascia, Mr. Hunter would have termed it a disease
in, not of the part."
The swelling is more prominent in the erect position, and is
also increased by exertion of the abdominal muscles; an impulse
is also imparted to it when coughing. As the sippuration continues, fluctuation is perceived, generally in some portion of
the groin, but large and neglected collections of pus may
make their way towards the surface in two or three directions.
Lumbar abscess most frequently arises from disease of the
vertebrae, but, says a distinguished surgeon, "it must be
confessed, that we can hardly ever know  the existence of the
disorder, before the tumor, by presenting itself externally,
leads us to such information."
The pus discharged from a lumbar abscess is generally thin,
gleety, and mixed with cheesy flocculi, or with a curd-like
substance; in some rare instances, however, the matter has
been found to be laudable.
From examinations made post mortem of patients, who have
died from this affection, we learn, that the purulent secretion
is completely enclosed in a cyst, which is often very extensive.
If the contents of such abscesses were not circumscribed by
such boundaries, the pus would spread rapidly among the cells
of the surrounding cellular texture, as does the water in
anasarca. The cysts are lined with the pyogenic membrane,
that, as has been before mentioned, appears to possess the
property of secretion; indeed, during the treatment of lumbar
abscess, it is wonderful to observe the immense quantity of pus
that is discharged.
This disease, as Mr. Liston remarks, is often attributable to
a sprain or wrench of the loins, or is induced by exposure to
cold, and over fatigue. Occasionally the mischief is confined
entirely to the soft parts; although the vertebrae, a portion of the
os innominatum, or the sacrum, may be denuded and of irregu



166    TREAT MENT OF LUMBAR ABSCESS.
lar surface, evidently the result of the pressure of the abscess.
A strong example of this, and of the extensive destruction of
parts, which this affection sometimes produces, may be briefly
stated. A very large lumbar abscess formed within a few
weeks, in consequence of great and continued fatigue, and exposure to bad weather. At first it had been trifled with. At
last it was opened, in the usual situation in the thigh, and a
large quantity of matter evacuated.  Thirty-six hours afterwardts, the patient was suffocated with a flow of purulent
matter into and through the air passages. On dissection, the
cavity was found to be a large opening, through the diaphragm
into the adherent lung, and communicating with the bronchi.
The fore part of the lumbar vertebrae were exposed, and in
some instances, stript of the theca; but there were no cavities
in the bone, and no disease of the interposed cartilages. Such
cases are now and then met with, of abscess in the loins, not
originating in any vice, either of the bones or of any other part
of the apparatus of the spinal column.  Most frequently, however, the collections have their foundation in disease of the
bodies of the vertebrae.
The causes of this complaint are generally very obscure. It
is most prevalent among the lower classes of society, who are
scantily clothed and fed, and exposed to vicissitudes of weather,
and extreme fatigue and other hardships. Individuals affected
with scrofula are most obnoxious to the disease, and it is said
to be more prevalent in Europe than on this continent. Dr.
Gibson* thus writes: "I have seen only four cases of the
disease during the last thirteen years, although professionally
connected with extensive hospitals and alms-houses during the
greater part of the time."
Dr. Physic also stated, he never met with a case of psoas
abscess in America, unconnected with disease of the spine.
In the treatment of lumbar abscess, the prognosis is always
unfavorable; the radical cure of the affection can scarcely be
effected, even when the patient applies for relief at the earlier
a Institutes and Practice of Surgery, vol. i., p. 214.




TREATMENT OF LUMBAR ABSCESS.   167
stages of the disease, which in far the greater majority of
instances is not the case, because the pain in the loins, and
other premonitory symptoms, are attributed to some other cause.
The following medicines, although they may not effect a
cure of the disease, will greatly alleviate the sufferings of the
patient; indeed, there have been cases in which, by the careful
administration of medicine, the abscess has been partially healed,
and there is every reason to believe, that if the diagnosis is
formed correctly, at an early period of the affection, a cure
may be reasonably anticipated.
The medicines chiefly to be used are, ars., asaf., aur., calc.-c.,
hepar, lyc., mere., mez., phosph.-ac., silic., sulph.
Jrsenicum  is indicated in the first stages, when there is
painful stiffness in the small of the back, or bruised sensation,
with inability to walk as easily as usual, with burning pain
around the sacrum; or if, after the pus has been, or is being
evacuated, there is great prostration, shivering, brown tongue,
hot dry skin, constant unquenchable thirst, the secreted matter
being thin and bloody, or consisting of a fetid ichor.
A.safcetida is called for particularly, when the abscess arises
from diseases of the bones, when there is tearing in the lumbar
region, or tensive sticking pains, which are aggravated by
moving the body; when the pus is transparent and thin, or
ichorous and fetid; when the skin is cold and dry, and the
patients are scrofulous, with disposition to rachitis../urum may be used, when there is pressure and pain in
the lumbar region and os innominatum, when the pains in these
parts are particularly aggravated at night, and when the
patient has been formerly subjected to large doses of mercury;
when the pus is thick, yellowish, and contains cheesy flocculi.
Calcarea-carb. should be administered, when the disease
arises from curvature or ramollissement of the vertebra, with
constant aching pain in the lumbar region, with stiffness of the
whole spinal column, and heaviness of the limbs with inability
to move them; when there is profuse discharge of pus, and the
cavity shows no disposition t6 heal.
Hepar-sulph., when the suppuration is profuse, and the skin




16S    TREATMENT OF LUMBAR ABSCESS.
surrounding the abscess presents an unhealthy appearance; excessive fever at night, at which time the pains are aggravated;
tired sensation in the lumbar region, or violent pain in the
small of the back, as though it would break or were being cut
through.
Lycopodium is indicated by stiffness and aching in the small
of the back, the patient being unable to maintain the erect
posture, or when there is chilliness in the lumbar region, with
large swelling of the psoas muscle and much heaviness and
uneasiness of the lower extremities..Mezereum, when there is dull, pulsative pains in the lumbar
region, or drawing and aching extending to the groin, with
intolerable burning pains which are aggravated at night;
when the periosteum of the vertebrae is affected and the abscess
discharges a yellowish pus; excessive failing of strength.
Phosph.-ac., when there is smarting and burning in the
abscess, with bruised sensation over the whole person, excessive
prostration, with irregular pulse, profuse debilitating night
sweats, with intense pain in the lumbar region.
Staphysagria should be employed when there is reason to
believe that the disease arises from caries of the bones or
curvature of the spine; when there are burning or tearing pains.
If there is unhealthy granulations and disposition in the
abscess to spread, silicea may prove beneficial. The treatment, in many cases, may be commenced with the administration of suilph., which will prove serviceable as an anti-psoric.
There is frequently some difficulty in diagnosing a lumbar
abscess, as it often points very readily at that region where an
inguinal hernia would protrude; however, by carefully examining the patient, and inquiring particularly into the history of the
case, the error of mistaking the one disease for the other may be
avoided. In opening a lumbar abscess, the method recommended by Abernethy* should be resorted to. As the disease
is chronic, and the matter has been secreting for some time, it
must not be forgotten, that the evacuation of a large quantity of
pus at one time, might be productive of serious consequences.
~ See chapter on Abscess.




P A R   N Y C H I A -- W H I T L O W.      169
Section 5.-Paronychia —-Whitlow.
A whitlow is an inflammation, very much disposed to suppurate, and generally productive of severe pain, commencing in
the extremities of the fingers, though the toes are sometimes
the seat of the disease.
Writers generally divide whitlows into four varieties. In
the first and least severe, the disease commences under the cuticle near the root or side of the nail; the pus not being deep
seated and soon evacuated; sometimes, however, the abscess
takes place under the nail, in which case the pain is severe, and
not unfrequently shoots up as far as the external condyle. The
second variety is situated chiefly in the cellular tissue, under
the skin, and generally occurs at the very ends of the fingers.
In such cases the inflammatory symptoms, especially the pain,
is far more violent than in other common inflammations of not
greater extent. However, though the pain be severe, it does
not generally extend far from the affected part. The intensity
of the sufferings and the severity of the inflammatory process
are owing to the hard, unyielding nature of the integument
covering the fingers; consequently, when the laboring classes
are affected by the disease, the pain is much more pungent and
deep seated than when those in the higher walks of life are
attacked; for the same reason there is often great difficulty in
perceiving any fluctuation after the formation of pus.
The third kind of whitlow is distinguished from the others,
by the following circumstances. The pain is excruciating, there
is very little swelling in the affected finger, but very much in
the hand, particularly about the wrist, and sometimes even extending throughout the entire fore-arm; the pain is experienced
along the hand and wrist to the elbow, and in the most severe
cases to the shoulder; suppuration proceeds slowly, and after
the formation of pus, fluctuation can only be perceived in the
hand, the affected finger appearing swollen and tense. The
patient is deprived of all rest, and suffers for nights and days
together; considerable fever also being present, and sometimes
delirium.




170         TREATMENT OF WHITLOW.
The disease in this variety, is situated in the tendons, and
their sheaths, consequently the power of moving the finger, and
often the hand, is entirely lost.
In the fourth variety, the inflammation appears to attack the
periosteum. The peculiarity of this form of paronychia appears
to be, that however violent the pain, it seldom extends along
the fore-arm, nor is there any external swelling of the affected
finger. Suppuration is soon established, and unless the disease
be checked and the matter evacuated, caries or necrosis of the
sub-adjacent bones may be the result.
Whitlow generally arises from local causes, such as splinters,
pricks with needles or other sharp instruments, bruises, warmth
suddenly applied to parts cold from exposure, &c. Those individuals whose occupation requires frequent immersion of the
hands in warm water and other fluids are particularly liable to
the disease; however, there are some cases in which it is impossible to assign any cause.
Treatment.-In the first variety of whitlow, when the disease is superficial, hepar must be used, it is also suitable for the
swelling, allays the stiffness and numbness of the fingers,
hastens the formation of pus, and mitigates the pain, itching
and throbbing; indeed, in the Materia Medica this medicine is
spoken of as being " a specific against panaritia."
MIercurius should be administered when the pains are intolerable at night, with intense aching and burning under the
finger nail, when there is hardness of the surrounding skin and
the suppurative process is slow.
Jrsenicum is a valuable medicine, when the part assumes a
bluish-red appearance, with intense burning pain, with stiffness
and rigidity of the joints.
The pus in this form of the disease generally soon accumulates, and will evacuate itself without the aid of the knife; it
is well, however, if the skin is hard and unyielding, to wrap
around the affected finger four or five layers of lint, and keep
it constantly moist with tepid water. After the pus evacuates
itself, silic. or sulph. will generally facilitate the cure.
In the second variety, the inflammation being more deeply




TREATMENT  OF WHITLOW.                      171
seated, when there is tearing and burning in the affected part,
and if the surrounding skin have an unhealthy appearance, with
brittle and discolored nails, silic. is to be administered; or if
after the evacuation of the matter unhealthy fungous granulations appear, this medicine is of the utmost importance.
Sulphur is indicated, when there is coldness of the fingers,
with stiff red joints, when the patient is of a psoric diathesis,
or where the finger appears dead and shriveled, with sticking
and darting pains-hepar and mercurius may also be well
adapted to this variety of whitlow, and should be administered
if symptoms correspond.
If the affection arise from  wounds, a lotion of calendula
should be applied to the part.  Carbo-veg., or arsen., must be
given, if there appears a black angry-looking sore, with burnings and tearings, and throbbing pain, and strong disposition
to ulceration. There is no doubt that in many cases a free incision with a bistoury should be made, as soon as the surgeon
is fully convinced that pus is present, as the non-elasticity of
the parts, the slow suppurative process that takes place, together wlth the imperfect formation of matter, all tend to increase the sufferings of the patient, and cause an extension of
the disease, until more important parts are involved. If the
inflammation arise from a puncture, and the patient complains
of coldness and alternations of heat, ledurn is recommended by
M. Teste.  Of course in treating any case of panaritia, if
there be any extraneous matter present, giving rise to the inflammatory process, it should be removed immediately.
In the third variety of whitlow, when there is violent burning aching under the finger nails, with sensation of ulceration
when touching anything, or if the panaris causes a digging
burning pain, with tingling, and if there be proud flesh, causticum is the medicine. If there be numbness or tearing, thus
tox. may be indicated. Sepia will be beneficial if there is tearing under the nail, with contraction of the finger with violent
beating and stinging. These medicines allay the pains, but
often it may be useful to alternate with them either hepar, merc.,
silic., or sulph.




172         TREATMENT  OF WHITLOW.
It is necessary also in this variety of whitlow to have recourse to the knife; the surgeon must not be content merely to
plunge into the sore a lancet, but should lay open with a bistoury the whole sheath, taking care, however, not to sever
the tendon; after which, by applying a solution of calendula to
the part, and inclosing the fingers in lint, the disease may
be in a short period cured —if there are unhealthy granulations,
(proud flesh,) and the cut surface shows little disposition to
unite, sepia, silic., or calendula may be administered, and sometimes the unhealthy granulations will have to be slightly
sprinkled with alum-ust.
In the fourth variety, mnerc., mez., phosph-ac. silic., are
chiefly to be relied on..Mez. may be given when there is intense pain. But the matter, as has been before remarked, often
forms quickly; here also the knife must be called into requisition.  It is useless for homceopathic physicians to decry the
knife in all cases, and in every variety of whitlow; in the first,
and sometimes in the second form of the disease, the proper
manipulation and administration of medicine may produce the
desired result, but in the third and fourth, when the pus has
formed within the sheaths of tendons, or beneath the periosteum,
incision is imperative, and he who neglects it, should be held to
a certain degree responsible for the future pain, and perhaps
the loss of the finger, to which the patient may have to submit.
In the ordinary progress of abscess the majority of the surrounding textures are pushed aside, and the pus approaches
the surface, where a point is destroyed by ulceration, and the
matter evacuated. But if nature be balked in her endeavors
by resisting textures, as the sheaths of ligaments, periosteum,
&c., the pressure is increased to a dangerous degree at various
points, areolar tissue is broken up, muscles are detached, bone
ulcerates and dies, blood-vessels perforate, joints stiffen, and
are rendered useless; therefore, although medicine may relieve
pain, hasten suppuration, and after the evacuation of matter
exert a controlling influence over the processes of granulation
and cicatrization, still the knife must be employed; it must
penetrate the periosteum down to the bone.




TREATMENT OF WHITLOW.                          173
The toughness of the integuments, and the high grade of
inflammation that are present in panaritia, render the incisions
very painful; the surgeon therefore must operate quickly, with
a very keen-edged knife; but at the same time must do his
work thoroughly.
A whitlow may be prevented in almost every case, if, as
soon as the pain and the inflammation are perceived, the skin
of an egg which has been boiled be wrapt around the affected
part. At first the patient will experience aggravation of the
symptoms, but if the application be allowed to remain, or perhaps applied at intervals, the affection will often be arrested.
Electricity is also said to prevent and cure the disease.
The medicines that have been above stated are those frequently employed in panaritia; however, the following, as they
may prove usefuil in some cases, are subjoined.
For Panaritia in general.  (1.)./rs., calc.-carb., caust., hepar, lach., merc., nit.-ac., pet., sep., sil., sulph. (2.) Alum.,
amm.-mur., baryta.-c., carb.-veg., con., jod., kali.-c., natr.-m.,
puls., rhus., sang., mgt.-arc., mgt.-aus.
Under the integument. (1.) qdrs., hep., merc., silic., sulph.
(2.) Calc.-c., graph., nitr.-ac., puls.
In the deeper tissues.  (1.) Carbo-veg., caust., hepar, sep.,
silic., sulph. (2.) Graph., merc., nit.-ac., phosph., puls.
Between the tendons. (1.) Rhus., ledurn., caust. (2.) Hepar,
lacll., merc., silic., sulph.
Affecting the periosteum.  (1.) Calc.-carb., mez., phosph.ac., silic. (2.) Hep., lye., mere., nitr.-ac., sulph.




174                     ULCERS.
CHAPTER X.
ULCERS.
THIOSE sores that are created by the action of the ulcerative
process, or in other words, solutions of continuity, effected by
ulceration, are termed ulcers.
All the textures of animal life are liable to be attacked,
although some are more susceptible of invasion than others,
but it is more particularly the formation of those sores that
appear on the surface of the body, that at present demands
attention.
There is no class of diseases in which the truth of the
homceopathic law is more fully tested, and the results more
satisfactory, both to patient and practitioner, than that now
under consideration.
It frequently happens, that those ulcers that have resisted for
years all the means to effect their cure, employed by the most
skilful physicians of the old school; and that have been successively submitted to the roller, the poultice, adhesive straps,
the cautery and the knife with but little benefit, yield to the
infinitesimal doses of a medicine exhibited in accordance to the
law " Sirmilia similibus curanter."
Although there are some ulcers that are capable of being
healed rapidly and permanently, by the internal administration
of the appropriate remedy; yet there are many cases, particularly when the sore has assumed an indolent and chronic
character, that require the steady and repeated exhibition of
medicine for weeks and months together, to produce the desired
effect. An ulcer may remain stationary for a length of time
after the commencement of the treatment; and the patient
perceiving no beneficial change in the nature of the sore,
becomes complaining and dissatisfied; when such is the case,
it too frequently happens that the practitioner, being weary of
treating a disease in which no perceptible improvement is




ULCERS.                         175
manifested, either becomes neglectful of his duty or entirely
relinquishes the case.
Great patience and forbearance on the part of the physician
are absolutely requisite, together with the continued exhibition
of the remedy, which should not be administered in too low a
dilution, (perhaps it is better always to commence with the
30th,) or at too short intervals.
The arrangement into classes of the varied forms of ulcers,
simplifies much their description, and to a certain extent their
treatment, but the classification differs with different authors.
Dr. Gibson mentions three varieties, viz: simple, indolent and
irritable ulcers, arranging other ulcerated surfaces under the
diseases that cause them. Sir Everard Home forms them into
six classes:
1. Ulcers in parts that have sufficient strength to carry on
the actions necessary for their recovery.
2. Ulcers in parts that are too weak for that purpose.
3. Ulcers in parts whose actions are too violent to form
healthy granulations, whether this arises from the state of the
parts or of the constitution.
4. Ulcers in parts whose actions are too indolent, whether
this arises from the state of the parts or of the constitution.
5. Ulcers in parts which have acquired some specific action,
either from a diseased state of the parts or of the constitution.
6. Ulcers in parts which are prevented from healing from a
varicose state of the superficial veins of the upper part of the
limb.
Mr. Miller mentions ten varieties, viz: 1. Simple purulent,
or healthy sore. 2. The weak. 3. The scrofulous. 4. The
cachectic.  5. The indolent.  6. The irritable.  7. The inflamed.  8. The sloughing.  9. The phagedenic.  10. The
sloughing phagedaena.
Probably the most simplified method of classifying ulcers,
is that of arranging the whole into two divisions; the first
comprising the simple, indolent and irritable ulcer; and the
second, embracing those sores that have acquired a specific
character from the diseases with which they may be associated,
scrofulous, syphilitic, cancerous, &c., leaving the more minute




176        SIMPLE, OR HEALTHY ULCER.
consideration of the diseases themselves, to be studied in their
appropriate places.  This appears, also, the more requisite,
because there are many important symptoms that may present
themselves in any or all the varieties of ulcers, without regard
either to name, classification, or the specific disease upon which
they may be dependent.
Section 1. —Simple, or Healthy Ulcer.
This is, in truth, an example of healthy granulation, following a wound or abscess; or of inflammatory disintegration of
a part, previously unbroken in its surface.
The discharge is thick, creamy, easily detached from the
granulations, almost inodorous and not profuse; in fact, it is
laudable pus. The granulations are numerous, small acuminated, florid, sensitive and vascular; if touched at all rudely
they bleed and are pained, the blood is arterial, neither too
profuse nor abnormal in quality, and the pain is but the just
appreciation of injury done to healthy tissues. The general
sensation in the part, when not injured, is slight tenderness, or
a feeling of rawness, rather than actual pain; not unfrequently,
a sensation of itching is present, to a degree even troublesome.
As soon as the granulations arrive at the surface of the skin,
cicatrization commences, and proceeds steadily until the part
is repaired.*
The treatment of such sores is quite simple. The part
should be kept at rest, and in a position that may relax those
muscles upon which the ulcer is situated, and above all, the
strictest cleanliness enjoined. Milk and tepid water commingled in equal parts, should be allowed to dribble over the part,
from a sponge or piece of lint saturated in the liquid; this
appears to be the best abstersive method, as the frequent
passing of a sponge, &c., over the healing parts, may prove a
source of irritation, as well as causing a destruction of the
M MAiller's Principles of Surgery.




IRRITABLE  ULCER.                     177
delicate granulations, and the healing process thereby be
retarded.
The simple ulcer generally heals rapidly, without the exhibition of any medicine. Sometimes, however, after cicatrization has progressed for a time, there appears to be a diminution
of action in the healing process; if this be the case, a few doses
of silicea 30th, repeated every twelve or twenty-four hours,
will overcome the difficulty, and complete the cure.
Section 2.-Irritable Ulcer.
This form of ulcer is generally preceded by an irritable
state of the system, or if such be not the case, the const.itutional may be produced by the local irritation.
The digestive function is frequently impaired in those persons
afflicted with irritable ulcer, and consequently the sore is often
found among those in the higher walks of life, who eat and
drink to excess; or among debauchees, &c.
The appearances presented by an irritable ulcer, are as
follows: The edges are ragged, undermined and serrated,
the bottom appears deeper in some points than in others, and the
parts around are red, inflamed, and frequently Pedematous; the
discharge, which is always considerable, is a thin, greenish
or reddish matter, which is frequently so acrid, that it excoriates the surrounding skin, and is sometimes mingled with solid
matter. Granulations are wanting, and in their place may be
found a grayish film, or a dark-red spongy mass, which is
acutely sensible, and bleeds at the slightest touch, the blood
being of a dark grumous character.
The medicines that have proved most effectual in removing
this form of ulcer, are, arsen., asaf., carbo-veg., lyc., hepar,
merc.-sol., nit.-acid, silic., mez., con., sulph., thuja, staphys.
fJrsenicum.-This is an admirable medicine for irritable
ulcer, when it appears in individuals of exhausted, impoverished
constitutions, or in those in whom there is a tendency to abdominal plethora, when the serrated edges of the sore are high,
12




178    TREATMENT OF IRRITABLE ULCER.
and when the pain is burning or tearing; the discharge is
greenish, thin, acrid and mingled with blood, the base of the
ulcer is covered with a yellowish or whitish film, the pain is
severe and is felt at night even while sleeping; and the surrounding parts are bluish, inflamed, and Edematous..fsafaetida is adapted to nervous individuals or to those of a
phlegmatic temperament, with a venous or hemorrhoidal constitution; when the ulcer is extremely sensitive to touch, the
margins deeply serrated, and of a bluish color, and elevated
above the surrounding textures, the discharge is ichorous, thin
and perhaps fetid in character.
Carbo-veg.-This medicine is to be exhibited, when there
is pressure and a sensation of tension around the ulcer, which is
exceedingly irritable, and bleeds profusely at the slightest
touch. The bottom of the sore has a bluish tinge, and there
is an areola of the same color, extending to some distance
around the part, the discharge is aqueous and corrosive, or
may consist of degenerated pus. The remedy is peculiarly
adapted to peevish and irritable individuals, or in those in
whom there is predominant action of the venous system, as
indicated by the bluish tinge of the whole body, particularly
around inflamed surfaces.
Hepiar-sulph. is indicated, when the pain in the ulcer is corrosive, with burning and throbbing sensations, particularly at
night, stitching pains through the sore when laughing, excessive sensitiveness of the surface, which bleeds profusely when
lightly touched. There is a disposition in such ulcers to
become chronic, and the surrounding tissues present an unhealthy appearance. It is beneficial when the patient is easily
irritated, and when the accompanying fever is exacerbated at
night.
Lycop., in individuals of mild or melancholy disposition,
when the pains in the ulcers are worse at night, with stitching,
tearing and itching, or when there are burning and painful
stitches in the sore. The pains are aggravated by remaining
in a warm room, and ameliorated when in the cool air.
JMerc.-sol. —The indications for the employment of this




TREATMENT OF IRRITABLE ULC:ER.   179
medicine are, when the pains in the sore become intolerable at
night in bed; when, instead of granulations, there is a spongy,
bluish mass, which is sensitive and bleeds readily. The ulcers
are extremely painful when touched, and discharge an acrid
corrosive ichor; the elevations are very irregular at the base,
and there is present a sensation as if the part were corroded by
insects, together with unequal quick pulse, sleeplessness and
dripping night sweats, with great nervousness and excessive
irritability.
NJit.-acid must be employed, when the patient is sad and
desponding, or impatient, irritable and vehement; when there is
coldness of the whole person at night with profuse sweat; when
the ulcer at the slightest irritation bleeds copiously. There is
a thin, ichorous discharge mingled with blood, that corrodes the surrounding skin, together with shooting, stitching
pains in and around the ulcer, with burning as from nettles;
or there are itching and prickings in the parts around, or the
pains may be so violent, that the patient appears unable to
tolerate his condition.
Silicea is useful to complete, after the healing process has
commenced, the cicatrization, or when there is a disposition in
the sore to become chronic; where there are stinging, burning
pains in the surrounding parts, with aching, smarting pains in
the sore.  It is also indicated, when there is a secretion of
thick discolored pus, or of a thin acrid sanies, and when there
is frequent formation of large flabby vegetation.
It may be often advantageous to commence the treatment of
irritable ulcers with a few (loses of sulphur, after which, the
medicine best adapted to the case may be administered.  If
the constitutional symptoms presented are such as require
treatment, they must be encountered by the proper homceopathic specific.  If the above remedies are not sufficient to
establish a healthy action in the sore, recourse must be had to
some of the following: phosph., mez., acid-mur., lach., puls.,
con., sulph., bell., thuja, staphys.




180              INDOLENT ULCER.
Section 3.-Indolent Ulcer.
This variety of ulcer is of much more frequent occurrence
than either of those already described. It has received from
several authors the appellation "callous," and is the fourth
variety in the classification of Sir Everard Home.  " Ulcers
in parts whose action is too indolent to form healthy granulations, whether this indolence arises from the state of the parts,
or of the constitution."
The appearances presented are a complete contrast to those
of the irritable sore, although in the first instance it may have
assumed the characteristics of that variety of ulcer; indeed, a
healthy or simple sore may pass through a variety of stages,
and ultimately become indolent, because cicatrization may
have been opposed or protracted by its situation, or other adverse circumstances.
From such reasons it is obvious that the ulcer must be most
common among individuals belonging to the laboring population, upon whose efforts depend the subsistence of their families,
and who therefore are unable to make use of appropriate means
(rest, &c.) so necessary to be observed at the first appearance
of the sore, that the ulcerated surface may be repaired. As
long as the erect posture is practicable, the poor man must
strive for the maintenance of his household, and even when the
sufferings become aggravated, the cry of his little ones for
bread urges him to increased exertions, until finally a simple
purulent ulcer becomes inflamed and irritable, and at length
assumes those appearances which are the sure characteristics of
the indolent sore.  But it is not among such alone, that this
variety of ulcer is found, nor does it so fiequently arise from
such continued exertion consequent upon a laudable energy engendered by domestic affection, as from filthy and dissolute
habits or long continued intemperance.
An indolent ulcer presents the following appearances:
The edges are elevated, protruded, smooth and rounded,
giving to the sore an appearance of deep excavation. The
surface is smooth, glossy, pale, and generally void of granula



INDOLENT ULCER.                       181
tions, although in some instances there is a feeble attempt at
such formation; or it is covered partly with a pellicle, or crust,
of a whitish or dark gray color, so tenacious that it is inseparable from the ulcer without considerable force. Sometimes
the sore is dry), but generally there is a profuse discharge of a
thin and serous fluid, nearly destitute of fibrin; the surrounding integument is swollen and discolored.
The most striking characteristic of the indolent sore is the
elevation of the margins, which are very callous, and present a
whitish appearance, resembling "a dense, high ring of cartilage." The pain is so slight that the patient frequently experiences but trifling annoyance, and is able to perform his usual
avocations.
When an irritable ulcer has become indolent, the appearances vary from those described above. The granulations are
large, round, pale and flabby, extremely sensitive, and bleed
from the slightest scratch, and sometimes rise into a fungous
form above the skin. This is what is termed by some writers
the "fungous ulcer;" by Mr. Home it would be denominated
as " an ulcer in parts too weak to carry on the actions necessary for its recovery"-or by others as the " weak sore."
" This variety," writes Prof. Gibson, "may, and often does,
accompany an ulcer with carious bone, sprouts from the mouth
of a sinus, or covers the surface of many specific ulcers. From
whatever source it springs, its characters are uniform, and its
disposition so truly indolent, that it cannot without impropriety
be referred to any other head."
There is another variety of indolent ulcer, which precedes or
follows a varicose enlargement of the veins of the leg or thigh,
which has been denominated the varicose ulcer; it generally
makes its appearance on the inner side of the leg, and is often
very difficult to cure. It resembles an indolent ulcer in a somewhat advanced stage; the edges of the skin, however, bounding the sore are not tumid; the sore is seldom  deep, usually
spreads along the surface, and is oval in shape, The branches
and trunk of the avena saphena are enlarged, and this varix of the
veins prevents the healing of the ulcer. The pain that is pre



182     TREATMENT OF INDOLENT ULCER.
sent appears to be deep seated, and extends up along the course
of the veins, and is exasperated by maintaining the limb in the
erect posture.
Treatment. —In the treatment of indolent ulcers, it is necessary that the utmost cleanliness be observed; and if the patient
be one whose constitution has been impaired by unwholesome
diet, exposure to a foul atmosphere, or by intemperance, these
obstacles should be overcome by the substitution of nutritious,
easily digested food, proper ventilation and regularity of habits;
in fact, as far as possible, every effort should be made to effect
the removal of the predisposing cause.
The indolent sore is capable of cure, under homeopathic
treatment; indeed, in some instances, without having recourse
either to the bandage, straps, or escharotics, and it is not absolutely necessary that the patient be put to bed,* although overexertion tends to retard recovery.
The restoration of continuity in parts destroyed by the indolent sore is often very gradual, and attended with variations in
the healing process. The ulcer may appear to be doing well,
when, from some irritation, a retrograde action takes place, but
if the practitioner have reason to believe the medicine correctly
chosen, it must perseveringly be administered; always endeavoring not to interfere with its action by the too frequent
repetition of the dose.
The surgeon, if the sore progresses slowly, is often strongly
tempted to administer the medicine at too short intervals, and
in a lower potency than that which he is employing, but when
allowing himself to be thus led astray, disappointment is invariably the result. So long as there is a perceptible improvement in the appearance of the ulcer, the medicine must be continued, as there is nothing that more retards the progress of
cure, than the repeated change of the means employed for the
accomplishment of that purpose.
The medicines that are most serviceable in the treatment of
* See Whately's Practical Observations on the Cure of Wounds and
Ulcers on the Legs, without Rest.




TREATMENT OF INDOLENT ULCER.    183
indolent ulcers, are ars., carb.-veg., lyc., graph., phosph.-ac.,
sang., sepia, silic., sulph.
The medicines that appear most eminently useful, whose
symptoms are most frequently similar to those presenting in indolent ulcers, and that are best adapted to the constitutions of
those individuals among whom the sore is most prevalent, are
ars., and carbo-veg.
Afrsenicum is suited to individuals of exhausted constitutions,
in whom all eruptions have a disposition to become chronic.
There may be a tendency to general plethora of the whole
system, or general emaciation. When the sore is consequent
upon long continued abuse of spirituous liquors. When the
ulcers are of long standing, with burning and lancinating pain,
or the sore is covered with a gray scurf, and surrounded by
an inflamed margin, or when it is accompanied with shining,
hot swelling of the feet. When the ulcer is burning on the
surface and in the edges, with tearing pain, particularly when
the part becomes cold-also when the edges are raised high
above the surrounding skin, and when the areola around is red
and shining, the base bluish colored, and having a scurf resembling lard. Further, this medicine is extremely useful, when
the discharge consists of thin bloody pus, and the granulations
are unhealthy, and the sore has a fetid odor-or the ulcer has
slight discharge.
Carb.-veg. is indicated when the constitution has been weakened by excessive losses, or when the sore appears upon cachectic individuals, the tone of whose system has been weakened by
gastric affections arising from various excesses, when the margins of the ulcer are elevated, and when they are of a deep
blue color, the surrounding skin also assuming the same tinge,
and is quite hard and painful to the touch, also when there is a
heaviness of the limb, and the pus discharged from the sore
emits a cadaverous smell.
These two remedies are indispensable in very many cases of
indolent ulcers; indeed, cures have been accomplished by their
administration, without the exhibition of any other homceopathic medicine.




184     TREATMENT  OF INDOLENT  ULCER.
But though ars. and carb.-veg. are adapted not only to
many of the local manifestations presented by the indolent
sore, but also to the constitutions of those individuals among
whom it is most prevalent, the student cannot fall into a greater
error than administering them  for every case of the kind for
which he is called to prescribe, and neglecting other medicines
which are of great importance in the treatment of these particular instances.
Graphites is adapted to individuals having a tendency to
corpulency, blond hair, unhealthy skin, with disposition to
chronic eruptions, when the ulcers appear covered with a scurf,
with pain at night, the whole limb is affected when touched or
moved, as if the bone would be dashed to pieces, even in those
parts distant from the ulcer; itching and pressing in the sore,
or there may be tearing or stitching pains; likewise when the
scurf upon the ulcer smells like herring pickle,.or when there is
a fetid odor from the sore.
Phosph.-acid is a remedy for indolent ulcers, particularly
when there is much itching, or when there is burning pain; for
those that are inveterate or flat, with dirty looking pus and
indented base.
Sang. In the pathogenesis of this medicine we find-old
indolent ulcers, ill-conditioned ulcers, with callous borders and
ichorous discharge.
Sepia, lycop., silex and sulphur are other medicines that
have been employed with great advantage in the treatment of
this variety of ulcer.
Lycopodium is very serviceable in some cases, when the ulcer
is old and has a tendency to become fistulous, with hard, red,
shining edges and swelling pf the affected part.
Silicea is an admirable medicine when the ulcers have become
putrid, particularly when they occur in old, psoric, cachectic
persons, living in poverty and filth, when there is inflammatory
redness extending for some distance around the sore; also for
fistulous ulcers, of a dingy appearance, with shaggy, callous
edges, extending through to the bone, or when the parts surrounding are hard, swollen, and bluish red.




TREATMENT OF INDOLENT ULCER.    185
When proud flesh makes its appearance, or has attained to
considerable growth, which frequently is the case in this species
of ulcer, the medicines most available are, ars., petrol., sepia,
silic., sulph.
When the ulcer is attended with, or arises from a varicose
condition of the veins, the following medicines are to be employed: am., puls., lach., sulph., sil., or in some cases, ars.,
carb.-v., acid.-phosph.
By some homceopathic physicians, the Hamamelis Virginiana
has been strongly recommended; however, as there has been
no regularly instituted proving of the drug, it is impossible to
mention to what particular symptom it is applicable, and,
therefore, until its pathogenesis is established, it must be considered as unreliable.
The limb affected with varices should always be bandaged,
or a laced stocking constantly worn, as it is of great service in
supporting the column of blood, which, continually tending to
increase in size the already distended vessels, acts as a
mechanical obstruction, and tends to retard recovery.
It has been previously remarked, that indolent ulcers can be
radically cured by the proper administration of homceopathic
medicines, without the necessity of the patient remaining in
bed, but there are some individuals in the daily performance of
whose duties, the erect posture is required for hours together,
and no opportunity offered for any rest being allowed to the
part.  In such persons, when afflicted with the indolent sore,
this excess of exercise may be counterbalanced by proper
mechanical support, applied to the limb.
The method best adapted for accomplishing this end, is that
advocated by Mr. Critchett, F. R. C. S., and also recommended in the British Journal of Homceopathy,* as an adjunct
to the treatment of the variety of ulcer under consideration.  It
consists in tightly strapping the limb, in the manner presently
to be described-the use of straps being considered preferable
to the application of the roller, as the bandage is liable to slip,
or become loose.
* Vol. vii., pp. 423-425.




186    TREATMENT OF INDOLENT ULCER.
Instead of the plaster (Empl. plumb.) recommended by Mr.
Critchett, the straps should be made from simple wax, or
isinglass plaster, as such will not interfere with the medicine
administered internally.
The following are the words of Mr. Critchett: " You must
seat the 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 print 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
to eighteen inches, according to the size of the limb.
" You then take the centre 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 very 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 that very important point, the amount
of tightness you may wish to employ. As you proceed with
the remainder, you must always remember the principle is to
make one portion fold over another; you must, therefore,
alternate them around the foot and ankle. Your second piece
should be placed in a similar manner underneath the heel, and
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 upwards, 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 covered; 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."
Referring to this method of dressing, the editors of the
British Journal, remark, "over this a bandage is to be applied
in the usual manner. Small ulcers, situated in the hollow
between the malleolus and the os calcis, require more pressure




TREATMENT OF ULCERS.                       187
than the rest of the limb, which may be produced by applying
small pieces of plaster in a crucial manner over the wound,
before putting on the strapping."
Twice a week, in the majority of cases, will be sufficiently
often to renew tlis manipulation. If there be a profuse discharge, a piece of dry lint may be placed upon the sore.
The above concludes the description and a portion of the
treatment of those ulcers, that were arranged under the first
division. Those sores included in the second division will be
mentioned, with their most appropriate medicines, in a different
portion of this work. As the symptoms recorded in the next
section may be present in any of the different forms of ulcer,
without regard to classification, the student should become in
some degree acquainted with the corresponding medicines.
Section 4.-Index to the Treatment of Ulcers.
Ulcer with pain as if bruised. (1.) Hepar. (2.) Sulph. (3.)
Ars., con., nux-v.
With biting (smarting.)  (1.) Puls.  (2.) Euphorb., lach.,
led., lyc., sulph.
Turning black. (1.)./rs., sec.-cor. (2.) Asaf., plumb. (3.)
Silic.
Turning black on bottom..Jrs.
Turning black on the edges..Ars.
Bleeding. (1.).Jrs., lyc. (2.) Asaf., carb.-veg., hepar,
kali-c., lach., mere., nit.-ac., phosph., puls., silic., sulph.
Bleeding on edges.  (1.) Irs.  (2.) Lyc., mere., silic.
With blisters around. (1.) Lach. (2.) Ars.
Bluish.  (1.) Lach.  (2.) Carb.-veg.  (3.) Con., hepar.
Boring.  (1.) Silic., sulph.
Burning. (1.) firs., caust., lyc., merc., thus, silic. (2.)
Carb.-veg., con., hepar, mez., puls., sulph.
Burning in the edges.  (1.) dqrs., lyc., merc., silic.  (2.)
Caust., hepar.




18             TREATMENT OF ULCERS.
Burning in the circumference.  (1.) Puls.  (2.) Ars., asaf.,
caust., lach., lyc., mere., rhus, silic.
As if burnt.  (1.).rs.  (2.) Carb.-veg., eyc.
With sensation of cold. (1.) Bry. (2.) Ars., silic.
With gnawing  pains.  (1.)  Staphys.   (2.) Plat., puls.,
ranc.-scel.
Crusty. (1.) Con., lyc., silic., sulph. (2.) Bell., calc.-c.,
graph., mere., sep.
With Cutting. (1.) Bell. (2.) Calc.-c., natr.
Deep ulcers. (1.) Calc.-c., puls., silic. (2.) Bell., con.,
hep., lye., nit.-ac., sulph.
With digging pains. (1.),qsaf.
Flat, even ulcers. (1.) Lach. (2.) Ars., asaf., lye., mere.,
phosph.-ac., selen., sep., silic.
Ulcers destitute  of feeling.   (1.) dJrs., con., lyc.  (2.)
Calc.-c., carb.-veg., silic., sulph.
Fistulous. (1.) Calc., lyc., puls., silic. (2.) Asaf., bell.,
carb.-veg., caust., nit.-ac., sulphur.
With tendency to gangrene. (1.).3rs., plumb., sec.-cor.
(2.) Asaf., scill.
Hard to the touch. (1.) dIrs., bell., lyc., puls. (2.) Asaf.,
bry., calc.-c., chin., clern., hepar, lach., mere., silic., sulph.
Hard on the  edges.  (1.).Jrs., lyc., merc., silic.  (2.)
Asaf., hepar, puls.
Hardness within the circumference. (1.) J.saf., puls. (2.)
Ars., bell., lye.
With high, hard edges. (1.)./rs., asaf., silic. (2.) Lye.,
mere.,, puls.
Difficult to heal. (1.) Hep., silic. (2.) Calc.-c., cham.,
con., graph., lye., mere., nit.-ac., petro., rhus, sep., staphys.,
sulph.
With jerking pains. (1.) Caust., puls., silic. (2.) Asaf.,
calc.-c., natr.-mur.
With inflamed margins. (1.) dqcon., arsen., hepar, merc.,
silic. (2.) Bell., bry., lye., puls., rhus, staphys.
With itching. (1.) Hepar, lyc., silic. (2.) Ars., caust.,
chin., graph., phosph.-ac., rhus, sep., staphys., sulph.




TREATMENT  OF  ULCERS.                         189
With itching in surrounding parts. (1.) Hepar, puls., silic.
(2.) Lach., lyc.
With scurf having the appearance of lard. (1.) Rep., merc.
(2.) Ars., nit.-ac.
Painless ulcers.  (1.) Lyc., phos.-ac.  (2.) Ars., bell., cocc.,
con., phosph., puls.
With pressure. (1.) Silic. (2.) Graph.
With pricking.  (1.) Jfrs., merc., nitr.-ac., puls., silic.,
sulph.  (2.) Rhus.  (3.) Asaf., hepar, lyc., petro., sep.
With tingling.  (1.)./rn., rhus, sep.  (2.) Clem., con.
With pulsation.   (1.) JkIerc., sulph.   (2.) Calc.-c., kalicarb., silic.
With pustules around.  (1.) AIrs., caust., lach., pulsa., sep.
Putrid. (1.) Hepar, mulr.-ac., silic. (2.) Ars., calc.-c.,
chin., rhus, sulph.
Sensitive ulcers. (1.) qrn., asaf., hep. (2.) Ars., bell.,
caust., lach., lyc., mere., puls., sep., silic.
With soreness. (1.) Hep., puls. (2.) Graph., merc., phos.ac., sepia.
Spongy  ulcers.  (1.)./rs., carb.-an., silic.   (2.) Clem.,
lach., phosph., sep.
With  much swelling.  (1.) Bell., merc., puls., sep., sulph.
(2.) Bry., hepar, kali.-c., rhus, silic.
With tearing, drawing pains. (1.) Lyc., sulph. (2.) Ars.,
cale -c., mere., sep., silic.
With tension. (1.) Con., puls., sulph. (2.) Asaf., Baryta-c.,
caust., lach., merc., phosph., rhus, spong.
With  pain as of sub-cutaneous ulceration.   (1.) Phosph.,
puls., silic. (2.) Am., asaf., bry., con., graph., ranunc-bulb.
Ulcers with unhealthy pus.
Pus serous, aqueous, sanious.  (1.) JMerc., nitr.-ac., sulph.
(2.) Silic. (3.) Ars., carb.-v., lyc.
Pus albuminous.  (1.) Jrs., sulph.  (2.) Amm., sep., silic.
Pus brownish. (1.) AIrs. (2.) Carb.-veg.
Excessive secretion of pus. (1.) Sep. (2.) Chin., lye.,
phosph.-ac., puls., silic.
Pus gelatinous. (1.) AJrg., merc., sep., silic.




190           HISTORY OE SYPHILIS.
Pus gray.  (1.).1mb., merc.
Pus yellow.  (I.).1rs., lyc., puls.  (2.) Kreos., thuja,
silic.
Pus acrid.  (1.) dIrs., m.erc., silic.  (2.) Staphys., rhus,
sep. (3.) Sulph.
Pus sanguineous.  (1.) Rrs.. asaf., hep., merc.
Scanty secretion of pus. (1.) Lach., merc., silic. (2.) Calc.-c.
Pus fetid. (1.) Hep., phosph.-ac., sulph.
CHAPTER Xl.
VENEREAL DISEASE.
Section 1.-History of Syphilis.
UNDER this head will be classed, not only that specific
disease, which has the power of penetrating the organism and
producing constitutional syphilis, but also gonorrhcea or blennorrhcea.
The question concerning the origin of syphilis, has given
rise to much argument, and to many learned discussions. The
three suppositions that appear most worthy of observation, are:
1st. That the disease was brought from America by the
Spaniards.
2d. That it originated in Europe.
3d. That it has been noticed from the earliest periods of
human existence.
The first of these suppositions was promulgated to a great
extent by Oveido, a Spaniard; indeed, he received from writers
upon this subject, the entire credit of having traced the source
of the  disorder.  To whatever reputation, however, may
attach to such research, Oveido was not entitled, inasmuch as
Leonhard Schmauss, Professor at Saltsberg, in the year 1518,
had declared the same fact. The opinion of Schmauss was
adopted by Chevalier Ulric Van Hutton, (known afterwards
for his zeal and attachment to the cause of Luther,) A. D. 1519.
The assertion, nevertheless, of its American origin, did not find




HISTORY OF SYPHILIS.                  191
very many supporters, notwithstanding it was strenuously advocated and enforced by Oveido. Among those, however, whose
minds were impressed with its truth, were several individuals
of much celebrity. If Oveido was quite sincere in the opinion
he expressed, it is certain that'feelings of a personal nature,
very much contributed to augment the warmth and energy
with which he maintained his position.
Among the distinguished opposers of the American origin of
the disorder was Van Helmont, who, however believed it to
be a new disease, supposed its birth-place to be Europe, and
that it was generated in the army of Charles VIII. at the siege
of Naples. Howard, at a later period supported the same
opinion.
In the year 1680, Samuel Janson, who had resided for some
years in the West Indies, not having observed the appearance
of syphilis endemically, supposed that it was brought by the
slaves from Africa. It is well known that both Sydenham and
Boerhaave favored this opinion, and the latter defended it
warmly in 1751. But slaves were not carried to America,
previous to the year 1503, and at that time the disease was
prevailing over all Europe.
An Italian alchemist propagated, also, a very curious idea,
concerning the origin of this disease. Lord Bacon credited the
story, and endeavored by his writings, to render it more plausible. "The length of the siege of Naples," says Leonardo
Fioravanti, " having caused a famine among the French and
Spanish troops, the merchants who brought food to the soldiers,
sold them various articles prepared from human flesh, and all
those who made use of the horrible aliment, were soon affected
with syphilis, which was disseminated by contagion through
Italy, France and Spain." Finally, J. Astruc,* a man of much
learning and great natural talent, but whose acquirements,
according to Jourdan, have been greatly exaggerated, endeavored, and succeeded in many instances, in convincing the
world, that the disease was imported from America. He was
" De Morbus Veneris Libri sex, Paris, 1736.




192            HISTORY  OF SYPHILIS.
supported, also, by Christopher Girtanner, a person of many
and varied literary and scientific attainments.  But Jourdan,
taking up the arguments that were brought forward by them,
disposes of them one by one in a most satisfactory manner.
His pamphlet* bears the impress of deep thought, and of a vast
amount of learning, toil and research, and should be perused by
every student who is interested in this subject. He says (p. 44,)
" the question is generally put, did syphilis appear for the first
time, towards the end of the fifteenth century? The terms are
not sufficiently explicit, since, as a preliminary matter, it is
necessary to explain what is meant by syphilis. Now this
definition, which has been neglected by all writers, is the only
way of duly appreciating, judging and reconciling the different
opinions successively advanced on the subject.  By the term
syphilis, therefore, is to be understood, 1st. A general affection
of the system, which presents itself under a most frightful aspect, with many particular modifications, assuming a
real epidemical character. In this sense the word designates
the disease which broke out towards the end of the fifteenth
century.   2d. It may serve to express morbid symptoms
arising from an intercourse with a disordered person, communicated in the same way to other individuals, and having with
each other a more or less intimate connection.  Now, if we use
the word syphilis in this last sense, it can be incontestibly
proved, that from the remotest antiquity the diseases which it
designates were known."
He then proceeds to prove his above statement with a
"' master hand," and mentions among others who have noted
the disease, Guy de Chauliac. Peter Argelata says, that pustules arise on the penis ex materia "venemosa quce retinetur
et remanet inter prveputium et pellem cutis exactione viri cumn
fceda muliere." In the thirteenth century, Lanfranc, Salicet,
and others, spoke of the same disease, in terms which prove
how far they considered it worthy of attention. There has
been also, many passages collected by Becket, from manuH* istorical and Critical Observations on Syphilis.




HISTORY  OF SYPHILIS.                  193
scripts which make mention of it. What likewise proves that
the diseases of that period were considered of a serious and
formidable character is, that the authorities in order to prevent
their propagation enacted severe laws, the penalties for the
violation of which were rigidly exacted. Hence the regulations for the houses of pleasure in London, in the years
1162 and 1430. Similar establishments and regulations existed in most of the large cities of Europe, from the time
of Charlemagne. Medical and historical writers, make mention of diseases contracted at such houses, called clapiers.
Jourdan then quotes many authorities in favor of the affection having been noticed and mentioned, by writers at a
very early date,* but it is unnecessary that they should be
mentioned here.
He is also of opinion, that the terrible epidemic which prevailed about the close of the fifteenth century, originated with
the MJarranes, (hogs.)  This term  was applied to those
Moors and Jews, who had entirely disregarded the teachings of
Christianity, and refused to enlist under its banner; for this
offence they were expelled from Spain by an edict of King
Ferdinand, dated March, 1492. The persecutions were unremitting, and the tortures to which this unfortunate class
were subjected, were horrible in the extreme, to avoid which,
they concealed their belief, but secretly practised those rules
that were prescribed by their religion. They are described
as living in the most disgusting and loathsome manner, and
leprosy among them was alleged to be common. They were
driven from their homes, not allowed to carry with them
any of their property, and very many of them retired to the
northern coasts of Africa, where they propagated a disease so
terribly contagious, that of 170,000 families who crossed to
Africa, 30,000 were destroyed. Jourdan says,t "when we
compare the testimonies of the most veridical historians and
physicians, we think it impossible to doubt its being derived
* See Leviticus, chap. xv., v. 2-27.
t Loc. cit., p. 99.
13




194            HISTORY  OF SYPHILIS.
from the Marranes, who were expelled from  Spain before the
discovery of America." Fulgosi, among others, tells us that
it originated  in Ethiopia, "quae  pestis, ita enim  visa est,
primo  ex Hispania in Italia  allata, et ad Hispanos ex
Ethiopia."  At that time all the parts of Spain occupied by the
Moors were called Africa, and afterwards Ethiopia. Infessura,
who noticed the first ravages of the epidemic at Rome, calls it
pestis JMarranorum: JMortui sunt quam plurimi ex peste et contagione JMarranorum.  Beniveni, Benedetti and Trascatorius
derive it from Spain. John Trithamius, abbot of Spanheim, likewise informs us, that it originated in that country: habet suce
infectiones pestiferce principium in Hispanio.  The period of
its appearance exactly corresponds to that of the expulsion of the
Marranes. Fulgosi announces its existence in Lombardy, as early
as 1492. We find it among the Germans in 1493 and 1494.
John Pomarus says it appeared in Saxony in 1493. Henry
Bunting affirms the same thing for Brunswick and Lunenburgh.
According to John Sciphover, it broke out in 1494 in Westphalia, from whence it soon spread from the coasts of the
Baltic Sea to Pomerania and Prussia. And as mentioned by
Linturius, it manifested itself in 1494, on the borders of the
Rhine, in Suabia, Franconia and Bavaria. Now the expulsion
of the Marranes dates from the year 1492. These unfortunate
wretches, who left Spain, according to Fabricius, to the
number of one hundred and twenty-four thousand families, or
of one hundred and seventy thousand, as mentioned by
Mariana, lost, according to the same Fabricius and John
Nauclerus, thirty thousand families, of a most fatal epidemic,
which appeared to be of a peculiar nature. The disease not
merely spread to Rome, as mentioned by Infessura, but also
infected Naples, according to Zureta and Collenuccio, and
even was propagated to the coasts of Barbary. Leo, the
African, says, that the disease anterior to the landing of the
Marranes, was unknown in Africa.  Paul Jovius attributes,
also, the extension of the disease to these exiles. Finally
some passages from Peter Martyr, Francis de Villaloros and
Peter Pinctor, which, owing to their want of clearness, have




HISTORY  OF SYPHILIS.                  195
been refuted by the partisans of the American origin, seem to
indicate that the epidemic already existed in Spain, during the
last twenty years of the fifteenth century; consequently before
1490. It cannot at all appear surprising, that such considerable collections of people, whom the avarice of Ferdinand had
deprived of all the necessaries of life, and consequently thrown
into the most disgusting filth, the inseparable attendant on
misery, should have spread, wherever they passed, a contagious
cutaneous disease, complicated with scorbutic symptoms,
which were necessarily produced by the dampness and the
excessive heat of the weather. This is the idea we naturally
form of the terrible epidemic of the fifteenth century.
The epidemic thus spread over all portions of Europe.
In Germany, the propagation of the disease was principally
attributed to the Lansquenets,* a military rabble, who were
constantly ready to sell their life and blood to the highest
bidder. In the latter end of the fifteenth century, the whole
of Europe being engaged in war, the disease once propagated
among the common soldiers, must readily have been spread
over the whole continent. A similar confusion prevailed in
regard to the mode in which the disease was propagated. It
was believed by many, that the virus could be carried in the
atmosphere, or that any article which a person afflicted with
the disease had touched, was capable of imparting the disorder.
Fallopius supposed that the disease might be propagated by the
holy water, into which a syphilitic patient had dipped his finger.
In the year 1556, Fernel proved that the disease originated
from a specific cause, emanating from some affected individual,
and acting upon one in health; he opposed the idea of the transmission of the virus by the atmosphere, and denied the belief
in cosmic, astrological or teleological influences; he also
described, with tolerable accuracy, its mode of transmission.
After a lapse of three hundred years, Fernel's picture of the
syphilitic disease is still true, as is shown by the descriptions
of the most enlightened and learned physicians of the present day.
* See Gollmann on Diseases of the Urinary and Sexual Organs, p. 45.




196                   GO NO  R HCE A.
Section 2.-Simple Venereal Disease.-Gonorrhoea.
Gonorrhoea, or a specific morbid secretion from the urethra
in males, and from the urethra and vagina in females, is a disease of very ancient date; it arises from impure connection, and
presents the following symptoms.
A few days, generally from four to six, or even more,* after
copulation, a tickling or slight itching is felt in the urethra,
near the frwenum; this sensation continues one or two days,
when the mouth of the urethra acquires an increased sensibility,
becomes red and swollen, and there oozes or is discharged a
limpid or yellow matter, which stains the linen.  When the
running occurs the titillation increases and becomes more painful, especially during the emission of urine, which is followed
by a smarting and burning in the affected part. In some persons the first symptom observed is the discharge of thick mucus;
in these cases the patient experiences a painful scalding when
passing water.
These symptoms usually increase for three or four days;
sometimes, however, not sensibly, for eight to twelve days.
The glans penis acquires a dark red livid color; the discharge
becomes more profuse, the matter becoming of a yellowish green
color, the swelling of the glans and sometimes even of the
whole penis becomes considerable, the patient experiences a
frequent desire to void urine, and suffers, particularly when he
has been some time in bed, lying on his back, from involuntary
erections, so frequent as to disturb his rest.
In many cases, the inflammation extends to the reticular substance of the corpus spongiosum; the erections, when this is
the case, become extremely painful, the fraenum being drawn
down, while the body of the penis is forced upward, from extreme turgescence; such a condition is termed chordee. When
in this state the vessels of the urethra are often ruptured,
* Gonorrhoea may lie dormant in the system for a considerable time, or
it may be retarded in its course, by some other disorder attended with
fever. For corroboration of this, see London Lancet, June, 1845, p. 526.




G O N O R R H IE A.               197
occasioning considerable hemorrhage, while at other times,
the discharge is only streaked with blood. The prepuce is also
at the same time so inflamed and swollen that it cannot be
drawn back, or when retracted it cannot be returned.*
In some instances the urethra discharges small clots or even
fluid blood, and there are evident marks of an ulceration of the
urethra.
The inflammation may increase to such an extent that there
will be no secretion from the glands and the membranes lining
the canals.  All discharge then ceases, and it is to this form of
the disease that some authors have improperly applied the term
gonorrhcea sicca, or dry clap.
But the symptoms, their time of appearance, and their violence, vary greatly in different individuals. Mr. Hunter has
well remarkedt that " the variety of symptoms in a gonorrhcea,
and the difference of them in different cases, are almost endless. 
The discharge often appears without any pain, and the accession
of pain is not at any stated time after the appearance of the
discharge. There is often no pain at all, though the matter
thrown out may be considerable in quantity and of bad appearance. The pain often goes off, while the discharge continues,
and will sometimes return again. An itching in some cases is
felt for a considerable time, which sometimes is succeeded by
pain, though in many cases it continues to the end of the disease. On the other hand, the pain is often troublesome and
considerable even when the discharge is trifling or none at all.
In general, the inflammation in the urethra does not extend beyond an inch or two from the orifice; sometimes it runs all
along the urethra to the bladder, and even to the kidneys; and
in some cases spreads in the substance of the urethra, producing
a chordee. The glands of the urethra inflame, and often suppurate.  The neighboring parts sympathize —as the glands of
the groin, the testicle and the pubes-with the upper parts of
the thighs and abdominal muscles."
In the worst cases, small indurations may often be felt in the
* See Swediaur on Syphilis, p. 4. t tHunter on the Venereal, p 61.




198       TREATMENT OF GONORRHCEA.
course of the urethra, and the prostate gland partakes of the
inflammation; in which event a sense of heat, weight, and fulness is experienced in the perineum, with pain in the hypogastrium, dysuria, and tensemus, particularly when the disease has
spread to the bladder or its cervix. Abscess, fistula, and permanent disease of the prostate, or stricture of the urethra, are
the occasional results of such complications. Phimosis, orchitis,
and bubo, not unfrequently take place from the extension of
the inflammation to the prepuce, testes and glands of the groin,
during the course of gonorrhmea.
Gleet, or the existence of a serous or muco-purulent, pale
green, or colorless, discharge from the urethra, is not an unfrequent occurrence after an attack of acute inflammation. It is
commonly attributed to chronic inflammatory action. The most
trifling error in diet, and particularly the use of spirits, wine,
and pungent condiments, is generally followed by a frequent
inclination to void water, a degree of ardor urinae, and increased
oozing of matter. This state often continues for years, and
grows more and more aggravated, until at length a permanent
stricture is formed, or thickening of the bladder, disease of the
prostate, or even of the kidneys becomes established.
Treatment. —Gonorrhmea sometimes proves very intractable,
even in homaeopathic practice; but if the treatment is commenced sufficiently early, it terminates much less frequently in
the secondary form of the malady, and the other serious consequences that have been detailed, than results from allopathic
treatment. The medicines which have hitherto been chiefly
employed by homceopathic practitioners are, copaiba, petroselinum, cannabis, aconite, sulphur, canth., capsicum, silicea, lycopodium, acid-nitric, sepia, &c.
In the milder forms of the affection, or in cases occurring in
healthy subjects, the cure is generally easily and speedily accomplished when the patient applies before the second stage
* The treatment of gonorrhcea is mostly taken from Laurie's HIomceopathic Practice of Physic. The remedies are well selected, and bear the
impress of considerable experience in treating this affection.




TREATMENT OF GONO R R H (EA.                 199
has set in. The disease has frequently been arrested at its outset (when the orifice of the urethra looks fuller and redder than
natural, and a disagreeable itching is felt in the canal, together
with frequent desire to urinate, and some pain during micturition) by means of the alternate employment of aconite and cannabis, at intervals of at first six, and subsequently twelve to
twenty-four hours.
So soon, however, as the discharge begins, and ardor urinae
experienced, copaiba often proves very serviceable; but should
there be a constant desire to make water, petroselinum. should
be used in preference. Cannabis is better than either when the
inflammation is somewhat of a higher grade, and the pain and
difficulty in passing water are constantly more intense. In
gonorrhcea with phimosis, or extension of the inflammation to
the prepuce, merc. is the most important medicine; but it is
sometimes necessary to prescribe a dose or two of aconite in the
first place, when the inflammatory action is excessive, and the
gland and prepuce are very much tumefied. MJerc. is further
of considerable efficacy at the commencement of the second
stage of the disease, when there remains a muco-purulent discharge, of a white or greenish yellow color, and some degree
of pain in passing the last drops of water; or when there is
swelling and induration of the lymphatic glands of the penis.
Silic., or hepar, is sometimes required after mere. in the latter
case; and caps. is often useful in removing any ardor urine
that may remain.  Sulph. is still more frequently required than
mere., after the inflammatory stage is over, and particularly
when the discharge has become serous, and a feeling of uneasiness alone remains in the urethra when voiding urine. In
painless gonorrhcea, accompanied with swelling, mere., sulph.,
or silic., are useful.
In the severer forms of the disease, acon., cam. and canth.
are especially applicable. The curative power of these medicines is frequently very striking, and. the rapidity with which
they afford relief is highly satisfactory. A.con. is more or less
useful in cases of gonorrhcea occurring in young and vigorous
subjects, and attended with headache, restlessness, and other




200       TREATMENT OF GONORRHCEA.
febrile symptoms; but it is almost indispensable when the inflammation is severe and extensive, the pain during micturition
excruciating, the glans, or indeed the entire penis, much swollen,
and the sufferings greatly exacerbated by frequent and almost
constant erections (priapismus.)  Canth. is generally required
after aconite; it may be given from six to eight hours after the
secon(l or third dose of the latter, when the intensity of the
pain and any febrile irritation which may have been present
have yielded, but the dysuria, ardor urinwe and chordee still
continue distressing; canth. may be exhibited without the previous employment of aconite, when there is no marked degree
of constitutional disturbance; but the scalding during inicturition and the chordee are very severe, and the discharge is
greenish and tinged with blood. Cannabis is sometimes required
after canth., especially when the dysuria proves obstinate; and
when cannabis effects little or no improvement, petroselinurm
may be administered. Sometimes the alternate use of the latter
with cannabis or canth., is necessary to subdue the urging to
urinate, and the pain during micturition. JMerc., or sulph., are
not unfrequently useful in completing the cure, when the before
mentioned medicines have removed the active inflammatory
symptoms.
When gonorrhcea has reached the chronic stage before
the patient seeks advice, the difficulty in the treatment is greater
than during the first or inflammatory stage; the more so, if
the patient has previously drugged himself with large and continued doses of cubebs or of balsam of copaiba, or has fruitlessly
persisted for some length of time in the employment of astringent injections. In a number of cases, early benefit has been
derived from the use of caps., merc., sulph., and nit.-ac.
Capsicum is recommended when the discharge is whitish and
purulent, and ardor urinze experienced when making water.
Ferrum, pulsatilla, and also nux-vomica, are also stated to be
useful when capsicum failed to relieve the symptoms quoted.
Sulph. and merc. are considered the most useful in cases where
the patient has previously been under a course of copaiba or
cubebs. JVit.-ac. is often very serviceable in gonorrhoea as




TREATMENT OF GONORRH  A.                      201
soon as the inflammatory stage is over; but generally requires
to be followed by sulph., if the pain has subsided but the discharge continues. When the inflammation has evidently extended far down the urethra, much benefit has been derived
from the use of canth. and cann., and in some cases from nux-v.
when the discharge is serous and scanty, the desire to pass
water frequent and urgent, the act of urination painful and difficult, the stream of urine broken or forked; in short, when
symptoms present the appearance of the formation of stricture
or a tendency thereto.
In addition to the above medicines, nit.-ac. may be mentioned
as useful in gleet; likewise sep., lyc., cub., silic., calc., thuj.,
nat.-mur., and dulc. When, in consequence of errors in diet,
the use of wines, spirits, acids, &c., an increased discharge
takes place, accompanied with frequent desire to urinate, with
scalding pain, nux-vom., or one or more of those medicines
enumerated above, must be had recourse to.
Tussilago petasites has been recommended as a most efficacious remedy in recent as well as in chronic gonorrhcea.* If
aggravation follows the first dose or two of the medicine, it
must be given in a weaker or more dilute form. When there
is a complication of gonorrhoea and chancre, or when the discharge from the urethra is found to proceed from chancres
within the tube, merc. should be prescribed. And when there
are condylomata on or in the vicinity of the genital organs, or
there is reason to suppose that the discharge from the urethra
is of sycotic origin, thuj. and nit.-ac., or cinnabar, merc., or
sulph., are the principal medicines with which the cure is to
be accomplished. Against symptomatic buboes carb.-an. is
considered as one of the most efficacious remedies. Silic. and
merc. may also be named as likely to be useful in some cases.
If cytitis ensue in consequence of the extension of the inflammation to the mucous membrane of the bladder, canth. and
cann. will claim the principal attention.
During the treatment of gonorrhcea, wine, spirits, and malt
* British Journal of IIomoeopathy, vol. iii., p. 125.




202       TREATMENT OF GONORRH(EA.
liquors should be abstained from. Pure cold water is the best
diluent, and may be freely partaken of. Active exercise should
be shunned during the inflammatory stage, and when it cannot
be wholly avoided, a suspensory bandage should be worn. If
the inflammation be extensive, or the parts much swollen,
confinement to the recumbent posture becomes requisite.
The more minute indications for the medicines that are
serviceable, are as follows:.Jgnus-castus is especially adapted to a yellow, purulent discharge from the urethra, after the inflammatory symptoms have
subsided; and also to cases of gleet, accompanied by want of
erections and deficient sexual desire..Jrgen.-nit. is useful when the emission of urine is accompanied with burning, and if a sensation be experienced as though
the urethra were closed, not allowing a free passage for the
urine; it is also indicated by dragging and cutting pains in the
tube, with feeling of soreness after micturition, hemorrhage
from the parts, with painful tensive erections.
Balsam-cop. should be exhibited when there is smarting,
burning and itching, before and after micturition, with swelling
of the orifice of the urethra, and painful soreness of the whole
canal, with purulent discharge.
Cannabis presents the following symptoms. Smarting pain,
constant urging to urinate, with burning and stingings during
micturition, titillation, gluing together of the external orifice
of the canal, by a moisture which is forced out on compressing
the glans.
In regard to cannabis, it may be observed in this place, that
it is a medicine which accords in its pathogenesis with very
many of the symptoms of gonorrhcea. Its specific suitableness
to the complaint is attested by numerous physicians. In further corroboration of its efficacy, the author is assured by a
practitioner of this city, who has had much experience in the
treatment of gonorrhcea, that he has been not only gratified but
surprised at its efficacy in subduing the disorder. The symptoms which point to its use may be present at any period, but
exhibit themselves in cases somewhat advanced, and in those




TREATMENT OF G O N O R R H  A.                203
more chronic. In the latter especially, is its power apparent;
cases that for two, three, or more months had fruitlessly been
tampered with by allopaths of high station, were immediately
arrested and speedily cured. In truth, the disorder was checked
by the first dose, consisting only of a few globules of the medicine; and a few more doses, at intervals regulated by the
symptoms, accomplished complete cures.  The attenuation,
however, of the medicine is an important consideration in the
treatment; the exhibition of the lower causing disappointment,
while successful result is obtained from the higher potencies
only.
The gentleman whose testimony has just been given, commenced with the second and third dilutions, but failed; and it
was only by resorting to higher dynamizations that he learned
that the sphere of curative action for gonorrhceal disorder, exists in the preparations as highly attenuated as the thirtieth,
the latter being the strength of the medicine which he then
always administered.
Facts like these, attested by gentlemen of high social position, as well as of acknowledged ability, certainly convert the
childlike smile of incredulity into that of imbecility, as expressed upon the countenances of individuals, who with so
much pleasant self-sufficiency fancy themselves the sole depositories of all medical science.
Canth.  Cutting in the urethra during and after micturition;
discharge leaving a yellow stain on the linen, which is increased
as the disease becomes chronic. This agent frequently shortens
the attack, if administered as soon as the first signs of inflammation become apparent.
Capsicum. Burning at the meatus urinarius externus before, during, and after micturition, with cutting pain and sensitiveness to contact; pricking as with pins in the fore part of
the tube, and thick purulent yellow discharge.
Cocc. Tensive, aching pain in the orifice of the urethra,
between the acts of micturition, also itching stinging near the
fossa navicularis.
Ferrum.  Discharge of mucus from the urethra after a cold.




204       TREATMENT OF GONOR R H  A.
Mlerc.-sol. Burning pain in the corpus spongiosum when
touching the penis. Inflammation and swelling of the fore
part of the canal, with suppuration between the glans and prepuce. Redness and heat with painfulness of urethra, when
touching the part, or when walking, accompanied by severe
pain in the forehead; the urine being voided in a thin stream.
Itching and stinging pains accompanied with greenish discharge,
especially at night; secretion may not amount to more than a
moisture.
JIMez.  Stinging, titillating, with  discharge  of a little
moisture from the urethra. Tearing and drawing through the
whole canal, commencing at the perinaeum; also painful soreness of the tube when touching it, partly before and partly
during micturition, and discharge of watery mucus during
exercise..XNux-vom.  Pressive pain at the meatus urinarius between
the acts of micturition, accompanied by shuddering; sharp
pressure, as with a cutting instrument, in the fore part of the
urethra, also at the bladder perinaeum and anus, with contractive pain between the acts of urination, and discharge of
mucus.
Petroselinum.  Tingling  and  pressure in the region of
Cowper's glands, especially early in the morning in bed,
abating when standing or sitting; drawing and pressure in the
navicular fossa, with discharge of a yellow glutinous matter.
Puls. Thin stream of urine, occasioned by contraction of
the parts, with discharge of blood, swelling of the testes and
inflammation of the eyes, caused by suppression of gonorrhcea..Merc.-cor. Inflammation of the meatus urinarius, with itching, smarting pain during micturition, the discharge being at
first thin and watery, but afterwards thick and yellowish.
Sulph. Burning in the forepart of the urethra internally
and externally.  In the first stages of the disease, the medicine
should be employed, when there is redness and inflammation of
the meatus urinarius, the urine voided in a thin stream, itching
in the middle of the canal, with constant desire to void the
urine, with tearing and stinging between the acts of micturi



SYPH I L I S.                  205
tion, which is sometimes accompanied with tearing and stinging pain.
Thuja. Burning in the urethra, or piercing stitches near
its orifice between the acts of micturition; sensation as though
a drop of urine were passing from the canal, with drawing and
cutting pains.
During the treatment, the strictest cleanliness must be observed. The penis should be often washed with tepid or cold
water, and the rags that are used to prevent the discharge
from staining the linen, should be frequently removed, and
fresh ones substituted.
Sometimes, a short period after copulation, the glans penis
becomes red, hot and sensitive to contact, follicular secretion is
much increased, and soon becomes purulent, or of a thick,
greenish yellow. This affection has been termed gonorrhcea
glandis, or spurious gonorrhcea.  As, however, it does not
invariably arise from impure coition, the term is not entirely
correct, and Dr. Attomyr observes, that the disease should be
termed inflammation of the glans penis. The best medicines
for the complaint are, acon., cann., corall.-rub., merc., nit.acid and thuj.
Section 3. —Syphilis.
Syphilis is a disease, caused by a morbid principle or poison,
which applied, under certain conditions, to any portion of the
human body, will determine definite and characteristic phenomena; that this principle being absorbed and carried into
the system, will, during the existence of the local or primary
symptoms, and for an indefinite period subsequent to their
cessation, contaminate the economy; and finally, that this
principle is capable of being transmitted hereditarily, and that,
too, at a period when its presence in the system is not revealed
by any external sign.  This capability of quietude for a
number of years within the organism, without producing in




206                     SYPHILIS.
the mean time any appreciable effect upon it, is a character
not peculiar to syphilitic poison.
The existence of a special virus was denied by Broussais,
and his school, who believed that chancres were nothing more
than simple sores, and treated them accordingly. The existence of a specific morbid poison in syphilis can be demonstrated
alone by its effects.  The matter of a primary syphilitic sore
or chancre, introduced beneath the epidermis, is constant in its
results, whoever the individual, or whatever the part of the
body inoculated. This is conclusively proved by the numerous
experiments of Ricord, Wallace, Mayo, Carmichael, Mairion,
Parker, &c. No other secretion, or product of an ulcerated or
suppurating surface, will produce the same effects.
It is not necessary here, to enter into the vexed question of
the identity or non-identity of the venereal poison; that is,
whether the two classes of affections referred to, are due to one
virus, or result from the action of several.*  It appears, however, from  the latest experiments, that gonorrheal matter
applied to a mucous surface, will produce gonorrhcea, but in
no instance is it capable of producing true chancre; it may act
as an irritant, but does not produce the specific sore. Nor
do the phenomena of constitutional syphilis never follow
gonorrhcea, although the reverse has been stated, and that, too,
by respectable authorities; but in the cases that have been
cited to prove the identity of the two viruses, it has been said,
that a diseased individual, having had connection with several
healthy persons, these latter would be variously affected; some
would have chancres, some gonorrhcea, and others both
together. Now in these cases, the two diseases coexisted in
the diseased person. Had he or she been properly examined,
larvated chancres would have been discovered, either in the
urethra, or about the neck of the uterus, or in the cul de sac of
the vagina or elsewhere.  The speculum  should always be
use(l in such cases, for, says Ricord, "all syphilitic cases in
* See Hunter on the Venereal, p. 25, and an article on Syphilis in the
Med. Chir. Review, July, 1851, p. 182.




SYPHILIS.                       207
women, where the use of the speculum has been neglected,
shall be for us as though they never were recorded."*
The classification of venereal diseases proposed by Ricord, is
as follows: 1. Primitive or direct, when they occur at the
inoculated spot, from the immediate action of the virus.
2. Successive, when they originate in the latter, and are produced elsewhere by absorption, or contiguity of tissue, or
accidental contact, as chancrous bubo, and the conversion of
neighboring abrasions, or leech bites, into chancres. 3. Secondary, when the skin and mucous membranes are affected after
the reception of chancrous matter into the system; and, 4. Tertiary, when the cellular, fibrous and bony structures are the
seat of the constitutional symptoms. 5. Diseases unconnected
with syphilis.
Concerning this classification, however, it has been remarked,
that it is unphilosophical, and wanting in simplicity, and that
many of the grounds on which it is founded, are incorrect and
untenable. The two first may certainly without violence be
included under one head; the second and third divisions are
not susceptible of separation, on the grounds given by Dr.
Ricord. The so-called tertiary symptoms may arise without
the necessary intervention of the secondary. Dr. Ricord asserts,
that whilst the former may be transmitted hereditarily, the
latter cannot be, except in a degenerated form, as scrofula.
This, however, is not well substantiated, and many of the profession, believe both secondary and tertiary syphilis equally
liable to propagation by inheritance. With regard to the fifth
class, viz: " diseases unconnected with syphilis," it is difficult
to understand.
The whole subject may be much simplified by dividing it,
1. Into primary, or local syphilis; and, 2. Into general or constitutional syphilis, which is always strictly the consequence of
a chancre.
By chancre is understood, a solution of continuity in the soft
parts, produced by the disorganizing action of the syphilitic
* Extract from a Lecture on Syphilis.




208                    SYPHILIS.
virus upon the inoculated spot. Chancre, wherever its seat,
is the consequence of the application of a specific matter, which
a chancre alone secretes, and which produces a chancre, whenever placed in circumstances favorable to contagion. The
question of time, between the application of the virus and its
action, has been productive of much discussion. Ricord has
denied that there is a period of incubation, on the ground that,
in no instance after his experiments with inoculation, did he
observe any.
When the virus is introduced beneath the epidermis, its
action may be immediate, but this is far from being the case
when the affection is natural. Two friends, after a debauch,
had connection with the same woman; three days subsequently,
one was attacked with a chancre, but it was not until the
twenty-first day that his friend became similarly affected,
although he had, in the meanwhile, daily examined the parts,
and abstained from all sexual relations.* The period of incubation varies with the degree of susceptibility of the organ, and
the manner in which the affection is contracted.
The physical characters of chancres vary with their number
and their location. If several of these sores exist at the same
spot, the form is irregular, and the edges are jagged and
notched; in the natural folds of the skin, and in mucous membranes and in depending parts, where the virus acts in a longitudinal direction, their form is of the same character. The
appearance of' chancre differs in different tissues. On the lips,
which are highly organized, the chancre is granular; on the
labia majora, and other cellular parts, the chancre is of a grayish appearance; when situated on the body of the penis, if the
ulceration has penetrated to the fibrous envelop of the corpora
cavernosa, the ulcer will present that white, shining, brilliant
appearance peculiar to fibrous tissue.  When on the glans
penis, the granulations are generally of a bright red, and bleed
when touched lightly. The edges of a chancre are generally
* The above case is reported by Dr. Huguier, one of the physicians to
the Female Venereal Hospital, at Paris.




SYPHILIS.                        209
perpendicular, and look as if they had been cut out by a sharp
instrument, the primitive venereal virus nearly always acting
centripetally. If, however, the virus comes in contact with
previous abrasions, the cellular tissue is more rapidly destroyed.
than the skin or mucous membrane, and the latter are, in some
instances, dissected up.
The character of the pus varies with the period that the
ulcerations have existed, at first serous, thin, even sanious, and
mixed with the disorganizing tissue; then healthier, thicker,
and often mixed with blood; and it finally becomes consistent,
of a yellowish tinge, of a better character, resembling that on
the surface of a blister in full suppuration. It varies too with
the nature of the ulcer. There is generally recognized two
stages to chancre, one of ulceration, and the other of cicatrization. There is an important difference in these two stages; in
the first a specific matter is secreted, which retains its inoculable properties. The specific period has no absolute period of
duration.  Dr. Ricord, in one instance, saw  it last seven
years, and inoculate at the end of that time. The usual duration is from one to two months. In the second stage the
chancre ceases to be inoculable, granulates and heals. If a
chancre is in the second stage, in the progress of cicatrization,
connection will not be followed by disease; but if the ulcer
is in its first stage, the secreted matter is specifically contagious. Chancres may be divided according as their location is
either external or concealed, hence we have external and larvated.  Larvated, or concealed chancres, in the male are
situated in the urethra, and in the mucous fold of the prepuce,
and at the base of the glans, in which latter situation they are
complicated with phimosis; in the female, they are found in
the urethra, at the orifice of the vagina, and in or about the
neck of the uterus; likewise within the anus, in the rectum, in
the fauces, larynx, &c., in both sexes.
It may be well in this place, to describe a chancre induced
by artificial inoculation, to which the experiments of Ricord
have drawn so much attention. During the first twenty-four
hours after the introduction of the virus beneath the epidermis,
14




210              PRIMARY SYPHILIS.
there is slight inflammation, followed on the second day by
tumefaction, and a small ecthymatous papula, surrounded by
an areola; from the third to the fourth day there is a vesicle,
filled with a fluid more or less opaque, with a dark point at
the apex; about the fourth or fifth day this becomes purulent,
with the centre depressed, resembling a small-pox pustule.
The areola, which up to this period had increased, now diminishes, and after the fifth day, the surrounding tissues, hitherto
unaffected, become of a cartilaginous hardness. After the sixth
day the pustule dries, is covered with a laminated crust, and
this, when detached, becomes a characteristic ulcer with a
broad base.
Section 4.-Primary Syphilis.
Chancres may be divided, according to their characters, into
superficial, indurated or Hunterian, and phagedenic primary
syphilitic ulcers. Some authors mention two other varieties,
viz: the follicular and furunculous.
The superficial chancre is confined to the upper layer of the
skin, destroys only a very small portion of its tissue, and the
exudation is trifling.
The indurated chancre was first described by John de Vigo.
Hunter considered it as the type of the primary venereal ulcer,
and from him it receives the name, Hunterian chancre.  Ricord
has asserted, that a chancre never becomes indurated before
the fifth day, and considers the induration as the index of the
constitution being affected. This variety of syphilitic sore is
certainly the most annoying of all forms of chancre, and the
most certain to be followed by constitutional symptoms. The
induration is due to the effusion of plastic lymph into the
cellular tissue, or, as Ricord believes, into the lymphatic capillaries.
Dr. Fricks, of Hamburg, proved conclusively, that the
application of corrosive sublimate to the prepuce, will occasion




PRIMARY  SYPHILIS.                      211
ulcers with a hard base, and the only means of true diagnosis
between these and true chancres, is the non-inoculable character
of the former. The indurated chancre is usually very indolent,
the hardness commencing at the base. It is, in most instances,
round when situated in homogeneous tissues, has regular edges,
and is of a very dark color. The base may be indurated and
not the edges, and the reverse may also, sometimes be found,
but usually the whole chancre equally participates in the hardness. Immediately around it, ulcers may exist, which do not
present any of these characters.
A phagedenic chancre is usually very rapid and destructive in
its progress, increasing in extent, but not in depth, and accompanied with severe pain.   Its extension is irregular and
serpiginous. It occurs generally in constitutions worn out by
intemperance, and follows very often irritating dressings,
which have been injudiciously applied to irritated or inflamed
chancres, especially mercurial ointment. It is called the black
slough in England.
There is a form of phagedenic sore, called the diptheritic or
pultaceous, which is exceedingly chronic; (Ricord has seen it
last for seven years,) it is covered, either entirely or partially,
by a pultaceous diptheritic secretion.  The base is cedematous,
and the edges are elevated, irregular and serrated; it is surrounded by a dull, purple areola, and it increases by successive
ulceration of the depending parts.  The constitution becomes
seriously implicated, and the patient finally sinks. This form of
chancre occurs in ill-fed, badly lodged individuals, in whom
there is previous organic disease.
In some cases chancres become gangrenous.  In such a case
the destruction of the tissue proceeds so rapidly that the whole
glans is destroyed in a short period.
The treatment of the chancre must be in conformity with its
character. Simple chancre is sometimes cured in from two to
three weeks, without any signs of constitutional syphilis. The
indurated chancre, even under the most careful allopathic
treatment, never is eradicated without symptoms of constitutional syphilis supervening after five or six weeks of treatment.




212         TREATMENT OF CHANCRE.
Under homceopathic treatment, which may last from six to
eight weeks before the cure is perfected, constitutional disease is in a very large proportion of cases prevented.* The
medicine must be continued until every trace of induration is
removed, for frequently the sore disappears, leaving induration
surrounding the cicatrix; if this hardness be not removed, constitutional syphilis will in all probability develop itself.
In treating chancres, no matter of what description, the external treatment must be accompanied with the utmost cleanliness.  The ulcer should be frequently cleansed with tepid water, and the lint that is used as a covering and protection to
the sore should be changed several times during a day.
Dr. Attomyr observes, " Syphilitic patients, with very few
exceptions, are young unmarried men, who either board at the
hotels or sit at table with their relations, or probably superiors.
In either case it is unfortunate for the observation of homceopathic diet. To this must be added the fact that patients conceal their disorders, and in order not to excite suspicion, dare
not venture on the slightest aberration from their accustomed
diet. In consequence of these uncertain dietetic circumstances,
I resolved in treating such patients to administer larger doses
than usual.' I am still of opinion that the lower dilutions recall reaction quicker, but that their effects are less extensive and permanent than the higher. Four grains of calomel in the space
of a few hours operate violently and excite diarrhcea, while the
same four grains, if taken in minute portions, result in an indisposition, which continues several days, and in more intense
commotion of the organism. I moreover concluded from these
premises, that the larger doses could be repeated more frequently, which would seem essential, on account of the necessarily frequent dietetical errors. Within the period of two years
I treated one hundred and fifty-six patients laboring under venereal disease. Every physician knows how it is with office practice, how difficult to learn any thing, or obtain any certain
experience in this manner. Generally one half of this class of
* See Gollmann on Diseases of the Urinary and Sexual Organs, p. 110.




TREATMENT OF CHANCRE.                    213
patients stay away, so that it is impossible for us to decide with
certainty upon the termination of their disorders. The one remains away because the effects of the treatment did not fulfil
his anticipations, the other (and among syphilitic patients the
majority) because he is approaching convalescence, and is desirous of avoiding the burdensome thanksgiving of his cure."
Dr. Attomyr also states that out of the one hundred and fifty-six
patients, so many did not return to mention the success of the
treatment, that only eighty-four can be cited as being perfectly
cured.
The medicines that have been found most efficacious in the
treatment of syphilis are, merc.-sol., merc.-corr., acid-nit.,
hepar-sulph., acid-phosph., lyc., sulph., silic., ars., carbo-veg.,
thuj., and sepia.
The selection of the potency should in a measure be guided
by the idiosyncrasy of the patient, although perhaps in the
generality of cases the lower dilutions are more effectual, and
in many instances this may be owing to circumstances mentioned
by Dr. Attomyr.
JMercurius-sol. is adapted to those chancres that present an
indurated base and margin, (of course this medicine must not be
prescribed if the patient have previously been subjected to its
action in massive doses,) and covered with a tenacious, thin,
offensive matter. Dr. Laurie says, " We should certainly most
unwillingly dispense with this valuable remedy in such cases,
notwithstanding the bad repute it has acquired from the frightful effects which have so frequently arisen from its abuse in the
hands of our allopathic brethren. Such results can never take
place in homceopathic practice, assuredly not in the hands of
any one at all deserving of the name of a homoeopathic practitioner. Where the health of the patient is remarkably good,
and the sore neither of long duration, nor has in any way been
aggravated by previous treatment, we have repeatedly succeeded
in effecting a cure in from ten to fourteen days, by means of
merc. viv. 6th, a few globules (about a dozen) night and morning for about five or six days. And subsequently, on the ulcer
assuming a healing aspect, every second or third day. In other




214           TREATMENT OF.CHANCRE.
cases, especially, in torpid constitutions, it was found requisite
to have recourse to the third, second, and first of merc.-corr.,
giving one fourth to half a grain daily, until a copious discharge
of healthy pus supervened, or the excavations began to be
filled up with healthy granulations. As soon as either the one
or the other of these changes took place, a pause of three or
four days was made. At the expiration of that period, a few
more doses were generally sufficient to effect a cure in the last
named instances; but in the former, if no signs of granulation
made their appearance, (which, however, was rarely the case,)
a dose or two of szdph. 6th produced a favorable effect."
JMVerc.-sol. is also adapted to the following appearances: Red
chancre on the prepuce; spreading and deeply penetrating
ulcers on the glans and foreskin; pale-red vesicles on the glans
and prepuce, forming small ulcers after breaking; readily bleeding chancres; distressingly painful chancres, secreting a quantity of yellowish-white fetid pus; small chancres with a cheesy
bottom, and inverted, red edges; inflamed, round chancrous
ulcers, with swelling of the vagina; chancres with edges resembling raw flesh; slightly painful ulcers, sensitive to the contact
of the linen; vesicles at the fore part and on the sides of the
glans, spreading and penetrating rapidly; ulcers of the glans
and prepuce, with cheesy, lardaceous bottom, and hard edges;
a number of small red vesicles at the tip of the penis, behind
the prepuce, breaking after a fortnight, and forming small
ulcers, which secrete a strong smelling, yellowish-white matter,
which stains the linen; afterwards the large ulcers bleed and
are painful when touched; from these latter the whole body
was sympathetically affected. These sores were circular, their
edges presented a raw appearance, and the bottom of the ulcer
was covered with a cheesy secretion.
When granulations appear in the ulcer, but instead of being
florid, and firm, are prominent, pale, and flabby, nit.-ac. is an
excellent medicine.
MIerc.-corr. 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.




TREATMENT OF CHANCRE.                     215
Jtrsenicum may prove serviceable when, after the administration of mercury, the sore has appeared to improve somewhat;
has nevertheless filled up with florid and too elevated granulations, with edges remaining hard, and very irritable, bleeding
at the slightest touch, the discharge being thin, acrid and offensive. Sulph. and nit.-acid may also prove serviceable for such
conditions..drs. is well adapted likewise to phagedenic, gangrenous
ulcers, and accordingly to the indurated chancre of Hunter; its
symptoms are, gangrenous ulcers, with bloody edges and corrosive pus; ulcers with copious secretion of watery fetid ichor;
painless ulcers with hard edges and lardaceous base; stinging
chancres with white places in the middle of the ulcer; gangrenous chancre on the glans penis.
When there is excessive pain, swelling and inflammation,
and these symptoms do not yield to the action of mercurius,
sulph. or aconite, or, if the sufferings be severe, these in alternation may be prescribed. When the irritation is excessive,
and the pain very great, the granulations unhealthy and readily
bleeding, nit.-acid may relieve. It is suited to chancres of the
orifice of the urethra, prepuce and its margin, with bloody,
fetid, ichorous pus; small chancres without inflamed borders,
flat edges and considerable swelling. Chancrous ulcers, with
flat edges, without inflammation, but with violent lancinations,
increasing towards evening, preventing sleep, and becoming insufferable in the morning on account of violent erections. Small
itching vesicles on the prepuce, bursting in a few days, and becoming covered with a small dry scurf; deep ulcer on the corona
glandis, which looks clean, but secretes a strong smelling matter; burning of the inflamed and swollen prepuce, the inside of
which is denuded of the epithelium, with small ulcers secreting
an ichor that has a pungent, nauseous odor, and stains the
linen.
In some cases, when the irritation and pain are excessive, the
exposure of the part to the vapor of hot water, together with
a spare diet and the recumbent position, greatly relieve the
patient. When the ulcer is not very painful the dressing may




216          TREATMENT  OF CHANCRE.
consist of a small piece of lint.  When the chancre is located
under the prepuce, and the latter is much swollen and inflamed,
an injection of tepid water should be thrown between the parts.
This practice is recommended by the most experienced practitioners of our school.  "The remedies," says Dr. Laurie,
"'that we employed against the ulcer with raised edges were,
acid-nit., hepar-sulph., sulph., arsen., silic., carb.-veg., lye.,
acid-phosph., sepia, mnerc. Most of the cases treated had
already existed from six to eight weeks, and upwards, and
had been subjected to a smart mercurial course, both outwardly and inwardly..lcid-nit. and hepar-sulph. were very
generally required; to the former the preference was given
when the gums were severely affected, and when aching pains
were complained of in the bones; the sore itself not painful,
yet disposed to bleed easily and profusely, presenting no signs
of central granulation, and having the margins elevated and
spongy looking. When there was a tendency to the production of condylomata, (sycotic complication,) with secretion of
a thin sanious discharge, sulph. or thuj. was sometimes required
after acid-nit. had effected all the benefit it seemed capable of.
The former when cicatrization proceeded slowly and imperfectly, and the latter (both outwardly and inwardly) when excrescences continued to form and discharge profusely. Hepar
proved particularly useful when the mouth and gums exhibited
unequivocal signs of mercurial action, and when the sore was
painful, irritable, and had assumed a disposition to spread
rapidly. Silic., and at other times nit.-ac., were sometimes
called for, to complete the cure, after hepar had subdued the
more prominent symptoms of mercurial aggravation, and given
a healthy character to the sore. Sulph., as has already been
observed, is sometimes of much utility in promoting healthy
granulation in the Hunterian chancre, and is also of great service in sores which present a red or bluish margin, and display
a tendency to take on a bad character; but it is especially in the
treatment of the superficial ulcer with raised margins, that
we have derived the most satisfactory results from its employment. When a sore of that character occurred in a strumous




TREATMENT OF CHANCRE.                    217
habit, or in persons of lymphatic or bilious temperament, or
who were subject to hemorrhoidal attacks and obstinate constipation-when, moreover, the edges of the sore were spongy,
very sensitive and prone to bleed rather copiously, however
gently the prepuce might be drawn back-and, finally, when
the secretion from the ulcer was thin and ichorous, or thick,
yellow, and rather copious, but the centre of the ulcer flat, and
presenting no signs of incarnation, we never failed to derive
the most satisfactory results from the employment of sulph."
When the patient has been mercurialized, the breath emitting the peculiar fetor it assumes in those medicated with mercury, and the ulcer presents a blue appearance, carbo-veg. may
be useful.
When the sore has been retarded in its healing process by
intemperance, nux or puls. should be prescribed, and afterwards
the medicines most adapted to the specific disease.
Phosph.-acid and lycop. are very serviceable when the sore
has been very obstinate and presents the appearance of indolent
ulcer.
If the margins of the chancre are elevated, and the sore appear to resist the ordinary administration of mercury, and still
there are some symptoms of that mineral present, mere. prcac.
rub. may be employed; and if the middle portion of the chancre
should be raised, and appearances indicate the formation of
condyloma, cinnabaris, first trit. should be administered, or, as
has been before mentioned, thuj., providing the symptoms correspond.
In Hunterian chancre, if the sore exhibit a disposition to heal,
but still a certain degree of induration remain, the iodide of
mercury, second or third trituration, at first at short, then at
longer intervals, will remove the remaining hardness.
Beside the employment of arsen. in phagedenic chancre,
merc. pracip. rub. is a most efficacious medicine. At a later
period of the disease, Hartmann has found more energetic and
penetrating  mercurial preparations necessary.  He  says,*
* Chronic Diseases, vol. ii., p. 227.




218           TREATMENT OF CHANCRE.
" Among these calomel is excellent, were it not for the ptya]ism
which it is apt to excite, and for the illusory disappearance of
the ulcer under this agent. For these reasons I resort to merc.
corr., commencing with one tenth of a grain several times a
day, and increasing the dose gradually until the spreading
chancre is arrested."
J.ur., caust., china, dulc., and staphys., may also sometimes
be requisite in the treatment of chancre.
In the treatment of chancres the physicians of the old school
employ all manner of cauteries; indeed in a late number of the
London Lancet there was an article extracted from Ricord's
treatment of venereal ulcers, in which searing the whole surface of the sore with a red hot iron (actual cautery) is highly
recommended. On.this subject Hahnemann writes,* "Instances
are recorded of small chancres having been burnt away by. the
repeated vigorous application of nitrate of silver, without being
followed by lues venerea; but so rare are such cases that it is
highly dangerous to reckon on such a piece of good luck.
"' But even let us take for granted that with proper care no
evil results ensue. Supposing the chancre to disappear without
these bad effects, still (I need only refer adepts in the medical
art to their own experience) caustics are cruel remedies in
chancres, which, from the torture they occasion in most cases,
change the local virus into a general affection, consequently do
more harm than good.
" If my enemy remains in front of me, I remain always on
my guard, I am convinced I have not yet conquered him; but
I cannot be said to overcome him if I drive him into an inaccessible corner.
" There is not a single one of all the so-called corrosive sore
cleansing remedies, from calomel to blue vitriol, from lunar
caustic to sugar of lead, which does not at the same time possess astringent vessel-contracting properties; that is to say,
the power of exciting the lymphatic vessels to absorb, and
which does not display all this power in the local treatment of
* Lesser Writings, p. 59.




BUBO.                         219
chancre. Could we find any remedies that would more certainly transform a chancre into lues venera than these?"
Section 5.-Bubo.
Bubo always takes place in those lymphatic glands in the
immediate neighborhood of chancre, while the deeper seated
and remote glands remain uncontaminated, or at least do not
enlarge or suppurate. As chancre generally occupies some part
of the penis, the glands of the groin are the ones most commonly affected. Sometimes several glands are enlarged and
form a cluster; but according to Mr. Hunter one gland only is
usually affected. A bubo does not invariably follow a chancre,
and yet the system is not less liable in such cases to contamination. This circumstance, amongst others, has induced some
surgeons to believe that bubo does not arise, as is commonly
imagined, from the absorption of venereal virus, but from an
inflammation in the extremities of the lymphatics excited by
chancre.* Bubo seldom arises from a chronic chancre, but
usually makes its appearance soon after the sore is established.
It is more frequently observed to follow venereal ulcers on the
prepuce or fraenum, than those situated on the glans penis,t
and is late or early in its appearance according to the degree
of inflammation existing in the sore. Oftentimes a bubo remains stationary for weeks, neither tending towards resolution
nor suppuration; in general, however, it is of a bright scarlet
color, exceedingly painful, and suppuration is speedily established. Sometimes erysipelatous inflammation is present.
The ulceration which follows a bubo does not differ from that
of common chancre, and the matter from it is equally infectious.
The bottom of the ulcer is hard and solid to the touch, and
the surface either of a dark red or brownish color, or of a yellowish cast.
* See Allan's Surgery, vol. i. p. 200.
f Gibson's Institutes and Practice of Surgery, vol. i., p. 339.




220            TREATMENT OF BUBO.
Very extensive ulcerations now and then follow a bubo, and
instances are recorded, in which each groin and the greater part
of the pubis have been laid bare by the severity of the affection.
In certain constitutions buboes degenerate into insensible and
very troublesome fistulme, that are exceedingly perplexing to
treat. In some instances the skin covering a bubo entirely
closes, but not uniting with the parts beneath, leaves a hollow
from which in a short time a thin serum is discharged through
small holes or pores formed in the skin. In such cases, the integuments generally assume a leaden or bluish color, and present an unhealthy aspect.
Buboes, or swelling of the inguinal glands, frequently arise
from other causes than the absorption of syphilitic virus. For
example, from wounds or injuries of the foot, from colds, fevers,
and from irritating applications. Such swellings are very difficult to distinguish from the true venereal bubo. The surgeon,
therefore, must carefully inquire into the history of each individual case, before he ventures to give a decided opinion respecting its nature.
In the treatment of syphilitic bubo there are three objects to
be attained.* 1st. To prevent their development (prophylactic
treatment.) 2d. To disperse the tumor. 3d. To heal the
ulcer after suppuration and discharge of the pus have occurred.
The prophylactic treatment implies, 1st. A rapid cure of the
primary chancre. 2d. The prevention of a return of the ulcer.
3d. Perfect rest of the diseased part.  To accomplish these objects the principal medicines are merc.-sol., kali-hydriod., silic.,
calc.-carb., acid-nit., graph., and thuj.
When the swellings are either small or of considerable size,
but neither excessively painful, merc. has been of great service,
administered in the second or third trituration, a quarter of a
grain night and morning until improvement is manifest.
If the bubo be excessively painful, bright red, with intense
inflammation, bell. will in all probability allay the sufferings.
After suppuration is established silic. frequently cures the
complaint.
* Gollmann on Diseases of the Urinary and Genital Organs, p. 107.




CONSTITUTIONAL  SYPHILIS.                    221
If the patient have been subjected to the previous use of
mercury, and the tumor is hard, hepar may hasten suppuration,
and thus produce relief. If the mouth and gums of the patient
are affected by previous drugging, and there is lancinating pain
in the hard tumor, staphys. will be an excellent medicine, or
perhaps acid-nit., aurum., carb.-veg., or sulph. may be indicated; spongia fluviatilis and spongia palustris have proved
of striking efficacy in some cases of schirrous glands, either of
a scrofulous or venereal origin.
Jsaf., hydriod. pot., or staphys. may particularly be called
for in cases which have evidently been aggravated by the previous use of mercury in massive doses.
Puls. is alleged to be frequently capable of effecting resolution in instances of bubo appearing after the healing of a
chancre.  Even when suppuration has become established, and
the tumor is red, soft, and the bursting of the skin apparently
inevitable, this medicine sometimes succeeds in promoting the
entire dispersion of the tumor by absorption.
Bell., hepar, silic., sulph., carb.-an, are important medicines
in treating sympathetic bubo; the indications for their administration have already been alluded to.*
Section 6.-Constitutional Syphilis.
The secondary or constitutional symptoms of syphilis, present themselves in several forms, which usually appear in
regular succession.  The parts that appear to be first affected
are the skin and throat; probably, in the generality of instances,
the latter is earlier attacked. After these, periosteum, bones,
fascia, tendons, eyes and ears become involved.
The first development of constitutional symptoms will, in
many cases, be noticed by palor of countenance, swelling of
" For an excellent description of Inguinal Bubo see Hahnemann's Lesser
Writings, p. 76.




222       CONSTITUTIONAL SYPHILIS.
the sub-maxillary glands, and shifting pains, apparently of a
rheumatic or neuralgic character, in different portions of the
body. When the tonsils are examined, they may be found to
be the seat of an ulcer, which is coated with an ash colored or
brownish matter, that causes the sore to present a foul and
unhealthy appearance, while the surrounding edges are slightly
inflamed and of a coppery hue.  In the more advanced
stages the ulcer is excavated, or, as Mr. Hunter has expressed
it, "ldug out;" if the ulceration still advance, one or both
tonsils, the uvulwe, velum palati, membranous portion of the
Eustachian tube, and even the epiglottis may be entirely destroyed; giving rise to permanent deafness, incessant cough, and
endangering the patient's life from suffocation, by permitting
food and drink to enter the larynx. In many instances a communication is established between the nose and mouth, from
the ulceration having destroyed the soft parts and bones of the
palate.  At other times the disease travels along the Schneiderian membrane, undermines the septum and cartilaginous
portion of the nose, destroys the periosteum covering the thin
and delicate bones, which are soon rendered completely carious,
and crumble away, destroying the nose and thereby causing pitiable disfiguration, and reducing the patient to a condition often
loathsome, with foul and fetid matter flowing perpetually
from the nostrils or into the throat, and a breath so extremely
offensive, as to render the sufferer hateful to himself and disgusting to others.
The peculiar eruptive fever generally precedes, with more or
less distinctness, the appearance of constitutional affections of
the skin aud mucous membranes. In many instances, the
whole skin becomes discolored, or mottled or covered by an
efflorescence; at other times circular patches appear in distinct
spots or different parts of the body, each of which proceeds
from an indurated lump of a pale red color. The patch slowly
enlarges, and in a little time its centre becomes flat, and
encrusted with whitish scales. These gradually desquamate
and are succeeded by others of a similar appearance, until
finally the skin cracks and discharges a puriform secretion,




CONSTITUTIONAL  SYPHILIS.                    223
which, hardening on the surface, is converted into a coppercolored scab. This seldom extends beyond half an inch in
diameter, and after a time drops off, exposing an ulcerated
surface, which gradually spreads and deepens, and becomes
covered with a thick, fetid, greenish matter.
The parts of the body most liable to be attacked by venereal
eruptions, are the back of the neck, the forehead, breast and
groin; sometimes, however, the palms of the hands and the
soles of the feet are affected.
It would be trespassing on the limits of a work like the
present, to enter into all the varieties of syphilitic erythemata, syphilides, maculae, tubercles, papula, &c.; but the
student must refer to works treating on these subjects, if he
wishes to become thoroughly versed in the subject.
The periosteum and bones are often contaminated in secondary and tertiary syphilis.
All the bones do not appear to be equally susceptible of
impression from absorption of the virus; those thinly covered
by integuments, or situated near the surface of the body, as
the cranium, clavicle, sternum, tibia, radius and ulna, are most
liable to suffer. The first evidence that the patient experiences,
as indicative that the disease has reached the bony structure,
is an enlargement, or a tumor called a node; this increases
slowly, never attains much magnitude, and is seldom painful
until it has existed for a considerable time. Finally, however,
the integuments covering the tumor become red and inflamed,
deep seated and acute pain is felt in the part, and extends from
it to a considerable distance, often throughout the limbs; the
sufferings are extremely aggravated at night when the patient
becomes warm in bed.  In a greater or less time the swelling
loses its hard and solid consistence, becomes soft and fluctuating, ulceration takes place on the most prominent part and
soon opens a communication with the interior, and a discharge
ensues of an ill-conditioned glairy matter. The bone may now
be felt rough and bare, and it may become completely carious.
When the node is seated on the skull, both tables are often
perforated with numerous holes, and resemble in some respects




224   TREATMENT OF SECONDARY SYPHILIS.
a piece of worm-eaten wood. Patients who have suffered from
repeated attacks of syphilis, and have taken large quantities of
mercury, often have the bones greatly enlarged, and thickened
throughout their whole extent. When examined, also, such
bones have been found to be much heavier than usual. When
a node proceeds from inflammation of the periosteum alone, the
swelling may frequently be removed.
Venereal warts, or, probably, " sycosis Hahnemanni, " often
follow chancres, and usually are found in the same situation.
They arise by a narrow neck or pedicle, and are expanded on
the surface, resembling a mushroom. They are sometimes
exceedingly painful, and bleed profusely upon the slightest
touch. Frequently the whole glans penis or vulva are completely covered by these excrescences.
Condylomatous tumors ussually occupy the verge of the anus.
They are firm and fleshy, broad at their bases, irregular on
the surface, and often ulcerate and become very troublesome.
Alopecia does not invariably follow the secondary symptoms
of syphilis, even when the system is thoroughly contaminated.
In many cases, however, large quantities of scurfs or scales
form about the roots of the hair, which are soon loosened and
drop out, leaving the scalp perfectly bare.  The eyebrows
also, not unfrequently fall off, and are seldem regenerated.
Syphilitic iritis will be alluded to in another chapter.
Treatment.-Syphilitic sore throat, which generally arises
from the continued abuse of mercury in the primary disease, is
successfully combatted, by nit.-acid, aurum, carbo-veg., or
lycopodium.
When the patient complains of dryness and scraping in the
throat, with swelling and inflammation of the tonsils, hepar is
an excellent medicine; when, however, there are superficial
ulcers of a grayish color situated within the buccal cavity,
nit.-acid may be employed. After the exhibition of these
medicines, when the more violent inflammatory symptoms are
mitigated, silic. or sulph. will often complete the cure.
If, during the first stages of the disease, mercury has not
been used in massive doses, this medicine is frequently sufficient




TREATMENT OF SECONDARY SYPHILIS. 225
in itself, to produce the desired effect.  Kali-hydriod. and
merc.-iod. are also useful in this affection, as are also ars.,
iod., aurum, bell. and staphys.
In the treatment of secondary syphilis, mercury is the chief
medicine, particularly for the syphilitic eruptions. Allopathic
physicians, writes Hartmann, "use jodium and sarsaparilla for
these eruptions, which homceopathic physicians only use for
syphilis complicated with mercurial symptoms. The principal
mercurial preparations which are of service in the treatment of
these secondary syphilitic diseases, are, merc.-prce.-rub., merc.corr., cinnabaris, merc.-nitros; though the other preparations
may likewise be usefill. Besides mercurials, we have thuj.,
nit.-acid, hepar, clenzmatis, staphys., phos.-acid, mez., etc."
The selection of the remedy does not depend upon the seat of
the sore, but upon the nature of the ulcer.  A mercurial preparation will have to be used, and the medicine will have to be
given in much larger doses than ordinary, otherwise the fauces,
mouth, nose, etc., may all be destroyed. The medicine
required is sometimes indicated by the attendant syphilitic
appearances in other parts of the body; for instance, merc.prcecip.-rub., cinn., merc.-nitros., nit.-ac. and thuja, are
demanded, when out of the secondary exanthematic ulcer,
whether it be Hunterian or phagedenic; condylomata have
developed themselves. If accompanied with bulle, (rupia,)
merc.-corr. is the principal remedy, unless merc.-prcecip.-rub.
or alb. is more specifically indicated; if complicated with mercurial ulcers in the mouth and throat, iod. and nit.-ac. deserve
the preference.
If, after the secondary syphilitic ulcer is cured, there should
be still a remnant of the secondary syphilitic eruption, some
other medicine must be chosen. Lepra and psoriasis syphilitica
will frequently yield to dulc., clem., lyc., mez. or calc.  The
scurfy eruption to lyc. and calc., or to conium, graph., ranunc.
The medicines for venereal nodes are, asaf., acid-phosph.,
aur., calc., mez., silic., and sulph.  The intolerable aching
pains in the bones are relieved, generally, by mez., nit.-acid,
staphys., aurum. or sulph.
15l




226                     CANCER.
For alopecia lyc. is almost a specific; if its use is not followed by success, nit.-acid, petrol., or phosph. may be serviceable.
Condylomata are controlled by merc.-sol., thuj., or sabina,
and also with aurum, causticum, and phosphoric acid.
To onychia syphilitica, the following medicines are adapted,
ars., graph., hepar, merc., lye. and petrol.
When the skin appears unhealthy, the slightest cut degenerating into painful rhagades or ulcerated fissures, mere., sulph.,
lyc., acid.-nit., hepar, are very useful medicines.
CHAPTER XII.
CANCER.
CARCINOMA, or, as it is most frequently termed, scirrhus, is
the occult form of the malignant disease, which, when in a
more  advanced  stage, is denominated cancer.  The term
scirrhus has been so much employed by practitioners to designate all tumors that possess the qualities of uneven surface
and hardness, that the appellation has been sanctioned by
custom, as applicable to, or synonymous with all malignant
swellings.  In this place, however, scirrhus is always used
to designate those tumors which, from their peculiarities, are
known to be the forerunners of cancer, properly so called.
Or, in other words, the ulceration of the scirrhous tumor constitutes cancer.
A true scirrhus is known by certain external marks, and by
a peculiar internal structure.  Its characteristics are, inequality
of surface, hardness, a great heaviness in proportion to its bulk,
besides a faint leaden hue and a puckering of skin that covers
it; likewise, by the peculiarity of the attending pain, which is
acute and lancinating. The growth of the tumor, though more
rapid than that of the fibrous tumor, is less than that of the
other simple formations, and very much slower than that of




CARCINOMA.                       227
the medullary. And it may be stated as a general rule, that
the older the patient the slower the growth. In the comparatively young —say those of thirty-months may suffice for its
advancement; and in the old —say seventy-years may have
passed away, with a tumor yet hard, small, occult, and but
little painful. When the swelling appears in the substance of
an organ, as in the mamma, the original texture may seem to
become smaller, as it grows hard; in other words, the tumor
slowly increases, and at the same time the normal texture
shrinks by interstitial absorption. As the surface is approached,
the intervening textures are involved in the morbid growth,
and the skin is ultimately incorporated, becoming dark-colored,
dense, depressed and adherent; and this usually happens at
comparatively an early stage.* The tumor is at first movable, but afterwards attaches itself to the superficial skin and
the muscle beneath, though it may be still capable of as much
motion as the elasticity of the surrounding parts will permit.
In all cases of true scirrhus, the matrix or stroma is constituted either by a new formation of fibrous texture, or an
induration proceeding from hypertrophy of the areolar tissue.
The larger and coarser filaments of this structure, finally
become converted into fibrous bands, having the appearance
of cartilage, and crossing each other in various directions. In
the interstices are found the cancer cells. There has of late
been much importance attached to the peculiarity of this variety
of cell formation, but it is apparent that there is considerable
difficulty in establishing any marked difference in the appearance of the cells that constitute cancer, from those that are
found in other malignant growths. Miller is of this opinion, as
is also Dr. Bennett, who has paid particular attention to this
subject. The cells of all malignant formations are associated
with a whitish or yellowish creamy fluid, which can be pressed
out in considerable quantities. There is, sometimes, molecular
matter discovered in the cancer juice, and, in some instances,
even in the cancer cells; when this is the case, the cellules
" See Miller's Principles of Surgery.




228                   CARCINO MA.
present a darkish appearance; and in cancerous formations,
there are generally portions of the structure that are more
opaque than the surrounding tissues.
In the Monthly Journal of Medical Science,* can be found a
description of an instrument for the diagnosis of tumors of diferent kinds.  "It consists in an exploring needle, having at
its extremity a small depression with cutting edges.  On
plunging this instrument into a tumor of any depth, we can
extract a minute portion of the tissue of which its various
layers are composed. In this manner a microscopic examination of the character of the tumor may be obtained, and its
nature ascertained, before having recourse to extirpation. The
utility of this method of diagnosis has been verified, and conscientious practitioners have renounced operations previously
determined on, when the cancerous nature of the tumor has
been thus demonstrated.t"
There is attendant upon cancerous formation, a peculiar
diathesis or cachexy; indeed, this may frequently be recognized
before the invasion of the local disease. The symptoms are
paleness or sallowness of complexion, sometimes irregular
attacks of hectic, and emaciation. Youth is not obnoxious to
this disease; it belonging more to mature and old age. Females are more disposed to the affection than males, and
women who have borne children are not so apt to be affected,
as those who have never been pregnant. The mammae and
uterus are most frequently the site of the disease, although there
are other organs and tissues that are very liable to suffer, viz:
skin, lip, testicles, tongue, &c.  When the carcinomatous
structure has opened and ulcerated, the term  cancer-properly
so called-expresses the disease.
The scirrhous tumor becomes soft in its interior, its texture
is broken down and ulceration and sloughing result; the disease
often spreads in different directions, and although there may be
sometimes a slight attempt at granulation, such formation is
* May, 1847.
t McClellan's Principles and Practice of Surgery.




CANCER.                        229
overcome by the ulcerated process, which continues its onward
progress unchecked.  Mr. Miller writes, " the characters of
the cancerous ulcer are very peculiar, and once seen can
scarcely again be mistaken. The edges are hard, serrated and
everted, the eversion complete, and the hardness equal to that of
cartilage. Sometimes the margin is white, like cartilage;
sometimes it is of a red angry hue. The surface discloses the
morbid structure, soft and in process of ulceration, studded at
some points, more especially near the margin, with the futile
granulations already spoken of. The discharge is thin, bloody
and profuse; possessed of an intensely fetid odor, so peculiar,
as generally to be held of a pathognomonic character. Pain is
burning and constant. There is no power of cleaning this sore;
under every application it looks foul and loathsome. Sometimes it is covered by a black tawny slough. Not unfrequently
a dark bloody oozing takes place from some part of the ulcer,
perhaps on separation of such a slough; sometimes there is
smart hemorrhage.
"' A peculiarity of carcinoma and cancer is, that the disease is
especially prone to extend by the lymphatics. Sharp stinging
pains are felt in the direction of the main lymphatics, and their
ganglia, shadows of the coming event. The hard and tender
cords are observed extending from the tumor on the lymphatic
aspect; sometimes with small indurations by their side. These
cords may stretch unbroken to the ganglia, as in the axilla;
and there a second tumor, in all respects like to the first, only
of more rapid growth, and more distressful in its symptoms,
begins to form."
By most authorities it is allowed that cancer is an hereditary
disease. It has been considered by some as contagious, but
sufficient evidence has not been adduced to render such supposition fact. The predisposing cause of this disease is probably
some constitutional taint; the exciting cause being generally
injuries of various kinds, unnatural stimulation of the scirrhus,
that tend to advance the ulcerative process. There are also
other causes that may hasten ulceration of a carcinomatous




230         TREATMENT OF CANCER.
tumor-such as bad nourishment, unwholesome atmosphere,
neglect of cleanliness, suppression of secretions, &c.
Treatment.-" It is impossible," says Hartmann, " to indicate any general treatment for cancer. In many cases the
symptoms are the only guides to the selection of remedies for
palliative purposes. It may not however be improper to mention in this place the medicines that have been of service in
this most dangerous affection, leaving the more minute characteristics of the drugs to be commented upon, when treating
upon particular organs affected with cancer."
Medicines that may be efficacious are ars., aur., bell., con.,
carb.-veg., caust., kreos., phosph., petrol., and sometimes lyc.,
nux-vom., calend., cicuta.
The iodide of arsenic has been partially proved, and from
the symptoms it has produced, and from certain cases in which
it has been productive of great benefit, it has been highly
recommended, as has also the phosphate of iron; the latter is
said to have produced " the most happy results; by its administration the pain is lessened, and the ulcer takes on a more
healthy appearance.".qrsenicum cured cancerous ulceration on the lip, of the size
of a bean, with fatty base, and hard, roll-like margins, surrounded by a dark red areola; at the same time a red spot on
the cheek.
In a case where cancerous ulceration had invaded the left
half of the upper lip; and the soft parts upwards to the bone,
and outwards to the angle of the mouth, arsenicumrn 3d, repeated every eight days, effected a cure.
Bellad. A man, aet. 40 ann., had suffered for three months
with a considerable swelling of the upper lip, which was very
inconvenient whilst eating or speaking, and considerably disfigured his countenance. In the swelling a hard body could be
felt, which was painful on being pressed. In cold, raw weather
there were flying stitches through it. Cause of the disease unknown. Bell. gtt. 1.12 was given, and in eight days the swelling was considerably diminished. At the end of fourteen days
the remedy was repeated in a smaller dose, and in a very short




TREATMIENT OF CANCER.                     231
time the swelling entirely disappeared.* The above is reported
as a case of scirrhus, but there are not sufficient indications
enumerated to prove conclusively that the disease was true carcinoma. However, bella. is often a very serviceable medicine,
and produces great alleviation of the pain, particularly in cancer of the uterus, when there is severe bearing down, and great
weight and pressure, or violent pain in the sacrum.
In a case of scirrhus and prolapsus of the uterus, in which,
in the earlier stages of the disease, there was metrorrhagia, in
varying quantity and quality; still later the discharge of a
fetid whey-like matter, pain in the back, flying stitches in
the pubic region, costiveness, the uterus in a state of scirrhus
induration: Bell. gtt. 1.20 every forty-eight hours, for two
weeks, and a dose of arsen. every four days, for some time
afterwards, together with the local application of a weak infusion of bell., by means of a sponge, effected a perfect cure.
Conium. In the case of a woman aet. 22 ann. Five years
before, she had been struck on the left breast, and afterwards a
scirrhus had formed in the spot; it had grown until at length
it had attained the size of a walnut. It was seldom painful,
but immovable. At times there was an itching in the skin over
it, which was not discolored. The disease appeared not to
affect the general system in the least. With reference to the
originating cause of the disease, con.-mac. was prescribed. Soon
after taking the medicine, the patient felt some additional
stitches through  the  scirrhus.  A  considerable  diminution
of the tumor could be perceived the next day, but the improvement soon ceased to advance. Chain. gtt. 1.3, was then
given, and was followed by peculiar exacerbations and remissions. In the evening the scirrhus would be larger, and somewhat painful, and in the morning smaller and movable. These
changes continued to occur for ten days, and during this time
the tumor had diminished in size. At the end of fourteen days
the improvement ceased. A number of other remedies were
* See also Dr. Buchanan Ker's case of Cancer of the Pylorus, treated with
arsenicum. British Journal of Homceopathy, vol. vii.




232          TREATMENT OF CANCER.
for some time tried, which exhibited no action on the induration. The physician therefore considered it most advisable
to employ local applications, and he directed some drops of the
tincture of conium, prepared from the fresh expressed juice of the
plant, to be rubbed in every evening over the induration. Under this treatment, the scirrhus entirely disappeared in the
course of eight days.
This remedy has also been found useful in cancer of the lip.
JMagnesia-murias removed scirrhus induration of the uterus.
JV'ux-vom. proved usefill in cancerous ulceration of the lips.
A man had a scirrhus of the size of a pea on the middle of
the lower lip, which was removed by a surgeon, by means of
repeated applications of caustic, but afterwards there appeared
at each extremity of the lower lip, adjoining the angles of the
mouth, eroding ulcerations, with elevated, uneven margins, of
a white color, pale red ground, and discharging a thin fluid,
without any perceptible bad odor. The patient had a constant
flow of saliva, which every one who trod in it with a bare foot
pronounced " very sharp and biting;" his disposition was passionate, but at the present time depressed, and he asserted that
his disease and his unfavorable circumstances had taken away
from him all desire of life. JVux.vom. gtt. 1.13, was given,
and was followed by great improvement. On the sixth day,
con.-mac. gtt. 1.21, was given, and by the tenth day the disease was completely removed.
Phosph. proved very useful in excessively painful and hard
indurations in both mammae, unaccompanied by inflammation.
Sepia has proved beneficial in scirrhous indurations of the
cervix uteri. " This remedy removed a cartilaginous and frequently bleeding scirrhus of the lower lip."
Silic.  An induration, commencing at the left angle of the
mouth, and involving nearly the whole of the left cheek, was
removed by silic. " This remedy also is said to have cured a
cartilaginous induration with a deep fissure, which was seated
in the upper lip."
The above cases are recorded from Dr. Jeanes' Practice of
Medicine, and serve to illustrate, to a certain extent, the medi



CANCER OF THE FACE.                    233
cines that may be employed in cancer. Other remedial agents
will be mentioned in the succeeding sections.
Section 1.-Cancer of the Face.
Cancer of the lip.* It is somewhat extraordinary, that
cancer, rarely if ever, attacks the upper lip, while the lower is
frequently subject to the disease, which appears under different
forms. In the commencement, there is generally observed a
small rounded tumor, resembling a shot both in color and size,
seated immediately beneath the integument covering the vermilion portion of the lip, and when pressed upon rolling under
the finger. The.tumor in this state gives no pain, but if
frequently handled by the patient, or otherwise irritated, it
grows rapidly and soon adheres to the surrounding parts. In
other cases, a firm and immovable lump of considerable size is,
from the first, deeply imbedded in the substance of the lip.
This gradually approaches the surface, finally ulcerates and
throws out a prolific fungus of a dark red color, so large, as in
some instances to envelop the whole mouth. A third variety
of the disease is found in the form of a chocolate-colored, warty
excrescence; this never attains a large size, but is constantly
casting off scabs, the place of which is speedily supplied by
others. These tumors are all capable of contaminating, by
extension, the adjoining portions of the face and neck,
especially the lymphatic glands, and when this occurs, there
is very little hope of the patient's recovery. Venereal ulceration of the lip and lupus have been mistaken for cancer, and
treated accordingly. The surgeon, therefore, should be strictly
on his guard, and never without full investigation, pronounce
decisively as to the nature of the complaint, or propose an
operation, unless well assured of the existence of cancer.
Cancer of the tongue. Tumors of the tongue having all the
appearance of scirrhus formation, frequently arise from disorder
* See Gibson's Institutes and Practice of Surgery.




234           CANCER  OF THE TONGUE.
of the digestive organs, or from irritation produced by carious
and ragged teeth. Sometimes, also, the whole tongue becomes
enormously enlarged, fills up the mouth and hangs below the
chin.  Many cases of this kind are recorded by writers, and in
particular two very remarkable ones by Percy. The tongue is
likewise studded over, in some instances, with small excrescences, having broad tops and narrow pedicles, resembling
mushrooms.  At other times deep fissures or irregular cracks
occupy the whole surface of the organ. But these are all
different from genuine scirrhus, or cancerous ulceration, which
is recognized by the hard, rough, broad bottomed, wart-like
tumor usually situated about the middle of the tongue towards
the tip; or by a ragged, ill-conditioned sore, covered with a
fungous growth, and bleeding upon the slightest irritation;
either of which is accompanied by a deep-seated lancinating
pain, extending to the throat and base of the skull, and terminates, eventually, if its progress be not interrupted, by the total
annihilation of the organ. Children are occasionally subject to
this disease, but it occurs most frequently in persons beyond the
middle age.
Carcinomatous affections of the cheek and nose commence in
the same manner, and pass through the same stages as have
been already noticed in the other forms of cancer.
Every cancer, including cancer of the tongue, depends (as
has been before stated,) upon a peculiar disposition of the
organism. The proximate cause may be a blow or contusion; injudicious treatment of ulcers, indurations or excrescences on the face, syphilis, suppression of natural secretions, &c.
The prognosis is very perplexing, although many cases are
said to have been cured.* The more extensive the cancer,
* Dr. Attomyr relates the following cure of cancer of the lip. " Aloysia
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." See British Journal of Homceopathy, vol. iv., p. 257.




TREATMENT OF CANCER OF THE FACE.  235
and the more enfeebled the constitution of the patient, the
more unfavorable is the prognosis.
The chief medicine in cancer of the face is arsenic, (not
Fowler's solution) but pure arsenic. This medicine is the
basis of all the " far famed " remedies for this disease; and
writes Dr. Wurmb, of Vienna, "there is no affection, except
ague, in which it has been, and still is, so often administered.
Even among the ancients it was held for a specific against
cancer, and at the present day it has the same reputation; it
was also known then, as well as now, to be capable of producing cancerous ulcers.  The whole difference, therefore,
between ancient and modern practice, lies in the fact, that now
it is known, or might be known, or ought to be known, that
the therapeutic employment of arsenic in cancer, rests on the
law of similarity; but that it is no absolute specific against that
disease, because there exists no such thing as an absolute specific; further, that we possess certain indications for its exhibition, and understand the method of giving it in suitable doses.
" As regards the criteria for the choice of arsenic in cancer of
the lips, it is an easy task for the physician, well acquainted
with the positive effects of medicines, to distinguish the cases
in which arsenic suits, from those in which other remedies are
indicated. Thus, arsenic is to be preferred before belladonna,
baryta-carbonica or conium, in very malignant ulcers, which
increase on all sides, bleed easily, and have not been caused by
any external injury, such as blows or bruises, but from the first
show plainly, that they are the outward sign of a deeply
seated inward disease, and are, therefore, often met with in
cachectic individuals.  Carbo-veg., indeed, approaches very
near to arsenic in this respect; yet the latter is to be preferred
unconditionally, when the tendency to destroy the surrounding
parts is distinctly marked in the ulcer."*
The pathogenetic effects of arsenic, which point to cancer,
are,t burning swelling in the nose, with pain to contact; tumor
* British Journal of Homeeopathy, vol. iv., p. 250.
t See Hartmann's Chronic Diseases, vol. ii.




236                TREATMENT  OF
in the nose; ulceration of the nostrils, high up, with discharge
of fetid ichor; ulcers in the whole face; wart-shaped ulcer on
the cheek; dry, cracked lips, brown streak in the lips, as if
burnt; bleeding of the lower lip; ulcerated eruption around
the lips; cancer-like eruption on the lower lip, with thick
crust, hard, pad-shaped edges, with burning pain, particularly
when the parts become cold, and with a lardaceous bottom;
spreading ulcer on the lip, painful in the evening, when in bed,
with tearing and smarting in the day-time during motion,
which is worst when touching the ulcer and in the open air;
disturbing the night's rest; corrosion of the edge of the tongue,
in front, with smarting; the tongue is blackish, and cracked.
A.rsenic may sometimes require to be administered in alternation with some other medicine, but it is, undoubtedly, the most
valuable when the cancerous dyscrasia has contaminated the
organism; it is a sovereign medicine for cancer of the nose,
tongue and alveolae.
Clematis is asserted to be useful in carcinoma of the lips,
arising from syphilitico-mercurial ulcers; when the pains are
drawing or jerking, and experienced chiefly in the circumference
of the ulcer, particularly when touching the part..urum-met. is also serviceable for cancer complicated with
syphilitic or mercurial symptoms; or this medicine may be
adapted to scirrhus, appearing in individuals of a scrofulous
diathesis.  The muriate of gold is also recommended for this
disease, and may, in aggravated cases, be alternated with
arsenic, when the tongue feels heavy, is elongated and its
motion much impeded. There may be also great dryness of
the mouth and fauces; painful blister on the tongue, accompanied with burning pain; deep ulcer within the buccal cavity,
with inverted edges and blackish base..Mercurius may be of service, if the bones have already
become affected; or nit.-ac. may be useful if the sore be irritable, bleed profusely, with stinging and burning.
iIsafoetida is indicated when the edges of the ulcer are hard,
bluish, and sensitive to contact.
Conium has been employed with success in carcinomatous




CANCER  OF THE  FACE.                   237
affections arising from  contusions; it is particularly indicated,
by a scrofulous diathesis, and when the ulcers on the face and
lips spread rapidly, present a blackish appearance, and discharge
a bloody and fetid ichor.
Symptoms which may lead to the use of silic., in cancerous
affections, are, erysipelatous blotches, lymphatic and suppurating glandular swellings; scirrhous indurations; putrid and
rapidly spreading ulcers, particularly when they arise from
abuse of mercury, and are attended with boring and stitching
pains, also for scurfs and ulcers in the nose, cracked skin and
scirrbous indurations of the face and on the upper lip; painful
spongy and carcinomatous ulcers on the lower lip.
Sulphur is considered by some as an excellent medicine in
cancer of the face.  It is generally useful as an intermediate
agent, and revives the activity of the organism, when it appears
unable to receive the impression of the proper specific.
In cancer of the nose, when the patient complains of violent
burning pain in the ulcers, which may be covered with large
scurfs, that spread rapidly and become very thick, sepia is
often the most appropriate medicine; it is also of importance
when there exudes from beneath the scab a corrosive ichor,
which, by irritating the surrounding parts, essentially favors
the extension of the disease.  The disposition of the patient
should also be remembered, when this medicine is to be prescribed.
Antim.-crud. and ranunc.-bulb. have been prescribed with
success in cancer of the face..Jit.-acid likewise has been
employed in carcinomatous ulcers, arising from syphiliticomercurial disease.
When it is deemed necessary by the surgeon to operate for
cancer of the lip,* the diseased growth may be taken away by
two eliptical incisions, which include the affected part-the
knife being entered in the middle of the prolabial space, and
made to pass first on the integumental and then on the mucous
aspect of the disease.  The morbid structure should then be
* See Miller's Practice of Surgery, p. 190.




238   TREATMENT OF CANCER OF THE FACE.
carefully dissected out, and the saved integument and mucous
membrane brought together by interrupted points of suture.
In some instances it may be preferable to make the including incisions in the form of the letter V, the apex pointing
downward, and care being taken not to transgress the general
rule, of removing a border of apparently sound texture,
together with the truly carcinomatous affection.*
There are two operationst in use for the removal of scirrhus
of the tongue-excision and ligature.  The former is at present
seldom resorted to, on account of the extreme difficulty in
arresting the attendant hemorrhage.
The operation by ligature is thus performed.' The surgeon
takes a curved needle, and having drawn it to the middle of
a strong ligature, passes it through the substance of the tongue
immediately behind the tumor. The middle being cut and the
needle removed, there are left hanging two ligatures, one of
which is to be drawn forcibly on the one side of the tumor, and
the other tied tightly on the opposite side; these together
include a segment of the tongue. A sharp pain is experienced
when tightening the threads, but this soon subsides, and the
patient experiences little inconvenience, except from salivation,
which usually ensues a few hours after the operation. In four
or five days the tumor sloughs away, leaving an extensive
granulating surface, that fills up with great rapidity.
These are the methods of operating for cancer of the tongue
and lip; there are cases on record, in which success is said to
have followed the use of the knife. Of course, the medicines
before alluded to should be exhibited, and if their administration is followed by amelioration of pain, and diminution of the
size of the tumor, even though the latter should lessen very
gradually, the practitioner must patiently persist in the use of
the remedial agents, and his endeavors may ultimately be
crowned with success.
The method of operating by excision was explained, that the
student and young practitioner might be able, if the case
* Miller's Principles of Surgery, 3d Am. Ed., p. 317.
t Gibson's Institutes and Practice of Surgery, vol. i., p. 277.




CANCER  OF THE MAMMVE.                   239
required, to understand the use of the knife; although it is
to be sincerely hoped, that, as our science progresses, medicines
will be discovered and so applied, that in future years surgical
diseases will be more frequently removed by the internal
exhibition of medicinal agents, according to the law of Hahnemann, than by the mechanical methods now usually employed.
Section 2.-Scirrhus and Cancer of the MJammce.
This disease frequently arises from small indurations, which
are sometimes discovered in the breasts at an early age. If
these do not receive timely attention they frequently enlarge
and become painful at the critical age.
The usual origin and development of cancer of the mammary
gland is as follows:
A hard tumor is discovered in the breast, appearing either
spontaneously, or in consequence of pressure, shock, &c. At
first the tumor is round and movable; as it increases in dimensions it becomes ragged and uneven; other swellings develop
themselves, all of which appear to be united by cords of indurated
cellular tissue. These tumors enlarge, combine into one, involve
the whole glandular structure, and sometimes spread to the axilla.
Lancinating pains at this stage are occasionally experienced,
extending to the shoulder and arm, and not aggravated by
pressure. The integument, if invaded by the tumor, assumes a
streaked, cicatrized appearance, and the follicular glands are
frequently filled with a blackish substance. The skin in a
short times adheres to the tumor, which becomes elevated and
inflamed. These symptoms may disappear, but finally the
veins enlarge, the nipple retracts, forming a cavity, the skin
breaks and reveals a spreading ulcer, with hard, dark red,
shining edges, and an unclean bottom; the discharge is
neither very copious nor fetid, and the ulcer resembles rather a
deep fissure devoid of excrescences. The axillary, the glands
in the clavicular region, and the cervical ganglia, may enlarge,




240          CANCER OF THE MAMMl.
provided swelling have not taken place previously. At this
period, when the tumors are seated, immovable, and hard as
stone, the patients complain of a troublesome feeling of heaviness, with almost constant stinging, boring, shooting, lancinating pains, the lancinations proceeding to the shoulder, and
from the mammae in various directions; also, of rheumatic
pains in various parts, particularly in the loins and thighs.  The
reproductive process suffers considerably; the face assumes a
livid appearance; the arm of the affected side commences to
swell, its movement is impeded, and at length excruciating
pains and supervening colliquations produce death.
Besides these phenomena, there are a variety of conditions
that may occur during the course of carcinoma of the mammae.
Sometimes the scirrhus remains for a long time latent, giving
rise to no unpleasant symptoms whatsoever; at others its development is quite sudden, and it extends with rapidity, attended
with severe symptoms of constitutional disturbance. Ulceration of the gland is frequently produced by external violence —
a blow, a fall, or a bruise, may create suppuration and its consequences, or sometimes the ulcerative process is established
immediately after the suppression of the menstrual discharge.
There are some cases on record in which cancerous ulcerations were accompanied with but slight pain; in the generality
of instances, however, the suffering is severe, and the peculiar
lancinating character of the pains is almost unbearable. The
duration of the pain when it is very severe, is said to be less
than when it is not so excruciating, and from this circumstance
a distinguishing characteristic might be drawn between acute
and chronic cancer of the mammae. The former commences
with a hard, deep seated tumor in the breast, which adheres to
the integument for a time, the skin then becomes slightly discolored, the whole mammae gradually partakes of the induration; elevations may be observed in some portions of the gland,
while at others there are marked depressions; the surface then
becomes soft and presents those appearances that designate the
presence of fluid; the pain becomes sharper, and resembles in
many respects that experienced by patients suffering from whit



SCIRRHUS OF THE MAMMI.                      241
low. The ulcerative process progresses rapidly, the pains increase, the countenance exhibits an expression of anxiety and
pain, the skin has a jaundiced appearance, and the patient is
much debilitated and very desponding; the edges of the ulcer
are raised, and present those characteristics of cancerous ulceration that have already been mentioned.
The chronic scirrhus is dry and of a cartilaginous hardness,
and shrinks after having attained a certain degree of development, the contraction and shriveling of the integument forming
various indentations; the accompanying pains are not very
great, and by proper treatment the disease may remain in this
condition for a considerable length of time. This form of the
disease is most frequently encountered in old females of a spare
habit of body, and of a dry, rigid constitution.
Treatment.-The scirrhous indurations in the breasts of young
girls, which arise without any assignable cause, yield to several
medicines. Cham. corresponds to the drawing rheumatic pains
in the indurated mammary swellings; these are painfully affected
by the open air, and are exacerbated at night; or to erysipelatous redness of the indurated mamma,* with drawing and tearing pain, increased by contact..rnica is adapted to the same
group of symptoms when the nightly aggravations are absent.
Bell. is useful when the indurated mammary glands are inflamed, with burning and stinging pains, which are increased
by the least motion or contact..trsen. is indicated by a burning pain, with tearing, decreasing by motion, aggravated by
external warmth, and rendering it impossible for the patient to
lie on the affected side. Bry. is suitable for a tensive, burning
pain with tearing, aggravated by contact, or by moving the
arm of the affected side.
Clematis is an excellent medicine for indurated mammary
glands that are painful only when touched; it is likewise useful
in open cancer, with burning and throbbing in the ulcer, and
stinging pains in the edges when touching them.
* For an interesting account of the pathological changes that occur in
the mamma to produce an induration of the gland, see Association Medical
Journal, July, 1853.
16




242                TREATMENT OF
Conium is quite an important medicine in this disease, but it
is especially serviceable during the first stages, when the indurated gland is liable to take on inflammatory action from every
little cold, and when the lancinating pains are accompanied
with burning and stinging, which are especially severe in the
evening or at night.
Kreasotum was very serviceable in a case characterized by the
following symptoms: The whole breast was indurated, blue-red,
and rugged; some of the eminences were covered with a scurf;
one of which, situated near the nipple, was of a large size, and
fell off frequently, leaving an opening, from which a quantity
of thick dark blood was discharged, after which the patient
generally fainted. Kreas. seemed to arrest the hemorrhage for
a long time, but it was impossible to remove the disorganization in spite of acid-nit., thuja, con. or hep.; the patient
finally died of hemorrhage. Nevertheless, kreas. is a prominent remedy for carcinoma of the mammae; but should be employed much sooner than in the above mentioned case.
Carbo-anim. is very useful in hard, painful tumors of the
breast, though carbo-veg. is preferable when the pains are burning, the patient complains of anxiety, want of breath and lowness of spirits, which latter, frequently increases to a whining
despondency.
Phosph. may prove suitable to patients with flat chests,
tuberculous disposition, great sensitiveness to cool weather; increase of pain; pain in the nape of the neck, stiffness of the
arms at every change of weather, &c.
But perhaps the medicines best adapted to cancer, not only
when it affects the mammae, but in any other organ, are, arsenicum and coniumr; the former has been used, and with more or
less success, from a very remote date; and the famed " cancer
curers" of the present day, no doubt following the example of
their predecessors, employ the arsenical pastes.  Conium also
is a superior medicine, and should always be remembered in
the treatment of this affection, particularly when some contusion or abrasion of surface has hastened forward the carcinoma.
The prognosis is always to be formed with the greatest fore



CANCER  OF THE MAMMIE.                     243
sight and judgment, but in the generality of cases it has always
been found unfavorable.
There has been lately much stress laid by writers upon the
treatment of scirrhus of the mammre, and indeed other forms of
carcinoma, by the application of pressure, and there have been
several instruments invented for maintaining the requisite
amount of compression; by this method it is said that portions
of the tumor are gradually absorbed, and that its further
growth is much retarded.  The application of all stimulating
plasters, pastes, friction, &c., are worse than useless; they only
tend to hasten the inflammatory process in the tumor, and must
therefore always be considered as dangerous in the extreme.
It is in these malignant and incurable affections that some practitioners of our school suppose that they may, without dereliction of duty, depart from  the law which guides them  in the
treatment of other diseases, but all deviations invariably fail to
produce the desired effect; and finally, in the generality of instances, to ameliorate the distressing accompanying symptoms,
the surgeon is obliged to return to those medicines whose
symptoms correspond to those which it is the object to remove.
The treatment must always be commenced as early as possible; the medicines must be exhibited steadily and for a length
of time, and the patient observe the most rigid dietetic rules.
If, after a repeated trial of different medicines, no impression
whatever be made either upon the size, color, hardness, or
weight of the tumor, the question of amputation of the breast
at once arises in the mind of the surgeon, and surely it is one
of a perplexing nature. Hartmann in his chronic diseases
makes a strong assertion concerning the removal of scirrhushe says that all operations are useless, or worse than useless,
that a cure has never been effected, and that all patients that
are supposed to have survived an operation were not afflicted
with true scirrhus, but only with indurated glands.* Although
* Hartmann appears to be partially correct in his statement. See article
"Statistics of Cancer," published in Clymer's Medical Examiner, August
5th, 1843, p. 179.




244                 TREATMENT OF
Hartmann was an acute observer, and no doubt a thorough homceopathic physician, yet it can scarcely be allowed that all
the most scientific, accomplished, and thoroughly educated
physicians and surgeons of the " old school" could possibly be
so egregiously mistaken; and although as followers of Hahnemann we cannot agree with them concerning their external applications-mineral acids-arsenic-chloride of zinc, potassa
usa-for the removal of scirrhus, still we must respect the extraordinary talent and learning of those who were considered
the most accomplished surgeons in the world, and allow freely
that they understand as well as ourselves the difference between
a true carcinomatous tumor and merely " an indurated gland."
This is a question, however, that must be settled in the mind of
every conscientious practitioner; but it is necessary in this
work to subjoin the prognosis with reference to the operation,
and the manner of extirpating the diseased structure.* The
following is quoted from a celebrated English surgeon, and
bears the stamp of great prudence and skill, as well as experience in the disease; of course the homceopathic practitioner
must first use those medicines faithfully that appear to correspond to the disease, and must be guided according to the result
of his treatment, with reference to the operation.
" Some, taking an abstract view of the subject, entertain a
question as to the expediency of operating at all in carcinoma;
inclining to regard the affection as wholly constitutional, and
not to be eradicated, or even restrained, by removal of only a
local portion of it. This view we do not propose to consider;
but, with the majority of the profession, granting that the disease is constitutional as well as local, and that in most cases it
shows more of the former than of the latter character; granting that very many cases occur-doubtless the majority-in
which operation is inexpedient; and granting that in all cases,
looking to the constitutional vice, we can never be certain of
* For a very interesting paper on this subject, see a lecture delivered at
St. George's Hospital, by Sir B. Brodie. Huston's Medical Examiner,
September 21, 1844, p. 217.




CANCER OF THE MAMMiE.                     245
immunity from return, and must invariably issue a guarded
prognosis accordingly; still we are of opinion, that there are
cases often presenting themselves to the surgeon of extensive
practice, in which it is his bounden duty, by operation, to afford
his patient the chance either of a definite or radical cure, or at
least of a postponement and palliation of the malady. Such
cases are those in which the tumor is yet small and comparatively circumscribed; the lymphatics unchanged either in the
immediate vicinity or at a distance; the integuments and muscles free from incorporation; the patient not far advanced in
years; and the cachexy as yet but little indicated, if at all. On
the other hand, affections of the lymphatics already begun, even
though to a trifling extent, contra indicate operation; for, according to experience, reproduction is sure to follow, even
when the surgeon is certain that not only the tumor itself, but
the adjoining changed structure as well, lymphatic or not, has
been thoroughly taken away. Incorporated skin and muscle
can be removed by wide and free incision; yet in such cases
it is often difficult, if not impossible, to say that what is left is
sound, free from lodgment of the materies morbi already in its
texture; and, in these circumstances, experience again speaks
loudly in favor of return. In the very aged a carcinoma may
exist for years in a latent or indolent condition; still occult and
still of small size and circumscribed; the seat of little uneasiness, and attended with but little disorder of the system;
indeed, the patient may die ultimately, of disease to all
appearances totally unconnected with carcinoma. Under such
circumstances, operation is withheld, and the tumor is left undisturbed, and guarded carefully from excitement."
When an operation has been determined upon, if the tumor
be small, a single incision through the skin, two or three inches
in length, will allow sufficient space for the dissection necessary
for the removal of the scirrhus, but, according to Mr. Hunter, as
the disease extends further than the eye can detect, the dissection should be carried beyond the immediate limits of the tumor.
If, however, the tumor be of large size, the patient should be
laid on a table previously prepared with blankets, pillows, &c.,




246   TREATMENT OF CANCER OF THE MAMMIE.
and the arm of the affected side carried off at right angles
from the body, and retained in this position by an assistant.*
The surgeon stands on the opposite side, and commencing his
incision at the arm-pit, below the edge of the pectoral muscle,
extends it along on the lower and outer side of the nipple, two
inches beyond the base of the breast. A second incision is commenced at the spot where the first started, and carried downwards, between the nipple and sternum, until the two meet
below the breast. An oval space is thus formed between the
two curvilinear cuts, which includes the nipple, areola, and
perhaps two or three inches, in breadth, of skin. The integuments are next elevated from the outer edges of the breast, until
the greater part of it be fairly exposed; then the breast must
be separated from the pectoral muscle beneath, by a regular but
careful dissection from below upwards as far as the axilla.
Should the lymphatic glands be found free from disease, the
breast may be removed at once; if, however, the glands are
enlarged, or otherwise so contaminated as to require extirpation, then the breast serves as a handle, and by it they are
drawn downward, and the whole cluster of diseased mass is
removed. During the progress of the dissection the arteries
should be taken up the moment they are severed, otherwise
they speedily retract among the cellular tissue, and do not
afterwards bleed, until the dressings are applied and the patient
put to bed. Owing to negligence in this respect, secondary
hemorrhage is more frequent after amputation of the breast
than any other operation in surgery.  Before the edges of the
wound are brought together, the whole surface, from which the
tumor has been taken, should be accurately examined, and any
diseased portions that may have been left carefully removed by
the knife or scissors. When the two curvilinear incisions are
made in the manner directed, there is no redundant skin, and
the edges meet with the utmost nicety; the surgeon has only,
therefore, to retain them in contact by a few adhesive straps,
supported by lint and a common roller."
See Gibson's Institutes and Practice of Surgery, vol. i., p. 282.




CANCER OF THE UTERUS.                     247
Section 3.-Cancer of the Uterus.
The uterus is frequently the seat of cancer, but there are so
many diseases to which the organ is liable, that the diagnosis
is often extremely difficult. Venereal ulcerations, polypus and
even prolapsus, have been mistaken for carcinoma, and have
been treated accordingly, the error not being discovered until
the disease was too far advanced, to admit of successful treatment of any kind. A minute examination and inquiry must,
therefore, be instituted, before venturing to offer any decided
opinion concerning the character or termination of the affection.
In the scirrhous stage, the cervix and mouth of the uterus
become heavier than usual; there is, likewise, some inequality
of surface; hardness and softness of structure may be detected
by touching; and the organ appears situated lower down in
the vagina than natural. There is pain during coitu, and the
lancinations which are experienced in cancerous affections, are
often exceedingly severe. As ulceration progresses, pain is
experienced when touching the part; ulcers appear with spongy
bottoms aud callous edges; and frequent fungi sprout from the
surface of the womb. In most cases the vagina also participates in the disease, losing its natural rugosity, and becoming
much contracted; and finally, as the disease advances, the
whole cavity of the matrix becomes filled with one mass of
corruption.
Canstatt distinguishes two other conditions of the uterus,*
that are very similar in regard to symptoms and termination.
The first is the cauliflower or strawberry-shaped excrescence of
the os tinca, seated generally on one of its lips, or in some
instances proceeding from  the whole circumference.  This
fungus grows from a broad base, is soft, of a bright flesh color,
presents a granular or strawberry-shaped surface, and by the
touch conveys somewhat the same sensation as that of the
uterine surface of a placenta. This abnormal growth may
* See HIartmann's Chronic Diseases.




248          CANCER  OF THE UTERUS.
spread over the whole vagina, and even involve the external
parts.
The second variety is the so-called phagedenic uterine ulcer;
this is not preceded by a carcinomatous condition of the parts,
but by a pseudo-plastic formation, or infiltration of the surrounding textures. The uterus around the ulcer may be almost
in a normal condition, but in the generality of instances, the
sore is surrounded by a diseased mass, which is soft and yellow
or of a reddish brown color. If the unhealthy action be not
arrested, the destruction may extend to the walls of the uterus,
to the vagina, rectum and peritoneum.
In the incipient stages of cancer of the uterus, the disease is
frequently mistaken for some irregularity of the menstrual
function. For leucorrhcea, or chronic metritis; the first symptoms are generally those of menstrual derangement; cessation
or too frequent return of the monthly discharge, irregular
discharges of blood in place of the catamenia; fluor albus, etc.
The menses, after their cessation at the critical age, suddenly
reappear, and even increase to a hemorrhagic condition. At
first the patient complains of a sensation of heaviness, or drawing within the pelvis, and pressing towards the external
organs, these symptoms being aggravated or excited by
various circumstances, such as lifting, fatigue, &c. Upon
examination, the vaginal portion of the uterus is found to be
preternaturally indurated, bleeding readily, of an irregular consistence, swollen, misshaped, tuberculous, and sensitive to pressure; the lips of the os uteri are interstitially distended, indented
and elevated, whilst the orifice is more distended than usual. In
the course of the disease, the pains become excessively violent,
particularly at night, pressing, stitching, shooting and burning,
not only in the pelvis, but extending into the lumbar region, and
along the thighs, with swelling and tension of the inguinal glands;
frequently there is a continual burning pain in the lower part
of the pelvis, accompanied with shooting pains in the uterus.
A pungent acrid ichor, of a reddish-brown or claret color,
and exhaling a deleterious effluvium, is discharged from the
vagina, excoriating the surrounding integument, and giving




CANCER OF THE UTERUS.                    249
rise to a painful itching of the external organs. Copious discharges of blood, containing coagulated and fibrinous substances,
are very frequent, and sometimes cause great exhaustion.  The
cancer has now changed to an open, irregular ulcer, which is
readily recognized by the touch. The neck of the uterus feels
rugged, and is studded with the above mentioned soft, readily
bleeding excrescences, which are narrow at their base, as
though a ligature had been placed around them; these fill up
the whole vagina, the walls of which are indurated or disorganized, conveying to the finger the sensation as of a hard,
contracted ring.
The symptoms of' the cancerous dyscrasia become more and
more apparent; the skin becomes of a pale straw-color; the
features exhibit an expression of deep suffering; the digestive
functions are impaired; sleep is rendered almost impossible, the
patient emaciates, and hectic fever supervenes. The disease
most frequently occurs between the ages of forty and fifty.
The prognosis is very unfavorable.
Treatment. When the disease is completely established,
the physician can do little else than palliate the sufferings of
the patient, though in the incipient stages it may be cured.
In this latter period of the disease, the uterus feels like a hard
body lying immediately above the pubic bones, frequently
giving rise to the belief that it is impregnated. Pregnancy is
really possible in this stage, and occasionally takes place.
The real carcinomatous condition can be ascertained by a careful external and internal examination. It is characterized by
the following symptoms, which correspond to belladonna.
Pressing and fullness of the inner parts, rendering it difficult for
the patient to stand, accompanied with pain in the sacral region.
Likewise when a sanguineous ichor is discharged from the
uterus, either continually or at intervals. Platina is indicated
by spasmodic, or pressing colicky pains, accompanied with a
discharge of thick, viscous, venous blood, especially if the
patient previously suffered with too profilse menstruation. If
constipation, nervousness and a long-lasting, though regularly
occurring discharge of acrid blood, with burning, smarting




250                TREATMENT OF
and itching be present, a few intermediate doses of nux-vom.
should be administered. The debility which sometimes supervenes in consequence of the pain and loss of blood, is best
relieved by repeated doses of china.
Jrsenicum is indicated by the following symptoms: Burning sensation in the internal sexual organs and abdomen,
exacerbation of the symptoms towards midnight; excessive
anguish in the chest, depriving the patient of rest; unquenchable thirst; the uterus is indurated, and there is continual
discharge of an acrid, excoriating mucus from the genital
organs. Cocculus should be given, if, instead of the above
mentioned pains, spasmodic contractions occur, attended with
discharge of a serous fluid. Chamomilla corresponds to laborlike contractile pains, accompanied with a discharge of dark,
coagulated blood.
The above mentioned remedies, together *with bryonia,
ignatia, and some others, are more suitable for the incipient
stages of cancer. Other important medicines likewise, areKreasotum, which is suitable when the following symptoms
are present: Stitches in the vagina, as if proceeding from the
abdomen, causing the patient to start as if in affright; voluptuous itching with burning and tumefaction of the external and
internal labia; hard tubercles on the neck of the uterus; pain
during an embrace, as if from ulceration; the menses appear
eight or ten days too soon, and continue for eight days, dark
and somewhat coagulated blood being discharged, attended
with pains in the back, and succeeded by the discharge of a
bloody, pungent, corrosive ichor, with itching and smarting of
the contiguous parts; the menses intermit for hours and even
days, after which they reappear in a more fluent condition,
accompanied with violent colic; the pressing downwards continues after the discharge has ceased; a metrorrhagic condition
may be present, or occasionally a continuous, corrosive leucorrhcea, the pains exacerbate during the night, and fainting
frequently occurs upon rising in the morning. Slight chills are
experienced during the menstrual discharge, accompanied with
lowness of spirits, livid complexion, etc.




CANCER OF THE UTERUS.                   251
Jodium is indicated by the following symptoms:-Induration
of the lower segment of the uterus; cancerous destruction of
the cervix; profuse, long-lasting metrorrhagia, coming on even
at every stool, accompanied with cutting in the abdomen,
pains in the small of the back and loins, emaciation, atrophy
of the breasts, yellowish-brown complexion, languor, with disposition to syncope, and spasms.
Thuja for indurations and rhagades of the neck of the uterus
and os tincae, cauliflower-shaped, readily bleeding excrescences,
with a pungent smell; or for dry, wart-shaped excrescences,
with severe stitching and burning pains during micturition.
Dr. Wahle, of Rome, Italy, prescribed graphites, for the
following symptoms:-The vagina hot and painful; swelling
of the lymphatic vessels and mucous glands, some of which
were of the size of a filbert; the cervix uteri hard and swollen,
and on its left side three large and painful tubercles of various
sizes, each consisting of several smaller ones, which threatened
to change to a bleeding excrescence; upon rising a sensation
as of great weight is experienced deep in the abdomen, with
increase of pain, debility and tremor of the lower extremities;
the sufferings are most acute shortly before and during the
period of menstruation; the discharged blood is black, coagulated, and emits a disagreeable odor; a sensation of heaviness
is experienced in the abdomen, with violent lancinations in the
uterus, extending down the thighs, somewhat resembling the
passage of an electric current; the pains are burning and lancinating, little appetite, constipation, frequent chilliness, without
subsequent heat and sweat; the patient is sad, anxious, and
sometimes desperate; complexion livid; pulse frequent and
rather hard.
Secale cornutum is indicated rather for putrescence than carcinoma of the uterus; it should not, however, be entirely
discarded as a remedy for the latter affection.
Sabina may be administered for the sensation of heaviness,
the labor-like contractile pain in the uterus and lumbar region,
and for the copious discharge of coagulated blood, which occurs
particularly during exercise.




252  TREATMENT OF CANCER OF THE UTERUS.
Jlercurius and staphysagria are suitable intermediate remedies for pains in the pelvic bones and femora. These medicines
are particularly indicated, when the disease is complicated
with symptoms of mercurial poisoning or syphilis. In the
latter cases acidum  nitricum  may be used, particularly when
the patient complains of pressure in the abdomen and pain in
the small of the back; spasmodic pains as if the abdomen
would burst, depriving the patient of rest, pressing even as
low down as the vagina, as though the contents of the abdomen would be ejected, attended with pain in the small of the
back, and drawing in the hips, down to the thighs, excessive
debility, etc., obliging the patient to assume the recumbent
posture.
Carbo-veg. is an excellent remedy for an intolerable burning
pain, seated deep in the pelvis, coming on at regular periods
throughout the course of the day, gradually increasing and
then decreasing.
Kali.-carb. may prove availing in this disease, when an acrid,
badly smelling menstrual blood is discharged, with chilliness
and spasmodic pains in the abdomen.
Coniunm, which is distinguished by its action on the female
glandular organs, is an indispensable medicine in carcinoma
of the uterus.
It may be considered necessary, under certain circumstances,
to extirpate the cervix uteri, for carcinoma of that portion of
the womb. In some instances the patient is entirely relieved
from suffering for a length of time, and life may be prolonged.
The case recorded by Dr. Croserio and mentioned in this work,
(p. 65) may serve for an example.
Professor Osiander, of Gottingen,* was the first to conceive
and execute so bold an operation, as excision of the cervix
uteri, and his example has been followed by Dupuytren and
other European surgeons. The first operation of the kind was
performed by Osiander in 1801, on a widow whose vagina was
filled by a very vascular fetid fungus, from the orifice of the
* See Gibson's Institutes and Practice of Surgery, vol. i., p. 288.




FUNGUS H LEHMATODES.                   253
womb, as large as a child's head. By means of Smellie's
forceps the fungus was brought down low in the vagina,
but being accidentally broken off, a fearful hemorrhage
ensued; undismayed, however, by this event, the operator
determined to proceed, and immediately pushed a number of
crooked needles, armed with strong ligatures, through the
bottom of the vagina and body of the uterus, until they
emerged at the inner orifice. These ligatures served to draw
down the uterus, and retain it in the vagina near the external
orifice. The surgeon then introduced a strong bistoury above
the scirrhous portion, and divided the womb completely in a
horizontal direction. The hemorrhage for an instant, though
profuse, was speedily suppressed, and the patient recovered in
three or four weeks.  Osiander afterwards performed eight
similar operations upon different patients, all of whom recovered without the slightest difficulty.
Dupuytren has also performed the operation eight times;
but instead of employing the ligatures and bistoury, recommended by Osiander, he drew down the uterus with forceps,
and divided it above the scirrhus, by knives and scissors.
This operation is also recommended at the present day.'
Section 4.-Fungus Haematodes.-Bleeding Fungus.
This formidable disease, although of not very frequent occurrence, is sufficiently often encountered by the surgeon to demand
attention in this place. The profession is indebted to Mr. J.
Burns, of Glasgow, for the first detailed account of the affection,t who, however, designated it spongoid inflammation,
from the spongy, elastic feel, which is peculiarly characteristic,
and which continues even after ulceration has far advanced.
* See Miller's Practice of Surgery, p. 620.
t Burns' Dissertation on Inflammation, Article Spongoid Inflammation.




254          FUNGUS H IEMATOD ES.
Afterwards Hey* and Abernethyt adopted the term Fungus
Hoematodes.
The bleeding fungus may appear in almost any part of the
body, but the extremities are particularly liable to it; when it
occupies the external parts it is characterized by the following
appearances:t In- the first stages a small tumor may be detected beneath the integument, almost devoid of sensation,
smooth on the surface, movable and elastic to the touch. This
may remain stationary for years, without causing the patient
the slightest uneasiness, until a blow, a strain, or some accidental injury, causes it to inflame, when it increases with wonderfill rapidity, the skin losing its natural color, becoming
mottled or red in some parts and purple in others. In a few
weeks the tumor attains considerable bulk, and in proportion
to its growth is rendered protuberant and lobulated; at the
same time the veins on its surface are greatly enlarged, and
very conspicuous, and at no very distant period, ulceration
takes place in one or more spots, from which a fungus sprouts
with the utmost luxuriancy. The abnormal growth is of a
dark red color, in most instances much contracted at the neck,
and thence enlarging, expanding, and presenting an irregular and
uneven surface. The disease having advanced thus far, soon contaminates the contiguous lymphatic glands, which are converted
into a substance exactly resembling that of the original tumor.
In the mean time the patient's health gradually declines, the
countenance assumes a yellow, cadaverous hue, the whole constitution is undermined by hectic, and death speedily follows.
In order to constitute a true fungus hbematodes, three things
are essential~-that there shall be a fungous projection of morbid structure-that the fungus be dark and blood-like, and that
it bleed more or less profusely. This condition may be of either
a primary or secondary character; much more frequently it is
the latter. Examples have occurred in which, without other
* Practical Observations on Surgery, 3d edition, p. 239.
t Surgical Works, vol. ii., p. 56.
t See Gibson's Institutes and Practice of Surgery, vol. i., p. 307.
~ See Miller's Principles of Surgery, p. 334.




FUNGUS HIEMATODES.                     255
morbid formation, a small dark fungus has shown itself, bleeding at intervals so profusely that life has been endangered; but
more frequently, there is first a tumor of malignant character,
which opens and ultimately throws out the bleeding fungus,
and the fungus haematodes in this, the most frequent case, is to
be regarded as the climax of malignancy in a formation already
of an evil nature. The morbid structure on which it most frequently supervenes is the medullary.
In tumors there may be two steps of degeneracy; from the
simple structure to the medullary, and from the latter to that
of fungus hbematodes.  But usually the medullary formation
from which the bleeding fungus springs is of primary origin.
All medullary tumors, when open, tend to fungate; but all
medullary fungi are not entitled to the appellation of fungi
haematodes. It is easy to understand, however, how the haematoid condition should not unfrequently occur, by softening and
breaking down of the medullary texture, whereby one or more
of the large vessels found permeating such growths are opened
into. A detached portion of the medullary mass, or a fresh
protrusion, may temporarily occlude the aperture, but, in its
turn, it crumbles away and the bleeding recurs. The part is
obviously incapable of adopting the ordinary natural haemostatics.
The morbid mass, when examined by dissection, exhibits appearances altogether distinct from those met with in any other
disease. A' very thin and undefined capsule invests the whole
tumor, and, within this, lobes separated from each other by
membranous partitions of soft pulpy matter, resembling brain
in consistence and color, compose the greater portion of the distempered fabric. In the midst of this medullary-like matter,
are often found cells filled with clotted blood; at other times
small cysts are met with, containing a thin, sanious, fetid serum.
So extensively involved are all the textures in the neighborhood of the tumor, that the muscles are often annihilated, or
their structure so subverted as to be scarcely recognized, arteries, nerves, veins and cellular tissue all being blended into one
confused mass. When the lymphatic glands and those in the




256            FUNGUS HiEMATOD ES.
course of circulation are examined, they are often found equally
diseased throughout the body. The same may frequently be
said of the liver, lungs, kidneys and brain, all of which exhibit
proofs of universal contamination.
When fungus haematodes attacks the eye, the first symptoms
are observable in the posterior chamber; an appearance like
that of polished iron presenting itself.* The pupil becomes
dilated, and is of a dark amber, or sometimes of a greenish
color. This change becomes more and more perceptible, and
is at length discovered to be occasioned by a solid substance,
which proceeds from the bottom of the eye towards the cornea.
The surface of this substance is generally rugged and unequal,
and ramifications of the central artery of the retina, may sometimes be seen running across it. The anterior surface of the
mass at length advances as far forward as the iris. At this
stage of the disease the amber or brown appearance of the pupil
has been mistaken by surgeons for cataract, and operations have
been attempted for the removal of the supposed obstruction of
vision. After a time, the disease continuing to increase, the
eye-ball loses its natural rotundity, and assumes an irregular
and lobulated appearance, and the sclerotica becomes livid or
dark blue. Sometimes matter collects between the tumor and
the cornea, the latter membrane being destroyed by ulceration,
after which the fungus shoots out. In a few instances, it forces
a passage through the sclerotica, and is then covered by the
conjunctiva. The surface of the excrescence is irregular, often
covered with coagulated blood, and bleeds profusely from the
slightest irritation. Portions of the fungus-if it be largeoften slough off, attended by a fetid sanious discharge.
On dissection the diseased mass is found extending forwards
from the entrance of the optic nerve, the vitreous, crystalline,
and aqueous humors being absorbed, together with the choroid
and the retina.
In the extremities the disease commences with a small, colorless tumor, which, when devoid of external covering-as
* Scarpa on Diseases of the Eye.




FUNGUS HEMATODES.                      257
fascia-is soft and elastic; but if the swelling commence beneath
a tough and unyielding tissue, there is at first no sensation
experienced, but after a time a darting pain occasionally is
present; this increases in frequency until at length it becomes
incessant.
The tumor during the first stages of the affection is elastic
and smooth, but the latter characteristic, when inflammation is
about being established, is superceded by a lobulated appearance. As ulceration progresses, the integument immediately
above the swelling is much attenuated, and finally gives way
in numerous places; from these openings, which are generally
at the apex of each cone-like projection, a thin, bloody matter
is discharged, and from them fungi protrude, which rapidly increase in size, assuming somewhat a carcinomatous appearance,
and bleeding frequently and profusely.  The discharge which
accompanies the abnormal growth is thin and exceedingly fetid,
and the pain becomes smarting in character. The surrounding
integument assumes a reddish color, and becomes exceedingly
tender. After ulceration has taken place, the neighboring
glands enlarge, and in a short time resemble exactly the spongy
appearance of the primary tumor. If the patient survive when
the disease has reached this advanced stage, growths of a similar
nature present themselves in other parts of the body, and finally
the patient, rendered disgusting to himself and unbearable to
others, expires, emaciated to a skeleton by profuse suppuration
and hectic.
The testicle, when affected by fungus hmamatodes, sometimes
bears such a strong resemblance to hydrocele that the most intelligent and experienced surgeon may be deceived. This illusion cannot continue for any length of time, for after the
medullary tumor attains a moderate bulk, the constitutional
symptoms are sufficient to lead to a diagnosis, and the lymphatic
glands in the thigh and groin sensibly enlarge. This disease
has also been mistaken for a scirrhus of the testicle, but by
careful examination, and a moderate degree of knowledge, the
two affections may be readily distinguished. A testicle affected
with fungus hamatodes is soft, fluctuating, pulpy, and in the
17




258                  TREATMENT OF
generality of instances free from pain, while a carcinomatous
affection of the gland is attended with increased weight and
firmness of texture.
Other organs have been attacked with this highly malignant
affection; the thyroid gland, lungs, liver, mamma., uterus,
ovaries, have exhibited unequivocal marks of the disease.
With regard to the treatment of fungus haematodes, little
can be gleaned from homceopathic works, but that little is
worthy of profound attention.
Treatment.-It is not desired either to vaunt homceopathy
above her deserving merits, or to cast into disrepute the older
method of practice, when it is here stated that fungi have been
cured by medicines exhibited according to the law, similia
similibus curanter; on the contrary, with thankfulness to those
master minds who, " in times gone by," have occupied the most
elevated position in the allopathic school, and with sincere respect for those who still stand foremost in the ranks of her professors, the statement above made, concerning the curability of
this terribly malignant disease, is unhesitatingly announced,
and maintained by the following " History of the Cure of Field
Marshal the Count Radetskey."*  The case is not only one of
great interest, but also serves as a guide in the treatment
of similar affections.
" His Excellency is now entering the seventieth year of his
age, and the fifty-sixth of his military career; notwithstanding
his many fatigues, both in war and peace, his mental exertions,
his eventful life, with all its excitement and activity, yet, as all
Europe knows, his mind has lost none of its former energy.
" For many years he has suffered from a cough depending on
no disease of the lungs, but on an excessive irritability of the
mucous membrane of the bronchia, and to which he never paid
much attention. Latterly he has been subject every autumn to
an attack of inflammatory catarrhal fever, which passes off in
a few days with slight medical assistance. In the year 1836,
* Being a series of letters which appeared in the Homceopathische Zeitung, July, 1841, written by Dr. Hartung, Staff-Physician in the Lombard
Venetian States. See British Journal of Homceopathy, vol. i., p. 147.




FUNGUS H  MATODES.                    259
his Excellency fell upon the edge of a bed and bruised his ribs,
on which accident an inflammation of the lung ensued, which
was cured in the course of seven days. It was rather remarkable that, on the seventh day, a great quantity of purulent
matter was expectorated, and from this time the inflammatory
fever ceased. In the years 1837 and 1838, he enjoyed pretty
good health. In the months of July and August of the year
1839, his Excellency was attacked with congestion, which produced such vertigo as to cause him to fall. This affection
passed away; but soon afterwards inflammation of the eye-lid
of the right eye, along with a sense of pressure of the eye-ball,
lachrymation, and occasional protrusion of the eye-ball occurred.
By remedies which seemed to correspond to the case, these
symptoms were alleviated, but the inferior eye-lid still remained
inflamed.
" Thus, with more and less inconvenience, did the spring of
1S40 pass away. In the month of May he was once again
attacked with severe vertigo. During the months of July,
August, and September, he remained well, except the lachrymation of the right eye, which still continued. On the 9th of
October, he was exposed fbr five hours to a burning sun and
piercing wind when on horseback. Soon afterwards his face
became red: in the evening urgent fever set in, attended with
a pain in the right side of the forehead, so severe, that although
he before never had uttered a complaint, he said to me, if it
lasted much longer it would be quite intolerable. The eye was
much inflamed and protruded from its socket; the pulse was
full, hard, apoplectic. I administered what seemed to me the
proper remedies. At one o'clock in the morning, the headache
abated, the eye returned to its place, and the following day his
Excellency attended the morning parade, (kirchen parade,) reviewed the troops, and was six hours in the saddle. In the
evening, except being fatigued, he felt quite well. He rested
the following day, and then pursued his journey to Milan; the
right eye was still red and full of tears.
" By perseverance in the treatment at Milan, the cure was so
far effected, that there remained only redness of the under eye



260                TREATMENT OF
lid, tearfulness, and a swelling above the external canthus,
without pain or impairment of vision.
"About the end of October his Excellency travelled to Verona, where he tarried six weeks, and made, during very cold,
damp weather, a journey to Modena. Here it was that a swelling the size of a bean, proceeding from the internal canthus,
became developed on the lower eye-lid; while the swelling in
the orbit at the external canthus, as above described, enlarged,
and the eye was considerably protruded from its orbit, with
occasional pain in the brow, and violent congestion of the
head.
"Eight days after this, his Excellency returned to Milan,
when I found him in the condition described above. His situation appeared to be alarming; for I plainly saw that a fungus
had formed in the orbit, and that there was danger of its increasing. I gave him emollient cataplasms to remove the inflammation, which embraced the whole cheek. They answered
the end. I discontinued them, however, lest their application
should injure the eye, and directed my treatment against the
growth, attempting, if possible, to check its advance, at the
same time striving to maintain the whole frame in its former
vigor, and to raise the depression of spirits.
"' The medical treatment was directed by the homceopathic
principle. The medicines which were administered and repeated
as occasion required-for respect had to be had not only to the
growth of the tumor, but also to the tendency to apoplexy, and
the general tone of the system had to be strengthened-were
(1.) AIcon. (2.) Baryt.-carb. (3.) Zinc. (4.) Anacard. (5.)
Calc. (6.) Euphras.  (7.) Merc.-sol.  (8.) Merc.-cor.  (9.)
Antimon.-crud. (10.) Digit. These were the chief medicines
which were used, along with occasional intervening doses of
palliatives.
" The consequence was, that his Excellency, on the whole,
enjoyed good health, with the exception of congestion of the
head. The growth of the excrescence could not be arrested.
Both the tumor at the external canthus, which was now evident from its blue color, as well as the tumor at the internal




FUNGUS HIEMATODES.                    261
canthus, were increased in size; and now there protruded between the eye-ball and the lower eye-lid, a spongy, elastic,
granular, pale-red, painless tumor; and by this the eye was
confined in its movements, the pupil looking upwards and outwards, but the power of vision was not impaired.
" I consulted with Professor Flaser of Pavia, who had recognized the disease which I had before believed it to be. He
gave the most unfavorable prognosis, saying that' there was
nothing left for us to do.' This opinion deeply affected the
spirits of his Excellency, and it was agreed to give him daily
one-fourth of a grain of merc.-cor.
"After Dr. Flaser, Professor of Ophthalmic Surgery in Pavia,
had seen the case upon the 6th of January, he publicly declared,
in the presence of myself and others, that in this case neither
by allopathy, homceopathy, hydropathy, nor any other method
of treatment, could any good be wrought; that his Excellency
must die of extreme exhaustion, (aus zehrung,) or of an apopletic stroke, and that he, Professor Flaser, would prescribe
nothing, being fully aware of the danger. For the sake of
giving his Excellency encouragement, I requested the professor
to propose something in my presence. So he recommended
merc. sub. cor., one-fourth of a grain daily, firmly believing it
could do no good; but, as he said to me,' he knew no more
suitable medicine.' In consequence of his advice, I gave the
one-twelfth of a grain; but even this he could not bear, on account of the violent congestion in the head, so that I was
obliged to give an antidote to allay the congestion.
" At this state of things I wrote out the history of the case, and
gave it to his Excellency to be forwarded to Vienna. Thus the
whole matter came to the knowledge of our chief nobility, and
even of his majesty. His majesty the emperor hereupon determined to send his staff-physician, Dr. Jiger, Professor of Ophthalmic Surgery in the Joseph's Academy at Vienna, to Milan,
to consult with me, and in conjunction with me (vereint mit
nmir) to apply all remedies that might prolong the life of the
field-marshal.
"In the mean time I did my best to maintain the general




262                TREATMIENT OF
health, having still respect to the fungus. The enlargement of
the fungus I could not arrest; on the contrary, it increased in
such a way that at the external canthus, near the lachrymal
gland, a grayish, blue, hard, spongy excrescence, of more than
eight lines broad, developed itself, which, gradually diminishing in its proportions, extended in a crescentic form to the internal canthus. From this place, under the lower eye-lid, a
grayish-blue tumor manifested itself, which presented a perpendicular wall, and lost itself in connection with the bones of the
nose. The tumor at the internal canthus had increased threefold, and had become harder, and of a deeper red color. The
whole fungous excrescence was affected with various pains, lancinating, burning, tearing, and itching; it bled readily; the eye
itself was free from pain, and lay in a depression between these
two eminences; it was protruded from its socket, motionless,
and directed outwards. The powers of vision were also impaired; for on the outside he saw black-like objects without
being able to distinguish what they were. The conjunctiva
was injected, and of a dark red color, playing into a blue red.
The fissure of the eye-lids was covered in the morning with a
white, pus-like, tenacious mucus; in the course of the day there
was increased sensibility of light, and copious lachrymation; in
the evening increased heat, dryness and pain.
" Such was the state of the disease when Dr. Jager arrived at
Milan. Dr. Flaser was also sent for; and on the 26th we three
met together to communicate our respective opinions of the
case, and consult on its further treatment.
" Professor Jager declared the disease of his Excellency to be
incurable, because, depending as it did on constitutional derangement, (dyscrasie,) an operation would do no good. He
knew of no internal remedy, as this disease never had been
cured.  (Da diese krankheit noch nic geheilt worden sei.)
" Dr. Flaser expressed himself again exactly as he had done
before.
"If I had been guided by my experience of forty years in
the old Rational School of Medicine, I should have been constrained to agree with my colleagues.




FUNGUS H AEMATODES.                   263
"It was very difficult to communicate this to his Excellency, without agitating his mind, and lessening his confidence
in me. The full particulars of the case, however, were told to
his Excellency, and it was explained to hinm that his only chance
of recovery lay in implicit reliance in me and my remedies. It
was explained that bleeding, pain, &c., would occur; that the
tumor would become purulent, and that for this the requisite
remedies would be administered.
" Professor Jager, out of his deep respect for his Excellency
the field-marshal, acquainted his Imperial Highness the Viceroy
with the whole matter, and then, after a three days' stay, departed for Vienna.
" The viceroy, on visiting the field-marshal, observed-' He
hoped that his Excellency would put confidence in me and my
remedies alone.' On my next visit his Excellency embraced
me and said-' My friend, now they are all gone, do with me
what you please; I have perfect confidence, and will have no
more physicians.'  These words affected me most deeply.
Two learned doctors and professors of great experience had,
with apodictic certainty, declared the complaint incurable, with
which I was constrained to agree. Here, in Milan, the most
different rumors were afloat, and I received letters with the
strangest contents; in short, I felt my situation to be desperate.
Day and night did the image of his Excellency stand before my
eyes. At last it occurred to me-it is true Professors J:ger
and Flaser are rational and long experienced physicians, but no
friends of homceopathy; already have I cured many patients
of diseases pronounced by the Rational School to be incurable,
by following bomceopathic principles; as for rumors, they are
but talk, which may not annoy me; so, comforted, and with a
quiet conscience, did I pursue the course I had begun.
" The consequence up to this time is favorable, for the hemorrhage, which had already commenced, is abated, as also the
threatened cancerous transformation (iibergang.) The pains
are entirely gone; the upper tumor, which appeared in the
form of a swollen prominence above the lachrymal gland, has
now only an inconsiderable elevation; the superior margin of




264                 TREATMENT  OF
the orbit is comparatively unaffected; the hard swelling at the
internal canthus, as well as the tense swelling or visible fungus
between the eye-ball and the under eye-lid, are every way less,
so that his Excellency can again look towards the nose, and
distinguish objects as formerly. The eye moves freely in its
socket, and, along with the surrounding parts, has assumed a
more natural color. In other respects his Excellency enjoys
good health; his mind and body both retain their former energy
and power.
" I shall continue the homceopathic treatment. I cannot say
whether I shall be able to improve the condition of his Excellency, inasmuch as the malignity of the disease, especially in so
aged a person, is but too well known, and cure never yet has
been effected; but even if no cure be effected, I should be well
pleased if his Excellency remained in his present condition.
"M Jilan, 19th Feb. 1841.-I continued to pursue the homceopathic treatment as mentioned above. The consequence was
so favorable, that I have attempted in a drawing to make it
manifest.*
" After so favorable a course the hope of ultimate cure might
be entertained, after this frightful disease-fungus-which before had extended over a surface of four inches, was now confined to a small fungoid swelling, which could only be perceived
by drawing aside the under eye-lid, and the general health of
his Excellency was perfect.
"' Although all this is true, yet comes the reflection, that a
fungoid tumor of so great an extent, in so important a part, and
at so advanced an age, has never yet been cured; wherefore I
do not venture to speak more of the cure, until this little tumor
also be entirely removed.
" The truly homceopathic operation of the medicines was
here most striking. Only two remedies were required; and of
these, besides their external application, only three globules of
* The drawing is interesting, and gives an excellent idea of the disease
and its course. We could not give a copy without risk of injuring the original. (Note to original.)




FUNGUS HfEMATODES.                    265
the decillionth dilution were given alternately, every eighth day
in the evening, and on the morning of the ninth. After every
dose, his Excellency experienced the sensation of all his previous
sufferings, but without pain, and going away like a breath;
then did the cure proceed.
"3Milan, 16th Mlarch, 1841.-Since my letter I have been
continuing the homoeopathic remedies, and I am happy to say,
that the tumor of the lower eye-lid is almost gone; there only
remains a slight projection of the eye-lid. As this has been for a
long time present, and often affects old persons from relaxation
of the muscles, perhaps it may remain as it is, without giving
further inconvenience-perhaps not.
" The appearance of the eye now shows that the horrible
fungus is dissipated, for it has exactly the appearance of the
other eye, and the power of vision is restored to it. His Excellency can now drive, and ride, and go through all his business with the eye exposed.
" On the 19th of this month, on the occasion of the emperor's birth-day, his Excellency attended divine service in the
immense vaulted cathedral, for an hour and a half, when the
temperature was very low, with his eye uncovered. After this
duty, his Excellency reviewed the troops, exposing himself for
more than an hour to the direct light of the sun (a change of
temperature of not less than 150 R.)  Neither extreme affected
the eye. In the evening he was present at a saloon, where
there was upwards of fifty persons present, and above one hundred lighted candles, with his eye uncovered, without experiencing the slightest inconvenience, not to say pain.
"Yesterday and to-day has his Excellency pursued his usual
avocations, without the slightest injury to the eye; and this
produces the conviction that the disease is cured, and requires
no further description.
" JMilan, 22d J.pril, 1841.-On the 26th of January, in consultation with Professors Jager and Flaser, at which both declared the disease to be incurable, and declined prescribing, I
proposed giving the 30th dilution of arsenic, then psorin, herpetin, and carbo animalis; at the mention of which last, Dr.




266                TREATMENT OF
Flaser ironically exclaimed, verbranntes bratl! (burnt chops.)
I heard him, and thought it is not rational, because Dr. Flaser
does not know its operation. I shall now give the result of
these medicines, which were administered in the order mentioned above. JArsenic alb., 30th dil., 6 globules produced the
first day severe pain in the whole of the head, with considerable congestion. He was very restless during the night. The
second, no change in the symptoms; the night sleepless. On
the third day the headache abated, and diarrhoea set in; the
night was quieter. On the fourth day weariness, somnolence,
continued diarrhcea. The growth of the fungus advanced; the
eye protruded further.
"Psorin 30k, given early on the fifth day, manifested, on
the first day, pressure on the right eye; severe pressive headache, extending to the upper jaw; tolerably quiet night. The
second day like the first, only the pressure on the eye was less.
On the third day the pressure on the eye and the pressive headache, were abated; in other respects no change. On the fourth
day no change, only the fungus grew, and hemorrhage was
easily produced in it.
"On the following day I gave herpetin 30 1. On the first
day, pressure, with giddiness of the head, which abated towards
evening; a quiet night. On the second day, less pressive headache, attended with slight giddiness, painless borborygmus;
a fluid stool in the evening; a quiet night. On the third and
fourth days, no pain; in other respects no change for the better, on the contrary, extension of the fungus, and tendency in
it to bleed.
" On the following day I gave carbo animalis 30X. The first
day, pressure of the right side of the head; itching of the internal canthus of the right eye; increased tearfulness of the
eye; the night quiet. The second day as the first; a quiet
night. On the third day, pressure on the side of the head
diminished; but itching of the canthus and tearfulness increased.
On the fourth day, no change in the general symptoms (in Allgemeinen.)
The hemorrhage had abated, and his Excellency felt light




FUNGUS H  M AT O DE S.                 267
and well; the fungus did not increase any more, but remained
unchanged, so I allowed the medicine to work for two days
more, but no further change followed. Thus I saw that from
the first three remedies no benefit, but rather the contrary, had
been derived, while the last seemed to have arrested its growth,
but did not cure it. Then I thought that as I had often cured
swollen and indurated tonsils with thuja occident. alternately
with petroleum; with thuja alternated with sulph. and graph.
I had often cured warty cutaneous excrescences; with thuja
alternated with carbo animalis I twice cured scirrhus of the
mammae; so here I determined to try the effect of thuja and
carbo animalis, and so I prescribed.
" Thuja occident. 30; guttam  unam.; aqua distill. conm.
uncias tres. JM. D. S., three times a-day a table-spoonful to be
taken.
"On the first day, all the affections from which his Excellency had suffered, as headache, night cough, slight diarrhcea,
pain in the renal region, with rose-colored deposit in the urine,
itching, with red marshy eruption on the inner side of the leg,
disappeared, except the cough.
"On the second day, no change, except that the pain was
felt at another place, and very slight.
" On the third, no more pain; itching of the internal canthus; excretion of a milky or sweet creamy-like moisture around
the whole circumference of the fungus.
"I ordered tinct. thujce occid. guttas sex, aquae distill. corn.
uncias quatuor MI. D. S. to be applied warm to the eye every
two hours. On the fourth day no pain; cream-like excretion
increased; the fungus, particularly at the upper margin of the
orbit, decidedly lessened. On the fifth, sixth, and seventh days
no pain; the excretion diminished; the lower part of the fungus,
and that at the internal canthus, diminished to the astonishment
of all who had before seen the case. The external application
of the thuja was continued.
"After ten days' use of thuja I gave carbo animalis 30A in
the evening, and on the following morning, a similar dose of
the same. On the first and second day, pains occurred in the




268                 TREATMENT OF
right side of the head, as after the thuja, only they extended
to the left side as far as the ear, and passed away like a breath
(wie ein Hauch voriibergeheand.) The discharge from the tumor
continued; there were no pains in the eye.
" On the third, fourth, fifth, sixth, and seventh days no headache; discharge continued.  I now moistened the prominent
part of the tumor with the 12th dilution of carbo animalis.
The thuja embrocations were then continued, the fungus decreased most markedly, the eye returned to the orbit.
" The internal and external use of these two remedies, thuja
and carbo animalis, alternately every eight days, was persevered in. The result was, beyond all expectation, so successful, that, in the course of one month and a half, the whole
fungus had disappeared, the eye, with its vision restored, moved
freely as the other in its orbit; only the lower eye-lid still protruded somewhat, and the eye ran with tears. These two symptoms likewise improved in the course of time.
As his Excellency had long suffered from both watering of
the eyes and protrusion of the lower eye-lid, brought on partly
from their natural conformation, partly from severe exerciseas also the latter symptom was caused by the failure of the
muscular action, the consequence of his advanced age-especially as the fungus had disappeared, and the eye was recovered,
further treatment was not considered necessary.
"' His Excellency has continued, under all changes of weather,
and after various considerable journeys, without the eye having
become in the slightest degree morbidly affected; hence, I can
say, this disease, declared incurable, has been permanently,
quickly, and harmlessly healed by the homceopathic principle.
" It is very remarkable, and confirms the permanent nature
of the cure, that many trifling complaints which used formerly
to annoy his Excellency, such as headache on the right side,
with congestion in the head, cough of long standing, without
any affection of the lungs, pains in the loins, itching of the
arms, and acid eructation from the stomach, all entirely disappeared on the disappearance of the fungus; and his Excellency
continues perfectly healthy and well."




FUNGUS HiA.MATODES.                   269
The following medicines have been recommended for fungus
haematodes:* Jrs., carb.-an., carb.-veg., phosph., sep., silic.,
thuja, calc., crot., lyc., merc., nit.-ac., sulph.
Phosph. Fungus hoematodes in the thigh, somewhat painful, accompanied with continued discharge of venous blood.
A small fungus on the finger disappeared after one dose of
phosphorus.
Fungus haematodes of the cornea, with chronic ophthalmia,
complicated with ulcers on the cornea, great photophobia,
burning, lancinating and boring pain in the eye, the sight fast
decaying; calc.-c. as the chief remedy, with lyc. 12, sep. 30,
silic. 12.t
An elderly negro man in Surinam, had a bleeding tumor on
his knee, which was removed by excision. Sometime afterwards a tumor formed in each hip near the trochanter major.
That on the right was much larger than the one on the left
hip. Two years and a half after the operation, it had a
diameter of four inches, was of a conoidal shape, slightly movable, hard, elastic, of the natural temperature, and without
pain or pulsation. After being ruptured by a blow, it bled
slowly, but almost incessantly, and became slightly painful and
somewhat warm. On wiping, the blood, which was apparently
venous, from the opening, " the structure of fungus haematodes
could be clearly discerned.  Cinchona 1.12, and shortly afterwards phosph. 1.30, were given. About the same time the
patient filled the wound with tinder. The tumor continued to
increase in size, as also did a fungus growth from the opening,
which had made its appearance previously to the administration
of the medicine, and the hemorrhage was considerable till the
fourteenth day, when there was a slight fever, which disappeared without medicine. After this period, the tumor began
gradually to diminish in size, and the hemorrhage ceased until
the thirtieth day, when it occurred suddenly, but soon ceased
of itself. After the second or third week, the patient being very
much debilitated, was allowed to take a glass of wine occasion* Jahr's and Possart's Manual, p. 620.
t See Guide to Practice of Homeopathy, p. 155. London, 1844.




270   TREATMENT OF FUNGUS H2EMATODES.
ally. The tinder remained adherent in the opening till after
the fiftieth day. On the sixtieth the wound was unclean, of a
bad odor, and again bled a little. But the tumor had greatly
diminished, as had also that on the left hip. By the eightieth
day the improvement had advanced much farther, which advancement was attributed by the patient to a common adhesive
plaster, which had been applied to gratify him with the idea of
active local treatment.  By the ninetieth  day, there only
remained an indurated cicatrix.  The induration gradually
diminished, and at the end of four months had entirely disappeared."*
The extirpation of the diseased mass, even in its most incipient stage, cannot be warranted by good surgery. Dr. Gibson
writes, "CC even extirpation of the tumor, and that too in its very
incipiency, answers so little purpose, that there is hardly a case
on record where the operation has succeeded."t  The futility
of operation in this affection is well illustrated by a case
detailed by Mr. Allan.t  The patient suffered during thirteen
years from a very large tumor which occupied the left hip.
When it attained the size of a child's head, it was dissected out
by Mr. Newbigging, of Edinburgh, apparantly with success,
for the wound healed and the patient felt perfectly well. At
the end of nine months, however, it grew again, and in seventeen months from the first operation, a second was performed
by Mr. Russel, upon a tumor as large as the two fists. The
wound soon closed, but in nine months following the tumor
recurred, and soon equalled in size a very large mamma. A
third operation was now undertaken by Mr. Allan, and so
extensive was the dissection, that the wound was as large as
the crown of a hat. In a few weeks it healed perfectly; but
the tumor appeared again in seven months. The late Mr.
John Bell was then consulted, and performed a fourth operation
upon it —the tumor at the time being as large as the head of
a child eight years old. Several months after the diseased mass
* See Jeanes' Homceopathic Practice of Medicine, p. 236.
t Institutes and Practice of Surgery, vol. i., p. 314.
t Allan's Surgery, vol. i., p. 264.




CHIMNEY  SWEEPER'S CANCER.                   271
was reproduced, and from the surface a fungus sprouted, in
shape and size resembling a large cauliflower.  This, Mr.
Allan removed by ligature, and the patient for the time was
relieved. His constitution, however, was completely ruined,
and although he lived for several months afterwards, he (ied at
last fromn the long continued discharge from the fungus, nearly
eight years having elapsed from the time of the first operation.
" This case," continues Dr. Gibson, from whose work it is
taken, "plainly shows how little we are to expect from extirpation."
Section 5.-Chimney Sweeper's Cancer-Soot Wart.
The disease of the external parts of the male genital organs,
commonly called chimney sweeper's cancer, is one of a very
formidable and often very intractable nature, but fortunately
not often met with.* The scrotum is the part usually attacked.
A wart forms, generally at the most depending portion, assumes
an irritable appearance and quickly degenerates into open ulceration of a malignant character. The ulcer extends rapidly,
consuming the neighboring integument, and involving the
testicle and other subjacent parts.  The induration frequently
extends along the spermatic cord, and the lymphatics participate in the diseased action at an early period.  The discharge
from the sore is acrid, sanious, and possessed of much fetor;
sometimes fungi protrude, but more commonly the surface is
excavated and smooth.  Not unfrequently the skin surrounding the ulcer is studded, to a considerable extent, with numerous clusters of warts of an unhealthy and angry aspect. The
general health is soon undermined, and the disease advances
from bad to worse, with the usual certainty and rapidity of
malignant action.
" Other people besides chimney sweepers," says Pott,t " have
cancers of the same part; and so have others, besides lead
* Liston's Elements of Surgery, p. 413.
t Pott's Works, vol. iii.




272      CHIMNEY SWEEPER S CANCER.
workers, the Poictou colic, and the consequent paralysis; but
it is, nevertheless, a disease to which they are peculiarly liable,
and so are chimney sweepers to the cancer of the scrotum and
testicles."
It cannot always be determined why a cancerous growth
should arise in one locality rather than in another, but there
appears to be conclusive evidence, that the habitual handling
of certain substances and direct violence are much concerned
in the development of cancer in particular regions. Mr. Lawrence once operated on a chimney sweeper, who presented
cancerous formation, anterior to the concha of the left ear.
This patient appeared especially obnoxious to the action of
soot, for previously a genuine chimney sweeper's cancer had
been removed from the scrotum; but it is probable that when
the disease reappeared on the ear, it was caused by the same
substance, for the patient was in the habit, whilst engaged in
his trade, to carry bags of soot on his left shoulder, and it is
very likely that the ear on that side was often covered with the
substance; thus the growth of the tumor' may be accounted for.*
Treatment..frsenicum appears to be very serviceable in
the treatment of this affection, when there is inflammation and
swelling of the scrotum, and the ulcer is particularly painful in
the morning, with burning in the circumference, and uneasiness
when the part becomes cold; also when the ulcerative process
rapidly consumes the adjoining structures, and the constitution
of the patient is in a debilitated and impoverished condition.
It would seem that this medicine, together with carbo-veg.,
were especially indicated by the habits and mode of life of that
class of persons who are liable to the affection.  The latter
medicine should be administered, when the parts surrounding
the ulcer are bluish or purple, and when there are pressure and
tension around the sore, which emits a corrosive humor.
Thuja may be prescribed in the commencement of the disease,
when the warty formation presents itself, and when the surrounding integument appears indurated, also when there is
itching and stinging in the tumor.
* London Lancet, Nov. 1850, p. 488.




SCROFULA.                        273
Secale should not be overlooked when the parts assume a
blackish hue, become dry, or, in fact, when gangrene threatens.
China may also be suitable if the swelling is large and the
gangrene humid.
Rhus-tox. may be useful when the ulcer spreads rapidly,
and the skin of the scrotum appears thickened, or becomes
thicker and harder, with itching; or when there is tingling and
smarting in the sore.
Clem.-erect., hell., iod., mur.-ac., merc.-corr.-sub., may
also prove serviceable in this affection.
CHAPTER XIII.
SCROFULA.
THE term scrofula is supposed to have derived its origin
from the circumstance, that swine were said to be subject to
the disease, though the correctness of this etymology has been
rendered very questionable, by the remarks of Dr. Henning,*
and the statement that these animals are really liable to be
attacked, appears to be erroneous.  The disease received,
likewise, the appellation of struma, or king's evil, from the
custom of submitting patients affected, to the royal touch.
It is an affection, one of the chief or most palpable symptoms
of which, is a chronic swelling of the absorbent glands in
various parts of the body, with a gradual tendency to imperfect suppuration. Our ideas of scrofula, however, would be
very indefinite, were we to define the disorder as a morbid
condition of the lymphatic glandular system; for, as a judicious
author observes,t the system of absorbent glands, it is true,
seldom or ever fails to become affected in the progress of the
disease; but there is reason to believe, that scrofula appears
for the first time, in parts that do not partake of a. glandular
nature. There are, perhaps, but few of the textures or organs
* Critical Inquiry into the Pathology of Scrofula.
t Thompson's Lectures on Inflammation, p. 134.
18




274                   SCROFULA.
of the human body that are not liable to attacks of scrofula,
even as an original idiopathic affection.
At the present day, the term scrofula is usually applied to a
constitutional affection, occurring for the most part in early
life, of essentially chronic development, and characterized by a
tendency to various destructive diseases of the bones and joints;
often accompanied by enlargement of the lymphatic glands, and
by disorganizing affections of the skin and mucous membranes,
occurring either separately or together, and without obvious
or adequate exciting causes.
Under this somewhat comprehensive definition, it is obvious
that a great number of different local disorders may, and
indeed must, necessarily find a place, and accordingly the term
scrofula or scrofulous disease, is applied by many writers to
types of local affections, which are only very indistinctly, if at
all, connected with a constitutional cachexy.
The cachectic tendency is either hereditary or acquired. In,
by far, the greater proportion of cases, it may be traced in
descent from parent to child, from generation to generation.
But, in some instances, a child may be born in all respects
healthy, and of healthy descent, both immediate and ancestral,
and yet in the course of years exhibit all the signs of a confirmed strumous diathesis.*  The circumstances likely to induce
the unhappy change, are those of a peculiarly debilitating
tendency; such as exposure to atmospheric vicissitude; to
insufficient clothing and shelter; improper and scanty food;
lingering and wasting disease; mercury; habitual deprivation of
healthy excercise. Or again, such circumstances may not be the
means of producing this disorder in a frame previously healthy,
but only the direct and exciting causes of it, in a system
already predisposed by hereditary taint.
The disease is not communicable by contagion or inoculation,
as has been proved by direct experiment; and it is found to prevail more in temperate climates than in either the extremely hot
or cold, variability seeming to be especially favorable to its acces* See Miller's Principles of Surgery, p. 54.




TREATMENT OF SCROFULA.                       275
sion. It is also more frequent in towns than in the country; as
are all other diseases of debility. Males are more liable to external scrofula, than females;* while in the latter the phthisical
diathesis is more frequent.t
The association of scrofula with a peculiar form of morbid product, called tubercle, has been long observed; this formation,
however, is not present in all cases, and therefore cannot be
relied on as pathognomonic of the disease.
The treatment of the various diseases, which either directly
arise from scrofulous cachexy, or are dependent thereon, would
comprise more space than can be allowed here; the following medicines, however, may serve as an outline to guide the
student in the selection of others, which may prove appropriate
to each presenting case. Many of the diseases dependent upon
struma will also be mentioned in different portions of this work.
The medicines are in general, ars., asaf., baryta-c., bell.,
calc., cina, con., hepar, iod., lyc., merc., rhus-tox., silic.,
sulph.; also aur., bromine, carb.-an., carb.-veg., cist., dulc.,
graph., kreos., merc.-iod., staphys.
At the commencement of the disease, when children exhibit
a tardiness in learning to walk, the principal medicines are bell.,
calc., silic., sulph., and perhaps ars., china, cina, ferrum,
iyc., magnesia-mur., pinus, puls., sep.
In the second stage, when there are glandular affections, the
medicines especially indicated are, bary.-c., bell., bro., calc.,
cist., con., dulc., hepar, lye., mere., phosph., rhus-t., silic.,
staphys., sulph.
Cutaneous affections, aur.-met., bary.-c., calc., cist., clem.,
con., dulc., hepar, lye., merc., mur.-ac, rhus-t., silic and
sulph.
For affections of the osseous system, aur.-met., calc., lye.,
merc., phosph., phosph.-ac., puls., silic., sulph.
Atrophy-marasmus:  ars., calc. and sulph., or perhaps
baryta-c., lyc., nux., puls., rhus.'Scrofula and its Nature," by Sir B. Phillips.
t Dr. Walsh's Report on Phthisis.  British and Foreign Med. Chir.
Rev., Jan. 1849.




276          TREATMENT  OF SCROFULA.
The more particular indications are as follows:.rsenicum.  Atrophy, with excessive swelling of the cervical and axillary glands; hard and distended abdomen, puffed
face, loose evacuations, excessive debility, with desire to lie
down, particularly in leucophlegmatic constitutions; scrofulous
cutaneous affections, particularly ulcers, ophthalmia, &c.
ssa.fcetida. Exostosis, caries, distortion, or curvature of the
bones; engorged glands; otorrhcea; ophthalmia and ozcena.
Baryta.-carb. Atrophy; enlargement and induration of the
glands of the neck, and nape of the neck; bloatedness of body
and face, with distention of the abdomen; physical and intellectual weakness; scald head; ophthalmia; herpes on the face;
frequent angina; great liability to take cold.
Belladonna.  Ihard, swollen or ulcerated glands, muscular
weakness of infants; ophthalmia, photophobia and blepharitis;
cough with rattling of mucus; otorrhcea; inflammatory swelling of the nose; swelling of the lips; frequent epistaxis; oftrecurring phlegmonous angina; asthmatic sufferings; enlargement and hardness of the abdomen; incontinence of urine;
precocity of intellect.
Calcarea-carb,   Enlargement of the head with open fontanels; distortion of the spine; incurvation of' the bones, and
other diseases of the osseous system; various cutaneous affections; engorged, indurated and suppurating glands; ulcers;
enlargement and hardness of the abdomen, with swelling and
hyperaemia of the mesenteric glands; excessive emaciation with
bulimy; wan, wrinkled face, with dull appearance of the eyes;
dry, flabby skin; difficulty in learning to walk; difhicult dentition; ophthalmia, photophobia and blepharitis; otorrhwca; red
swelling of the nose; leuco-phllegmasia; constipation or frequent diarrhcea.
Cina. when there are, besides other symptoms, verminous
affections, paleness of the face, emaciation, great voracity and
incontinence of urine.
Conitur.  Engorgement and  induration  of the  glands;
ophthalmia; photophobia; frequent bronchial catarrh, asthmatic
sufferings, cancerous affections, &c.




TREATMENT  OF SCROFULA.                     277
Hepar. Leucophlegmasia; induration and suppuration of the
glands; atrophy; scald-head; ophthalmia; otorrhcea; swelling
of the nose and upper lip; cancerous ulcers; tendency to
phlegmonous angina; unhealthy skin.
Iodium is useful when there is excessive emaciation; engorcerrment and induration of the glands, with affections of the
whole lymphatic system; diseases of the bones; ophthalmia;
blepharopthalmia; otitis and otorrhcea.
Lycopodium. Inflammation, suppuration, and ulceration of
the glands; affections of the mucous membranes; inflammation,
distortion, and other affections of the bones; atrophy; herpetic
eruptions; ophthalmia, otitis and otorrhcea; frequent angina, &c.
JlMercurius. Physical and intellectual weakness; inflammation of the mucous membranes; great liability to take cold;
diseases of the glandular system; exostosis, distortion, curvature, caries, and other affections of the bones; cutaneous affections, &c.
Rhus-tox. Engorgement of the glands; scald-head and
other cutaneous affections; emaciation; hardness and distention of the abdomen, &c.
Silicea.  Diseases of the bones and skin; cancerous affections; tendency to ulceration; swelling of the face.
Sulph. This medicine in many cases is useful when commencinog the treatment of scrofulous affections; it has very
many symptoms, which it is unnecessary to mention here.
A scrofulous ulcer is distinguished from  other sores by its
inert, pale and torpid appearance; and the peculiar character of
the pus, which at first contains many cheesy flocculi, but after
a time becomes thin and corrosive. The state of the atmosphere is remarked by some authors to possess influence over
the appearance of the ulcer. In fair weather it may appear
disposed to heal, but in damp, cloudy and rainy seasons it
presents a most unhealthy appearance. The bottom of the sore
is uneven, warty, fungous or ash-colored; it is extremely difficult to heal, but sometimes after suppurating for years the sore
closes, leaving a disfiguring cicatrix. These ulcers frequently
arise in glandular parts, after inflammation and suppuration.




278         TREATMENT OF SCROFULA.
If the gland is merely swollen when the surgeon is called, by
the exhibition of aur., baryt.-c., cistus-can., con., dulc., or
rhus-t., in accordance to presenting symptoms, suppuration may
be prevented.
Hartmann writes —" To judge by the symptoms, the cistuscanadensis seems to be a highly important remedy for scrofulous ulcers. It has swelling of the glands, also with suppuration; scrofulous ulcers, and other scrofulous ailments; violent
chilliness with shaking, followed by heat, with redness and
swelling of the ears, and swelling of the cervical glands; discharge of moisture and badly smelling pus from the ears; inflammation and painful swelling of the nose; caries of the lower
jaw; even the swollen, loose, readily bleeding, and sickly
looking gums. The frequent nausea, the diarrhcea after eating
fruit, and the pains in the larynx, are indications of the antiscrofulous nature of this drug."*
Dr. Hempel relates a case, in which the ulcerative process
had invaded the nose, and one whole side of the face, threatening to totally destroy all the surrounding parts, and to relieve
which American and European physicians of the highest standing had exhausted all the resources of their skill without any
apparent effect, that was radically healed by using an infusion of
cistus-canadensis internally, and embrocations of the same plant
externally. The patient was an interesting young lady of
eighteen years of age.t
The more minute treatment of scrofulous diseases will be detailed in other chapters.
* See Hartmann's Diseases of Children, p. 379.
t Loc. cit. p. 380.




SPLINTS AND BANDAGES.                    279
CHAPTER XIV.
SPLINTS AND BANDAGES.
A SUCCESSFUL treatment of casualties, as well as other surgical cases, can be accomplished only by a skilful application of
splints, bandages, and the other varied apparatus which have
been contrived and introduced within the province of surgery.
Much practice is required before that degree of neatness,
promptness and carefulness are attained, which are essential
components in the character of a good surgeon.
In regard to fractures especially, it is absolutely required that
a precise knowledge, likewise, be had of the indications to be
fulfilled for a satisfactory use of the means. Without the possession of such knowledge treatment should never be attempted.
There would be but little practical profit from an acquaintance
with all the very numerous kinds of bandages and other contrivances, however ingenious or highly recommended, which
from time to time have been introduced to the notice of the
profession. By such as are curious in these matters, the older
surgical writers may be examined. In the present work it is
designed to invite attention to means now in use, selecting those
only which by the most talented and experienced in the profession are considered best adapted to accomplish the ends desired.
The term dressings* may be used to denote those portions of
different substances applied directly to parts which have been
subjected to surgical operations or to injured surfaces, the object of which is to retain parts in proper coaptation; unite
them, or prevent their too hasty union; shelter them from the
action of the atmosphere or from external injuries; absorb discharges, prevent dessication of surface; and last, though not
least, ensure cleanliness.
The different articles employed, and the means for which
* Most of the following chapter is taken from Smith's Minor Surgery.




280           SPLINTS AND BANDAGES.
they are to be applied, are known under the general head of
Apparatus of Dressing. These consist of two parts, one containing the instruments for dressing, the other the pieces of
dressing to be applied.
The instruments for dressing must vary according to the nature of the case, but usually they may be limited to such as are
generally found in the assemblage furnished by the cutlers, and
known under the name of the pocket-case. This, if required
for general use, should contain dressing or ring forceps, simple
forceps, scissors, both straight and curved, probes, directors,
spatulase, bistouries, abscess-lancets, one male and female catheter, a tenaculum, straight and curved needles, ligatures, and
often such others as the taste of the cutler or his interests may
lead him to select. Under this head, also, the surgeon should,
in serious cases, include razors, basins, sponges, towels, buckets,
&c.; in fact, all that is requisite for the preparing of a part for
the application of a dressing, or the removal of the previous
one.
As the proper use of the instruments just referred to is not
always known by those purchasing them, a brief description of
the objects and method of handling each may not be out of
place.
The dressing forceps are employed for removing the different
pieces of dressing, not cnly in order to protect the fingers of
the surgeon from discharges that are often very irritating, but
also on account of their enabling him to seize them  with less
risk of injury to surrounding parts, especially by pressure. In
cases of fistulae or sinuses they are also often necessary, in order
to cleanse the bottom of the sinus, or remove deep-seated portions of dressing, or other foreign matter.  In using them, the
thumb and second finger are to be passed through the rings of
the handle, and the fore-finger extended towards the joint of
the blades, in order to render them more firm.
The simple or dissecting forceps may be frequently substituted
for the dressing forceps, especially where minute portions of
dressing, such as ligatures, &c., are to be removed. They are,
however, more frequently used for seizing such portions of in



SPLINTS AND BANDAGES.                     281
tegument as may require to be cut off by the knife or scissors.
As similar forceps are employed by each student in dissection,
no information need be here given as to the manner of using
them.
The straight scissors are employed in dressing, for the ordinary purposes of scissors; but those which are curved, either
on the side or front, are mainly required to facilitate the removal of such dressings as adhere closely to the body; as adhesive strips, bandages, &c., especially where it is desirable to
remove them without deranging the position of the part. Scissors are also occasionally used for excision of portions of integuments, as in hair-lip; but they do not answer as well as
the scalpel for such operations, because they are apt to bruise
the edges of the part divided, and thus interfere with its subsequent adhesion. If scissors have a rough edge and cut harshly,
light pressure of the thick skin of the thumb along the blades
will remove it.
Probes are intended as substitutes for the fingers where the
space to be examined is too narrow to admit a larger body.
But where it is possible to introduce the finger it should always
be preferred, on account of the greater accuracy of the touch.
The probe should always be made of silver, or some equally
flexible metal, in order that it may be readily bent, to suit the
position of the part to be examined.
The director is a broad probe with a groove in it, which is
generally used to direct the point of a scalpel or bistoury, in
the division of deep-seated parts, especially where important
organs are in the neighborhood of the incision. Sometimes it
is formed with a flat end for a handle, and sometimes it has a
ring, or other slight expansion, to enable the operator to hold
it firmly. When the director is required to facilitate incisions,
it should be held with the thumb on the top of the handle, and
the fingers of the same hand beneath its shaft, in order to prevent its slipping out of place. The knife being held in the opposite hand, is then made to pass along the groove as far as
may be desired.
The spatula requires but little description, and is used chiefly
in the preparation of dressings.




282          SPLINTS AND BANDAGES.
Bistouries and scalpels are of various shapes, and should
be selected mainly with reference to the probable wants of the
practitioner.  As their use varies much in the different operations to which they are applicable, these uses will be described
with the operations in which they are necessary.
The straight and curved needles, tenacula and ligatures, are
too well known to require notice.
The articles used for dressing are, lint, charpie, cotton, tow,
compresses; adhesive strips, &c., &c.
Lint is a soft, delicate tissue, or mass, prepared in two ways,
in one of which the transverse threads of soft old linen are drawn
out by a machine, leaving the longitudinal ones covered by a
sort of tomentum or cotton-like mass; whilst, in the other, the
cotton-like surface is produced by scraping with a sharp knife
a similar piece of cloth, previously fastened to some firm substance. The first is known as the patent lint, and may be obtained of any druggist, being now generally manufactured.
The second is the domestic lint, and may be made at a moment's notice, when the first is not convenient.
Charpie is a substance much employed by the French surgeons, and now gaining a more general application in the United
States. It is made by collecting the threads torn from pieces
of linen, four or five inches square, such as is used for patent
lint. The process, however, goes a step further than that for
making lint, and tears the threads entirely apart instead of
preserving the cloth. The linen from which it is made should
always be new, and not worn out table-cloths, &c., as sometimes employed; Gerdy having proved that when charpie is
made from new linen it absorbs better than when from old.
Charpie is usually divided into two kinds, according to the
length and fineness of the thread composing it; that which is
long and coarse being employed to keep open sinuses, fistulae,
and to act as an outer dressing; while the softer, finer kind is
placed in immediate contact with the part, especially where the
secretion of pus is abundant.
Various names are given to charpie, according to the way in
which its fibres are arranged previously to its application.




SPLINTS AND BANDAGES.                      283
Thus, we have the pledget, roll, tent, mesh, bullet, tampon,
pellet, &c., each of which has its peculiar advantage.
The pledget is a mass of charpie formed by collecting the
threads and laying them parallel to each other, with the ends
folded underneath; this being flattened between the palms of
the hands, may be moulded into any shape to suit the convenience of the practitioner.
The roll is composed of a smaller mass of charpie, rolled into
the form of a cylinder, the fibres all running in a longitudinal
direction, and then being tied in the middle. The roll is useful
for absorbing pus in deep wounds, arresting hemorrhages, &c.
The tent is a conical form of charpie, made by doubling the
roll, and twisting the free ends to a point; it is generally used as
a dilator. It is frequently made by soaking a sponge in melted
beeswax, and then cutting it to suit the emergency of the case.
Bullets, tampons, pellets are masses of charpie, generally
circular in form, and chiefly used for suppression of hemorrhages,
or absorption of pus.
Compresses are pieces of linen of various sizes, used to make
pressure, confine dressings, prevent external injuries, and
equalize the surface of limbs, in order better to adapt them to
the application of the bandage, or the compression of the soft
parts. Compresses should be made of some soft substance.
The various manner of folding compresses has given rise to
the names by which the different forms are designated; thus
we have square, oblong, triangular, and cribriform  compress.
The latter is made by folding a square piece of linen or muslin
several times, and nicking it in several points with the scissors.
There is also the perforated, graduated, and pyramidal compresses.
The perforated compress is used to relieve affected parts
from pressure, and to allow the slough or pus to escape at the
same time; it is formed by making a square soft pad, and cutting a circular opening in the centre; it is very useful in bad
sores, &c. These pads are now manufactured of India-rubber
cloth, and can be inflated in the same manner as the ordinary
circular life preservers, indeed they bear great resemblance to
the latter.




284          SPLINTS AND BANDAGES.
Graduated compresses are named from their construction, and
are of several kinds; the substance of each being folded differently, according to the object in view.
The common graduated compress is made by folding a piece
of muslin several times on itself, so that each fold may not entirely cover the one that has preceded it. It may be gradunted
at one end, or from end to end, as would be the case if it had
another folded end at its left extremity.
The pyramidal compress is one that is most accurately formed
by placing square pieces of muslin, gradually decreasing in size,
on top of each other, and stitching them together so as to form
a pyramid. It may also be made by folding a piece of 2- inch
bandage on itself, so as to form a pyramid graduated from end
to end, and then placing a piece of cotton, or other substance,
in the centre of the last turns.  Thus formed, it is very useful
in making pressure upon certain points, as in cases of hemorrhage from the deep-seated vessels of the leg or forearm.
The following excellent rules for dressing are laid down by
Dr. Smith, and cannot be too strictly observed by the young
practitioner, as they not only promote to a great degree the
comfort of the patient, but also facilitate the process of the removal of old, and the application of new dressings:
1st. Let the surgeon make, or see made, everything that is
requisite for the new dressing before removing the old one.
2d. Let him have a sufficient number of capable aids, to
whom special duties shall be assigned before commencing the
dressing, as this prevents confusion. Thus, in dressing a stump,
or wound, there should be one assistant to support the limb;
another to furnish hot water, and change it as required; heat
the adhesive strips, &c., &c., by which means the surgeon can
give his attention wholly to his own duty.
3d. Let him arrange the bed, as a general rule, after the
dressings are changed; or, if in a case of fracture, before the
patient is placed on it.
4th. Let the position of the patient be such as will cause him
no unnecessary fatigue.
5th. Let the surgeon, as a general rule, place himself on the




SPLINTS AND BANDAGES.                     285
outside of the limb, with his face to the patient, as this will
give more freedom to his movements, and prevent accidental
jars.
6th. Let all the assistants be especially careful to guard
against hasty and inconsiderate movements, in order to prevent
unnecessary pain to the patient.
The roller is to be prepared from a piece of muslin of the
requisite length and width, by tearing it from the piece and
then winding it into a cylindrical form, either by a machine
constructed for the purpose, or by the hand, that it may form
one or two masses, and constitute what is called a single or
double-headed roller.
With a machine at hand, there can be no reason why every
surgeon should not keep himself supplied with bandages.  But
as there is frequent necessity for the re-application of the same
bandage, both for economy and convenience, and to be able in
case of emergency to manufacture one speedily and neatly, the
surgeon should accustom himself to the manipulation required
in the formation of the roller. In order to accomplish this end,
the following directions have been found serviceable. Fold the
terminal end of the band five or six times on itself, that it may
form a sort of axis, and roll it a few turns on the thigh to give it
size, then place the cylinder between the thumb and forefinger of
the  left hand;  allow  the             Fig. 15.
body to run over the right
forefinger, seizing it firmly
between the thumb and finger
of that hand so as to make
traction,  and  tighten  the       l
cylinder.  Having  thus ar-  
ranged it, give a rotary motion to the band, and cause
the cylinder to revolve upon
its axis by means of the fingers  ) 
and thumb of the left hand,    /
whilst, at the same time, the
right thumb and  forefinger




286          SPLINTS AND BANDAGES.
revolve partially around the cylinder itself, which, by this
compound movement, is soon formed as required, See fig. 15.
The single headed roller consists of two extremities; of an
initial and a free end; of a terminal one or that found in the
centre of the cylinder; of two surfaces, an external and an internal; and of a body, or portion between the two extremities.
The double headed roller has the same portions as the single
one, excepting that both ends are wrapped into cylinders.
The application of this roller, therefore, always commences
with its body.
The spiral bandage is that which is most frequently employed
in the treatment of all affections, whether of the extremities or
trunk.
In applying this bandage, each turn should cover at least
one-third of the preceding; and as most parts to which it is
applied are conical in shape, especially in the extremities, it is
obvious that in ascending from the lower to the upper portion
of them, we must follow the direction from the apex to the
base, and consequently, that portion of the bandage which is
nearer the latter, will press firmly on the limb, while the
former will be but loosely covered, on account of the projecting
folds, thereby leaving not only openings or gaps, but causing
unequal pressure upon the parts.  The necessity of obviating
such inequality is important, and upon this subject Mr. Fergusson writes, "for whatever object a bandage is applied, it
is important to observe, that an equal amount of support or
pressure is afforded on all sides."  The surgeon, therefore,
overcomes the difficulty in making what are termed reverse
turns.
The following rules for making reverse turns, are taken from
Dr. Smith's Minor Surgery; indeed, many portions of this
chapter have been compiled from that practical work.
1st. Hold the roller in the position in which it is generally
applied, that is, either by its body or its two extremities, the
hand being in a state of supination.  2d. Apply the initial
extremity to the limb, and continue to make simple spiral
turns, until you approach the enlarged portion of the limb.




SPLINTS AND BANDAGES.                    287
Fig. 16.
3d. Apply a finger of the free hand to that portion of the
bandage, that is already in contact with the limb, not to assist
in forming the reverse, or to fold it down, but to prevent the
turns already applied from slipping or becoming relaxed while
the reverse is being made. 4th. See that no more of the bandage
is unrolled, than will enable you to separate the cylinder a
short distance, say four or six inches from the limb. 5th. Let
that portion of the bandage be loose, which is between the
finger fixing the body of the roller, and the cylinder. 6th. Turn
the hand holding the roller from supination to a decided pronation, by motion of the wrist alone, without moving the fingers
from the cylinder, as shown in (fig. 16,) taking especial care
to make no traction, nor to sink the cylinder below the level of
the limb till the fold or reverse is made, when it may again
proceed up the limb, it being recollected that each turn should
ascend spirally, and only cover in about one-third of that
which preceded it. 7th. Keep each turn and each reverse
parallel with its fellow.




288                   FRACTURES.
CHAPTER XV.
F R A C'1' U R E S.
Section 1.-Definition —Symptoms-Mode of Union.
FRACTURE, or solution of continuity in bone, is usually the
result of external violence;* sometimes it is effected by muscular action alone.  And this, too, is not a mere local causality,
but apt to be followed by inflammation, suppuration, gangrene
or erysipelas, bringing life into the greatest danger.
The parts of the skeleton most liable to fracture, are the
long bones, more especially of the extremities; and these may
suffer by violence applied either directly or indirectly.  The
flat bones, with the exception of those of the cranium, are less
liable, and seldom give way, except under violence which is
both direct and severe.
A bone does not always break at the point struck. A blow
on the symphysis menti often occasions fracture of the jaw,
near its angle; a concussion applied to the bones of the leg,
through the foot, ordinarily produces fracture of the tibia near
the ankle, and of the fibula at its upper part. The broken
fragments usually become more or less displaced. The force,
wherewith the injury was inflicted, may push one or both
aside; and the weight of the limb may increase displacement,
when the part is raised, or when an attempt is made to use it.
But the paramount displacing agent is the action of those
muscles which are implicated in the injury. Sometimes there
is retraction of the fragments, and elongation of the part; as in
transverse fracture of the patella.  Most frequently the fragments cross and overlap each other, with consequent shortening
of the limb.  Sometimes one fragment alone is displaced; as
in fracture of the clavicle; the sternal portion remaining nearly
in situ, while the lower passes downwards and forwards. In
other cases, both suffer displacement, as in fracture of the
- See Miller's Principles of Surgery, 699-708.




FR ACTURES.                        289
humerus below its bicipital groove; the upper fragment passing in toward the chest, the lower being elevated, and displaced outward by the deltoid.
By the displacement, neighboring parts are liable to be
compressed, torn or otherwise injured; and hence the most
serious consequences may ensue; unless such displacement be
detected, understood, and speedily rectified. For example, the
displaced fragments of' a broken rib may puncture and irritate
the pleura and lungs, exciting violent inflammation there; and
displaced portions of a broken cranium may cause a like injury
to the brain and its membranes, followed by results still more
disastrous.
The symptoms of fracture are usually very plain; there is
obvious deformity of the part; and its muscular power is all
but lost. A fractured arm, for example, is swollen, and the
patient is unable to move it without the assistance of the corresponding member.  Sometimes, as in the case of the patella,
the part is elongated; much more frequently it is shortened;
the lower extremity, in fracture at the hips, may be abbreviated
to the extent of two inches or more. Voluntary motion is
much abridged; in many cases the patient of himself, can
move the injured limb little, if at all.
Involuntary motion on the other hand, is much extended;
that is to say, the surgeon can, though not without inflicting
much pain, move the limb in directions and to an extent of
which it was previously incapable; and at the site of fracture,
the slightest examination usually makes it abundantly plain,
that the part is remarkably and preternaturally mobile. Pain is
great and constant; and ever and anon liable to sudden exacerbation, fioom spasmodic twitchings of the muscles implicated in
the injury, whereby the bones are displaced anew, and the
soft parts irritated and torn.  If either fragment come in contact with nervous trunks, compressing, puncturing, or in any
way irritating these, the pain is likely to prove extreme.
Swelling invariably occurs, and is of three kinds.  1. The
displacement and overlapping of the fractured ends, produce a
greater or less enlargement of the part immediately after the
19




290                  FRACTURES.
infliction of the injury. And if muscles be relaxed by the displacement, the bulging into which they are consequently thrown
will contribute to the immediate swelling. 2. The first swelling is increased by extravasation of blood; which inevitably
follows solution of continuity of the bone, and coexistent laceration of the soft parts. If any considerable vessel have been
injured, this kind of swelling may prove very great; partly by
blood accumulating around the fracture, partly by its being
infiltrated into the surrounding tissues. The second swelling in its turn, is followed and modified by the 3d, which
attends inflammatory action; beginning to form after the lapse
of some hours. The tissues then become infiltrated; partly by
serum, partly by fibrinous exudation.
But the peculiar and diagnostic sign of fracture, is what is
termed crepitus; a sensation of rubbing, grating, or crackling,
which is imparted to both hand and ear, when the fragments
are moved one upon the other, with contact of their broken
surfaces. When there is no great displacement, the fractured
ends remaining partly in opposition, this crepitus may be felt
on the slightest movement of the limb; and often both the
patient and his attendant are made very plainly aware of its
existence, by the involuntary movements, which spasm of the
muscles from time to time occasions. But when the fracture is
transverse, the displacement great, and the fragments completely overlapping, crepitus is not so easily found. Reduction
must be effected in the first instance; in order that the broken
surfaces may be brought into contact with each other; and
then by movement, the desired sound will be plainly enough
emitted.
Certain fractures termed impacted rarely afford crepitus.
One fragment is driven into and lodged in the cancellous texture
of the other, by the same violence which caused the fracture;
and so the bone is scarcely broken, when it again becomes
fixed, with its continuity apparently restored.
The manipulations neccessary to ascertain the nature of an
accident, and which are specially directed towards detection
of crepitus, are to be conducted with all gentleness, that




UNION OF FRACTURES.                    291
unnecessary pain may not be produced, or the soft parts further
endangered by aggravation of subsequent inflammatory action,
and yet with determination, sufficient for fully satisfying the
examiner as to the diagnosis.  It is much better that a
thorough examination should be made at once, painful though
it be, than that more gentle movements and inquiries should be
made with frequent repetitions, delaying the means of cure.
Also, let it be borne in mind, that, at whatever cost of suffering to the patient, it is our paramount duty to make such a
thorough examination; for two reasons. In the first place, in
order that the required repose and treatment of the part may
be immediately instituted; in the second place, and mainly,
that error of diagnosis may be avoided.
The mode of union or reparative process, is a subject of
much importance; on the right understanding of which, the
indications of treatment depend.  It may be conveniently
divided into the following stages; understanding that the
fragments have been duly readjusted, and are so retained.
1. Blood is extravasated at the site of fracture; and accumulating, distends the surrounding parts into a kind of pouch, in
which the fractured ends are laid; and the cavity of this pouch
is occupied by the extravasated blood, partly fluid, partly
coagulated. The surrounding parts are condensed; and obeying the stimulus of the injury and displacement, become more
energetic in their circulation, prepared for the unusual effort in
nutrition which is about to be demanded of them. 2. The
extravasated blood is absorbed, and the ends of the fractured
bone also undergo alterations, being deprived of their earthy
matter to a great extent, and so prepared for higher efforts as
a vascular tissue. Liquor sanguinis is exuded from the parietes
of the pouch, from the ends of the bones, and from the periosteum which invests them; and this plasma assumes the position
which the blood occupied. The pouch, however, has somewhat contracted from its first dimensions, by tumescence of the
parietes; favored, or at least permitted, by gradually decreasing extravasation. It has been a source of hot dispute, to
determine from what tissue this plasma proceeds. Probably it




292            UNION OF FRACTURES.
is the offspring of every tissue implicated; exuded from bone
and from periosteum, and also from the textures constituting
the parietes of the containing pouch, whether these be muscular, fibrous, fatty, or areolar.  Perhaps, it may be held
enough for the practical inquirer, that there is the plasma,
come whence it may; the plasma having been exuded, consolidates, its serous portion is absorbed; the fibrin remains and
becomes organized. And this organizing plasma not only
occupies the pouch, but is also situate between'the fractured
ends of the bone, and in their interior. At the same time,
fibrinous exudation is taking place in the soft textures exterior
to the pouch, whereby they are still further condensed. A
portion of this is imperfectly organized; and remains for a
time, sometimes of considerable duration. The rest is absorbed, previous to organization, on subsidence of the excited
action by which it was exuded. 3. The period of plastic
exudation may be said to have passed, after eight or ten (lays.
Then the process of organization advances.  The plasma sometimes passes into the transition state of fibrous tissue; at others
into fibro-cartilage, or even true cartilage. 4. The organized
and transitional mass contracts, by interstitial absorption; increases in density; and gradually passes into the condition of
bone. At the same time, the surrounding parts, that are immediately in contact with the ossifying mass, are more and more
condensed, they become continuous with the ruptured and
engorged periosteum; and assume the general characters of that
texture, as well as its function of investing and administering to
bone. 5. Ossification advances from the periphery. The most
exterior part of the plasma is the first ossified; and thence
ossification gradually approaches the interior; as it advances
the mass contracts more and more, ultimately restoring the
bone.  This ossifying mass, commencing at the circumference
and contracting, forms an osseous ferrule, by which the fractured ends are tightly clasped.  This new  formation is termed
provisional callus.  6. The definite callus is that which is
formed between the ends of the bone, and which constitutes
the final medium of incorporation of the ends. Its organization




FRACTURES.                        293
and ossification are accomplished by a more slow and gradual
process, than that of provisional callus.  7. The definite
callus is at first preternaturally dense and compact; but is
gradually modified by absorption, and ultimately is so changed,
as to render continuity of the normal texture of the bone complete. On making a section of a recently united bone, a dense
compact mass of new osseous matter is found intersecting
the cancellous texture at the site of fracture; but after a few
years, section discloses that part of the bone's interior, perhaps
a little more dense than elsewhere, yet open and quite of the
cancellated character. And thus it would seem, that not even
the definite callus can be said to be truly permanent. On the
contrary, all callus is temporary; it has a certain duty to perform; and that having been achieved, it is taken away more
or less gradually by absorption.
The exciting causes of fractures are mechanical violence and
muscular action. Mechanical violence may be direct or indirect. It is direct when the fracture is produced at the point to
which the force is applied. It is indirect when the force is
applied at one point and the fracture occurs at another.
The predisposing causes of fractures are old age, mollities
ossium, fragilitas ossium, and original brittleness.
Fractures occur in three directions, viz., transverse, oblique,
and longitudinal.
There are several varieties of fractures, viz., simple, compound, comminuted, and complicated.
A simple fracture is a solution of continuity in the osseous
tissue at one point, without external injury to the soft parts.
A compound fracture is a solution of continuity in the soft
parts and osseous tissue, with an external opening.
A comminuted fracture is where the osseous tissue is separated at several points, or crushed, thus producing many fragments of bone. It may either be simple or compound.
A complicated fracture is one in which the fracture is accompanied with luxation of a joint, laceration of large vessels, rupture of ligaments and tendons, or gun-shot wound.
The danger from simple fracture is inconsiderable; but from




294       FRACTURE OF THE CRANIUM.
the other varieties it is often extreme, and may terminate fatally
in a few hours, from loss of blood and shock to the system, or
from inflammation, fever, tetanus, and typhoid fever or hectic,
dependent upon excessive suppuration.
The homeopathic treatment of fractures will be mentioned
hereafter; it may, however, be well in this place to remark,
that immediately after the injury, if the patient appears to suffer from the shock, either arnica, ignat., or chain. should be
prescribed. The former of these medicines deserves the preference in the generality of cases, but there may be occasion for
the exhibition of the other two.
Ignatia may be used when the patient is not so much affected
by the shock as he is fearful of consequences; when there is
trembling and excessive weakness, or vertigo, violent anguish
about the pit of the stomach, and cold sweat.
Cham. may be prescribed when the patient faints frequently,
with uneasiness about the heart, twitching of the limbs, and
oppression of the chest.
After reaction has taken place, the limb should be adjusted,
if the parts require it; arnica or calendula applied, according
to the presenting circumstances of each particular case. After
the more violent inflammatory symptoms have subsided, to
hasten the deposit of ossific matter, either calc.-carb., calc.phosph., ruta, or symphytun  off., may be used.
If there are excessive pains in the periosteum  and bones,
with nightly aggravations, phosph.-ac. mez., or rhododen.,
relieve.
Section 2.-Fracture of the Cranium.
In fracture of the skull, there may be simple fissure of the
bone, or fracture with depression; or the outer table alone may
be fractured and driven into the diploe. This can only occur
in middle age, since the diploe does not exist in infancy or old
age. The inner table alone may be fractured. Generally both




F RACTURE OF THE CRANIU M.                  295
tables are broken, and the bones are sometimes split to a very
great extent.
Diagnosis. —This is not difficult. These fractures are the result of great violence; and when the seat of fracture is upon
the surface it can be felt by the finger, which should be passed
into the wound if there be an opening in the scalp. If the patient be not seen until a hard, puffy tumor has formed upon the
scalp, the exact nature of the injury cannot be ascertained until
this subsides. It should be remembered that, although the
fracture generally occurs at the seat of the injury, yet it often
takes place at a part of the arch more distant from the application of the force. Thus, a blow or fall upon the top of the
head may, and often does, produce fracture of the base of the
skull. This injury may be recognized by the escape of blood
from the ears, nose and mouth, (caused by tearing the sinuses
of the dura mater,) with early and severe symptoms of compression of the brain, and, after the lapse of some days, a discharge of watery fluid from the ear, (thought to be due to the
escape of serum from the sac of the arachnoid membrane.) In
fracture with depression there are symptoms of compression;
yet these symptoms accompany fracture without depression of
bone, where there is effusion of blood or accumulation of pus
upon the brain. Crepitation can be felt when there are detached fragments of bone. Symptoms of concussion are observed in simple fracture, as well as in more serious cases,
preceding the more dangerous symptoms of compression.
Prognosis is always doubtful in these cases, and generally
unfavorable.
Treatment. —A dose of arnica should be immediately administered internally, and afterwards a lotion of the same drug
applied to the wounded part; or if there be a tendency to
encephalitis erysipelatosa, the meningeal membranes being the
seat of the inflammation, which is manifest by sudden violent
headache, delirium, etc., bell. is one of the most suitable medicines. If effusion should have actually commenced, arnica
should be at once administered; indeed, from the commencement of those symptoms indicative of inflammation of the brain,




296       FRACTURE  OF THE CRANIUM.
and particularly when such arise from fracture, arnica appears
to be the specific medicine.
".A/rnica," writes Dr. Henriques,* "is the antivulnerary
specific, (if I may be allowed this expression,) which is employetl in homceopathic surgery to prevent as well as to cure
local pain, swelling, and inflammation, following an injury. In
the old system it is by antiphlogistics that these effects are controlled.  I allude to these without discussing their effects on
the organism, or their ultimate results in inflammation."
In fracture with depression of bone, accompanied with compression of brain, it is necessary to relieve the patient by the
use of the trephine; the elevator can scarcely ever operate advantageously until the trephine has made a suitable point for
its application.  Another great advantage in performing this
operation is that of giving egress to the blood escaping from
wounded vessels. Even where symptoms of decidedcompression have not yet supervened upon depression of a fragment of
bone, it has been advised to elevate the depressed structure,
provided the danger of inflammation and compression appear
urgent or very likely to occur from the presence of the foreign
body; this is both reasonable and good practice. But the
trephine should not always be resorted to when depression and
slight symptoms of compression manifest constitutional treatment-application of arnica or calendula to the head, and perfect
rest, should be the means looked to for relief. The instrument
above mentioned has also been employed successfully in relieving the brain from compression and effusion of blood.
In the application of the trephine it is generally advisable to
avoid the sinuses and the meningeal artery.  The most advantageous point near the seat of mischief should be selected for
the operation, and great care taken, upon approaching the inner
table of the cranium, to avoid wounding the membranes of the
brain. If the integuments be not sufficiently divided by the
accident, an incision must be made through them, sufficiently
extensive to allow the free application of the trephine. Either
* British Journal of Homceopathy, No. XLI., p. 452.




FRACTURE OF THE NOSE.                    297
of the following forms of incision may be made for this purpose,
and the flap raised by a scalpel.
Fig. 17.
In cases of comminuted fracture of the cranium, where fragments of bone are detached, they have become foreign bodies,
and should be removed. In fractures of the cranium generally,
however, little can be done with the fracture: the main points
in the case are compression and inflammation; these must be
guarded against, if possible. Non-interference with the seat
of injury, with the exception of the local application already
alluded to, is the best general rule that can be given.
Section 3.-Fracture of the Jose.
Fracture of the nose is ordinarily a very simple accident, but
may be dangerous by great violence being applied to the bones
of the nose, and through themn breaking the cribriform plate of
the ethmoid bone, and forcing it in upon the brain. Ordinarily
there is mere fracture of the nasal bones, which is easily recognized by the deformity produced.
Treatment.-The bones should be re-adjusted by pressure
upon the outside with the fingers, and from within by a director
or other convenient means, a solution of arnica applied externally, and the same medicine administered internally. By
these means the tumefaction is soon subdued and inflammation
prevented.
Section 4. —Fracture of the Lower Jaw.
Fracture of the inferior maxillary bone is of frequent occurrence, and is always the result of considerable force; it is




298                BANDAGES FOR
Fig 18.            generally broken in the mental region, (Fig. 18,) or the
middle of the horizontal ramus. In children it sometimes takes place at the
symphysis, but fracture may,ii81~,l' aoccur in any part of the,//!4.,,,,,,j,,,, [t lower jaw.
Diagnosis is very easy
in this injury: the anterior fragment is drawn downwards;
there is pain on moving the jaw, crepitus, and irregularity
in the teeth and alveoli.
Prognosis is favorable.
Treatment consists in coaptating the fragments and insuring
rest by pressing the teeth (which makes an admirable splint)
firmly together, and securing the part by the application of a
piece of pasteboard, or a compress of linen applied under the
jaw, and secured by one of the following bandages.
The four-tailed bandage is probably the best that can be applied. It is made of a piece of muslin about four inches wide,
and one and a half yards long: this is torn longitudinally at
both ends, leaving eight inches in the middle entire; in the
centre of this a slit is made, to allow the chin to pass through;
the two ends of the lower half are carried up the side of the
face, and tied on the top of the head; the remaining ends are
carried around the neck and fastened behind, the bandage being
so arranged as to embrace the chin and keep the jaws firmly
applied to each other. This bandage is more firm, and sets
better, when long enough to pass several times around the face
and neck.
Dr. Gibson's bandage (Fig. 19) consists of a roller an inch
and a half wide. This is passed in circular turns under the
jaw, up the face, and over the head several times; it is then
pinned at the temple and turned at right angles, encircling the
back of the head and forehead by several turns; it is pinned
again at the temple, and carried down the side of the face and
pinned on a line with the chin; carried then, at right angles,




FRACTURE OF THE LOWER JAW.                   299
several horizontal turns are made, em-     Fig. 19.
bracing the chin and back of the neck.
A strip of roller is then carried over              i
the top of the head and pinned to the
several turns, to secure the bandage
from slipping.,
Dr. Rhea Barton's bandage, with
the use of a pasteboard splint, (see
fig. 20,) is one of the simplest and,
best that has been recommended. It
consists in a narrow roller, the initial
end of which is to be placed under the     Fig. 20.
occipital protuberance; the bandage is
carried over the right parietal bone,
obliquely across the coronal suture to   i~
the left temple, down the left sideface, under the jaw, up the right sideface, and obliquely over the coronal
suture to the left ear, (above it,) being carried around under
the occipital protuberance to the right side, then passing under
the ear, is carried around the chin, embracing the neck and
chin by a circular turn; it is then carried on under the occipital
protuberance, over the right parietal bone, and again obliquely
over the coronal suture to the left temple, and continued in
these turns until expended.
With each of these bandages it is necessary to have the
compress or wet pasteboard well adapted to the jaw. The
patient must be supported by sucking liquids, the teeth always
leaving sufficient space for this purpose. When the position of
the fracture makes it practicable, it is a good plan to bind the
teeth together at the seat of fracture, by passing a silk ligature
around them.
Section 5.-Fracture of the Scapula.
Fracture of the scapula, in its body, occurs from great violence directly applied.




300       FRACTURE OF THE SCAPULA.
Diagnosis.-In this injury there is but little displacement.
Voluntary motion is impaired; the part is swollen and painful.
By placing the hand flatly upon the seat of injury, and communicating motion to the scapula, crepitus can be felt.
The treatment of this injury consists in restraining motion
by passing a roller around the thorax, so as to bind the scapula
firmly to it, and placing the hand in a sling.
Fracture of the.Jcromion Process
Fig. 21.  Fig. 21) is caused by direct violence.
K)   Diagnosis.-It may be recognized
apt by flatness of the shoulder, the fragment being drawn downwards by the
deltoid muscle.  The clavicle and
broken fragment are drawn downwards and forwards by the action of
the subclavius, deltoid and pectoralis
x l',': Ad         major muscles. By forcing the head!; lz USof the humerus upwards against the
acromion process, crepitus can be felt,
whilst rotation of the arm does not
cause crepitus.
The treatment consists in elevating the humerus, thus making
a splint of the head of the bone, which keeps the broken parts
in apposition. The arm should be maintained in this position
Fig. 22.        by the application of the apparatus
for fractured clavicle, without the
wedge-shaped pad, the indication
in fracture of the acromion being
merely to raise the arm.
Fracture at the NCeck of the Scapula (Fig. 22). In this accident
the broken fragment consists of the
glenoid cavity and coracoid process.
Diagnosis.-Much care is necessary to distinguish this accident from
ii,,g/3          dislocation. The fractured portion
of the scapula is retained in contact




FRACTURE  OF THE CLAVICLE.                    301
with the head of the humerus by the long heads of the biceps
and triceps muscles: the head of the humerus, with the detached fragment of the scapula, is drawn downwards and forwards into the axilla by the subscapularis, pectoralis major,
and latissimus dorsi muscles.  There is flatness of the shoulder,
prominence of the acromion, with a vacancy beneath it; the
limb is somewhat lengthened, and the head of the humerus
lodged in the axilla, as observed in cases of dislocation of the
head of the humerus. But, by very gentle effort, the head of
the bone may be replaced, and the deformity disappears. When
support to the part is withdrawrn, the displacement and deformity re-appear, which is not the case in dislocation. Crepitus
may also be distinctly felt by placing the thumb on the coracoid
process, (~Which can be readily felt under the outer end of the
clavicle,) and pressing the fingers in the axilla; then, by pushinrg the arm upwardls and outwards, signs of fracture, not to be
mistaken, are made evident.
Treatment of fracture of the neck of the scapula consists in
coaptating the broken fragments, and keeping the parts at rest.
For this purpose the apparatus for fractured clavicle is probably
the best, and should be applied so as to arrest both the movements of the arm and scapula: here the wedge-shaped pad meets
one of the most important indications.
The coracoid process and articular s'urface of the scapula are
occasionally fractured; but it is not of frequent occurrence.
When these accidents are met with, the fore-arm  should be
placed in a sling, and the part kept at rest.  M. Velpeau's
bandage for fractured clavicle answers the indications for fracture of the coracoid process of the scapula better than any
other.
Section 6.-Fracture of tle Clavicle.
Fracture of the clavicle is of very common occurrence.  It
usually takes place near its middle, (Fig. 2,,) and is generally
oblique.  It is the result of force applied either directly or indirectly.




302                BAND AGES FOR
Fig. 23.             Diagnosis in this case is
perfectly easy. By passing
H -H i  _~    the finger along the clavicle,.,""<4 ~   the natural line of the bone is
]]\\>";        A        observed to be interrupted,,,~ lie                 and the broken extremities
perceptible: the shoulder falls
q,,~,:~ 1 rforwards and inwards; the
outer fragment is drawn downsgk~zl'',5,'''r  wards by the action of the
subclavius and deltoid muscles. By pressing the shoulder upwards and outwards crepitus can be felt at the point of
separation.
Treatment of fractured clavicle consists in adjusting the broken
extremities of the bone, by forcing the shoulder upwards, outwards, and backwards, and retaining it in this position.
The following apparatus is employed for this object. A
padded belt is placed around each shoulder, and drawn together
Fig. 24.           on the back by a strap, and
the fore-arm placed in a sling:
or a folded towel is placed in
the axilla, and a bandage is
passed from shoulder to shoulder, forming a figure of 8 (see
fig. 24) across the shoulders.
This plan is recommended by
Mr. Fergusson.  Mons. De-. sault's apparatus consists in a
wedge-shaped pad and three
rollers: the base of the pad
is placed in the axilla (see
fig. 25) and secured to the
body by passing a roller in circular turns around the chest.
(Fig. 26.) The fourth and fifth turns of the bandage are carried over the sound shoulder and under the arm-pit. The arm
is now brought down upon the pad, which acts as a fulcrum,




FRACTURED CLAVICLE.                      303
Fig. 25.
and the fracture being adjusted, the fore-arm is placed across
the chest. The second roller is now applied, by placing the
Fig. 26.




304                 BANDAGES FOR
initial end in the axilla of the sound side, and carrying it to the
shoulder of the injured side, around the body; then continue,
by circular turns, binding the arm to the pad from the shoulder
down below the elbow.  (Fig. 27.)  A compress of muslin is
placed upon the injured part, and the third roller is commenced
at the arm-pit of the sound
Fig. 27.              side, and carried obliquely
over the shoulderl of the injured side, down the back
of the arm, under the elbow, across the  chest,
under  the  arm-pit of
the sound side, across the
back, over the  injured
0/::::d. clavicle  and  down  in
__- - 2i!_Z___l~. A   front of the arm, under the
elbow, obliquely  across
the back to the arm-pit,
—'~>- / -' —,' ~- G.' ~   and continued, forming a
~  "~"i. ""~_  4~___'~~triangle in front and be-'j~:._hind,    until    exhausted
the hand is then placed, He:~    — a~ —:~~:5  I i n a sling.  (Fig. 28.)
-o<,  as5   -- < The last and best apparatus is that of Dr. Fox,
which consists in a sling for the elbow, made of stout linen, or
other material; this should be in length about two-thirds of the
fore-arm, and deep enough to embrace the fore-arm; it can easily
be made out of a piece of stuff, cut into a parallelogranm, twice
the width of the fore-arm, and two-thirds of its length; this is
to be doubled in its shortest diameter, and one eind sowed up;
at the upper angle, and the corner of each side, a strong loop
of tape is attached.  A ring of linen, stuffed with carded cotton, is made to embrace the shoulder and axilla; a wedgeshaped pad(, which should be three inches thick at the base,
six inches long, and four or five wide; strong pieces of tape
or bandage complete the apparatus. The application of it is




FRACTURED  CLAVICLE.                    305
as follows: (Fig. 29.)              Fig. 28.
the base of the pad is
placed in the axilla of
the injured side, and                 b
temporarily secured by
being held, or by tapes
tied around the neck;
the arm of the sound
side is passed through
the padded ring, which
rests in the axilla and
over the shoulder: the
sling is applied to the
fore-arm, the elbow
placed firmly in its angle, and the arm  is.    A m
now brought down to
the side, the fracture
coaptated; tapes having
been passed through the             Fig. 29,
loops attached to the/ I
sling, are now carried                    /
through the ring at the         \:\'
sound shoulder;the tape
at the elbow carried
behind the chest, and  
those at the wrist in                           i
front; these are firmly........
drawn so as to place
the shoulder and clavicle in proper position, the hand being
put in a sling. Raw
cotton should be placed under the tapes where they touch the
skin, to prevent excoriation. It is necessary to avoid much
pressure in young subjects, as well as to exercise great care in
protecting the skin from abrasion. This apparatus is easily
20




306        FRACTURE OF THE STERNUM.
applied, and can be worn without inconvenience, and probably
fulfils the indications better than any that has yet been proposed.
Section 7.-Fracture of the Sternum.
Fracture of the sternum is generally transverse, and the result of great violence, so that the injury done to the thoracic
contents is often of more moment than the fracture.
Diagnosis is readily made in this case; there is deformity by
displacement, and crepitus during respiration.
Prognosis is unfavorable in fracture of the sternum, from the
probability of inflammation and suppuration in the thorax, with
caries of the bone; this accident often results in death.
Treatment of the fracture consists in passing a roller around
the chest, to arrest its motions; compresses, moistened with a
solution of the tincture of arnica, should be applied to the fractured part, and a dose or two of the medicine administered internally.
If the fever is synochal, the pulse hard, quick, and full, the
face red, excessive chilliness or heat; the pains in the chest
violent, and the respiration oppressed and accompanied with
anxiety, aconite should be given in repeated doses.
If the pain in the chest is not exceedingly severe, but there
is evident signs of inflammation being established in the
lungs; if a loose cough be present, the oppression not excessive, with constant desire to inspire, bryonia should be exhibited.
Bella. will be found suitable, when the fracture has occurred
in plethoric subjects, when there is a tendency to congestion
of blood to the brain, with delirium, when the face is bloated
and very red, the lips and tongue cracked and dry. This
medicine may, in severe cases, be used in alternation with
aconite.
When there are evident symptoms of violent pneumonia,
with sticking pains in the chest excited by coughing or




FRACTURE OF THE RIBS.                    307
breathing, (also pleuro-pneumonia,) when the pains are violent
and extend over a large surface, when a considerable portion of
the lung is inflamed, also dyspncea, when the cough is dry and
the sputa rust-colored, phosphorus is indicated, and will probably relieve the patient in eight or twelve hours. This medicine
may be given in alternation with aconite or bella., agreeably to
the presenting symptoms.  For further treatment of pneumonia the student is referred to works on the Practice of
Medicine.
Carious portions of the bone can be removed by Hey's saw,
bone-nippers, and forceps; but aid in this way should not be
rendered too officiously, lest harm instead of good result.
The trephine has been successfully used in evacuating collections of pus in the anterior mediastinum.
Section 8.-Fracture of the Ribs.
Fracture of the ribs is generally transverse, and may be produced by direct force, or by violence applied at their extremities; in the former instance the displacement is internal; in the
latter, external.
Treatment in these cases consists in lessening the respiratory
motions of the chest, by passing a roller around the thorax,
thus causing the patient to breathe by the action of the diaphragm.  If there be internal displacement at the point of
fracture, pressure should be made upon the extremity of the
rib, by placing a compress upon it, and binding it down firmly
by the bandage; if the angular displacement be external, the
compress should be placed upon the point of fracture. If the
lungs have been wounded, or any of the internal structures
implicated, arnica or calendula lotions should be kept applied
to the peart, and either administered internally, according to the
character of the wound and the symptoms manifested.  If inflammation of the pleura supervene, arnica is an excellent
internal medicine; its characteristic indications are, stinging
pain in the affected part, dyspncea, short, dry cough, general




308           FRACTURE  OF THE SPINE.
internal heat with coldness of the hands and feet. Other medicines are sulph., scill., bry., rhus, nux-vom., bella., &c.
Section 9.-Fracture of the Spine.
Fracture of the spine rarely occurs, but when it does, it is
always the result of great violence.
Diagnosis in fracture of the spine is not always easy; in
some cases paralysis of the lower extremities occurs from violent
concussion of the spine, without fracture.
In fracture of the spine above the fourth cervical vertebra,
death follows almost instantly, from injury to the phrenic nerve.
In cases of fracture below the fourth cervical vertebra, there
is paralysis of the upper extremities, with difficult respiration,
and death occurs in four or five days.
When the dorsal vertebra are the seat of fractures, there
is paralysis of the lower extremities and torpor of the intestines;
the abdomen is frequently enormously distended by air contained in the intestines. Death usually occurs the third or
fourth week.
In fracture of the lumbar vertebrae the bladder and rectum
are paralyzed, and the urine and faeces pass involuntarily; the
lower extremities are paralyzed, and insensible to stimulants,
but retain their heat and circulation undiminished. Death follows, at latest, in five or six weeks.
Fractures of the spinous processes of the vertebrae are not
followed by serious consequences, unless accompanied by concussion or some other injury.
Prognosis in all cases of fracture of the vertebrae is unfavorable.
Treatment.-If there be violent fever, with inability to pass
urine, acon. may be prescribed; at the same time compresses
moistened with arnica solution may be applied to the seat of
fracture. If there be much urinary tenesmus, canth. alone, or
in alternation with arnica, will probably relieve the patient; if
not, bell., camph., hepar, piuls., or sulph., may produce the de



FRACTURE OF THE PELVIS.                   309
sired effect. If these means also fail, the catheter should be
used.
If there is a tendency of the spinal cord to take on inflammatory action, acon. should be used; it is one of the most
highly recommended medicines in the treatment of myelitis.
When the inflammation is seated in the lumbar and sacral
regions, when the adjoining abdominal organs are affected, and
the alvine evacuations difficult, bry. should be administered.
lirs., bella., cocc., dulc., dig., ignat., nux-vom., puls., and
veratrum may also have to be employed.
Effusion of blood and suppuration sometimes occur in the
course of the spinal marrow, and in its sheath, which give rise
to very untoward symptoms.
The patient must be kept at perfect rest, in the horizontal
posture, and the greatest care be taken to prevent gangrene
of the nates. This may be effected by arranging pillows
or Macintosh air-cushions in such manner that the parts may
be equally supported. If the skin assume a bluish appearance,
or, from the constant irritation of the parts, bed-sores are present, a solution of arnica applied to the part greatly relieves
the sufferings of the patient.
Section 10.-Fracture of the Pelvis.
Fracture of the pelvis occurs only from great violence; the
displacement is not great, and little can be done to remedy it;
the injury sustained by the soft parts within is of more interest
than the fracture.
Prognosis in this fracture is always unfavorable, for when
the fracture is extensive death usually follows; and when the
injury is less severe, inflammation and abscess result; making
the case tedious and doubtful.
Treatment consists in placing a broad bandage around the
pelvis, and combatting inflammation received by the pelvic
viscera. Here again arnica would be one of the first medicines




310        FRACTURES OF. THE FINGERS.
employed; and if the intestines have suffered from the contusion, this medicine would be peculiarly applicable. Other
remedial agents, however, must be employed for the symptoms
presenting, and the organ or organs chiefly involved.
In fractures of the os pubis, coccyx, and ischium, by passing
the finger into the vagina or rectum the fragments may be adjusted, but low diet, perfect rest, and the usual applications,
must likewise be relied on in the treatment of these accidents.
CHAPTER XVI.
FRACTURES OF THE UPPER EXTREMITIES.
FRACTURES of the bones of the fore-arm and hand are of
common occurrence. In all instances where amputation is not
requisite, there is little trouble in replacing the fragments, or
in keeping them in proper position.
Section 1. —Fractures of the Fingers.
In fractures of the phalanges it is occasionally difficult to
detect the nature of the case. In such examples the fragments
are not displaced, and there is scarcely any necessity for apparatus, as the pain which the patient suffers, on any considerable motion of the part, will induce him to keep it sufficiently
steady. When there is displacement, a slight extension will
suffice to put the fragments in apposition; and a little slip of
pasteboard in front, and another behind, kept on by a bandage,
or by a few turns with a narrow strip of adhesive plaster, will
constitute all the apparatus required. If the phalanx connected with the metacarpal bone happen to be the one under
treatment, it will be most satisfactory to prevent all motion of
the joint above; and this may be done by carrying the splint
along the palm of the hand, and fixing it by a few turns of a
roller, broader than that used for the finger.




FRACTURE OF THE FORE-ARM.                    311
Fractures of the Mletacarpal Bones.-The metacarpal bones
when broken are seldom much displaced, and there can be no
difficulty either in detecting such injuries, or in replacing the
fragments. There is no need of a splint, (except when the destruction of the soft parts has been considerable,) as the neighboring entire bones will answer the same end. However, should
one be deemed necessary, a piece of pasteboard, about the
breadth of the hand, should be placed on the palm, and fixed
there by means of a bandage. The splint should extend a little
above the wrist, and as far down on the fingers as to allow
them to rest upon it; by such means the most perfect quietude
will be insured.
Fracture of the Carpal Bones.-When the bones of the
carpus are broken, the injury is generally of such a nature as
to endanger the safety of the hand; for violence sufficient to
cause such fractures is likely to have produced great destruction of the soft parts. Should amputation not be deemed necessary, a splint of pasteboard should be applied in front, so as
to prevent all movement. As little fbrce as possible should be
used in putting or keeping the fragments together.
Section 2.-Fracture of the Fore-arm.
The bones of the fore-arm are often broken, either singly
(Figs. 30 and 31) or conjointly, (Fig. 32,) and the radius is
most frequently the seat of injury. This bone generally gives
way, in consequence of a fall, when the hand is thrown out to
support the body; and when fractured near the wrist (see fig.
33,) may be mistaken for dislocation, but can easily be recognized by crepitation, and the deformity returning after having
been once reduced. The ulna may be broken whilst the radius
is left entire.
The olecranon process of the ulna may be fractured-,either
by the action of the triceps muscle or direct violence.
The coronoid process is sometimes fractured, but this is of
rare occurrence.




312                TREATM IENT OF
Fig. 30.     Fig. 31.           Fig. 32.
Diagnosis in fracture of both bones is evident from the angular deformity which exists: in fracture of one bone alone
crepitation can readily be felt, by taking hold of the hand and
making the movements of pronation and supination; the other
hand placed upon the seat of injury, will feel the crepitation
from the upper fragment of bone not rotating with the other.
Fracture of the olecranon process is recognized by the space
between the broken points; the upper portion of the olecranon
is generally drawn up, by the action of the triceps, some distance above the joint. The joint can be readily bent, but is
straightened with difficulty.
In fracture of the coronoid process there is dislocation of the
ulna backwards, with great projection of the olecranon process,
and difficulty in bending the elbow.
Treatment of Fractures of the Fore-arm.-The treatment of
fractures of the fore-arm consists in making the soft parts in
the interosseous spaces serve as a splint to force the fragments
outwards, and to keep the bones in apposition. Two splints,
long enough to reach from the elbow beyond the fingers' ends,




FRACTURE OF THE FORE-ARM.                   313
and wider than the fore-arm, Fig. 33.            Fig. 34.
(this is an important point,)                     I i
so as to avoid lateral pressure,
are requisite. These splints
should be convexly padded
with lint, tow, or cotton,
along that part of their length
which corresponds to the interosseous spaces, and wrapped with bandage. The fracture should be coaptated by
extension, and the fore-arm
placed with the thumb uppermost, or intermediate between pronation and supination. The splints must now
be applied upon each side of
the fore-arm, to press firmly
on the interosseous spaces,
and should be applied with care, so as not to bear hard upon
the condyles of the humerus, else troublesome excoriation is
sure to take place. The elbow should be well protected also,
by placing cotton under the ends of the splints; the splints being firmly bound to the limb by circular turns of a roller; the
fore-arm is then placed in a sling.
The deformity, and consequent loss of pronation and supination of the fore-arm, and great impairment of its utility, by
neglect of the foregoing rules, are demonstrated in fig. 34, an
error that cannot be too anxiously avoided.
In the treatment of fractures of the fore-arm, it secures more
perfect rest to the part, and answers remarkably well, to have
the internal splint made like the right-angle splint for fractured
condyles of the humerus, binding its upper limb to the arm, thus
preventing motion of the elbow joint.
Fracture of the Lower End of the Radius may readily be
mistaken for dislocation of the radius at the wrist joint.  (Fig.
35.)  Great care should therefore be used in making a diagno



314         FRACTURE  OF THE RADIUS.
sis in injuries about this joint.  Fracture of the radius at this
point may be distinguished from  dislocation, by crepitus, and
the easy reduction of the deformity, also by the return of the
deformity as soon as forcible distension is discontinued.
Fig. 35.
The fracture should be reduced by extension and direct pressure upon the broken fragments, and the padded splints recommended in fractures of the fore-arm, or the apparatus of Dr.
Rhea Barton, applied to keep the bones in apposition. This
last consists in two wedge-shaped pads, about three inches
long, and as wide as the wrist; two splints, as directed for
other fractures of the fore-arm, and a roller.
The fracture being reduced, the pads are placed one upon the
front and the other upon the back of the wrist, pressing upon
the broken ends of the bone in such a manner as to insure and
continue their coaptation. The splints are then applied as in
the former cases, (without being padded,) and secured by circular turns of a roller; the fore-arm is then placed in a sling.
After the lapse of a couple of weeks, passive motion of the
joint should be commenced with care, and continued to the end
of the treatment, to prevent anchylosis.
Fig. 36.             In fracture of the olecranogn
process (Fig. 36) the elbow
joint is to be straightened, and
bandaged by circular and reversed turns of a roller, from
the hand to the injured joint;
the fragment should then be
brought down and adjusted,
the roller passed above it, and




FRACTURE OF THE HUMERUS.                     315
around the joint, in the form of a figure 8, until it is firmly
fixed; the roller is continued up the arm to the shoulder, to
annul the action of the triceps muscle. A splint is now placed
in front of the joint, extending some distance along the arm and
fore-arm, and the roller passed in circular turns, binding the splint
firmly to the limb. In three weeks' time passive motion should
be communicated to the joint, and frequently repeated, to prevent anchylosis. The union in this case will be ligamentous.
In fracture of the coronoid process the joint must be restored
by extension, the limb bent at right angles, bandaged to keep
it in this position, and the fore-arm placed in a sling. Union
will be ligamentous here also.
In this fracture the coronoid process is drawn upwards by
the action of the brachialis anticus; probably, therefore, the
best treatment is to flex the fore-arm upon the arm, binding
them together by circular turns of a roller.  If there should be
a disposition to displacement backwards in the ulna, apply an
angular splint in such manner as to rest upon the back of the
arm and fore-arm, and embrace the elbow joint.
Section 3.-Fracture of the Humerus.
Fracture of the humerus may occur in any part of the bone,
but its middle is oftener the seat of fracture than any other
point.
The surgical neck of the bone is sometimes the seat of fracture.  (See fig. 37.)
(The surgical neck signifies a point without the capsular
ligament, just below the tuberosities of the bone.)
The condyles are also liable to be broken off obliquely, by
force directly applied; one or both may be fractured at the
same time.
Diagnosis in fracture of the shaft of the bone, (see fig. 38,)
is quite easy. There is pain, and incapability of using the
limb, which is the case in all fractures; the line of direction of




316                TREATMENT OF
Fig. 37.                 Fig. 38.
the bone is altered, consequently deformity of the limb exists;
by fixing the upper fragment with one hand, and rotating or
moving the lower with the other hand, crepitus can be felt.
Fracture of the neck of the humerus generally occurs in old
subjects; this accident has often been mistaken for luxation,
and a little care is necessary to avoid the error. In fracture,
the natural form and roundness of the shoulder-joint are unaltered, because the head of the bone remains in the glenoid
cavity, and by taking hold of the elbow, and rotating, or moving it, crepitation is distinctly perceptible.
The condyles are often fractured, and sometimes have been
falsely diagnosed for luxation of the radius and ulna backwards.
Fracture may be distinguished by crepitation, induced by moving the fragments one upon the other; also by pressure upon
the olecranon and bend of the arm, increasing the width of the
elbow, when both condyles are fractured.
The head of the humerus is sometimes fractured by direct
violence, or by gun-shot wounds.




FRACTURES OF THE ARM.                      317
Prognosis is favorable, except in fractures of the condyles;
in these cases inflammation and anchylosis are apt to follow the
injury; still, excellent cures are frequently made.
Treatment of Fractures of the Arm.-Treatment of fracture
of the shaft consists in coaptating the broken bone, by extension from the wrist or elbow; the application of a roller by
circular and reversed turns from the hand to the shoulder; four
wooden splints, nearly a quarter of an inch thick, shorter in
length and breadth than the humerus, the inner one being the
shortest, and placing one upon each side of the arm, and binding them firmly over the fracture with the remainder of the
roller; place the fore-arm in a sling across the chest. It sometimes happens that the bandage on the fore-arm causes swelling
and pain; where these effects are produced, commence the roller
just above the elbow, bandaging the arm only, leaving the forearm bare, and slinging it as in the former case.
Fracture of the N\eck of the Humerus should be accurately
adjusted, and Fox's apparatus for fractured clavicle, or any
other suitable apparatus applied; the wedge-shaped pad forming the best possible support to the inner side of the separated
bone. If in any case additional support be found necessary,
the leather splint of Mr. Liston should be applied, or a roller
passed around the arm and thorax, binding the former firmly
to the pad; the elbow should not be as forcibly raised in this
case as in fractured clavicle.  What most contributes to prevent deformity in the management of this injury, is in getting
a firm, well fitting padding in the axilla, high up, so as to bear
upon and firmly support the fragments.
Desault's apparatus consists in passing a roller from the
fingers to the shoulder by circular and reversed turns; arriving
at the shoulder, the bandage is carried across the breast, around
the shoulder and arm-pit of the sound side, and across the back
to the shoulder of the injured side; three splints, two inches
wide, and the length of the arm, are now placed on the anterior, posterior, and outer parts of the arm, and the roller passed
firmly over them in circular turns to the elbow, placing cotton,
tow, or lint, under their extremities, to prevent excoriation; the




318           L      I S T O N S APPARATUS.
wedge-shaped pad is fixed in the axilla, the injured arm brought
down upon it and secured by passing around the chest and arm
his second roller for fractured clavicle; the fore-arm is then
placed in a sling.
Mr. Liston recommends the following apparatus for injuries
about the shoulder joint and clavicle, (see fig. 39,) he says:
"The separate bandaging of the fingers, hand, and fore-arm,
Fig. 39.       for this purpose, the position
of the pads, the mode of fixing the shawl which contains
the  wedge-shaped  axillary
cushion, and the bandage surrounding the chest, are here
exhibited.  In bandaging the!   )      _       M         hand a pad of lint is first
placed on the palm to fill up
the hollow where the band~ /            age would probably exert no
pressure.  A sling completes
the apparatus for all the injuries of the clavicle and shoul|/  i\  der joint."  He also recommends a leather splint in
these cases.  "If the fracture have occurred in the upper
end of the bone, betwixt the insertions of the tendons of
the latissimus dorsi, pectoralis major, and deltoid, then a
leather splint may with advantage be applied from over the
shoulder-joint to the point of the elbow. A piece of skirtleather, (as it is called by saddlers,) dressed without oil, is cut
so as to fit the limb; it is soaked and softened in warm'water,
and then applied and retained by a roller.  It soon becomes a
firm mould to the limb; it can then, after its edges are well
pared and rounded off, be stuffed with wadding, or lined with
wash-leather, and thus forms an excellent support and protection to the injured part."
Fracture at the A./natomical.J\eck of the Bone, (which is
above the tubercles,) occurs sometimes in young subjects. The




FRACTURE OF TIlE HUMERUS.                  319
articular head of the bone is also the seat of fracture; but both
of these accidents are rare, and do not differ in management
from the former case.
Fracture of the Humerus, occurring above the insertion of
the deltoid, and below the insertion of the pectoralis major,
latissimus dorsi, and teres major, requires some care to prevent
deformity; for the lower fragment is drawn forcibly outwards
by the action of the deltoid muscle, whilst the upper fragment
is drawn strongly inwards by the latissimus dorsi, teres, and
pectoralis major.
The treatment consists in reducing the fracture by extension
of the arm, the application of splints to the fore, outer, and
back parts of the arm, and the nice adjustment of a wedgeshaped pad to the axilla, so as to pass high up, and give equal
and firm support to both fractured extremities of the bone. The
arm is brought down to the side, properly placed upon the pad,
and then bound down firmly by a roller passed around the arm
and thorax: the fore-arm is placed in a sling.
Fracture of the Lower Extremity of the Humerus, when just
above the condyles, (see fig. 40,) so closely resembles dislocation of the radius and ulna backwards, that much care is
necessary to distinguish the true nature of the injury.
Fig 40.
Diagnosis.  In fracture, crepitus can be produced; the deformity can also be readily removed by moderate extension of
the arm, but the deformity returns as soon as the extending
force is withdrawn; the length of the arm of the injured side,




320       FRACTURE OF THE HUMERUS.
when measured from the acromion process to the fore-arm at
the bend of the elbow, is shorter than that on the sound side.
None of these conditions are found in dislocation at this joint;
they serve, therefore, to distinguish fractures.
Treatment.-Remove the inflammation and tumefaction by
rest, and the application of the appropriate homceopathic means;
reduce and coaptate the fracture by extension, and apply two
angular splints, narrower than the elbow; placing one on the
anterior and the other on the posterior surface of the arm, the
two horizontal limbs of the splints resting upon the upper and
lower surfaces of the fore-arm; pass a roller around the forearm and arm, binding the splints firmly to the limb.
Dr. Physick's angular splints for fractured condyles answer
very well also for this injury.
In Fracture of the Condyles of the Humerus it is necessary
to reduce the fracture, and distortion of the joint, by extension
and manipulation about the point of injury, in order to adjust
the broken portions of the humerus: retain them in this position by Dr. Physick's apparatus, which consists in four pairs
of splints, or one pair with a movable joint, to vary the angle
long enough to reach from the shoulder to the elbow, and thence
three inches beyond the ends of the fingers, being about two
inches broad. The first pair is to be made at a right angle,
the second more obtuse, the third a more obtuse angle still, and
the fourth straight; these, with a roller, complete the apparatus.
The fracture being reduced, and the elbow bent at a right
angle, the roller commencing at the hand ascends the fore-arm
and arm by circular and reversed turns to the shoulder; the
two right angle splints are applied, one upon the outer and the
other upon the inner side of the limb.  The roller is then
brought down by circular turns, binding the splints firmly to
the extremity, and the fore-arm is placed in a sling: the ends
of the splints must always be padded with cotton or lint, to
prevent excoriation of the skin. After two or three weeks the
rectangular splints can be taken off, and obtuse splints substituted; removing the dressings, after two or three weeks, every




FRACTURES OF THE FOOT.                      321
five or six (lays, passing alternately from a right angle to a
straight line, making gentle flexion and extension of the joint,
to prevent anchylosis.
CHAPTER XVII.
FRACTURES OF THE LOWER EXTREMITIES.
FRACTURES of the lower extremities are, generally speaking,
more serious in their nature than those of the upper, being accompanied with more danger to life and limb.  They likewise
cause much more trouble in their treatment.
Section 1.-Fractures of the Foot.
Such injuries are of comparatively rare occurrence; and when
they (ldo happen, the destruction of the soft parts is usually so
extensive that each case must be considered more as a contused
and lacerated wound of all the textures around, than as a fracture, whether simple or compound.  One or more of the toes
may be thus injured by heavy weights, as happens to coalheavers, quarry-men, stone-masons, and others similarly exposed; and as amputation is the advisable recourse in most of
such cases, the question of greatest importance for consideration will be with reference to the seat of operation. Unless the
tarsus be involved in the injury, the idea of amputating the foot
ought not to be entertained: and as a general rule applicable
here, as in most other parts of the body, the smallest possible
degree of mutilation ought to be inflicted, consistent with the
object of the operation, which is to remove such parts as are
irrevocably injured, and, at the same time, leave a properly
formed stump.  In instances of fracture in the foot where there
is no necessity of resorting to the knife, it is scarcely requisite
to use any apparatus to keep the fragments in apposition; in
21




322          FRACTURES OF THE LEG.
the toes the phalanges are so short that, if properly adjusted at
first, they will remain so, unless the patient injudiciously bears
his weight upon the foot at too early a period: even in the
longer metatarsal bones it is not found necessary to employ
splints. The application of arnica, etc., at first, and complete
rest of the foot for about twenty days afterwards, constitute the
most important parts of the treatment.
Section 2.-Fractures of the Leg.
Fracture of the Head of the Tibia is the result of direct violence, the fracture extending into the knee-joint.
Treatment.-Inflammation must be reduced by the appropriate means, the fractured bone and joint being kept straight
by the application of splints, behind the joint, so that the condyles of the femur may act as splints, and keep the fragments
in place.  Passive motion should be communicated after five
weeks, or as soon as the consolidation has advanced so far as
to admit of it.
Fracture of the Tibia or Fibula, or of both bones, by careful examination, can be readily recognized. Both these fractures require the same treatment, except fracture of the fibula
near the ankle.
Treatment of fractures of the tibia and fibula is effected by
two different kinds of apparatus: one consists in laying upon a
firm mattress four pieces of tape or roller, over these a splintcloth, upon this a soft pillow, on this sufficient strips of the
bandage of Scultetus to cover the leg from the ankle to the
knee. The fractured leg is then laid upon this bandage and the
centre of the pillow; the fragments are coaptated, and the
bandage of Scultetus applied from the ankle up; two splints,
three inches wide and a half inch thick, longer than the leg,
are rolled, one in each end of the splint-cloth, and brought up
so as to cause the pillow to fit the leg snugly; the tapes are
tied, and the foot is supported by a sling.  Pressure from  the
bed-clothes is prevented by two halves of a hoop crossed at
their centres.




FRACTURES OF THE  LEG.                       323
Fig. 41.
The fracture-box is preferable, (see fig. 41) it consists of




324           FRACT URES OF THE LEG.
which may be of leather. The sides an(l bottom of the box
should extend from the knee beyond the foot. Fastened to the
lower end of the bottom should be a foot-board, and the upper
end of the sides should have mortise-holes in them, to fasten
counter-extending bands, when this is necessary. In this simple
box a pillow, filled with oat-chaff or feathers, is placed, and
the fractured leg put upon it.  The fractured extremities are
adjusted, and the sides of the box brought together and retained
by strips of bandage. Where extension is necessary, a gaiter
or bandage of a handkerchief, in the form of a figure 8, is
placed around the ankle, and fastened to the foot-board.
Counter-extending bands, if needed, are made fast to the upper
part of the leg by means of a roller, and tied in the mortiseholes of the side-pieces of the box.
Fracture of the tibia just below the insertion of the ligamenturn pateilce is exceedingly difficult to treat, from the tilting
forward of the upper fragment by the action of the rectus femoris muscle.  In this injury there is no  lifficulty in the diagnosis.
Treatment.-The best mode of treatment in this case is to
reduce the fiacture by extension of the leg, and pressure upon
the superior fragment.  Counteract the action of the extensor
muscles of the leg by passing a roller firmly around the thigh;
place the base of a wedge-shaped pad upon the upper fragment,
over this a splint extending down the front of the leg, and bind
them  down firmly by a roller extending from the foot to the
knee. If it be thought necessary, the limb may then be placed
in a fiacture-box.
Fracture of the Fibula, about three inches above the anlklejoint, is not uncommon, and is often accompanied by dislocation
of the foot. (Fig. 42.)
Diagnosis is very plain. The foot is turned outwards, and
the natural line of direction of the fibula is lost. By turning
the foot inwards, and placing the thumb on the seat of fracture,
crepitus can be felt.
Treatment in this injury is accomplished by the application
of Dupuytren's apparatus, which consists in applying the base




FRACTURE OF THE FIBULA.                     325
Fig. 42.             Fig. 43.
of a thick wedge-shaped pad just above the internal malleolus;
a splint, three inches wide, extending from the knee three or
four inches beyond the foot, is laid upon the compress, and
fastened to the leg by a few turns of a roller passed just below
the knee. A roller is then passed in the form of a figure 8
around the heel, external malleolus, and end of the splint: the
foot is in this way carried inwards and retained there, and the
fractured extremities of bone are thus brought in contact by
making a fulcrum of the pad, and converting the lower fragment of the fibula into a lever.
Fracture of the Internal MJkalleolus (Fig. 43) occurs by violently twisting the foot inwards.  Sometimes the fracture includes the whole of the lower end of the tibia.
Diagnosis is not difficult.  The foot is turned or dislocated
inwards, and crepitus can be readily recognized.
Treatment for this injury is the same as for fracture of the
lower part of the fibula-merely applying the apparatus upon
the opposite side.




326        FRACTURE OF THE FEMUR.
Section 3.-Fracture of the Femur.
Fracture of the femur should be made a subject of careful
study, from the fact, as Mr. Pott remarks, " they so often lame
the patient, and disgrace the surgeon."
Fracture of the neck of the femur (Fig. 44) occurs both
within the capsular ligament and external to it.  Fracture
within the ligament is the
Fig. 44.           more common, but it is very
rare in persons under fifty
years of age, and is mostly
met with in old women; in
addition to the changes which
jd    /  ~       the bones undergo in advanced life, as deficiency of. _  bone-earth, and sponginess
r  t  of the cancelli-the neck of'   the femur is always peculii  i\  arly  atrophied,  shortened,
and shrunk, from the oblique
to the horizontal position;!!I  changes  which  necessarily
render it more liable to fracture.
Diagnosis in fracture of the neck of the femur is sufficiently
easy, with a little care, to avoid the error of confounding it
with luxation. In fracture there is pain in the hip, the limb is
shortened half an inch to two inches; the foot is turned outwards, (see fig. 45); crepitus may be felt by placing the hand
on the trochanter, and extending the limb to its proper length,
then rotating it. The trochanter is less prominent than on the
sound side, and the limb may be freely moved, although with
pain. In some cases the shortening of the limb does not occur
until some days after the accident, and is in some cases inconsiderable. The limb is sometimes turned inwards. But fracture should be suspected, whenever an old person has received
an injury about the hip, and complains of pain in it, whether
there is shortening of the limb or not.




FRACTURE OF THE FEMUR.                     327
Prognosis is very unfavorable in these      Fig. 45.
cases; they are always tedious, bony
union rarely taking place in the old sub-,'
ject, and sometimes no union at all
occurs.
Treatment in very old subjects con-.,
sists merely in placing the patient in bed  "        W
and keeping the limb quiet, or by a felt          -
splint, or the curved splint of Dr. Physick for coxalgia, for a couple of weeks,   /
or until the shock and contusion occasioned by the accident have passed off, 
and then allowing the patient to get
about as well as possible on crutches.: "!
After a time a false joint is formed, the
stump of the cervix becomes rounded
and covered with a smooth porcellaneous
deposit, and plays in a socket formed by
the absorption and hollowing out of the    i,
head of the bone.  But if the patient
be young, this fracture may unite by 
bone; the fractured extremities therefore should be coaptated
and kept in apposition by Physick's Desault's apparatus for
fiacture of the femur, or Liston's long single splint, which acts
on the same principle, but is less complete in answering the indications.
Fractures immediately outside the joint, through the trochanter, unite readily enough even in very old persons. It
may not always be possible, Mr. Liston observes, " to decide
exactly whether the joint is involved or not; but the greater
degree of shortening and mobility of the limb, with the more
distinct feeling of crepitation, will often enable the surgeon to
distinguish the nature of the case, and to decide upon the practice.  Mr. Druitt remarks that "fracture of the femur just
below the trochanters, is liable to be followed by great deformity
and non-union; because the upper fragment is tilted up forwards by the psoas and iliacus muscles. The best plan of




328                  FRACTURE OF
treatment is to place the patient on a fracture-bed, with the
trunk and thighs bent at a very acute angle, in order to relax
the counteracting muscles."
Fracture of the Trochanter MIajor is produced by great
violence.
Diagnosis.-The trochanter is displaced upwards, by the
lesser glutei muscles, and by placing the hand upon the seat of
fracture, and rotating the thigh, crepitus may be felt.
Treatment in this accident consists in recumbency, and a
position securing relaxation of the displacing muscles. Union
in this case is generally ligamentous.
Diastasis, or separation of the shaft of the bone from its epiphysis, may occur in the young subject, by direct violence or
twisting of the limb. Reduction in these cases is effected by
extending the limb, and fixing it by splints of wood or pasteboard.
Fracture of the Shaft of the Femur may be the result of
force directly or indirectly applied.
Diagnosis is very plain in this case; there is deformity of
the thigh, which may be angular in transverse fractures, and in
oblique fracture considerable shortening; crepitus is perceptible,
and the lower fragment is generally drawn backwards, whilst
the upper is tilted forwards.
Treatment of this fracture is accomplished by extension, and
coaptation of the broken extremities of the bone, and the application of Desault's apparatus, as improved by Dr. Physick,
which answers the indications better than any fracture apparatus that has been employed in this injury. This improved
apparatus consists of five or six pieces of broad tape, or pieces
of roller; a splint cloth (which is a piece of muslin a yard wide
and one and a half long); a splint of binder's board, two
inches broad and nine long.  Scultetus' bandage: two bags
four inches wide, and long enough to extend from the hip to
the foot; these are loosely filled with oat chaff; two silk
handkerchiefs folded diagonally, or some other material, for
extending and counter-extending bands; three wooden splints,
one four inches wide, and long enough to reach from near the




THE SHAFT OF THE FEMUR.                    329
axilla to some distance beyond the sole of the foot; at the
upper and lower extremities of this splint there are mortiseholes to pass the extending  and counter-extending  bands
through; about four inches from the lower extremity, a cleat
three inches long, with a notch in it, stands off at right angles
to the splint: the second is nearly as wide as the former, and
long enough to extend from the perineum to the foot: the third
is as long as the thigh.
The application of this apparatus is as follows: a firm mattress with a hole in it for the evacuations, is covered by a sheet.
Or what is far better and more convenient, is a frame the size
of the mattress (which should always be hard); in this frame
strong canvas is set, with a hole in the centre for the nates; it
is to be covered by a sheet, and laid upon the mattress. Under
each corner of the frame is a leg six or eight inches long, fastened to it by a hinge; when the frame and patient are raised
fiom the mattress, the legs fall and rest upon the bedstead, and
thus sustain the patient while he has his passage, with ease and
without disturbance of the fracture.
The patient may be raised with greater facility by having an
arm attached to each corner of the frame with a strong hinge;
these allow the arms to hang by the side of the bed when not
in use. This simple fracture-cot should be employed in all
cases of fractures, dislocations, or other injuries, wherein the
patient cannot rise from the bed to evacuate the bowels.
Upon the sheet is laid the pieces of strong tape or roller; the
splint-cloth is laid over them lengthwise across the mattress;
near the upper edge of the splint-cloth, midway between its
ends, is laid the splint of binder's board; over the splint is laid
the bandage of Scultetus, beginning at the top and laying down
sufficient to reach from the groin to the knee. The patient,
divested of clothing, is now laid upon the dressings with the
injured thigh over the strips of Scultetus, the extending band
is passed round the foot in the form of a figure 8, and given to
an assistant; the counter-extending band is placed in the perineum, between the genitals and the injured thigh, one end in
front of the body, the other behind it, and given to an assistant:




330                TREATMENT OF
by these, extension and counter-extension are made, and the
fractured bone coaptated by the surgeon, who then applies the
bandage of Scultetus, commencing with the strip nearest the
knee: the two long splints are rolled up, one in each end of the
splint-cloth, the stuffed bags are applied to fill the spaces between the splints and the limb: the extending and counterextending bands are passed through the mortise-holes and fastened; the lower one passing over the cleat at the bottom, to
make the extension in a line with the axis of the limb; the
tapes are now tied to keep the splints applied.
An equally efficient and more easily managed application of
this principle is to make a fracture-box, by taking the two
long splints of Desault, as the outer and inner sides, making
the inside splints long enough to extend beyond the foot; and
by applying a back splint of sufficient width, the same length
as the inner one, fastening the three splints by hinges, and by
attaching a foot-board worked by a screw, the fracture-box is
complete. In this should be laid a cushion loosely stuffed with
oat-chaff; which should extend from-the hip to the heel, embracing the limb. The extending and counter-extending bands
having been applied in the same way as before, or a laced gaiter
may surround the foot instead of the handkerchief; the limb
is placed upon the cushion, and extension and adjustment
of the fracture having been made, the sides of the fracture-box
are brought together and fastened by strips of bandage.
The plate (Fig. 46) is a representation of Hagerdorn's apparatus modified by Dr. Gibson, late Professor of Surgery in the
University of Pennsylvania. The wood-cut describes itself
better perhaps than would a labored description.
The apparatus of Mr. Liston (Fig. 47) consists of a single
splint, pad, roller, and extending band; the preparation of the
splint is shown in the treatment of fracture of the neck of the
femur.
The application of this apparatus consists in applying a narrow roller, from the foot to near the site of fracture, to prevent infiltration, the perineal band and splint are then applied,
and the roller, carried under the sole of the foot, turned round




FRACTURE OF THE FEMUR.                    331
the ankle and heel, being pro-          Fig. 46.
tected by wadding; the roller is
carried  repeatedly  through  the
notches in the end of the splint,'  l!i
and crossed over the dorsum of the   "\
foot, and ultimately turned round
the limb near to the groin.  This  ~ii ""'
is the only apparatus employed or
recommended by Mr. Liston in
fractures of the femur.          *      /
Oat-chaff is probably softer than  /   ( 
any material that can be employed     
for this purpose; it is the best chaff  >      -
that can be used..,                              i
Extending and counter-extending 
bands should consist of hose, or       j
tubes, made of cotton, linen, or
buckskin, well stuffed with raw or
carded cotton, the best material for i       _i
protecting the skin from painful          
pressure and excoriation. These
bands should always be made as
large as the part to which they are          __ m
to be applied will admit. Shawls               _ 
and handkerchiefs are objection-              =
able as extending bands, from the        m,         v
hardness of their edges and plaits,
cutting into the skin.
A foot-board fitted with a screw,
to an apparatus for the treatment     A     -'
of oblique fracture of the thigh,,
is of great advantage, by enabling
the same amount of extension constantly to be maintained, by turns
of the screw  counteracting the                A
stretching of the bands; whereas,
without such a foot-board, we are obliged to untie the extending band before we can tighten it.




332        FRACTURE OF THE FEMUR.
Fig. 47.
-~~~_ _NI_
Fracture of the Femur below the Trochanter is exceedingly
troublesome to treat, and is liable to be followed by deformity
and non-union. The upper fragment is tilted up by the action
of the psoas magnus and iliacus internus muscles, whilst the
abductor muscles of the thigh draw the lower fragment upwards
and inwards.
Treatment.-Probably the best treatment that can be pursued in this case is the double inclined plane, placing the
patient as nearly as possible in a sitting posture, to relax the
psoas and iliacus muscles; placing the base of a wedge-shaped
compress over the upper fragment, and applying over this a
splint extending down the front of the thigh near to the knee,
and binding down firmly by a roller.  The limb is then to be
placed over the double inclined plane, the weight of the hips
(for they should not press upon the bed) keeping up constant
extension upon the limb.
It is rare to see an oblique fracture of the femur cured without more or less shortening.
Fracture of the Condyles of the Femur may extend into the
knee-joint. Crepitus in this case is felt upon slight motion of
the part; there is also much pain and swelling of the joint.
Treatment. —The knee should be placed in an extended position, and the fragments of bone retained in apposition by splints
and bandages. After the first two weeks, if the part be not
too painful, passive motion should be frequently communicated
to the joint, to prevent anchylosis.




FRACTURE  OF THE  PATELLA.                    333
Section 4.-Fracture of the Patella.
Fracture of the Patella longitudinally is the result of direct
violence.
Treatment.-If motion of the joint be prevented by placing
a straight splint behind the knae-joint, and retaining it there
by bandage, bony union will readily take place.
Transverse fracture is more common, and is oftener the result of muscular action than direct injury.
Diagnosis is perfectly easy here; for whilst the lower fragment remains in situ, the superior portion is drawn up by the
extensor muscles of the leg, and a wide hiatus is perceptible.
(See fig. 48.)  The patient can flex the leg with facility, but
can scarce extend it.
Treatment in this case consists          Fig. 48.
in passing a roller, by circular and
reversed turns, from the foot to the
lower fragment.  The upper frag-   1
ment is then brought down in contact with the other, and the roller    
is passed above the patella and    |l
around the knee in the form of a a
figure 8, and with circular turns,,:
in such manner as to retain the  <li                      x
fragments in contact.  The roller,
by circular turns, next confines the
muscles of the thigh.  A straight
splint is now placed behind the joint, fastened by the roller,
and the limb kept quiet.
Union is generally ligamentous, but may be bony, if the
parts be kept in perfect contact. In six weeks' time, or sooner,
passive motion should be communicated to the joint.
Desault's apparatus for fracture of the patella consists in one
splint two inches wide, long enough to extend from the tuberosity of the ischiurn beyond the heel, two rollers, and a compress or strip of bandage the length of the limb. In its application the compress is laid along the front of the leg and thigh;




334                TREATMENT OF
a roller is applied by circular and reversed turns from the foot
to the knee; two longitudinal slits are now cut in the compress
at the knee-joint, into which the fingers are passed, the upper
fragment is drawn down and coaptated, the bandage passed
like a figure S around the joint, binding the fragments of the
patella together, and then carried up the thigh by circular and
reversed turns. The splint is applied to the back part of the
limb, and secured by circular, turns of the second roller, and
the thigh is flexed upon the body, to relax the rectus femoris
muscle. Ligamentous union generally results, and the patient
is enabled to walk with care in eight or nine weeks, by the aid
of a cane.
CHAPTER XVIII.
TREATMENT OF COMPOUND FRACTURE, ETC.
THE treatment in compound fracture differs from that of
simple fracture in the following respects:
If the end of a bone protrude, and cannot be returned, it
must be sawn off. All detached fragments of bone must be
removed at once, and if necessary the wound may be dilated
foi this purpose. After reduction, the great object is to procure
adhesion of the external wound, so as to convert the compound
into a simple fracture. In the application of splints and bandages, the wound of the soft parts should be so arranged, if
possible, that it may be dressed without disturbing the whole
limb. For the accomplishment of this important point, Dr. A.
Hays' splint is one of the best that can be employed in compound fracture of the femur, and the same principle may be
applied to compound fractures of other bones.
This splint (see fig. 49) is made by taking Physick's Desault's splint, and cutting out a portion of the long splint opposite the wound, sufficiently large to allow free access to it, so




COMPOUND  FRACTURE.                     335
as to dress it as often as necessary without disturbing the extension and counter-extension. The two pieces of the splint are
united by a strong strip of iron, secured by screws. The iron
is made of such shape as to keep the covering of the bed off
the wounded part. A thin piece of board should be placed
between the portion of the limb dressed and the ends of the
splint, so as to give support to the part whence the segment of
the splint has been removed.
Fig. 49.
Dr. Hays remarks: "This plan I found to meet my wishes
and expectations very fully. The extension and counterextension being continued, the dressing might be repeated as
often as requisite, without in the least disturbing the position
of the limb."
If inflammation and swelling supervene, the bandages must
be loosened, and a lotion of arnica or calendula applied to the
part; if the pain is very severe and synochal fever be present,
aconite may be prescribed, or if cerebral symptoms develop
themselves, arnica, bella., cuprum, or hyos. may be indicated;
if strangury be present, acon., nux, cann., canth., or some other
appropriate medicine must be resorted to —other indications for
the treatment have been already alluded to in the chapters upon
wounds and abscesses.
The great object in the subsequent treatment is to prevent
the lodgment of matter, by sponging and pressing it out carefully at each (Iressing, and applying compresses to prevent its
accumulation, and., if necessary, to make openings for its discharge. In this state of excessive discharge, dry bran, as an
absorbent, is one of the best beds the limb can be laid upon.
If the patient seem likely to sink under the discharge and irritation, notwithstanding the application of calendula, and the




336            cOMPOU ND FRACTURES.
administration of acon., bella., china, hepar, merc., and other
medicines that have been mentioned for such conditions, amputation is the last resource.
In all cases where the application of splints and bandages
is made, great care should be taken to avoid inordinate pressure. The integuments should be well protected by lint or
cotton from the excoriating pressure of splints and bandages.
Splints should never be applied over prominent processes of
bone, where it can be avoided, as troublesome ulceration is
apt to follow.
In fractures of the lower extremities, the use of the limb
should be resumed gradually, crutches being employed at first,
lest consolidation be not complete, and shortening occur.
The employment of the starch or dextrine bandage (the immovable apparatus) is very useful in cases of simple fracture
and dislocation, after all inflammation and swelling have subsided.
In the application of these bandages a dry roller should first
be applied next the skin, the cavities about joints being filled
up with cotton or lint, to make the surface as even as possible
for the starch  or dextrine bandage.  Where  considerable
strength is desirable, pasteboard, soaked in hot water, can be
neatly fitted to the part, and the starch or dextrine bandage
applied over it.
The immovable apparatus possesses the great advantage of
never slipping or slackening, and does not require reapplication. In its use, however, care should be employed; as
much mischief has sometimes been done by putting it on limbs
whilst they were inflamed and still swelling: in these cases
gangrene has followed.
Section 1.-Pseudo A.rthrosis, or False Joint.
False joint may result from fracture of any bone, but it most
frequently follows fracture of the shaft of the humerus and




PSEUDO  ARTHROSIS.                      337
neck of the femur. It arises either from premature use of the
limb, old age, peculiarities of constitution, disease of the
osseous system, or non-contact of the fragments of bone.
In pseudo arthrosis, the fractured extremities of the bone become round, smooth, and generally covered with a cellular or
ligamentous substance.  In some instances an arthrodial joint
is formed, the ends of the bone rolling upon each other.
This unfortunate termination of fracture may in some instances be prevented by the internal administration of calcarea
carb., or perhaps the phosphate of lime; the latter has been
recommended for such conditions, but there are no indications in
the meagre proving of this medicine which would lead the practitioner to have recourse to it. The former, however, is a well
known medicine in our school, and in numerous instances has
been of essential service in the treatment of fractures and other
injuries occurring in individuals of a weak, sickly constitution,
and scrofulous diathesis. This medicine improves the tone of
all the organs in the body, by giving additional power to the
functions of assimilation and sanguification, therefore it is a
valuable assistant in the treatment of those cases of fractures
in which the reproductive process appears to proceed tardily,
from a deficient activity.
Ruta has been employed by homceopathic surgeons to hasten
the formation of ossific matter. Dr. Henriques,* in recording
the treatment of a case of oblique fracture of the superior third
of the femur below the capsule, which occurred spontaneously
in an aged patient, of enfeebled and vitiated constitution, who
had been liable to periodical attacks of diarrhmea and cerebral
congestion, dysuria and cough, remarks concerning the action
of ruta, that it " appears to possess a decided elective affinity
for the periosteum, as well as the osseous system in general;
and it was in order to avail myself of the known specific property of ruta, that led me to employ it as a means of promoting
the process of ossification. I have no doubt in my own mind
* See British Journal of Homoeopathy, vol. x. p. 448-a paper entitled
Fractures, and their Homceopathic Treatment, by Dr. Henriques.
22




338             PSEUDO ARTHROSIS.
that it had the desired effect; for if the unfavorable prognosis
of the case be compared with the ultimate happy and prompt
result obtained, I do not think it possible to deny that the
action of this medicine contributed in some degree to the final
consolidation of the fracture."
Symphytum has also been recommended for the purpose of
inducing ossific deposit.
The general health of the patient should receive attention; if
the constitution is worn out by disease, or debilitated either
from hereditary taint or more proximate causes, the general
tone of the system should be strengthened by the administration
of the appropriate medicine; by such means the patient may be
restored to perfect health, and the performance of painful operations avoided. However, if, after the patient administration
of medicines, the formation of false joint does occur, it may
then be advisable to have recourse to friction of the broken
surfaces; this in some instances has produced the desired
effect.
Dr. Physick's method of treatment has been successful in
many instances; it consists in passing a seton between the fractured surfaces.  A  long, narrow  instrument, called "a seton
needle," is armed with a skein of silk or other material; the
limb is extended, to separate the fragments, and the seton is
passed between them, care being taken to avoid all large vessels and nerves. Violent inflammation follows the application
of the seton in all cases, and even in ossific structure, the
least liable to inflammation of all other textures of the system, this abnormal action occurs, and bony union may take
place.
Professor MUitter of this city has performed the following
operation to remedy pseudo arthrosis: the fractured extremities of the bones are exposed by incision, and by means of
gimblets, perforations are made on each side of the false joint;
into these openings ivory pegs are driven, and the wound
dressed as usual. Union is said to have followed this operation,
and absorption has removed the extraneous matter forced into
the bone.




TREATMENT OF PSEUDO ARTHROSIS.    339
Dr. Smith* of this city objects to all the modes of treating
this accident at present in use, as founded on a wrong principle.
He objects particularly to the opinion that absolute rest is necessary to the cure, and thinks that this idea is one very fruitful source of failure. His plan is to fix the limb in an iron
frame-work, constructed with joints to allow movement of the
limbs; by straps andt pads to steady the extremities of the
broken bones in a proper position. Fixed in this apparatus he
allows the patient to use the injured limb, and he asserts that
union is effected with much less constitutional and local disturbance, than by means of the various plans of treatment at
present used by old school practitioners, viz. violent friction,
the seton, resection, Dieffenbach's plan, and others-while at
the same time the patient is less exposed to phlebitis and other
risks, he escapes the disagreeble monotony of a long confinement.t This method appears to have many advantages over
the others, which savor much of the coarse practice of surgeons
a century back.  If, however, homceopathic medicines are administered, together with the use of the apparatus of Dr. Smith,
the results doubtless would be more speedily accomplished than
when the apparatus alone is used.T
Resection has also been practised, but generally it is a last
resource, for it should be remembered that cutting down to the
extremities of the bone and scraping or removing portions of
them, at once converts the simple to a compound fracture.
* American Quarterly Journal of Medical Sciences, January, 1855.
t See Rankin's Abstract, vol. xi., July, 1855.
*Dr. Smith's plan has been tried in several cases with these results:
Cases.  Cured. Relieved. Failed, but able to walk.
False joint in the femur,  4      3      0      1..4   4   leg bones,   8      7       0      1.. "   humerus,    2          0      2      0
Total,          14     10      2      2




340               CRACKED BONES.
Section 2.-Cracked Bones or Incomplete Fracture.
It sometime happens that a bone is cracked when the force
applied has not been sufficient to produce an entire separation,
but only adequate to break the continuity of some of its fibres,
whilst others remain entire. This injury is generally found
where there are two bones, as in the leg or fore-arm, when the
uninjured bone supports that which is partially broken. It is
probable that it occurs occasionally in both bones, although
the occurrence is rare.
Diagnosis.-Diagnosis is more difficult when the bone is
merely cracked, than when the solution of continuity is complete; still, with care, it may recognized.
The patient is unable to use the limb without considerable
pain; he has also a sense of pricking about the seat of injury,
and when the bone is closely examined, there may be a slight
deviation from the direct line of the bone, but there is no crepitus; yet, when the above signs follow a severe blow or fall
upon the part, and the pain and inability to use the limb freely,
exist after the effects of the contusion have subsided, it is
probable there is a solution of continuity in some of the fibres
of the bone. In other words, the bone is cracked, but not entirely broken.
Treatment.-The treatment for the repair of this injury is
the same as if the bone were broken into two fragments. It
is not necessary, however, to keep the apparatus quite as long
applied as in complete fracture.




DISLOC ATIONS.                     341
CHAPTER XIX.
DISLOCATIONS.
THE term dislocation, or luxation, is used to indicate the
separation of articular surfaces from each other, either by accident or disease. The former cause is the most frequent, but
the latter is by no means the least formidable, for in such cases
it is not only the displacement that the surgeon must encounter,
but the disease of which this displacement is a feature.
The separation of articular surfaces, when caused by external
violence, may be partial or complete. In the one instance the
cartilages may not be entirely severed, while in the other there
may be no contact whatsoever. The luxations of the knee
and hip are used by Mr. Fergusson* as illustrative of these different forms of dislocation. He writes-" The articular surfaces
of the knee-joint are so extensive that it rarely happens that
the tibia is completely parted from the femur, whereas in the
hip-joint, the articular cartilages are invariably thrown out of
contact, and the luxation is termed complete. The practical
value of such a distinction is, that the lesser degree of separation implies a proportionally small amount of injury.
"It is impossible for any displacement of the articular ends
of bone to occur, without extension and perhaps laceration of
the tissues connected with them; when the separation is very
palpable, the synovial membrane must be torn more or less
open, and when this tissue is exposed to the air the dislocation
is termed compound; when the parts are still covered, the luxation is denominated simple.
A dislocation is said to be complicated when, beside the injury inflicted upon the parts composing the articulation, the
neighboring tissues or organs are involved.
Luxations are generally occasioned by great violence, but
* Practical Surgery.




342                  DISLOCATION.
diseases and peculiarities of constitution render some individuals
more susceptible to receipt of such injuries; among these may
be noticed, peculiar conformation of bone, diseases of the
osseous system, and laxity of a joint.
A simple dislocation may be regarded in many respects as a
severe contused or lacerated wound, having, however, a strong
disposition to heal rapidly; but if the injury be compound, or,
in other words, if the injured joint be exposed to the air, then
inflammation is almost the inevitable result, and suppuration and
ulceration, as consequences thereof, may be expected; but such
untoward events need not follow necessarily, for there are occasional dislocations of such joints as the knee and shoulder, in
which such unfortunate complications are entirely wanting.
It should always be remembered that so long as the displaced
extremity of the bone is allowed to remain in its unnatural condition, that its action is similar to that created by any extraneous matter, and therefore if the luxation be reduced in a short
time after the injury has been received, a considerable amount
of inflammation will be prevented.
Occasionally dislocation is complicated with fracture: the
fibula is generally broken in dislocation of the tibia; in dislocation of the hip the acetabulum may be either chipped or
broken through, or in dislocation of the elbow the coronoid
process of the ulna may be detached.
The treatment of dislocation consists principally in reduction,
and this cannot be attempted too soon-it consists* by extension
to move the bone from its abnormal position, and to bring it on
a plane with the articulating surface from which it has been
forced; counter-extension, to steady the latter part, and to admit of extension being satisfactorily effected; and coaptation,
to replace the surfaces in apposition.  If the patient be seen
immediately after infliction of the injury, still faint, with his
frame prostrate and relaxed, and incapable by effort of throwing any part of his muscular system into strong resisting reaction-reduction may be expected to prove comparatively
* See Miller's Principles, p. 132.




TREATMENT  OF DISLOCATION.                  343
easy. But when hours and days have passed, the obstacles to
reduction are ever on the increase. The muscles, which at first
are spasmodically rigid, by degrees adapt themselves to their
new position; the track from the original articulating surface,
through the lacerated ligamentous apparatus, is becoming more
and more occupied with plastic exudation; and the displaced
extremity of the bone is busy accommodating itself to the parts
with which it is now in contact.  Sometimes the head of the
bone merely projects through a narrow fissure of the capsule,
and this, tightly embracing the bone's neck, becomes agglutinated thereto by plastic exudation, constituting a most serious
obstacle to replacement.
If only a few hours or days have elapsed, the extension may
be intrusted to assistants, but when a considerable period of
time has passed, mechanical aid must be employed; extension
being accomplished by ropes and pulleys, by which means a
less degree of force may succeed when applied with steadiness
and precision. A sudden pull or jerk may often reduce a recent
dislocation, but never can accomplish this end if the injury have
been allowed to remain without treatment for a considerable
time.
The method of extension by pulley is as follows:
The patient usually being in a recumbent position, a broad
belt is passed under the perineum, if the dislocation is of the
lower extremities: or over the chest if the superior limbs are the
seat of the injury-this belt is fixed to some stationary point.
This secures a fixed position to the patient while counterextension is being exerted; a damp towel is then wrapped
roind the affected limb, to prevent excoriation from the bandage which is afterwards applied, and secured by what is termed
a clove-hitch, (see fig. 56,) the advantage of which is, that it
cannot be tightened by the force exerted by the pulleys to
which it is attached. The points of application of the bands
will be mentioned in the succeeding chapters.
There is some risk, however, to be encountered when using
the pulleys to reduce luxations; a muscle may be ruptured; an
artery or vein may be lacerated, and extremely serious compli



344       TREATMENT  OF DISLOCATION.
cations ensue. Therefore, there must be great caution observed
when attacking an affected limb with mechanical force.
But there are powerful auxiliary means, which, if called to
the assistance of the surgeon, will not only render the condition of the patient similar to that which is noticed immediately after the receipt of the injury, when the opportunity is so
favorable for reduction; but will relax every voluntary muscle
in the system as completely as in death, rendering these tissues
more thoroughly inert than by any other agent; and, at the
same time exempting the patient from considerable pain, which
otherwise would be the necessary attendant of reduction. Such
a condition is effected by allowing the patient to inhale an
anaesthetic agent until its full effect is produced upon the system; by such means the use of hot baths is dispensed with;
antimonials, in repeated doses, that formerly were administered
until the already suffering patient was nauseated to a most distressing degree, are not needed; tobacco in fume, by chewing,
or in the form of enema, is either forgotten or intentionally
thrust aside; and for an expenditure of the precious fluid ad
deliquium animi, is substituted a simple and effectual means,
which, if skilfully and judiciously employed, is destitute of
danger.
Two fluids are employed to produce anaesthesia, the oxide of
ethyl, or ether, commonly called sulphuric ether; and chloroform, ch]oroformyle, or the perchloride of formyle.
Mr. Horace Wells, a dentist of Hartford, Connecticut, in
1844, when under the influence of the nitrous oxide, had a
tooth extracted without experiencing pain. He was informed
that the inhalation of sulphuric ether would induce a similar
state of insensibility, the truth of which information he confirmed by trials upon his patients. To this gentleman, therefore, and not to Dr. C. T. Jackson, or Dr. Morton, as is generally supposed, is due the credit of introducing sulphuric ether
as an anaesthetic agent to the notice of the public.
The ether used for inhalation should be highly rectified; it
should be deprived of its acid and alcoholic properties by washing; and its specific gravity should be about one half more than




MODE OF ADMINISTERING  ETHER.                  345
that of distilled water. The following method for its application is extracted from the work of J. F. B. Flagg, M. D.*
" No apparatus should be used as an inhaler which does not
amply provide for the admission of atmospheric air, or that
would render the breathing difficult. A good sponge, well and
frequently saturated with ether, is probably the best and simplest method of administering it.t
"The pulse should always be consulted. Its general tendency is upward, or quickened; when this takes place very
rapidly, it is proper to cease giving the ether for a few inspirations, or until reaction takes place, when a repetition of the
ether will not unfrequently promote its downward tendency.
Under ordinary circumstances, I consider it safe to increase a
pulse to 160 (one hundred and sixty) beats in the minute; or
to suffer it to decrease to 50 (fifty); but, of course, there must
be exceptions to this rule, too obvious to need particularizing.
" The expression of the countenance and temperature of the
head should be observed. When the face becomes suddenly
turgid, cold water should be applied to the forehead and temples, suffering the patient to breathe ammonia, or concentrated
vinegar, allowing at the same time plenty of fresh air, and directing full and rapid inspirations. The variation of the temperature of the head is best detected by the habit of taking the
pulse from the temporal artery.
"'The ether should always be brought gradually to the
mouth of the patient; by so doing all irritation of the larynx
and lungs is avoided. Direct to take natural and regular inspirations, to avoid swallowing the vapor, and should the
breathing become stertorous, or in any way distressing, desist
from its use until the natural breathing is restored.
" Never suffer yourself to be thrown off your guard by any
demonstration on the part of the patient. It is not unfrequent
* Ether and Chloroform, their Employment in Surgery, Dentistry, Midwifery, Therapeutics, &c., by J. F. B. Flagg, M. D., Surgeon Dentist.
Philadelphia, 1851.
t Before dipping the sponge into the ether, wet it with warm water, then
compress it, and leave it slightly damp.




346      MODE OF ADMINISTERING ETHER.
that a loud outcry may be induced, a distressing groan or other
manifestations of inconvenience or pain, which invariably pass
off, and the strongest assurances are given by the patient, if
aware of this fact, that he knows of no particular reason for
such conduct.
" It will be found, after inhaling for a minute or two, if no
effect is produced, that by allowing the patient to take one
breath of atmospheric air, considerable dizziness is felt; as a
general thing, a very few inhalations after this are sufficient;
and if the patient should resist, it is best not to meet that resistance by any physical force, but by a firm, yet kind treatment.
" If ether should produce much prostration (which it is apt
to do when the atmosphere is least charged with oxygen) it is
well to recommend self-exertion, as walking about, &c.; but if
the desire to sleep is too strong to be resisted, entertain no fear
from that indulgence, as the patient will soon awake refreshed.
"' After inhaling for a certain period, should any spasmodic
action occur to retard breathing, sprinkle suddenly a little cold
water upon the face; or a pretty active slap between the shoulders will be sufficient to relieve any obstacle in this respect.
The knife should not be used until the patient is brought completely under its influence; and fresh ether and fresh air be
alternately inhaled in such proportions as the case may require
to keep the patient perfectly passive. For an operation requiring ten minutes as much as six ounces may be necessary."
The other anaesthetic agent, chloroform or perchloride of formyle, although known as a chemical product so far back as
1831, and occasionally used in minute doses as an antispasmodic,
was unknown as an anaesthetic agent till the year 1847, when
Professor Simpson, of Edinburgh, after experimenting upon
himself and some friends, announced its power of producing a
state of insensibility to pain.
Chloroform, when pure, emits a pleasant and fragrant odor,
has a sweetish taste, evaporates rapidly, and is dense and
colorless.
Its mode of exhibition is as follows: Moisten well, but do




ADMINISTRATION  OF CHLOROFORM.    347
not saturate, a piece of lint or sponge, a glove, or what answers
better, and is always at hand, a cambric or muslin handkerchief
with the fluid; the handkerchief should be made to assume the
form of a cone, or cup. Its concavity is then brought gradually
to the face of the patient, not too slowly, lest too much of the
fluid should evaporate, and the mouth and nostrils be lightly
covered, avoiding all compression of the latter, lest a free access
of the vapor into the air vessels should be impeded.  Its entrance is likewise facilitated by laying the patient on his back;
the vapor of chloroform having a specific gravity much heavier
than atmospheric air.
The quantity required varies in different individuals; an average may be set down as from one to three drachms. The
purer the article used, the more promptly will it produce the
desired effect. W~hen it becomes necessary to remove the handkerchief, for the purpose of moistening it again, its reapplication
should be quick. Any effort made by the patient to push aside
the handkerchief must be resisted; these efforts are made just
before the period of insensibility.  That the chloroform  has
acted favorably is known by an increased loudness of respiration. During the application the patient's attention must not
be diverted by the conversation or movement of persons around;
to prevent vomiting, it should not be used soon after a meal;
if excitement or much muscular actior be produced, the handkerchief must be more closely applied and the dose renewed.
Its use is contra-indicated in persons who have a tendency
to congestion of the brain, or disease of the heart-likewise in
operations upon the nose and mouth; in these latter cases the
blood readily finds an entrance into the lungs, owing to the
patient's entire inability either to swallow or expel by coughing; hence suffocation must certainly take place.
Mr. Syme,* in a lecture upon chloroform, thus writes:
" So far as I can ascertain, from what I have heard and read
upon the subject, there are important differences between the
mode of administration of chloroform here (Edinburgh) and in
* London Lancet, March, 1855, p. 200.




348    ADMINISTRATION OF CHLOROFORM.
London. It appears that here it is given according to principle,
there according to rule. There great attention is paid to the
number of drachms or minims employed; here we are entirely
regardless of the amount used, and are guided only by the
symptoms of the patient. The points that we consider of the
greatest importance in the administration of chloroform are, first,
a free admixture of air with the vapor of the chloroform....
Secondly, if this is attended to, the more rapidly the chloroform
is given the better, till the effect is produced; and hence we do
not stint the quantity of the chloroform.  Then-and this is a
most important point-we are guided as to the effect, not by
the circulation, but entirely by the respiration; you never see
anybody here with his finger on the pulse while chloroform is
given.  So soon as breathing becomes stertorous we cease the
administration. Attention to the tongue is another point which
we find of great consequence. When respiration becomes difficult, or ceases, we open the mouth, seize the tip of the tongue
with artery forceps, and pull it well forward; and there can
be little doubt but that death would have occurred in some
cases if it had not been for the use of this expedient. We also
always give chloroform in the horizontal position, and take
care that there is no article of clothing constricting the
neck."
It is confidently asserted that chloroform does not increase
a susceptibility to erysipelas after surgical operations, and
although it may in some instances irritate the air passages, it
occasions no permanent ill effects; and that no apprehensions
need be entertained of its aggravating morbid sensibility in
hysterical females.! The surgeons of the United States, however, in their operations, almost universally resort to the inhalation of etherEuropean surgeons to chloroform.
Although habit, or prejudice, or both, may operate in the
selection of one or other of these powerful agents, an impartial review of the whole subject leads to a conclusion favorable to the sulphuric ether. It possesses all the desirable
properties of chloroform, without subjecting patients to ill




DISLOCATION  OF THE JAW.                    349
consequences, and danger of death itself, which well attested
testimony proves has been produced by the latter.*
As soon as the anaesthesia is complete, the luxation should
be reduced, and the part immediately washed with a solution
of arnica, and the same medicine should be administered internally; or cloths saturated with the solution should be laid on
the site of the injury. If the inflammatory symptoms are violent, and there be fever, &c., aconite may be alternated with
the arnica, and administered every one, two, or three hours.
If the patient is extremely restless at night, &c., cham. should
be prescribed.  Perfect rest for the first few days must be enjoined, after which, when pain and swelling have subsided,
motion may be gradually and gently essayed. To restore the
part more speedily to its natural strength and flexibility, caust.,
thus, or petrol. will be demanded, the selection depending upon
the group of symptoms which may present.
Section I.-Dislocation of the Jaw.
Dislocation of the jaw is produced by direct violence upon
the chin, or by muscular action in yawning, laughing, etc., and
can only take place forwards. It may be complete or partial,
as one or both condyles are dislocated.
Diagnosis.-The condyles rest in front of the base of the
zygomatic process (see fig. 50): the mouth cannot be shut, the
chin is depressed, the condyloid space is vacant, and a prominence may be felt beneath the zygomatic process; articulation
is indistinct and accompanied with pain.
Treatment.-This consists in placing the thumbs on the
molar teeth, and the fingers beneath the chin and base of the
jaw; firm pressure is then made downwards by the thumbs,
* Vide " Some Account of the First Use of Sulphuric Ether by Inhalation in Surgical Practice." Read before the Boston Society for Medical
Improvement, April 12th, 1847, by George Hayward, M. D.




350      DISLOCATION  OF THE CLAVICLE.
Fig. 50.              whilst the chin is elevated
by the fingers; the moment the bone is slipping
\ into place, the thumbs are
slipped off the teeth upon,; ( the gums, or they may be
0         protected  by a pair of
-'/',~i,,{~;~,gP —thick gloves. If there be
ditficulty in reducing both
condyles at the same time,
one should be reduced before the other is attempted; this plan rarely fails.
In those persons disposed to spontaneous dislocation of the
jaw firom gaping, &c., the recurrence of the displacement may
very probably be prevented by the exhibition of a dose of staphys., a few globules of the 6th attenuation every fourth day
for three months.  Should this medicine not accomplish the
desired object, rhus-tox., from its known specific action upon
ligamentous tissue, might be tried, in like manner.  A successful preventive treatment of this accident is much to be desired;
its frequent repetition in some individuals, especially females,
is a source of considerable annoyance as well as pain.
Section 2.-Dislocation of the Clavicle, Ribs and Vertebra.
Dislocation of the clavicle may occur at either extremity.
The Eternal end may be displaced forwards or backwards:
the former is the more common. The scapular articulation
may be displaced upwards, gliding over the acromion process.
Diagnosis is easy in these cases.  In luxation of the sternal
end forwards (Fig. 51) the dislodged extremity is plainly seen
and felt in front of the sternum, whilst the backward displacement leaves a hollow at the superior edge of the sternum.
There is likewise a tumor formed by the end of the bone, which
may be felt at the base of the neck.




DISLOCATION OF THE VERTEBRIE.    351
In luxation of the scapular            Fig. 51.
extremity (Fig. 52) the shoulder is (lepressed, and the end 
of the clavicle may be felt:;
above the acromion process.
In both these varieties the       E                    --
deformity (lisappears upon ele-           - 
vating and carrying the shoulder outwards and backwards.,i
The treatment of this injury
is effected by carrying the
shoulder upwards and outwards, pressing, at the same             Fig. 52.
time, the clavicle into its articulation, and retaining it in a
its proper position by means
of the apparatus for fractured
clavicle.  As the ligaments
unite slowly in dislocation of
the acromnion extremity, it is
necessary to keep the limb in
the dressings much  longer         /:  I;
than would be done in fracture.
Dislocation of' the Sternal             X 
Extremities of the Ribs from
their cartilages sometimes oc-:
curs, and may be recognized
by an unnatural protuberance.
Treatment.-These cases are managed by placing a compress
upon the extremity of the rib, and passing a roller around the
chest, to secure the compress, and control in a measure the action of the muscles.
Dislocation of the Vertebrae can hardly occur without fracture, andl is the result of such violence that other symptoms
demand our attention.  Absolute rest is the most important
object of treatment.




352       DISLOCATION OF THE THUMB.
CHAPTER XX.
DISLOCATIONS OF THE UPPER EXTREMITIES.
Section 1.- Dislocations of the Fingers.
DISLOCATION of the fingers takes place sometimes at the
metacarpal articulation, though generally between the first and
second phalanges. The nature of the injury is evident, (Fig.
53,) and may be reduced by extension, made by the hand alone,
by a bandage or tape applied by a clove-hitch.
Fig 53.
Dislocation of the Thumb backwards on the dorsum of the
metacarpal bone (Fig. 54) is of frequent occurrence.
Fig. 54.
It sometimes takes place in the opposite direction. (Fig. 55.)
Fig. 55.




DISLOCATION  OF THE THUMB.                353
The accident is easily recognized, but with more difficulty
remedied.
Treatment.-A clove-hitch (Fig. 56) should be placed upon
the first phalanx, and extension employed for some time.
Forcible and steady flexion is made
towards the palm of the hand, and        Fig. 56.
firm pressure applied by the thumb
of the surgeon at the same time upon,
the head of the bone. By these  I.
means the reduction is usually accomplished. This luxation is some-     /, \)
times so unyielding as to call for the (. I
subcutaneous section of one or both
lateral ligaments before the deformity can be removed.
Before division of the ligaments is made, the following mode
of action should be resorted to in difficult cases, and it will
generally succeed; for one of the greatest obstructions to the
reduction is the lapping of the extremities of the bones, which
from their form become completely locked. Soak the hand in
warm water; apply a piece of wet leather around the thumb,
and over this a clove-hitch of strong tape. In dislocation upwards, a loop of tape embraces the upper end of the phalanx,
and is drawn with great force, by an assistant, perpendicularly
upwards. Another loop of tape embraces the lower end of the
metacarpal bone, and is drawn downwards by another assistant.
Whilst the extremities of the bones are by these means unlocked, the surgeon draws the thumb, by the clove-hitch,
towards the pjalm of the hand, and the bone usually slips into
its normal position.
The metacarpal bones are, perhaps, never luxated, except by
a gun-shot wound or some similar violence, the effects of which
are generally more serious than the dislocation.
The carpal bones are so firmly connected to each other by
short ligaments, and by a ball and socket joint, as to be scarcely
susceptible of luxation. Instances, however, are now and then
met with of displacement of the os magnum and os cuneiforme,
23




354      DISLOCATION OF THE FORE-ARM.
either from violence or from extreme relaxation of their ligaments.
To restore a displaced os magnum or cuneiforme will often
be found very difficult, and to retain it fixed in its natural
situation still more so, especially when the luxation is occasioned by relaxation of the ligaments. Well directed pressure,
and an appropriate bandage, are the only remedies.
Section 2.-Dislocation of the Fore-arm.
Dislocation of the Elbow Joint may occur in five directions,
although from an examination of the structure of the joint it
might be supposed that luxation could scarcely happen in any
direction. Both bones may be dislocated backwards; both dislocated laterally; the ulna dislocated backwards, the radius
dislocated forwards; and, lastly, the radius may be dislocated
backwards. Luxation of both bones backwards, however, is the
most frequent.
Diagnosis.-In displacement of both bones backwards, there
is a projection at the posterior part of the joint; on each side
of the olecranon process there is a depression; the lower extremity of the humerus is felt at the fore part of the elbow
joint, as a hard tumor, the hand and fore-arm are fixed in supination, (see fig. 57,) and cannot be entirely pronated, whilst
flexion of the joint can scarcely be accomplished.
Treatment for this injury is as follows: Seating the patient
in a chair, the surgeon places his knee in the bend of the arm,
taking hold of the wrist, bends the limb, at the same time pressing on the radius and ulna with his knee, so as to separate them
from the humerus, and throw the coronoid process from the
posterior fossa of this bone. Whilst the pressure is kept up
by the knee, the fore-arm is slowly and forcibly bent upon the
arm, and the bones slip into their sockets.




DISLOCATION OF THE FORE-AR1M.                355
Fig. 57.
This reduction may be accomplished also by bending the arm
forcibly, yet gradually, around a bed-post, or whilst the patient is
seated in an arm-chair, passing the arm through the opening in
the back or side, thus fixing the body and limb, and reducing the
luxation by forcibly bending the fore-arm, with one hand placed
upon the olecranon process to lift the bones into their places.
The reduction having been accomplished, the fore-arm must be
placed in a sling, the elbow bent at an obtuse angle, and supported with a splint.
Diagnosis in lateral dislocation of both bones, backwards and
outwards, (Fig. 58,) is arrived at by the greater projection of
the ulna backwards than in the former case, and the coronoid
process rests upon the back of the external condyle of the
humerus. The radius forms a tumor on the outer side and behind the external condyle, and a depression is seen above the
head of the bone. If the hand be rotated, the head of the
radius is Distinctly felt to move.
In dislocation of both bones, backwards and inwards, (Fig.
59,) the same posterior projection of the elbow exists. The
ulna rests behind the internal condyle, whilst the head of the
radius occupies the posterior fossa of the humerus, the external
condyle of the humerus forming a large tumor on the outer
side of the elbow.
Treatment is the same as in the former case.
Dislocation of the ulna backwards is recognized by the contortion of the hand and fore-arm inwards. The olecranon process can be felt, as it projects behind the humerus. The




356      DISLOCATION  OF THE FORE-ARM.
Fig. 58.                 - Fig. 59.
fore-arm cannot be extended, nor even flexed to more than a
right angle.
Diagnosis in this accident is sometimes difficult, but its distinguishing features are the contortion of the hand and fore-arm,
and the projection of the olecranon process backwards.
Treatment in this case is more easily effected than where
both bones are dislocated. Bend the arm over the knee, grasp
the wrist, draw the fore-arm downwards, and the bone slips
into its socket.
Dislocation of the radius forwards. —(See Fig. 60.) —In
this accident the head of the radius occupies the hollow above
the external condyle of the humerus.
Diagnosis.-The fore-arm is slightly bent, but cannot be
flexed to a right angle, nor completely extended. When the
fore-arm is quickly flexed, there is a sudden check, and one
bone is distinctly felt to strike against the other. The hand is
pronated. If the thumb of the surgeon be pressed in front of
and just inside the external condyle of the os humerus, the head




DISLOCATION OF THE FORE-ARM.    357
of the radius may be felt; and by rotating the hand the head
of the bone rolls also. This last sign, and the sudden check
in bending the elbow, distinguish this accident from any other.
Treatment of this accident is effected by extension from the
wrist, supinating the hand at the same time, and with the
thumb pressing down the head of the radius, which slips into
its place. The fore-arm is placed in a sling.
Dislocation of the radius backwards (Fig. 61) may be recognized by feeling the head of the bone, (which makes a
Fig. 60.           Fig. 61.
prominence on the back of the external condyle,) and the partial loss of the movement of the joint.
Its reduction and treatment are the same as in the former
case.
Dislocation of the radius and ulna at the wrist may take
place backwards and forwards.
Diagnosis.-In luxation of both bones backwards, there is a
tumor upon the fore and back part of the wrist (Fig. 62); the
hand is bent back. The extremities of the radius and ulna can




358      DISLOCATION OF THE FORE-ARM.
Fig. 62.
be felt one one side, and the carpus on the other, if the injured
part be examined soon after the accident has occurred. In dislocation forwards, the relation of the bones to each other is
altered.  Sprains about the wrist, from severe falls, sometimes
assume the appearance of dislocation of the bones, but may be
distinguished from it by there being but one swelling in sprain,
and that having come on gradually; also the relative position
of the styloid processes of the radius and ulna with the carpus
is unaltered in sprains.
Treatment.-Reduction is effected with facility in these cases,
by making extension upon the injured hand whilst the fore-arm
is fixed; the bones are then easily forced into place. The wrist
and fore-arm are to be placed in splints and slung.
Dislocation of the radius at the wrist may take place anteriorly, posteriorly, and laterally. The signs and treatment
of these are so like the former case, that the same rules are
applicable.
Dislocation of the ulna from the radius at the wrist occurs
oftener than the last mentioned. It is easily recognized by the
altered position of the styloid process, the projection of the
ulna above the level of the os cuneiforme, and the twisting of
the hand.
Treatment in this case consists in replacing the end of the
ulna by extension and direct pressure on the end of the bone,
confining it there by means of splints on the back and fore part
of the wrist and fore-arm, and placing a compress upon the end
of the bone, (which has a tendency to displacement, on account
of the rupture of the ligament.) A roller is then applied to
retain the compress and splints.




DISLOCATION  OF THE HUMERUS.                 359
Section 3.-Dislocation of the Humerus.
Dislocation of the humerus from the glenoid cavity is usually
the result of indirect force. The head of the humerus may be
dislocated in three directions; downwards, into the axilla,
which is the most frequent; forwards, beneath the pectoral
muscle; backwards, on the dorsum of the scapula. Subluxation inwards on the coracoid process is sometimes met with.
Diagnosis. —In dislocation           Fig. 63.
downwards (Fig. 63,) there
is a hollow beneath the acromion; the roundness of the
shoulder is lost; the arm is                          --
somewhat lengthened; the
elbow  stands off from  the
side; the patient usually supports the fore-arm of the injured limb with the other
hand, to prevent its head
pressing painfully upon the 
axillary nerves. By carry-    /             \\
ing the elbow from the body
the head of the humerus
carn be distinctly felt in the axilla; the patient cannot raise
the arm to his head; the power of rotation is lost, but the motion of the limb backwards and forwards, as it hangs by the
side, is still retained. On moving the limb, a slight crepitus
will sometimes be felt. From the effusion of synovia and serum
into the cellular tissues, this crepitation is not like the grating
that fracture produces, and even disappears by continuance of
the motion. Added to these signs is a change in the axis of
the arm; a straight line, drawn from the elbow to the head of
the bone, leads to the axilla, instead of the glenoid cavity of
the scapula.
In dislocation forwards (Fig. 64) the nature of the accident is evident. There is depression beneath the acroinion;
the head of the humerus forms a tumor below the clavicle,




360      DISLOCATION OF THE HUMERUS.
Fig. 64.                     Fig. 65.
which rolls beneath the touch as the arm is rotated; the limb
is shortened, and carried backwards and outwards.
In dislocation backwards (Fig. 65) there is a protuberance
on the dorsum of the scapula, below the spine, which rotates
with the arm; the arm and fore-arm are approximated to, and
carried across the chest. To these are added the other signs
common to luxation of this joint.
Treatment of these dislocations is various. The reduction of
dislocation downwards is effected by putting the patient on his
back. A ball is placed in the axilla between the pectoralis
major and latissimus dorsi muscles; the surgeon's heel is placed
upon the ball, (Fig. 66,) whilst he takes hold of the wrist,
Fig. 66.
A.~~iiji\ 




DISLOCATION OF THE HUMERUS.                 361
and, by gradual and steady force, pushes the head of the bone
into the glenoid cavity. If this power do not prove sufficient,
a wet roller should be passed round the arm, above the elbow,
and an extending band tied over it, this the surgeon either
passes around his own shoulders, or allows several men to draw
steadily upon it until the deformity is removed. If the foregoing means fail, the patient must be seated in a chair, and the
scapula fixed by a bandage, which allows the arm to pass
through it, setting firmly against the axilla and the acromion
process, two men taking hold of this band, and two hold of the
one already applied to the elbow, steady strain is brought upon
the limb for some minutes, the surgeon places his foot upon
the chair (see fig. 67) and his knee in the axilla of the patient;
he should now raise the knee by raising the foot, at the
Fig. 67.
same time he presses the acromion downwards and inwards with
his hand. The head of the bone usually slips into the glenoid
cavity with a snapping noise. Sometimes these means fail for
want of power, and then pulleys must be applied to the bands,
instead of men. (Fig. 68.) When the pulleys are employed,




362      DISLOCAT1ON OF THE HUMERUS.
Fig. 68.
advantage may be derived from rotating the arm by using the
fore-arm as a lever; the head of the bone usually slipping into
the socket without noise.
An easy method of reducing luxations in old subjects, delicate females, and those of relaxed habits, is by seating the
patient upon a chair, the surgeon placing his knee in the axilla
and his foot upon the chair; taking hold of the elbow of the
injured arm, he presses with his hand upon the acromion, and
thus converts the arm into a lever and the knee into a fulcrum.
By engaging the patient in conversation, to attract his mind
from the injury, he bears down upon the elbow, fixing the
scapula, and raising the knee at the same time, the head of the
bone slips into the glenoid cavity, and the luxation is reduced.
Sometimes, even in muscular subjects, this plan succeeds. The
fore-arm should then be placed in a sling and the joint kept
quiet.
Sir Astley Cooper advises, as a general rule, that the reduction of dislocations of this joint ought not to be attempted after
they have existed twelve weeks.
Mr. White's mode of reducing this dislocation, and practised




DISLOCATION  OF THE PELVIS.                 363
by M. Malgaigne, is as follows: Lay the patient upon his back,
and raising the arm perpendicularly by the side of his head, so
as to relax the supra-spinatus muscle, the surgeon seizes the
elbow with one hand, whilst with the other he presses upon
the acromion process, to fix the scapula; and the head of the
humerus is drawn directly upwards into the glenoid cavity.
Dislocation forwards and backwards is reduced by the same
means and management as dislocation downwards.
CHAPTER XXI.
DISLOCATIONS OF THE LOWER EXTREMITIES.
Section 1.-Dislocation of the Pelvis.
DISLOCATION of the pelvis is the result of great violence.
The os innominatum has been displaced upwards, separated
from the sacrum at the sacro-iliac junction.
Diagnosis. —In this case the limb of the affected side is
shortened and powerless, but the signs of dislocation and fracture of the thigh-bone are absent, and the limbs, when measured
from the anterior superior spinous processes of the ilia, are
found to be of the same length. The anterior superior spinous
process, and the crest of the ilium of the injured side, are on a
higher level than those of the opposite side, and some difficulty
may be experienced in evacuating the bladder.
Separation of the symphysis pubis occurs occasionally from
a direct blow, or from difficult labor.
Treatment.-Efforts may be made, in both cases, to adjust
the displaced bones, and the pelvis should be kept quiet by a
broad bandage or belt. The bladder must be relieved by a
catheter, and the effects of internal injury and inflammation
combated.




364        DISLOCATION  OF THE TOES.
Section 2.-Dislocation of the Toes.
Dislocation of the toes and foot from the metatarsal bones,
as well as their phalanges, one from another, occur occasionally, and are with facility recognized, and easily reduced by
extension and counter-extension.
Dislocation of the astragalus, though rare, sometimes occurs,
and is always a serious accident. The nature of the injury is
evident; the bone is generally dislocated forwards, and is
readily felt.
Treatment for the correction of this accident consists in extension of the foot, with the leg flexed, and direct pressure
applied to the astragalus, and the bone usually slips into its
natural position. The tension of the integument may be so
great that sloughing is inevitable, unless the displaced bone be
restored, which is not always possible; therefore the dislocation may become compound secondarily, and calls for the same
treatment as if it were originally compound.
When the displaced bone cannot be replaced, three modes
of treatment present themselves, viz. to retain the parts as they
are, and risk suppuration; to amputate at the ankle joint, or
to excise the displaced bone in the attempt to save the limb
and joint. This last method is preferable.
Dislocation of the os calcis and astragalus from the other
bones of the tarsus may take place. The foot will then be
turned inwards, as in talipes varus.
Reduction is easily effected by extension and direct pressure.
The limb should then be supported by splints and bandages.
Section 3. —Dislocation of the Knee Joint.
Dislocation of the Patella.-Dislocation of the patella or
knee-cap may occur in three directions: outwards, (see fig. 69,)
inwards, (Fig. 70,) and upwards.




DISLOCATION  OF THE LEG.                 365
Fig. 69.                  Fig. 70.
A partial dislocation of the patella outwards is not uncommon, and is attended with faintness and a sickening pain.
Luxation outwards is the most common.
Diagnosis.-The nature of the accident is self-evident.
Treatment. —The patient is placed in the recumbent position,
the leg is raised by the heel, which relaxes the muscles of the
thigh; the surgeon now presses down the edges of the patella
farthest from the joint, and the bone glides over the condyle of
the femur into its natural position.
Dislocation of the patella upwards is caused by the rupture
of the ligamentum patellie, whilst the bone is drawn upwards
by the action of the rectus femoris muscle.
Treatment. —The same apparatus is to be applied as recommended for fracture of the patella, and continued for one month,
before passive motion is communicated to the joint.
Section 4.-Dislocation of the Leg.
Dislocation of the Tibia.-This accident may occur at the
knee joint in four directions; viz. backwards, forwards, inwards, and outwards; though the two latter are both rare and
incomplete.




366          DISLOCATION  OF THE LEG.
Diagnosis is very plain in these dislocations. In luxation
inwards the tibia projects on the inner side of the joint.  (Fig.
71.) Dislocation outwards is recognized by the tumor being
on the outer side of the knee-joint.  (Fig. 72.)
Fig. 71.                        Fig. 72.
In dislocation forwards the tibia is felt above and in front
of the thigh bone, (Fig. 73,) whilst the latter may be felt in
the popliteal space. Dislocation backwards may be readily
Fig. 73.               Fig. 74.




DISLOCATION OF THE LEG.                   367
known by the shortening of the limb, projection of the condyles, of the femur, (Fig. 74,) depression of the ligament of the
patella, and by the leg being bent forwards.
Treatment.-In these four varieties of luxations, reduction
is accomplished by extension of the leg, and direct pressure to
the ends of the dislocated bones. Inflammation is combated,
and the joint confined for two or four weeks, (or longer, according to the nature of the case,) by splints and bandages.
Compound dislocation of the knee joint is a very rare accident, and generally requires immediate amputation.
Dislocation of the head of the fibula from the tibia may
occur. The head of the bone is thrown backwards; it can be
readily felt and reduced, but slips from its position directly.
The patient suffers fatigue in walking and taking exercise;
much weakness is also experienced.
Treatment.-After having reduced the dislocation, a solution
of arnica should be applied to the part; this may have the
effect of producing absorption of the superabundant synovia;
or ledumrn may be used, as this medicine acts powerfully upon
the knee joint, and also upon the absorbent vessels generally;
after this a compress should be placed behind the head of the
line, which should be bound tightly to the tibia, either by a
bandage or a strap buckled round the upper part of the leg.
Dislocation of the tibia at the ankle joint may occur in
four directions: inwards, forwards, outwards, and backwards.
This last variety is rarely met with: dislocation inwards is of
most frequent occurrence.
Diagnosis. —In luxation of the tibia inwards, the internal
malleolus forms a tumor which threatens to burst the skin.
The foot is thrown outwards; it rotates easily on its axis;
there is a depression above the outer ankle; the foot can be
moved laterally, anti crepitus is felt about three inches above
the end of the fibula, at which point that bone is almost invariably fractured in this dislocation.
Treatment.-The patient should be placed upon his back,
and the leg bent at a right angle to the thigh; extension should
then be made upon the foot, whilst the thigh is fixed by an




368         DISLOCATION  OF THE LEG.
assistant, and direct pressure applied to the end of the tibia,
and thus the deformity is removed. Dupuytren's apparatus for
fracture of the lower part of the fibula is now to be applied,
or splints and bandages, to keep the foot at rest and at a right
angle to the leg, and the patient kept in bed five or six weeks.
Ten or twelve weeks will have elapsed before the use of the
foot is restored. After the eighth, passive motion will be required to restore the mobility of the joint.  Causticum, lycopodium, or rhus, will very much facilitate this latter object.
First, however, the inflammation of the joint must be attended
to, as in all other cases of dislocation.
Diagnosis in dislocation of the tibiaforwards.-The foot is
fixed, and appears much shortened, the heel projects backwards,
and is firmly fixed; whilst the toes are pointed downwards.
The end of the tibia is felt as a hard tumor upon the tarsus.
Treatment.-The reduction and management of this case is
the same as for luxation inwards, with the exception that Dupuytren's apparatus is not applicable. Side splints, and bandages to keep the foot at right angles to the leg, with the heel
on a pillow, are preferable.
Partial dislocation of the tibia forwards sometimes occurs.
In this case the tibia rests half on the os scaphoides, and half
on the astragalus. The fibula is broken in this accident.
Diagnosis.-The foot appears shorter, is pointed downwards,
and cannot be placed flat upon the ground without difficulty.
The hetl is drawn up and slightly projects; the foot is almost
immovable.
Treatment. —This luxation is reduced by extension and direct
pressure upon the tibia and heel, and retained by means of Dupuytren's apparatus for fractured tibia.  Dilute tincture of
arnica should be applied to the joint.
Dislocation of the tibia outwards is attended with more injury to the joint, and is more dangerous than either of the other
varieties. The malleolus internus is separated from the shaft
of the bone, and sometimes the fracture passes obliquely through
the articular surface of the tibia.  The astragalus is sometimes
fractured, and the lower extremity of the fibula is broken into
several pieces.




DISLOCATION  OF THE LEG.                   369
Diagnosis.-The foot is turned inwards, the tibia thrown
forwards and outwards upon the astragalus, and can be readily
felt. There is great deformity of the joint, and the nature of
the accident is evident.
Treatment. —The reduction of the dislocation is effected by
the same means as in the other cases. A pad is placed upon
the fibula above the ankle, extending up a few inches; two
splints, with a foot-board, are applied to the sides of the leg
and ankle; the foot is bandaged and fixed in the splints, so as
to prevent the slippling of the tibia and fibula from the astragalus, and the limb laid upon its outer side. The local and general treatment is the same as in other cases.  Some time will
generally elapse before the patient can leave his bed, and even
then crutches may be necessary.  Passive motion and friction
are then to be employed, and in ten or twelve weeks the cure
is complete.
Compound Dislocation of the.Ankle Joint is always a serious
injury; of it Sir Astley Cooper says, "The first question
which arises upon this subject is the following —Is amputation
generally necessary in compound dislocation of the ankle? My
answer is, certainly not."
The nature of this accident is evident at the first glance.
Treatment.-The treatment of compound dislocation of the
ankle must depend in a great measure upon the extent of the
injury and the constitution of the patient. The displacement is
reduced as in simple dislocation, and the principles before given
for the management of compound fractures and simple luxations
must be combined in these instances.  There are many cases
that require immediate amputation; but if this be not imperative, an attempt to save the limb should always be made,
whenever there is the least ray of hope. A proper rule of
action in such accidents is to keep the part quiet, and to
meet symptoms as they arise.
Partial or complete anchylosis is almost an unavoidable result from these injuries. Under the most favorable circumstances,
three months generally elapse before the patient can walk even
with crutches, and many cases far exceed this time.
24




370     DISLOCATION OF THE HIP JOINT.
Section 5.-Dislocation of the Hip Joint.
Dislocation of the hip joint takes place in four directions:
upwards, upon the dorsum of the ilium (Fig. 75); downwards,
into the foramen ovale (Fig. 76); backwards and upuwards into
Fig. 75.                         Fig. 76.
the ischiatic notch (Fig. 77); and forwards and upwards upon
the body of the pubes (Fig. 78).
Diagnosis. In dislocation of the head of the femur upwards
upon the dorsum of the ilium, the limb of the injured side is
from one to two inches and a half shorter than the opposite
limb. The toe rests upon the top of the other foot, and the
knee and foot are turned inwards (Fig. 79); the knee is a little
advanced upon the other, and the thigh cannot be turned outwards, but may be carried slightly across the other. In the
absence of swelling, the head of the femur may be felt moving,
upon the dorsum ilii, when the knee is rotated. The trochanter major is much nearer the anterior superior spinous process
of the ilium than is natural; though less prominent than on the




DISLOCATION  OF THE HIP JOINT.                  371
Fig. 77.                 Fig. 78.
other side: the roundness of the hip              Fig. 79.
on the injured side is lost.
This dislocation differs from  fracture of the neck of the femur (for
which it has been mistaken) in the
following points, viz.: In fracture, the
knee and foot are generally turned
outwards; the thigh can readily be
bent towards the abdomen; and what
makes the nature of the accident still
more clear, is that the limb, by mode-     |  ] 
rate extension, is made the length of     (..,
the other, but returns again to its
previous position as soon as the extensive force is removed; and there is
also crepitation at the seat of injury.'i  /
Treatment.-In all dislocations of
the hip joint the constitutional means
recommended  are  necessary.   The
muscles being  relaxed, the patient




372     DISLOCATION OF THE HIP JOINT.
should be laid upon his back, and a strong band placed in the
perineum, made fast to a fixed point (Fig. 80): above the knee
is passed a wet roller, over this is fixed a band or towel by a
clove-hitch, and hooked to a pulley at a point in a direct line
to the perineal band.
Fig. 80.
The knee is bent at a right angle: a strain is brought upon
the limb by the pulley, which must be steady, continuous, and
without violence; stopping occasionally when much pain is experienced. As the head of the bone approaches the acetabulum,
the surgeon rotates the limb inwards, and the bone slips into
its socket.
As the head of the femur often catches against the edge of
the acetabulum, it is good practice, when the bone is yielding
to the traction of the pulley, to pass a towel or band under the
thigh, near to the groin, and by this lift the head of the bone
over the acetabulum.
The injured limb should then be kept parallel with the sound
one by means of a bandage embracing both limbs, and the
patient placed quietly in bed for two weeks or more. Subsequent inflammation must always be looked to in cases of dislocation, and be treated by acon., am., &c.
Dislocation downwards into the foramen ovale.-Diagnosis.
The injured limb is two inches longer than the other. In thin subjects the head of the bone can be felt towards the perineumn;
the trochanter is less prominent; the body bent forward; the
knee is advanced and separated from the other: the foot is
generally straight.  (Fig. 81.)
The position of the head of the bone is below, and a little




DISLOCATION OF THE HIP JOINT.               373
anterior to the axis of the acetabulum,  Fig. 81.
and there is a depression below Poupart's
ligament.
Treatment. —The patient is to be
placed upon his back; a band or girth.
is passed in the perineum, around the
injured thigh, and hooked to a pulley,
made fast to a point obliquely above!i  
the hip.
A counter-extending band or girth
surrounds the ilia c this is made fast to
a point opposite the injured hip. Traction is gradually made by the pulley,
and when the head of the bone is mov- _      _0'
ing from the foramen ovale, the surgeon
should grasp the ankle, and draw it to-    6
wards the middle line of the patient's
body, (see fig. 82,) when the head of
the bone readily passes into the ace-',_~  _
tabulum.
Dislocation backwards into         Fig. 82.
the ischiatic notch is the most
difficult to detect and to reduce.
Diagnosis.-The limb is half
an inch, sometimes one inch,
shortened; the trochanter is behind its natural position; the
knee and foot are turned inwards, but less than in dislocation upwards, upon the dorsum
of the ilium; the toe rests against
the side of the other foot (see
fig. 83); the heel does not reach
the ground; the knee is a little
in advance of the other, and
slightly bent; the limb is fixed,
so that rotation and flexion is
scarcely possible.




374      DISLOCATION  OF THE HIP JOINT.
Fig. 83.              Treatment.-The reduction
of this dislocation is extremely
difficult. The patient is laid
upon his side (Fig. 84); the
bands and mode of reduction
are the same as in the former
) TlIllll-d I,case; but in this injury  the
band, or towel, to lift the head
of the femur, is indispensable;' 2~ t    i AX the trochanter should also be
thrust forward by the hand of
the surgeon at the same time.
Dislocation on the pubes is the
most easy of detection of all the
1 1~l IA\&\X~, x,,dislocations of the hip joint.
Diagnosis. —The limb is an, }S4 \    /             inch shorter than the other; the
knee and foot are turned outwards, and cannot be rotated
~5__                 inwards (Fig. 85); the head of
the bone can be distinctly felt
upon the pubes, at the outer side of the femoral artery and
vein, and above the level of Poupart's ligament; upon moving
or rotating the thigh, the head of the bone is felt to move
with it.
Fig. 84.
This dislocation has been mistaken for fracture of the neck
of the femur. It should be remembered that shortening and




DISLOCATION OF THE HIP JOINT.                 375
eversion  are common  to  both;            Fig. 85.
therefore, care is necessary in the
diagnosis.
Treatment. —The  patient  is
placed upon the sound side; a
girth is passed in the perineum
and fixed to a point in front of the
line of the body.  The pulley is \
hooked to the band above  the
knee, (Fig. 86,) and made fast to            7'}
a point behind the axis of the body,      1,lia
so as to draw the bone backwards.              i i
The head of the bone is lifted over'- 
the pubes and edge of the acetabulum by means of a band or towel,       l        /
and drops into its place. The sub-    ".       I
sequent treatment is the same as in
the other cases.
A much more extensive description, and many minutia, might t =
have been introduced into the preceding chapters on fractures and
dislocations, but it is presumed that sufficient detail has been
entered upon, to instruct the student and young practitioner in
the management of most injuries of this description.
Fig. 86.;%jj




376      SUBLUXATION, SPRAINS, ETC.
CHAPTER XXII.
SUBLUXATION, SPRAINS, ETC.
THESE injuries are sometimes very painful. They arise often
from momentary displacement of bones, which strain or partially tear the ligamentous apparatus of the joints. They are
accompanied frequently with some constitutional disturbance;
the affected part swells, and the synovial membrane may be
involved.
The treatment of such injuries, consists in restoring the bones
to their normal position by extension and direct pressure, and
applying a solution of arnica to the part, which must also be
bandaged to support the limb, and prevent recurrence of the
accident, and a few globules of the same medicine of the 12th
dilution administered internally.
When an individual muscle has been injured by the effect of
a violent strain, Dr. Goullon remarks that rhus will more
readily restore its tone, and remove the pain, than any other
medicine. This is a truthful observation, as most practitioners
of our school can testify. Rhus is particularly adapted to
sprains occurring in tendinous parts with swelling and great
pain. It may be used both externally and internally; the solution that is used as a lotion should be adapted to the sensitiveness of the skin of the patient. There are some individuals
who are particularly susceptible to the action of the poison
oak; and the surgeon should therefore exercise caution and discretion when prescribing this medicine: it possesses considerable power over the tendons of the lower extremities and the
submaxillary bone, it is also recommended for the bad consequences of strains, and prevents liability to such accidents.
This medicine has been alternated with arnica in some cases,
but the indications for its use are generally sufficiently well
marked to render entirely unnecessary any such alternation.
If the patient should have injured himself by lifting heavy




TREATMENT OF SPRAINS.                   377
weights, thus is also an important medicine, particularly when
the dorsal and cervical muscles and the vertebral column are
affected, and there is headache, accompanied with general
bruised sensation of the whole body, pains in the back or gastric ailments. Bryonia should be exhibited if the pains are
occasioned by the same cause, but are aggravated by motion,
and the muscular system is chiefly involved.
If pain is experienced immediately after raising a heavy
weight, calc. will prove serviceable, and may also remove the
existing predisposition to such accident; it should also be remembered, when, after the injury, there is congestion of blood
to the head, or there are pains, as from bruises, in the joints
and small of the back, the parts being sensitive to touch.
a1mm. carb. has been mentioned by some authors as useful in
the variety of injury under consideration, but there have been no
particular indications given. In its pathogenesis we find sensation as if bruised in the whole body, with fatigue and weakness of the limbs; pains, as if sprained in the joints; drawing
and tension in the joints, as though the tendons were too short:
Sprains.*
Lycop., petrol., or ruta may be applicable in some cases.
Sepia is recommended by Dr. Goullon for many troublesome
constitutional symptoms that may supervene upon a sprain.
If an inguinal hernia should have been caused by lifting. or
straining the part, or if an old protrusion becomes painful,
nux-vom., sulph.-ac., cocc., or sulph. should be administered.
If a prolapsus of the womb has been occasioned by such causes
nux has proved almost a specific medicine; after its exhibition
bell. or sepia may be required.
If the accident occasion nausea and vomiting, veratrum or
sulph. may be required, either of which may be used in alternation with arnica.
For the ill effects of making a mis-step, or pressing the foot
to the floor with too much violence, arn. and bry. are often
sufficient; sometimes, however, con., puls. and rhus may be
indicated.
* See Mat. Med., vol. i. p. 80.




378           RUPTURE OF MUSCLES.
Section 1.-Rupture of JMuscles und Tendons.
Laceration of muscular fibres often occurs from violent muscular action. It is characterized by immediate lameness. The
patient falls and is unable to resume the erect position; much
pain is experienced at the seat of injury. There is generally
consciousness of something having given way, accompanied
with a sensation of a blow upon the part. There are seldom
more than a few fibres of a muscle separated. This accident
usually occurs in the gastrocneinius, and is generally situated
at that part of the muscle at which the tendon commences. In
rupture of tendons the same symptoms are observed as in the
former case, accompanied often with an audible snapping noise,
and the gap between the ends can be detected by the touch.
The tendo achilles is more frequently ruptured than any other.
Treatment. —A great portion of the management of these
cases consists in position and rest. J.rnica may be applied in
some instances, particularly when muscular fibres have been
torn.  Rhus and ruta are preferable when the tendons are involved.  11con. and bella. may also be used if the constitutional
symptoms call for their administration.  If the seat of the injury be the gastrocnemius muscle or tendo achilles, a slipper
should be placed upon the foot; a belt or band secured around
the waist or loins, and to the heel of the slipper a stout cord or
tape attached; the leg is flexed on the thigh, the foot is extended, and the tape made fast to the belt or tape around the
body. This position is maintained until the divided parts unite.
Reparation is slow, especially in rupture of tendons. The application of the apparatus must be continued for some time, indeed, even longer than necessary when treating fractures.
When the patient commences to walk he should use a stick or
crutch, and wear a high-heeled shoe.




DISEASES OF THE PERIOSTEUM.                    379
CHAPTER XXIII.
DISEASES OF THE PERIOSTEUM AND BONES.
IT appears proper in this place, after having mentioned the
injuries to which the bones are liable, to record the diseases or
morbid conditions which affect the osseous system, the chief of
which are periostitis, caries, necrosis, exostosis, rachitis, mollities ossium,fragilitas ossium, spina ventosa, osteo sarcoma,
&c.
To effect a cure of diseases of the bones, the causes upon
which such affections depend must be removed; a want of
such knowledge induces the most distinguished surgeons to employ severe methods of treatment, which, in the generality of
instances, rather aggravate these affections than produce upon
them a beneficial effect. But by the administration of the proper homceopathic medicines, the constitution of the patient can
be improved, and the disease more successfully treated; the
dilution of the medicine, and the repetition of the dose, are
of paramount importance. Experience teaches that the exhibition of medium dynamizations, from the 12th to the 30th,
(better to (comntnence with the latter,) is more speedily followed
by beneficial effects than when the lower potencies are employed;
the system by the latter being excited to a reaction prejudicial to
favorable results, whilst the frequent repetition of medicines often
disturbs their curative action, and thereby retards recovery.
" We are often at a loss to determine," writes Dr. Jeanes,*
"C which of the remedies that are indicated by the morbid condition, or its particular development, as caries, hyperostosis,
&c., is the appropriate remedy for the individual case. The
circumstances which can guide in the choice of the remedy, are
the temperament, the disposition, the character of antecedent
diseases, and the treatment to which they have been subjected,
* Homceopathic Practice of Medicine.




380         DISEASES OF THE BONES.
and the nature of the exciting cause of the existing disease of
the bone. The symptoms which indicate the remedies are those
of the disease of the bone: viz, the appearances, the pains and
other molestations which accompany it, and the symptoms
which affect the whole system, or particular parts of it, other
than those immediately implicated by the disease of the bone.
But most of the latter, which may be termed the general symptoms, namely, hectic, loss of appetite, emaciation, debility, &c.,
are often merely the result of the local irritation."
It is also of some importance for the practitioner to become
acquainted with the manner in which any antecedent disease
may have been treated, as all such circumstances tend to aid in
the selection of appropriate remedial agents.
Section 1.-Periostitis.
Periosteum is the name given to the strong white fibrous
membrane that closely envelops bones, excepting such of them
as are covered with cartilage. This membrane is connected externally to adjacent cellular substance, and therefore indirectly
with muscular tissue; the inner surface adheres closely to the
bone, by means of short strong fibres, which enter the numberless foramina that are noticed on the surface of ossific structure.
Although fibrous tissues are not as liable to be attacked by
inflammation as other textures of the body, still, when such abnormal action is found, the sufferings of the patient are often
exceedingly severe; and if the inflammatory process be considerable or acute, it is seldom limited to the tissue originally
affected, but extends to all the surrounding parts.
Great pain is the usual attendant upon this disease, whether
acute or chronic, and when in the former variety, if the inflammation has extended to the bone, the sufferings of the patient
are excruciating. This increase of suffering may be readily
accounted for, if we remember that the inflammatory process
progresses with greater rapidity in tissues which are seconda



P E R IOSTIT I S.                  381
rily involved, consequently there is a greater amount of exudation, which, being confined by the external membrane, tends
greatly to increase the pain.
The swelling in periostitis is small, compared to the violence
of the inflammatory action; this may also be explained in the
same manner alluded to when speaking of the unusual degree
of pain that is present in the disease, viz. the confinement of
the exudation. All the symptoms are aggravated at night.
The constitutional symptoms are well marked in periostitis.
If the disease be acute there is a high degree of inflammlatory
fever; if' chronic, the system is gradually undermined by the
continued loss of sleep, caused by the severe nocturnal sufferings. Emaciation, loss of appetite and spirits, and hectic, often
supervene, rendering the patient extremely miserable.
In the acute form of the affection the membrane is softer,
and loosened from  its connection with the subjacent bone; in
the chronic variety it becomes more dense, and adheres with
unnatural firmness.
When inflamimation does not become fully established, or, in
other words, if active congestion be only present, fibrin is exuded, and the swelling is termed a node, which, when arising
from syphilis, is denominated the venereal, when complicated
with the results of large (loses of mercury, the mercurial, or
the two causes may be combined, giving rise to the mercuriosyphilitic node.
If inflammation proceeds a step further, and the bone becomes involved, a purulent formation (abscess in the bone) is
the result, which not being able to approach the surface, from
the strength and non ulcerative property of the periosteum extends laterally, denuding the bone of its membrane.
The same process may be present in ossific structure as has
been heretofore related concerning inflammation occurring in
other textures; the inflammatory process having established
suppuration, gradual "'molecular disintegration" (ulceration)
of the bone may ensue, and if this be not restrained necrosis
may take place.
Sometimes, in the acute form of this disease, these termina



382         TREATMENT OF PERIO STITIS.
tions may become apparent in a short time after inflammation
has developed itself; if chronic, weeks and months may elapse
before caries or necrosis is established, but the patient will exhibit unmistakable signs of severe constitutional irritation.
Treatment.-The medicines that are of service in periostitis
are aur., calc., carb -an., caust., kali.-c., lyc., merc., mez., nit.ac., ruta, rhododen., staphys. and sulph., or croc., fluor-ac.,
magnes.-c., natr.-mur., petrol., pulsat., silic../Jurum should be prescribed when the periostitis has arisen
from  or is complicated with a mnercurio-syphilitic dyscrasia;
it is suitable for the nightly aggravation of the pains, and also
to nodes.  This medicine possesses considerable power over
inflammations of the membrane covering the bones of the
nose and palate, and may, if timely exhibited, prevent caries,
necrosis, or exostosis; it may likewise be used when the right
nasal bone and the superior maxillary are sensitive to touch,
when there is cramp-like tearing in the metacarpal bones, with
swelling of the samne; when there are nodes on the inferior extrernities, with stinging and burning. Also, when the patient
is of a scrofulous diathesis.
Calcarea carb. is adapted to a scrofulous habit, and is especially stuited to children, who, though they appear tolerably
healthy, are extremely weak, with bloated, distended abdomen,
uneasiness of the whole body, with trembling, languor, and
emaciation.
Kali-carb. is curative when there are aching and tearing
pains; if the parts around the knee joint are affected, or when
there is stiffness and tension of the part, with throbbing and
beating, tearing on the inner side of the foot and sole, tearing
in the tarsal joints, &c.; when the patient dreads the open air,
easily takes cold, loses his appetite, is affected with feverish
chills, diarrhoea, &c.
Lycopodium possesses a special influence on the periosteum
and bones; it is recommended for periostitis and ostitis with
nightly pains, even when occasioned by the abuse of mercury.
It may also be used when there are drawing pains in the bones
of the arms as far as the fingers, nightly bone pain in the elbow,




TREATMENT OF PERIOSTITIS.                    383
pains in the tibia when touching the part; all the limbs are
painful when touched or pressed. The pains are mostly drawing, tearing and pricking.  Sensation in the bones as though
they contained no marrow.
lMercurius. —This medicine should always be remembered in
periostitis, and in nodes, as it exercises considerable influence
on the periosteum and bones. It should, however, never be
administered when the patient has been previously subjected to
the action of the drug in massive (loses. The diseases of the
bones and periosteum that so frequently are encountered by the
homceopathic practitioner, when treating secondary syphilis, in
very many instances result from the injudicious administration
of mercurial preparations by old school physicians when treating the primary disorder.  It is recommended for nightly bone
pains, inflammation of the periosteum, characterized by stinging, boring and gnawing pains, becoming intolerable at night;
redness and swelling of the soft parts covering the bones;
sticking, cramp-like pains in the muscles or periosteum; boiing
pains along the tibia, and aching in the bones.
Manganum aceticum has been highly extolled for periostitis.
MJezereum. —This is a highly serviceable medicine, and should
be administered when there are nightly pains in the bones;
periostitis of the tibia consequent upon ulcers of the leg,
the parts being covered with a brown dry skin and surrounded
by reddish-blue spots, with violent burning pains caused by the
slightest pressure; swollen periosteum; the pain is so violent
that it is impossible to place the foot on the ground; nightly
aggravation of the pains, with cramp in the calves; violent
tearing in the left ulna, or in the fore-arm  and elbow; pain in
the periosteum  of the right olecranon, which is much aggravated by pressure; violent pain in the tibia after midnight, as
if bruised, or as if the periosteum would be torn off, with chilliness passing rapidly through the whole body, and continual
violent thirst; dull darting in the middle of the tibia or in the
periosteum covering that bone.
JVit.-acid has been used with success in periostitis and diseases of the bones, and especially when the inflammation is




384       TREATMEMT OF PERIOSTITIS.
chronic; when there is tearing in the bones of the limbs, pain
in the periosteumn of the os calcis, drawing pain in the periosteum
of all the bones, pain in all the limbs, apparently in the bones.
Ruta should be employed when the pain resembles that
caused by a bruise, aggravated by the slightest touch; it is
also recommended for contusions and injuries of the bones and
periosteum; bone pains with burning and gnawing in the peiiosteum, which increase during rest, relieved by motion, and
are worse in damp and cold weather.
Rhododendron.-Tearing pain in the right tibia; sharp pains
in the left tibia, commencing in the knee, as if in the periosteum;
boring, beating pain in the right tibia; tearing, as if in the periosteum, in tihe right arm, only when at rest.  Almost all the
suflerings reappear, or are aggravated, at the approach of rough
weather.
Staphysag'ria and sulph. have also symptoms that may be
present in periostitis, but for the precise indications of these, as
well as the other medicines before mentioned, the student must
refer to the repertory and symptomen codex.
By the administration of some of these medicines the disease
may be arrested before the inflammatory process has reached
the suppurative stage; at all events, many of the most distressing symptoms of the patient certainly will be alleviated, thus
rendering him comparatively comfortable.
But when pus has formed and collected beneath the periosteum, the matter must be evacuated, and that as speedily as
possible, or caries and necrosis may be the result of delay. If
the operation of dividing the periosteum be performed, as soon
as the surgeon has satisfactory reason to believe that matter is
present, simple ulceration only may have taken place, and as
soon as the pressure occasioned by the pus is removed, the reproductive process will in all probability complete the cure in a
short time.  But although this practice is eminently beneficial
in acute abscess of the bone, it must never be employed unless
the signs of suppuration are sufficiently obvious to render it
certain that pus is accumulating rapidly and in quantity, between bone and periosteum.  Cod liver oil, (ol. jec. asc.) has




CARIES.                         385
been employed by practitioners of our school for this disease,
when it arises from a scrofulous taint.
Section 2.-Caries.
Ulceration of bone.
The term caries is used to denote a peculiar ulceration of
bone, in which reparation is scarcely effected by nature, and is
with difficulty obtained by the most skilfully applied artificial
means.* Or, according to Mr. Miller,t a breach of continuity
of bone of altogether a peculiar kind; of itself very (lifficult to
cure, yet not in any degree partaking of truly malignant action.
Every portion of the osseous system is liable to be attacked
with caries; but it has been observed that those bones that
partake most of the cancellated structure are more frequently
the seat of the disease than those of a more firm and compact
conformation; thus the vertebrae, the bones of the carpus and
tarsus, the sternum and the extremities of the long bones are
the most frequent seat of this disease. For a similar reason the
ossific structure in young persons is more subject to it than
those of advanced years.
Surgeons of the olden time confounded caries with necrosis,
the latter being termed by them dry caries; others have considered it the same as necrosis.  These suppositions appear the
more strange, when we consider that the caries was described
by Galen as being somewhat analogous to ulceration of the soft
parts.t
It has been previously remarked that ossific matter, when
attacked by inflammation, becomes acutely sensible, hence, in
the commencement of this disease, in which the inflammatory
process is always present, the patient often suffers considerable
* See Liston's Elements of Surgery, p. 70.
t Principles of Surgery, p. 435.
* See Cooper's Surgical Dictionary, vol. i., p. 320.
25




336                     c A R I E S.
pain; so great in the generality of instances as to prevent the
enjoyment of repose for weeks and months together. The
affected part is considerably swollen, but the enlargement is
seldom so general or so great as is present in the diseased condition of the ligaments and other apparatus of the joints,
although affections of the bursae, ligaments or synovial membrane may in time extend to the adjacent bones, and breach of
continuity be the consequence.
In caries, the affected portion appears neither to possess vital
action enough to enable it to repair the solution of continuity,
nor is the diseased mass sufficiently deprived of vitality to be
thrown off by the surrounding tissues. When the affected
parts have remained a considerable time in this inactive state,
the surrounding vessels become somewhat excited, and the surface of the bone in the vicinity is studded with small points of
new osseous formation; these new deposits, however, are not
limited to the affected bone, but may be traced to those with
which it is articulated. The soft parts surrounding the diseased
mass are commonly more or less thickened, and rendered exceedingly dense by effusion of lymph into the cellular tissue,
which sometimes becomes of a cartilaginous hardness.  As the
ulceration proceeds, a cavity forms in the bone, with soft spongy
margins with an unequal bottom, deep at one portion and comparatively shallow in another; the substance of the bone may
crumble easily, or the part may be covered with pale and unhealthy granulations; often a loose, fungous growth sprouts
from the interstices formed on the surface of the diseased bone,
bleeding readily at the slightest touch; from  the decaying
structure also a thin, fetid and corrosive ichor is discharged,
in many instances through a sinus which has been formed in the
soft parts; these symptoms, however, as well as the tendency
in the accompanying ulcer or sinus to produce large fungous
granulations, are more constantly met with in necrosis than
caries, for the latter disease has been known to exist for a considerable length of time unattended with any outward sore,
abscess or sinus.
A superficial caries may be ascertained without much diffi



CARIES.                         387
culty, and when the affected bone is deep-seated it may be discovered by the use of the probe; for if the disease exist, the
surgeon can often readily detect the inequalities of surfiace,
and, owing to the spongy character of the diseased part, the
instrument can readily be made to penetrate the substance of
the bone; in some instances, however, when there exists the
unhealthy granulations already mentioned, a moderate degree
of force is required; the latter fact, if remembered, may prevent in some instances an incorrect diagnosis.
There are some bones which may be diseased, and which,
from their situation, do not admit of the use of a probe; in
such cases the diagnosis may be more difficult; however, if a
fistula, from  which a fetid, corrosive and dark-colored matter
is discharged, be found leading directly from the surface of a
bone, and if the surrounding part be at the samre turgid and
indurated, there is every reason to suppose the existence of
caries.
" If a person," writes Boyer,* " affected with certain constitutional disease, feel deep-seated or acute pains in any of his
bones, and if the pained part swell and become the seat of an
abscess, from which a purulent matter of a bad quality flows,
there is reason to believe that the bone affected with pain is
carious.  Inert abscesses are attended with nearly the same
symptoms, with this difference, that they are not preceded by
pain. Caries occasioned by syphilis affects most commonly the
tibia, os frontis, ossa nasi, ossa palati, and sternum. Whenever, therefore, any of these bones become carious, whilst the
person labors under syphilis, there is just ground for concluding
that the caries is a symptom of the venereal affection.
Caries may be divided into three varieties, simple, scrofulous and tubercular. The simple form is such as has been described; the scrofulous variety is dependent on a constitution
affected with scrofula; and in tubercular the disease is accompanied by deposit of tubercle in the loose texture of the bone.
* See " The Lectures of Boyer upon Diseases of the Bones, Arranged by
Richerand, Translated by Farrell, and Edited by Joseph Hartshorne, M.
D.," p. 167.




388           TREATMENT OF CARIES.
The causes of caries are various. It may arise from disease
of the soft parts-ulcers, &c., having extended to-the bone, or
constitutional taint may be the remote, and recent injury the
proximate cause, but probably the disease most frequently arises
from scrofula, syphilis, or abuse of mercury.
Treatment. —Much vigilance should be exercised, with a view
to prevent the occurrence of this morbid condition; therefore,
if there be ulcers, abscess, &c., in the soft parts, which appear
to have a tendency to involve the bones, they must be carefully
watched and judiciously treated.* If simple suppuration occur,
as a consequence of diseased periosteum, the medicines before
mentioned for periostitis should be administered, in accordance
with the presenting symptoms.
By careful watching, the formation of matter may be averted;
but to accomplish such desirable result, the treatment must be
commenced early. When there is merely an inflammation of the
bone, with slight swelling, redness of the integument, and extreme sensibility to touch, bryonia and pulsatilla are recommended. The latter being more adapted to the disease when
it occurs in persons of a phlegmatic temperament, with mild
disposition, apathy, &c.; the former deserving preference if the
patient be of a dry, meagre habit, with bilious or nervous temperament. MJercurius is an important medicine for ostitis as
well as periostitis, and by its administration the inflammatory
action occurring in the bone may be checked before other untoward symptoms present themselves.  The indications for the
administration of this medicine, as well as others, have been
mentioned in the previous section. If inflammation of the bone
is chronic, the following medicines may be resorted to, according to the correspondence of symptoms in each indivi(lual case,
asaf., calc., phosph., phosph.-ac., silic., staphys., and sulph.
When the affection has arisen from the abuse of mercury, and
the disease is accompanied with mercurial, or mercurio-syphilitic
symptoms, aurum, hepar, or nitric-acid may be used.  If from
a blow or bruise ostitis threaten, arn., calen., ruta, or symphy* See Abscess Chap. IX. —Ulcers, Chap. X.




TREATMENT  OF CARIES.                      389
tum, may be employed; but when there is considerable erysipelatous redness around the wounded part, bella. may be used,
and in some cases in alternation with arnica.
Other medicines that have been serviceable in the treatment
of bones are, baryta., carb.-veg., dulc., fluor.-ac., lyc., mang.,
mez., staphys., &c.
If a patient affected with caries apply for relief, the first duty
of the physician must be, if possible, to remove the causes
which have either proximately, remotely, or both, given rise to
the disease.
The paucity of symptoms recorded in our Materia Medica,
belonging to caries, makes it difficult to select appropriate
medicine for each case.  The medicines mentioned, however,
have proved beneficial, ex usu morbis, in the treatment of this
disease. The following cases were cured while subjected to the
use of the medicines which are appended:*
Caries of the right fore-arm and right leg, with much swelling, ichorous discharge and slow fever. china, asaf., phosph.,
suiph., silic., acid-nit., carb.-an.
Caries of the fore-arm after a fall, arn. 24, silic. 30, caic.
30, sulph. 30.
Caries of the leg, sulph, silic.
Caries of the elbow joints with fistulous ulcers of the bone,
calc., silic., lycop., and sulph.
Caries of the thigh in a scrofulous boy, sep. 30, and nit.-ac.
Caries of the lower jaw with fistula of the parotid gland,
silic.
Caries of the bones and face, calc. and silic.
Caries of the phalanges of the third middle finger, silic. 30.
Caries of the foot, with hectic fever, am., lyc., silic.
Caries of the radius, with bluish red swelling of the fore-arm,
with hectic fever, puls., mez., sabin., silic., calc., lyc.
Caries, syphilitic, of the palate and nasal bones, aur.
Caries, syphilitic, of the alveolar processes with ozcena,
aur.-mur.
* See A Guide to the Practice of Homceopathy, by Edward Hamilton,
M. D., p. 44. London, 1844.




390            TREATMENT  OF CARIES.
Caries of the tibia, with swelling of the whole foot. The
slightest touch cannot be borne, fetid ichorous discharge, silic.,
asaf. 1S, calc -carb. 30, mez. 18, sulph. 30, acid-nit.
Caries, recent of the tibia, silic. 30.
Caries, tibiae, in the inner side of the left leg, a very painful,
bluish ulcer, with hard edge; a fetid, dark colored pus exuding; at the inner side of the left ankle a cold tumor, asaf. 18,
gatt. 1.
Caries of the tibia and left fore-arm, with many fistulous
ulcers; sinking of the vital powers, and debilitating diarrhmea,
suiph., asaf., acid-nit., and acid-phosph.
-.saf. In a caries of the leg with exfoliation of a piece of
dead bone.
/Aurum. Caries of the palate and nasal bones from abuse of
mercury.
JVit.-ac., with the assistance of silic., asaf.. calc., mez., and
sulph., in caries of the tibia, with great pain in the bone, and a
bad colored, fetid ichor discharged from the ulcers; in a boy
eight years of age.
J.ngustura is said to have cured caries, when given daily
in doses of the 1st to 6th. The use of coffee being avoided.
Sepia. Caries femoris, with fistulous openings on the outside
of the thigh, discharging a watery ichor. A probe introduced
into this after a long progress towards the knee, touched a
rough carious spot upon the bone. At the lower extremity of
the radius there was an enlargement of bone, which was painful when touched, sepia, and after six weeks acid-nit., effected
a cure in little short of two months.*
In caries ossium digitorum, silic. has proved very serviceable.
Fluoric acid is said to possess a powerful action upon the
osseous system, and from recorded cases appears to be especially adapted to caries.t
* See Jeanes' Practice of Medicine.
t See Laurie's Homoeopathic Practice.




NE CRO S I S.                   391
Section 3. —Necrosis.
The term Necrosis, which literally means only destruction,
is by surgeons applied to bone deprived of its vitality. It was
first used in this particular sense by M. Louis, who restricted
its appellation, however, to cases in which the whole thickness
of a bone was destroyed.  The ancients termed the disease
"dry caries."
Between caries and necrosis, says Weedmann, there is all
that difference which exists between ulcers and gangrene, or
sphacelus of the soft parts.  In caries, the nutrition of the bone
is impaired, and an irregular action disunites the elements of
bony structure, which consequently sustains a loss of substance.
In necrosis, on the contrary, the vitality and nutritive function
cease altogether in certain portions of the bone, the separation
of which then becomes indispensable.
Bones are not as extensively supplied with blood vessels as
other textures of the body, and their natural powers are inferior
to those of the softer parts; and this circumstance may serve
to explain the frequent occurrence of the disease under consideration.
Necrosis may appear at various periods of life, but is most
commonly met with in young subjects, in whom the inflammatory action is allowed to make some progress before it is noticed
or attended to. It may affect the external or internal structure
of a bone, or nearly its whole thickness. An entire bone seldom dies in consequence of increased action; and it is in rare
instances that the whole thickness of any portion of it is found
necrosed,* although a large proportion may be involved.
Mr. Miller divides the process of necrosis into several stages.
1st. The bone or portion of bone inflames. 2d. The bone dies.
3d. The dead portion is separated from the living. 4th. Separation of the dead portion is complete. 5th. The dead portion
is extruded.
The following symptoms characterize the whole process.* Liston's Elements of Surgery, p. 75.




392                     NECROSIS.
Intense pain is experienced in the part; and as there is no very
prominent swelling in the commencement of the disease, the
sufferings are generally attributed by the patient to rheumatism
or neuralgia. The pain which was first felt about the middle
of the bone, extends towards its extremities-that is, if one of
the long bones be affected. The part then becomes somewhat
swollen; the surrounding integument is inflamed; and the
tumor, which was at first hard, becomes soft and fluctuating,
and gives evidence of the formation of abscesses: these are
either allowed to open spontaneously, or the pus is evacuated
by incision; in either case, however, fistulae form, through
which there is a frequent discharge of a thin, fetid, and often corrosive ichor. The surface of the bone, if not deep seated (as
the tibia), is often visible through the fistulous orifices, in
which case the nature of the disease may be readily ascertained: if the bone is well covered by other textures, the surgeon must have recourse to gentle probing.
When the disease has not far advanced, there is a copious
discharge of purulent matter,* and the external openings,
through which the pus finds exit, are found to lead to cloaca,
or apertures in the new bone which encases the old; through
these the dead portions can be discovered by the probe. Sequestra are also sometimes cast off, the hue of which resembles
that of ossific matter which has been for some time buried in
the earth. When a sequestrum is discharged, the disease may
be considered at its height; for nature is throwing off the dead
structure, which can no longer be of any service to the economy. Often at this period, by introducing a probe, several
pieces of detached bone may be readily felt. These symptoms
of necrosis, thus evident in affections of those bones that are
covered with thick muscular fibre, are still more so in cases of
flat superficial bones, and those of the skull: in disease of the
latter, the skin at first becomes thick, hard, and reddish; but
* " Formation of matter is occasionally the cause of necrosis. I have
seen several instances in which it occurred from neglected erysipelas of the
leg." Liston's Elements, p. 76.




NECROS I S.                      393
soon ulcerates, and discharges matter of the character before
mentioned.
The prognosis varies according to the situation of the bone
affected, and the circumstances with which the disease may be
complicated. If necrosis occurs, and is confined to a small surface of a bone, it is not very difficult to cure; but when large
portions of the osseous system are involved, andi if the introduction of instruments be required to separate the exfoliated
portions (sequestra), the prognosis is extremely unfavorable.
In cases of necrosis, in which the dead bone is entirely inclosed in that newly formed, the prognosis may vary, according
to the state of the surrounding soft parts, the age and strength
of the patient, and the form of the new osseous substance.
The tumefaction of the limb may be excessive; the fistulae numerous; the suppuration abundant; and the patient reduced by
colliquative diarrhcea and hectic: under such circumstances the
danger is much greater than if the suppuration were trifling,
the patient young and healthy; and favorable termination of
the disease may be anticipated, if, together with these latter
conditions, the newly formed bone is perforated by nature, that
the dead portion may be readily withdrawn.
The causes of necrosis may be divided into internal and external:* among the latter may be classed-contusion, excessive
pressure, imprudent application of caustic,t &c.; and of the former, syphilis, scrofula, or mercury.  In persons thus constitutionally affected, a blow, or other external accident, may prove
an exciting cause of the disease.
Concerning the death of bone, and the reproduction of new
ossific matter, Dr. Gibson writes:$ "So far as opportunities
have been afforded me of ascertaining this point, I have no
hesitation to express the belief, that the periosteum is the chief
agent in both processes.  If from any cause the periosteum in* See Boyer on the Bones, p. 159.
t As happened in the case of a woman, who had caustic potash applied
to an exostosis on the internal side of the tibia.
f Institutes and Practice of Surgery, vol. ii., p. 55.




394          TREATIMIENT OF NECROSIS.
flame, and matter is poured out between it and the bone, so as
to separate one from the other, all vascular intercourse must
cease —or, at least, the bone then depends exclusively for its
support upon the internal periosteum and marrow; but these
being inadequate to furnish the requisite supply, a part or the
whole of the bone will necessarily perish."
Violent inflammatory fever attends the excited action of the
bone and periosteum, which precedes necrosis. But, after the
matter has accumulated, and been discharged, most of the painful symptoms subside.
Frequently fresh collections of pus are generated, as each
portion of the dead bone approaches the surface. When the
effusion of new ossific material has extended to the neighboring
joint, its motion may be very much impeded, and if the limb is
kept at perfect rest, anchylosis may occur.
Treatment.-In the treatment of this disease,* as in caries,
the great object is prevention; by the successful treatment of
ostitis, periostitis, caries, and of the constitutional affection (if
any be present), upon which death of the bone may follow as a
consequence.
One of the principal indications is the evacuation of the purulent formation, which frequently bathes the inflamed bone and
detaches from it the periosteum.
Separation of the sequestrum may be hastened by the administration of medicines, which, acting beneficially upon the surrounding osseous structure, tend to increase the action by which
exfoliations are cast off. The affected part must be allowed
to remain at rest, and all stimulating applications avoided. In
the first stage of the disease, if there should be severe or extensive inflammation of the soft parts, acon., bell., bry., hepar.,
merc., or sulph., are indicated.
/lsaf., calc., phosph., silic., sulph., and, according to some
" For an interesting paper on this subject. see Quarterly Homeepathic
Journal, vol. i., p. 86-an article entitled,' "Case of Necrosis of the Posterior Portion of the Superior Maxillary Bone, and Gangrene of the Gums and
Cheek." By J. Lloyd, Martin, Md.




TREATMENT OF NECROSIS.                    395
authorities, symphytum, when properly prescribed, materially lessen the tendency of parts to renewed inflammatory action, and also exert a specific action upon the osseous system;
either of them may be administered, according to the presenting
symptoms, to hasten the separation of the dead from the living
bone. After this is accomplished, it is the duty of the surgeon
to interfere, and, by the requisite incisions and proper mode of
extraction, liberate the necrosed portions of bone-w —hich, if
allowed to remain, acting as extraneous matter, irritate the
parts and give rise to increased inflammation, and profuse suppuration.  But the surgeon must ascertain that the sequestrum
is entirely detached before attempting its removal. On this
point Mr. Miller writes: "A common error in practical surgery
is, interference with the sequestrum before it has become loose.
To lay hold of it, and use violence, after exposure by incision, is certainly to induce a combination of evils. The evulsive effort fails, and consequently the patient has been put to a
grave amount of pain, unnecessarily and fruitlessly. By the
violence, inflammatory reaccession is certainly induced in and
around the part originally implicated. In other words, a fresh
ostitis-probably, both acute and extensive-is induced; and
aggravation of the necrosis is most likely to follow. Also the
loss of blood which attends on such attempts, whether successful or not, is invariably considerable; coming from a wound of
soft parts, which are not only unusually vascular, but besides
unfavorable to natural hemostatics. And the patient's state of
system is generally such, in the advanced stages of necrosis, as
to be altogether intolerant of a repetition of such hemorrhages.
Therefore, on this last ground alone, it is plain that the operation for removal of a sequestrum should never be undertaken,
unless the surgeon be tolerably certain that his efforts will then
prove successful.
"In probing, the simultaneous use of two instruments is
sometimes advantageous. One probe resting on the end of the
sequestrum,: a second is introduced through another cloaca;
and by pressing with each alternately, looseness of the seques



396          TREATMENT OF NECROSIS.
trum may be made plain in circumstances otherwise extremely
doubtful."
If the disease arise from syphilis, or scrofula, or if from scorbutic symptoms complications arise, the medicines must be
selected with the view of meeting, if possible, both the constitutional vice and the local affection; although in many cases
by removing the former, the latter will also be remedied. If
the disease originate from injury, the application of arnica externally, and the administration of a few globules of the same
medicine, greatly relieves pain.
A.saf., in alternation with phosp.-acid, have cured necrosis;
and these two medicines with nit.-ac., after an improved secretion of pus had been induced by sulph., cured the disease, which
was situated in the shaft of the tibia.
Calc. carb. effected a great improvement in a necrosis of the
tarsal bones, in the case of a boy.  Shortly after the administration of the medicine, there was a separation and painless discharge of a large spiculum of bone.
J/it.-ac., preceded by a dose of sepia, proved very efficacious
in an osseous swelling above the knee on the external part of
the thigh, from which portions of dead bone were discharged.
Silic. In a case of diseased phalanges, occurring in a female
of sixty-two years of age, who had for a whole year covered
the part affected with all kinds of ointments; from the part a
necrosed portion of bone had been extruded; relieved the pain
in eight days; after the discharge of another sequestrum, a
cure followed.
A man, awt. 28, ann., fell from a tree, and seriously injured
his arm by striking it against a stump: for the space of four
months all motion was prevented; after which, though mobility in a degree returned, the limb was somewhat painful,
and at times quite rigid. Two years subsequent, several fistulous openings were formed, through which fragments of bone
frequently were discharged..Arnica relieved the pain. Silic.,
calc,, and sulph. effected a cure. A remaining stiffness of the
joints was removed by colocynth.*
* See Jeanes' Homepathic Practice, pp. 55-57.




E XOS T OSI S.                     397
The forceps are the best adapted instrument for the removal
of sequestrum: in many instances, when the dead portion
of the bone is large, the ordinary forceps of the pocket case are
too small, and not possessed of sufficient strength; therefore,
in their stead, strong, blunt pliers, somewhat resembling those
used by locksmiths for twisting wire, should be substitutedwith this difference, however, that the blades and handles
should be somewhat larger. By means of these the dead portion is firmly grasped, and moved to and fro to ascertain the
complete freedom of the bone from surrounding structures, and
then by steady traction the sequestrum may be brought to the
surface-leverage being used, if necessary.
Section 4.-Exostosis.
Exostosis is a preternatural growth of ossific matter, generally producing a circumscribed swelling on the bone upon
which it originates.*
The formation of exostosis is similar to that of new bones; a
plasma is exuded and becomes organized; then it passes into
transitional cartilage, and thence the osseous structure is gradually completed. At one time the term was made to include all
growths —fleshy, osseous and cartiliganous — but with propriety it is limited to growth of bone from bone.t
Sir Astley Cooper writes, " Exostosis has two different seats;
it is either periosteal or medullary. By the periosteal exostosis
I mean a deposition seated between the external surface of the
bone and the internal surface of the periosteum, adhering with
firmness to both surfaces; and by the medullary is to be understood a formation of a similar kind, originating in the medullary
membrane and cancellated structure of bone."
With regard to the nature of this disease, it is found to con" Cooper and Travers' Surgical Essays.  Exostosis, by Mr. Astley
Cooper. See p. 123.
t Miller's Principles, p. 475.




398                    E XOS T O S I S.
sist of two varieties. The first is the eburneous, or dense ivorylilce exostosis, and the other is the common cancellated exostosis.  The first is smooth, shining, and presents a polished
appearance, resembling ivory or pearl, is solid throughout, and
appears almost destitute of those vessels by which an internal
circulation is carried on. It usually appears on the flat bones,
especially on the cranium, but the most frequent site of this
form of the disease is the supercilliary ridges.* The growth of
this tumor is slow, and it is often unattended with pain.
Cancellated exostoses appear to be mere enlargement of processes of the parent bone, the cancellated tissue extending itself
and forming the interior of the new bony formation, while the
exterior resembles a proportionate extension of the outer lamina.t
This kind of exostosis seldom occurs but in the long bones of
the extremities, and is most frequent in the femur at its lower
part. The cancellated texture usually predominates; the external laminae being thin and delicate.
Exostosis, according to Boyer,$ rarely proceeds from an external cause, such as contusion.  In most cases it is produced
by an internal disease, and principally by lues venerea, or
scrofula.
The effects of exostosis may be divided into general and special; thus the swelling is accompanied by a sense of weight,
pain is produced by the morbid action, and the affected part is
necessarily  deformed.  Its particular or special effects arise
from its situation; thus, if an exostosis forms in the orbit, the
eye is expelled from its cavity, and the patient deprived of
sight; if a tumor of this nature arise from the clavicle or sternumn internally, death might result by compression of the principal blood vessels.
The prognosis differs according to the nature of the primary
disease from which the exostosis originates, and according to
the particular change in the texture of the bone. The ivory
* See M'Clellan's Principles and Practice of Surgery, p. 343.
t Liston's Elements, p. 114.
f See Boyer on the Bones, p. 177.




TREATMENT OF EXOSTOSIS.                    399
exostosis if so situated that it does not impede the action of any
organ, is said to be the least dangerous of all.
Treatment. —The medicines that are best adapted to exostosis are am., asaf., calc.-c., dulc., led., lyc., merc., mez., phosph.,
rhus, sep., silic., sulph.  The primary ostitis must be treated
as before recommended, and if the disease still progress, any of
the above mentioned medicines may be selected in accordance
to the presenting symptoms. For exostosis syphilitica aur.,
bell., nit.-ac., and phosph. are recommended..Imrnica administered in a case of exostosis femoris, arising
from injury of the thigh by a blow, produced immediate relief
of the pain, and subsequent abatement of the swelling and suppuration.
flurum. Syphilitic exostosis and caries; nodes on the head,
fore-arm and tibia; extensive caries of the palate bones; discharge of fetid ichor from the nose; ulceration of the throat,
syphilitic rheumatism; excessive emaciation and debility; night
sweats. Ten grains of the first (lst trit.) of aurum. were triturate(l with two drachms of sugar. This was divided into eight
powders, of which the patient took one twice every day. The
medicine was thus taken for ten days, with evident improvement. Again, two grains of aurum. of the same trituration as
before, were mixed with two drachms of sugar. This was divided into six powders, of which the patient was directed to
take one every six days. In three weeks he was perfectly well,
and remained so at the end of three years. d/uruzm. also cured
entirely, in fifteen days, a swelling of the frontal, nasal and
superior maxillary bones, complicated with syphilitic ozcena
and rheumatism.
For exostosis after abuse of mercury, bella. has proved effectual.  It also was useful in a case of exostosis on the forehead,
with intolerable pain; the palate being covered with deep gray
painful ulcers, arisinig from the abuse of mercury.
Lycop. 30th, silex 24th, three doses, then mez. 24th, and
finally ledum., cured exostosis in the foot of a scrofulous boy,
eight years of age.
JIlerc. has proved very serviceable in exostosis of the tarsal
bones.




400         TREATMENT OF EXOSTOSTS.
Meez. Exostosis of the radius of the left fore-arm.  AJsaf.
had previously been administered in large doses. To counteract this, puls. 12 was given on the sixth day; me-., one
drop of the 6th, on the fourteenth day. On the thirty-first
day, silic. 18.  On the sixty-second (lay, cad. carb. 30.  The
improvement both in the local disease and the general health,
which had been progressive under previous medicines, continued
also to advance after the administration of calc., until the joint
recoveredl perfect mobility, the bone had regained its natural
size, and a fistulous orifice which existed at the commencement
of the treatment, had become completely cicatrized. The cicatrix was covered by a scurf, which, after the employment of
lyc. 30, speedily disappeared.
Phosph. has cured exotosis on the frontal, the parietal, and
occipital bones, from the size of a bean to that of a hazel-nut;
it has also, in the 30th dilution, proved effectual in the treatment
of large exotosis of' the clavicle, where the pain was intense,
aggravated by the slightest touch, of a tearing or boring character, with nocturnal exacerbations.
Sepia. At the lower extremity of the radius, enlargement of
the bone for a length of four inches; painful when touched;
sepia 30, and after six weeks nit.-ac. 30 effected a cure.
Silex. Exostosis femoris, in a man ret. 28 ann. The disease
commenced two years before, apparently from a blow on the
thigh.  Sticking, boring, and tearing pain in the anterior surface of the thigh, so severe that sleep was impossible. The
thigh was very much swollen from the knee to the groin.
The femur much enlarged. From the fistulous openings nearly
a pint of pus, mixed with blood, was discharged every morning
and evening, upon the removal of the dressings. The patient
was excessively emaciated, and suffered from 1" phthisis pituitosa" and constant sweat.  As the pain in this case appeared
to be an important symptom-since it had commenced with the
disease, and apparently originated from the effects of mechanical injury-and, as it had not diminished through the whole
course of the disease, arnica was prescribed. Immediately
after the administration of this medicine the patient slept for




SPINA VENTOSA —-OSTEO  CYSTOMA.    401
eight hours, and when he awoke the pain had in a great degree
abated. From this time there was improvement, as evinced
by increase of appetite, and abatement of the swelling and suppuration. The improvement continued progressive until the
tenth day; and on the eleventh, as there appeared to be a cessation of favorable symptoms, lycop. 28 was administered.
Improvement again commenced, and in its course the phthisis
pituitosa gradually disappeared.*
If the bony tumor is large, and medicines do not appear to
produce any beneficial effect, the surgeon may think proper to
remove it by mechanical means. This may conveniently be
(lone by the knife, Hey's saw, and trephine. Sometimes a
spring saw will be found to answer a better purpose than any
other instrument.
Section 5. —Spina Ventosa-Osteo Cystoma.
By this term is understood an expansion of a bone from a
collection of matter, which is not purulent but serous, or of a
glairy or gelatinous character. The cyst is not a pyogenic
membrane, but is composed of a structure resembling that
which is found in some encysted tumors. Its growth is slow,
but the bulk acquired may be enormous.t The disease may be
produced by external injury exciting inflammation, and consequently suppuration in the cancellated tissue; or the inflammatory action may be of a less acute kind, particularly in weakened and unhealthy constitutions. As the disease progresses,
the fluid accumulates, the cancelli are broken down, and the
much attenuated parietes of the bone are pressed outward. Occasionally the inflammatory action may be excited on the external surface, from the pressure of the contained fluid; and,
when this is the case, minute nodules of osseous matter are
effused, as if nature endeavored to strengthen the parietes,
* The above cases are taken mostly from Jeanes' Homceopathic Practice.
t Liston's Elements, p. 117.
26




402     sPINA  VENTOSA —OSTEO  CYSTOMA.
which from diseased action daily become thinner and more incapable of affording support. Sir Astley Cooper describes this
disease as a species of exostosis;* Boyert mentions it under osteo
sarcoma; but the difference between the latter and the affection
now under consideration appears to be, that in spina ventosa
the discharge is uniformly fluid and of a serous character, though
sometimes mixed with a cheesy matter, there is no fungus protruding after a portion of the attenuated bone has given way,
and the tumor is not of a malignant character.
There is considerable pain while suppuration is being established; but after the formation of matter the more acute sufferings subside, and in some instances there is but slight inconvenience, and the tumor remains stationary. In other cases
the enlargement is enormous, and the constitution of the patient
is very materially affected.t
Treatment.-Previous to the development of the disease, if
the patient complain of weariness, heaviness, and aching in
the limbs, arnica or phosph.-acid may be prescribed.  These
medicines are also suitable, if, upon careful examination, slight
swelling of the bone be detected, which is sensitive to pressure.
By the exhibition of those medicines, together with mezereum,
this disease may be arrested in its incipient stage.
JMerc.-sol., according to Hartmann, appears suitable when
the bone is swollen, but not much inflamed.  He further says,
" It seems to me, however, that inflammation was rather promoted, than arrested by mercurius; and I now never give it
until I feel perfectly convinced that it is adapted to this particular dlisease."
JIez. is a valuable medicine in the treatment of spina ventosa, particularly when psora, syphilis, or scrofula exist in combination, or the patient has been poisoned by large doses of
* See Gibson's Institutes and Practice of Surgery, vol. ii., p. 62.
t On the Bones, p. 182., For a very interesting case of Spina VTentosa of the Cranium, whicll
was skilfully and effectually removed by the late Dr. Geo. McClellan, sec
McClellan's Principles and Practice of Surgery, pp. 348-352.




OSTEO  SARCOMA.                      403
mercury. Although the proving of this remedial agent is not
as complete as it might be, still its general physiological character is sufficient to convince the student who examines the
symptoms that have been produced by this drug, that it must
be an admirable remedy for diseases of the osseous system,
particularly when there is swelling of the part and burning
pains, which are aggravated at night.
stsaf., phosph., sulph., and silic., the two last never lower
than the thirtieth potency, have also been recommended for
this disease.
Other medicines are: Calc., phosph., staphys., hepar, sepia,
&c.
Together with this treatment, a moderate degree of long
continued pressure upon the part may also be resorted to.
This method alone is said to have effected the cure of the
disease.
Should any of the large cylindrical bones be the seat of spina
ventosa, and after a thorough trial of remedial agents, the disease appears to be steadily advancing, amputation may be resorted to.*
Section 6.-Osteo Sarcoma.
An osteo sarcoma-as its name implies-is a tumor consisting partly of osseous matter, and partly of a fleshy substance.
This morbid change appears to be the consequence of inflammation, and its origin is frequently attributed to some mechanical injury or local irritation. In the commencement of the disease the bone is slightly enlarged, perhaps somewhat thickened
in its outer laininae; and if a section of it be made, it is
found to contain a brown fleshy substance instead of the usual
cancellated structure.t The osseous portions of the tumor are
* See Question of Amputation,
t Liston's Elements of Surgery, p. 115.




404                OSTEO S A R CO M A.
in the form of spiculae, radiating outward, leaving interstices
which are occupied by the sarcomatous tissue; partly cartilaginous, or fibrous, resembling ordinary fleshy substance, or cystic.
Most frequently it is composed of sarcomatous substance, containing portions of cartilage.* If the structure is composed of
cysts, these are lined by a secreting membrane, and it is thought
by some that on the perverted action of this formation that
the increase as well as peculiar structure of the disease depends.
By the pressure of the new formation, the parietes of bone
are forced outwards; in some cases attenuated, in others thickened by deposition of new osseous matter, inflammatory action
having been induced by the pressure. As the disease advances,
the bone becomes more attenuated, becoming in some places extremely thin, diaphanous, and somewhat flexible and elastic.
From the latter condition it would appear that the part of the
osseous system affected had lost its proportion of earthy matter.
The pains experienced by the patient are at first dull and
deep seated, but in a short time they become more intense, the
volume of the bone increases, though the soft parts appear yet
in their natural state.  The latter, however, soon become red
and inflamed; the pain becomes severe, and is lancinating in
character; the system is deranged, the tumor softens, often presents a sense of distinct fluctuation, and on being freely handled,
is found to crepitate in consequence of loose spicula of bone
being pressed against each other.  Ultimately the integuments
become livid, or dark red, ulcerate, and allow a portion of the
softened tumor to protrude, in the form of a frightful fungus.
There is profuse discharge, thin and sometimes bloody; and as
may be supposed, much constitutional irritation and exhaustion.
Not unfrequently during the progress of the disease, especially
if it be situate in the cylindrical bones, fractures occur either
from muscular contraction or external injury. This accident
gives rise to serious complication, as the process of reproduction in the diseased bone is very slow, if indeed, it is not altogether suspended, consequently the fracture does not unite,
* Miller's Principles, p. 482.




TREATMENT OF OSTEO SARCOMA.                  405
suppuration is increased, and the disease is therefore much
hastened.
Although after the protrusion of the fungus, the soft parts
are not readily involved, the tumor may properly be pronounced
malignant. At an earlier stage of progress it is confined to
the tissue in which it originated by laminae of bone, but after
this barrier has given way, it projects further through the aperture, and contaminates all the surrounding structures until again
held in check by bony formation.
In the commencement of this affection, several medicines may
be indicated in accordance with symptoms which present themselves, among which are bell., merc., mez., phosph., phosph.ac., nit.-ac., suiph.
If the constitution of the patient suffers severely from the exhausting suppuration, china or hepar should be administered.
If the disease has- been occasioned by a blow, arnica, ruta.,
rhus or symphytum may be called for.
From the action of thuja upon fungous formation, this medicine must be remembered, and should be prescribed if the sarcomatous formations are red and fleshy, pouring out blood profusely at the slightest touch, if the patient is debilitated both
in body and mind, and the symptoms are all aggravated towards evening or at night.
Calc.-carb. must be prescribed when the constitution presents
evident marks of scrofulous cachexy, and when the parts around
are red, swollen and indurated, with several fistulous openings.
Causticum and silicea may also be called for. And arsenicum or carbo-veg. may be indicated by the prostration, excessive thirst, dryness of the skin, and frequent shudderings.
In allopathic therapeutics the mercurial preparations are
often used. Sir Astley Cooper highly recommended the oxymuriate of mercury, and, according to other authors, the treatment has proved quite efficacious. The latter treatment is noticed in this place with the hope that some may be incited to
experiment with the mercurial preparation just mentioned.
If medical treatment fail, surgeons of the present day have
recourse to amputation or extirpation; the result, however, is




406              MOLLITIES OSSIUM.
seldom favorable, the disease returning with renewed vigor
either in the stump or in some other portion of the body.
There is another malignant disease of the osseous system, to
which the term medullary sarcoma is applied; it arises in the
cancellous structure, the pain being very intense, because the
affection progresses rapidly and the bone is mechanically forced
open, from the continued and increasing pressure of the diseased
mass in its interior.
The characteristics which distinguish malignant from nonmalignant tumors in bone, are that the former increase with
greater rapidity; are accompanied with more severe suffering;
are softer, and have a tendency to involve the subadjacent
textures.
The chief indication in the treatment of these tumors is to
commence early the medicinal treatment. Frequently, if the
primary affection can be subdued, or the constitutional symptoms successfully combated, the disease may be eradicated;
these ends may be accomplished by the treatment that has previously been mentioned for disease of the periosteum and bones.
The medicines that are best adapted to the medullary sarcoma are asaf., bell., calc., mez., merc., phosph., phosph.-ac.,
silic., or sulph.
Section 7.- Mollities Ossium and Rachitis.
Both of these affections are occasioned by a deficiency of the
requisite proportion of earthy material in the bony structure,
and differ only in this, that in the latter the cretaceous matter
is not deposited originally, while in the former it is absorbed
after having been deposited.
Softening of the bones, according to Liston,* " is met with
at all ages and in different degrees. It often follows dentition,
measles, hooping-cough, or other infantile diseases which in* Liston's Elements of Surgery, p. 80.




MOLLITIES OSSIUM.                      407
duce general debility; and in females it appears to be produced
by the weakening effects of leucorrhcea, miscarriages," &c.
Mercury, administered in inordinate quantities, also produces the
disease; but by far the greater proportion of cases are said to
depend on scrofulosis. As all other chronic dyscrasiae, the development of the affection is gradual; the first symptoms that are
noticed being generally those of derangement of the digestive
functions, alteration of secretion, &c.; by degrees, a material
change in the solids of the body takes place, particularly in the
osseous system, and the alterations of composition in the latter,
give birth to many functional derangements.
The gastric symptoms that are noticed, as precursors of the
disease, especially when children are affected, are: flatulence,
acidity of the stomach, distention of the abdomen, sour eructations, and vomiting. The appetite is impaired, the patient
usually desiring those articles of food which are particularly
indigestible, the countenance is pale and cadaverous, the urine
becomes turbid and cloudy, and if subjected to chemical analysis, is found to contain a superabundance of phosphate of'
lime, and probably benzoic and oxalic acids.
In children* there is much emaciation; the skin and muscles
become flaccid, the face is wrinkled, distorted, and resembles
that of the aged.  The growth of the child is arrested, walking is difficult, and in the more advanced stages altogether impracticable; the teeth become yellow, brown, or streaked transversely, are at length attacked by caries, and soon fall out.
During the progress of the disease the bones flatten and bend,
are soft, cellular, and of a brown color, contain a dark fluid,
and are very deficient in earthy matter. In many instances, this
latter component of ossific structure is almost entirely removed
-the bones consisting of an extremely thin external osseous
shell, covered by thickened periosteum, and containing a pulpy
substance resembling fatty matter. Although this disease has
been said by Mr. Liston to attack individuals of all ages, by
far the greater proportion of those affected are young children.
* lIartmann's Diseases of Children, p. 397.




408                TREATMEMT OF
Certain rare cases, however, have been recorded, in which all
the bones of the adult were softened to a very great degree.
The vertebral column is particularly liable to be affected
with rachitis, and the disease may be in certain instances confined to it alone. When the cervical vertebrae are attacked,
the anterior part of the neck projects, the head falls backwards, and appears sunken between the shoulders. When the
affection is general, the vertebral column becomes shorter, and
is curved in various directions; the breast becomes deformed,
not only in consequence of the curvature of the spine, but by
the depression of the ribs and projection of the sternum; the
bones of the pelvis fall inwards, and generally the pubis approaches the sacrum.*
According to the observations of Mr. Stanley, when the tibia
and fibula become affected they acquire increased breadth in
the direction of the curve, losing a proportional degree of
thickness in the opposite direction.t
The proximate cause of softening of the bones is involved in
much obscurity; various authors have endeavored to explain
the origin of the affection, in accordance with their own peculiar views. These conflicting suppositions, although possessed
of much interest to the curious, are of no practical value, and
therefore need no comment in this place.
Treatment. —In this disease great advantage is to be derived
from the general treatment; the patient, if residing in a city,
should if possible be removed to the country, where an elevated and dry situation should be chosen, nourishing diet, with
a moderate quantity of wine may be allowed, and the strictest
cleanliness, with regularity of habits, should be observed. But
as the poor, among whom the disease is most frequently observed, are not enabled to procure change of residence, the patient should be placed in a room that is well ventilated and
clean, and in temperate weather be allowed to walk or sit in
the sunlight. A straw or wheaten chaff mattress should be
* See Boyer on the Bones, p. 190.
f Med. Chir. Trans., vol. vii., p. 402.




MOLLITIES OSSIUM.                      409
used, as it is dry and does not yield to the weight of the body;
the clothing should be sufficient to prevent uncomfortableness
from extremes of heat and cold, and should be changed to
suit the variations of temperature. In the first stages of the
disease, when gastric derangements predominate, ipecac., bry.,
nux and verat. are indicated, and their administration is frequently followed by beneficial results.
In children, when the abdomen is hard and distended, the
gait unsteady and staggering, and the complexion pale, with
occasional flushes of heat, bell. is particularly indicated.
Stulph., catc., hepar and silic. are also powerful agents in
the treatment of' rachitis; by their exhibition the general health
improves, and the disease has been known to be arrested in a
short period of time. The attenuation of these medicines, however, is an important consideration; the practitioner will fail in
his endeavors if recourse be had to the lower, inasmuch as the
most beneficial results are more certainly attained by the administration of the thirtieth dilution and upwards.
Hartmann writes,* "I have employed with great success
brucea antidysenterica, particularly when the feet were turned
outwards and the children walked on the inner ankles."
In another work,t he further says, "According to my experience, it is in the preliminary stage that cod-liver oil will do
the most good, and actually effect a cure, and remove the danger of a relapse, provided a proper dietetic and hygienic regimen
is observed. The oil may be used internally, and at the same
time rubbed on the abdomen.  If no improvement should set
in after using the oil a fortnight, or if the child should evince
an insurmountable repugnance to taking the medicine, it is a
matter of course that some other remedy will have to be used.".lcid-phosph., ruta., staphys., mez., lyco., calc., and asaf.
may be indicated in the treatment of this disease.
According to Dr. Patzack, pinus-sylvestris is often of great
benefit in the treatment of rickets. The medicine may be used
internally and externally.
* Chronic Diseases, vol. i., p. 63.
t Diseases of Children, p. 401.




410                  TREATMENT OF
CurVathtre of the bones are either congenital malformations,
or constitute the most aggravated form of rachitis.  The same
medicines will therefore be indicated.*  But it must be clearly
understood, that together with the internal medicinal treatment
appropriate mechanical apparatus must be employed to retain
the parts in situ.  These consist of stays, belts and straps,
which must be selected by the surgeon as best adapted to each
particular case.  The mechanical means employed by Mr. Thomas Engall,t with so much success, in connection with homceopathic treatment, is here mentionedl:
"A  couch is provided, twenty-six inches wide, the same in
height,,and a foot longer than the patient, with head and footposts above the mattress; into the former a board is fitted, and
into the latter a winch, formed of a bar of iron, with a rack
wheel at one end, into which a catch turning on a centre in the
footpost, falls, and prevents its return when extension is made
by it; the floor of the couch is made throughout of wood, and
twenty-six inches from  the foot an iron bar is placed across it,
on which the floor turns, so that it may become an inclined
plane; on the under surface of the upper part a frame is placed
on hinges, which, falling into teeth formed on the side rail keeps
the floor elevated to any inclination desired; a footboard is provided, fitting, by means of two pins, into the end of the inclined
plane. On the floor of the couch is placed a horse-hair mattress, made perfectly firm and smooth, divided into three compartments.  The extension is performed by the winch, from
which two straps pass, which are attached to others coming
from  a belt fastened round the patient's pelvis, the head or
arms being fixed; when the former is the case, a well-stuffed
band is placed round the occiput, another round the chin, these
are laced together and secured to the headboard, when the latter two stuffed bands are passed under the axilla, and fastened
* For an interesting paper on the " IMechanical and Itomceopathic Treatment of Spinal Curvature," vide British Journal of IIomceopathy, vol. v.,
pp. 63-165.
-t British Journal of Homoeopathy, vol. v., p. 193.




MOLLITIES OSSIUM.                     411
like the former. Extension is not employed upon young children, nor upon cases in which the parts can be replaced without
it; hence it is inadmissible in cases of distortion from ligamentous lengthening, as it would only increase the malady. The
patient wears a common dress, all the garments made to open
behind, the stays to open in front also. In a case of posterior
distortion a pad is made the length of the spine, and nearly the
breadth of the back, so arranged as to cause at first very little
pressure upon the prominent parts; this is placed upon the
back, the stays laced over it, and the patient laid supine.
Every morning the stays are opened in front, and the chest
well rubbed, Florence oil being used to prevent abrasion of the
skin and to relax the parts; the oil is then washed off, the
stays laced, the garments drawn on at the feet first, and the
patient turned prone in a sheet held tight at the side; the stays
are then unlaced behind, the pad removed, and the back treated
as the chest, (luring which time the spine is elongated; after
this process the pad and stays are replaced, the garments fastened, and the patient again turned supine, which position is
constantly maintained. In the evening the dress is unfastened
and drawn off at the feet, everything being remove(l in this
way except the stays and shields; ordinary night habiliments
are worn, bed-clothes are drawn under, and placed over the
patient, who thus passes the night on the couch.  As the
patient can bear it, the pressure is increased by placing a splint
behind the pad, which is then termed a shield, and raising the
centre of it so that the ribs shall not be pressed upon; and, by
lessening the support of the parts above and below the protrusion, the pressure is also aided by the manipulation of the
medical attendant. For this purpose various instruments have
been used; but I prefer that formed by the Divine Artificer,
the hand, which possesses a sensibility so acute, as to inform
the mind of what is passing under it.  Every procedure in the
treatment should be gentle; if pain is felt by the patient, something in the arrangement is certainly wrong. The object of the
manipulation and pressure being to reinstate the parts, this end
must be attained by causing them to retrace their steps; hence




412     TREATMENT OF MOLLITIES OSSIUM.
the parts last protruded should be the first replaced; all the
means adverted to are aids; the recumbency suspends all muscular action; the extension destroys the form of the arch by
weakening the ends on which its strength depends; manipulation and friction assist these means. In semi-lunar distortion,
a back splint is applied to keep the parts in their natural positions; the lateral curve is reduced by means of a side shield,
which consists of a piece of wood half an inch thick, three
inches wide, as long as necessary, with pads at each end to
keep the centre hollow, in this case extending beyond the extreme ends of the arch, and applied on the concave side, over
the centre of which and round the convex side of the body a
broad band passes, which, aided by extension and pressure,
will generally succeed. A modification of this plan must be
adopted in double lateral distortion. In lateral distortion,
with a projecting shoulder from rotation, the posterior and lateral treatment must be combined. In this case it is of importance
to ascertain if the projection preceded or followed the lateral
distortion; if you cannot obtain this information from friends,
you will by observing the direction in which the spine most
readily yields. If the spine rotated before the curvature took
place, the curvature must be first reduced, and the projection
after; if the contrary, the projection must be first reduced; if
both originate at the same time, pressure must be applied in
the opposite direction to that in which it came out, by means
of a tilting-board sufficiently wide to press on the projection,
having another piece rising at right angles to it at one end, and
formed internally so as to press equally on the side and back of
the projection, which is covered by a properly adjusted shield.
On this the patient lies; by means of a block placed under the
opposite end, the inclination can be adapted to the requirements
of the case; a band fixed to the horizontal and buckled to the
vertical piece will increase the pressure as needed, and aid in
depressing the prominent parts of the chest. A modification of
this plan is also very useful in lateral curvature, where the ends
of the arch extend beyond the axilla, in which case the shield
on the concave side will be inefficient; here pressure on the




FRAGILITAS  OssIUM.                      413
convex side, with the prolongation of the splint above the
shoulder and to the ilium, without touching either, with a band
from each end extending over the opposite extremities of the
arch, will effect the desired intention. For simple lateral and
semi-lunar distortions, the pressure of the medical attendant
must be directed against the spinous processes, for which purpose an instrument made of either wood or metal, with a
rounded edge four inches long, and a handle attached to it,
will be found useful; in distortion from rotation, where the object is to untwist the spine, this pressure, for the reasons already
given, must be made on the concave side."
Section 8.-Fragilitas Ossium.
This disease occurs chiefly in old people whose osseous system contains an undue quantity of earthy material. Boyer*
states, that a certain degree of fragilitas ossium  necessarily
occurs in old age, because the proportion of lime in the bones
increases with age, while the organic matter decreases in the
same ratio; but Mr. Wilsont observes, that they are never
found so fiiable and fragile as to crumble like calcined bone, but
on the contrary contain a large quantity of oil. The latter fact
is also noticed by Mr. Liston,$ who gives as a definition of the.disease, that the bones become brittle on account of an undue
proportion of earthy matter, are endowed with little vascularity,
and are full of an oleaginous fluid.
In persons who have been long afflicted with cancerous diseases, the bones are said to become as brittle as if they had
been calcined. In inveterate syphilis, deprivation of organic
material in the osseous system has been noticed, and in those
individuals who have been frequently afflicted with severe
* On Diseases of the Bones, p. 197.
t On the Skeleton and Diseases of the Bones, p. 258.
f Elements of Surgery, p. 80.




414          DISEASES OF THE J01NTS.
attacks of scurvy, the bones become so brittle that they are
fractured from the slightest causes.
Treatment. —This disease, particularly when occurring in the
aged, is very difficult to cure, the patient should be allowed a
generous diet, and prohibited from much muscular exertion;
indeed all circumstances that would be likely to produce sudden action of any particular combination of muscles, should be
studiously avoided.
The medicines that are best adapted to this affection areruta, phosph.-ac., nit.-ac., and from the effects that have been
produceid by symphytum, this medicinal agent should exercise
much influence in this peculiar disorder. If the fragility of
bone depend upon constitutional affections, syphilis, scrofula,
S&c., great advantage may be derived from  the internal treatment of these diseases.
CHAPTER XXIV.
DISEASES OF THE JOINTS.
Section 1.-Synovitis.
THIS disease may be either acute or chronic. It generally
commences with severe aching in the joints, together with
shooting pain, sometimes extending into the surrounding parts.
After a short period of time the joint enlarges, becomes of a
reddish hue, is extremely sensitive to pressure, and symptoms
of severe constitutional disturbance develop themselves.  The
fever is intense, with redness of the cheeks, glistening eyes,
coated tongue, high-colored urine, and, in some instances, derangement of the digestive functions. The swelling often advances rapidly, and is caused by rapid effusion into the synovial
cavity. If the joint be superficial, fluctuation is distinct; the
inflammation may terminate in suppuration, and the formation




SYNO V I T IS.                    415
of purulent secretion within the cavity, to which the term arthropyosis is applied.
In chronic synovitis, the pain is not so severe and is of a
dull aching character, the part is but little sensitive to pressure,
and there is experienced a sensation of weakness and relaxation
of the limb.  The swelling appears a few days after the pain,
which in cases of an indolent character may be of trifling moment. To such, the term hydrops articuli is applied.
The disease may follow  local injuries, or be dependent on
constitutional causes; as rheumatism,  gout, syphilis, scrofula,
abuse of mercury, &c.  Children are seldom attacked; and the
knee joint is most generally the site of the affection. In such
instances the patella is protrudrled, and there is fulness at each
side of it, and also at the lower and anterior portion of the
thigh.  At the elbow, the swelling is most marked above
the olecranon: at the hip and shoulder articulations, there is
general swelling of the surrounding muscles.
The disease is considered of a serious nature when it arises
from penetrating wounds of the joint, as in such instances the
constitutional disturbance is so severe, that life is brought into
imminent danger.
Delirium and typhoid symptoms are very unfavorable. In
severe cases suppuration within the cavity may ensue, or ulceration of cartilage and complete anchylosis may result.
Treatment. —The limb should be kept at rest until the violent
inflammatory symptoms have been subdued-which may be
accomplished in the first stages by the employment of aconite.
This medicine is especially indicated by the severity of the fever,
and when there are drawing and sticking pains in the affected
joint, with tension, aching and gnawing; when the patient
complains of frequent chilliness and thirst, together with prostration and trembling of the limbs.
Bella. should be employed in acute synovitis, when there is
congestion to head, with flushed cheeks, &c.; when the pain is
excessive, with sensation as if the surrounding ligaments were
contracted; or when there is bubbling, as from drops of water
in the fore part of the knee, with cutting and drawing pains.




416        TREATMENT OF SYNOVITIS.
Calc.-carb. is more suitable to this disease when it assumes a
chronic character; when the patient is pale, debilitated, or of
a scrofulous habit; with drawing pressure in the joints; or
when the disease is accompanied with other affections of the osseous system.
Caust. may be employed when there is stiffness of the joints;
bruised, tearing, and sticking pain; profuse sweat; numbness
of the parts, and the sufferings aggravated in the evening.
Ledum is especially adapted to disease of the joints, but particularly to affections of the knee. It possesses a powerful
action on the absorbent vessels, and should be used in both
acute and chronic synovitis when there is effusion, with sensitiveness of the parts to pressure; aching, tearing pains; great
coldness, or constant chilliness.
lodiurn is an important medicine where there is much swelling of the parts, with erratic, tearing pains.
JIerc. should be prescribed when the disease is accompanied
with syphilitic complication; when there are drawing pains,
with aching in the bones, and rigidity of the parts; particularly
when the symptoms are exacerbated at evening and at night,
with profuse sweat.
Lycop. may be used if there is stiffness of the joints, when
the pains are relieved by warmth, and aggravated in cold rainy
weather.
Kali-carb. may in some instances prove valuable, when there
is aching in the joint, dread of the open air, and liability to take
cold.
Rhus-tox. is indicated, when, beside the ordinary pain, there
are stitchings in the tendons surrounding the joints, accompanied with tingling and burning, with rigidity of the joints; or
when there are sticking pains with stiffness, and especially if
the constitutional symptoms tend to a typhoid condition.
Sepia should be remembered when the patient is delicate;
or, if females are affected, when there are jerking, sticking
pains; or when the disease has been occasioned by violent
strains of muscles or tendons.




MORBUS COXARIUS.                       417
Silicea is also highly recommended for diseases of the synovial membrane, particularly that of the knee joint..Aur., calc., lyc., nit.-ac., phosph.-ac., sulph., together with
silic., have been found useful in inflammation of the synovial
membrane, in consequence of effects of mercury; and bry.,
china, lyc., nux-vom., rhus, and sulph., when the disease
occurs in gouty or rheumatic individuals.
Calc.-carb. and sulph. have been chiefly recommended in
lymphatic or scrofulous enlargements of the knee. If suppuration ensue, silic., merc., and hepar; and in that of serous infiltration, silic. and sulph., or calc., merc, and iodium.
Other medicines are: hell. (particularly in hydrops articuli),
ign., petr., phosph., rhod., ruta, stront., and sulph.
Section 2.-Morbus Coxarius.
The hip joint is exceedingly liable to disease: persons of all
ages may be affected, but children of a scrofulous habit are
particularly obnoxious to it. The disease has been supposed
by many to commence in the cartilages. It appears, however,
according to Mr. Liston, to originate indiscriminately in the
cartilage and the bone, as well as in the capsule and investing
membrane of the joint; but it is of little import what particular structure the diseased action invades.
The first manifestation that is experienced, is awkwardness
in moving the limb of the affected side, or slight lameness.
No severe pain is experienced; and, if there is any uneasiness,
it is generally referred to other parts, and particularly to the
knee.  This circumstance should lead the practitioner to close
investigation-for frequently other diseases than the true one
are diagnosed; and the patient may thus be led to believe, that
the affection under which he is laboring is slight and easily
curable, until the true nature of the affection is detected, when
considerable censure, with charges of dishonesty or insincerity,
may be cast upon the surgeon.
27




418                TREATMENT OF
The pain in the knee joint is generally the prominent symptom in this affection, but occasionally it is referred to the ankle
or sole of the foot. As the disease advances, severe suffering
is occasioned by moving the hip joint, or by suddenly forcing
the head of the femur against the acetabulum. The limb of
the affected side is apparently lengthened; the patient moves
with the hand grasped round the thigh, and otherwise contrives
to prevent the affected limb from supporting the body; the
spinal column becomes curved, and other deformity of the trunk
occurs.
The nates are much altered-they become flattened; and
those parts which are naturally the most prominent, are reduced
to the level of the surrounding parts. The inguinal glands enlarge, are painful, and emaciation of the limb is more and more
visible. If the disease still progresses, the leg is considerably
shortened; large collections of matter, occasioning much swell.
ing, are found behind the trochanter major, and the part assumes various accidental positions.  Sometimes it is turned
inward, as in dislocation of the dorsumn ilii; or outwards, as in
fractures of the neck of the femur.
Treatment.-In the first stages of morbus coxarius, when
the patient complains of pain in the knee, bella. is a medicine,
by the administration of which, in some instances, in alternation
with mercurius, the disease may be entirely subdued../conite
may also be used with great advantage in the commencement
of the affection. If there is tension of the part, with severe
pain, colocynth should be employed; and, if there are evening
exacerbations, puls. is indicated. The chief medicine, however,
is bella., which, according to Hartmann, is characteristic to the
pain in the knee, though this symptom is only symptomatic of
the disease of the hip. He has never used it below the 24th
dilution, and speaks in the most unqualified manner regarding
its action.
Rhus-tox. should be employed when there are darting, or
dragging, tearing pains in the hip joint, increased by pressing
the head of the femur into the acetabulum, accompanied with




MORBUS COXARTUS.                       419
tension or stiffness of the muscles; painful while at rest, but
increased when arising from a sitting posture.
Colocynth is particularly indicated when the pain extends into
the knee, and the patient experiences a sensation as though the
part were clasped with an iron band.
Cacl.-carb. removed the disease from a scrofulous child, who
without previous injury commenced to limp; in walking dragged one foot along the ground; complained of little or no pain,
except when pressing the femur into the acetabulum. The
diseased limb was longer than the other, and the foot always
turned outward.  In another case, tinctura acris cured the
affection.
Sulph., lyc., hepar, silic., zinc., mez., phosph., phosph.-ac.,
bry., cham., puls., staphys., and sepia, should also be remembered in the treatment of this disease.
Absolute rest must be enjoined; and the starch or dextrine
bandage,* leather or felt splint be applied. When shortening
of the limb has commenced, great comfort and advantage may
be derived by maintaining constant extension of the limb, by a
weight attached to the thigh above the knee by means of a
cord passing over a pulley at the foot of the bed. During the
suppurative stage, the patient's strength must be sustained by
nourishing diet, and hepar, merc., silic., sulph., or calendula,
be internally administered, and other means resorted to which
have been recommended in the treatment of abscess.
Dr. Physick's mechanical treatment was as follows:
After placing the patient upon a hair mattress, he then applied a curved splint, which was constructed in such a manner
as to fit the limb perfectly, extending from the middle of the
side of the thorax to the internal malleolus. This splint should
be wide enough to extend nearly half way round the limb to
* Dextrine is a substance obtained by the continued action of diluted
sulphuric acid upon starch at the boiling point. The bandages are soaked
in a solution of the dextrine in water, having been previously moistened
thoroughly with tincture of camphor, to prevent it from leaking when the
water is added. The solution should be of the consistence of molasses.




420           FUNGUS ARTICULORUM.
which it is applied; and, to prevent excoriation, the inside of
it is carefully wadded, and retained in its position by rollers.
After a time, when inflammation and swelling have been relieved, a straighter splint may be substituted.*
Section 3.-Fungus.idrticulorum.
In fungus of the joints the synovial membrane becomes inflamed, ulcerates, and is finally converted into a thick pulpy
substance, intersected by white membranous lines. There is
not much pain, but there is stiffness together with considerable
swelling of the joint, which is elastic, but there is no fluctuation. The tumefaction presents an irregular appearance, being
more protruberant in one part than in another, from the accumulation of fluid or solid matter in the directions where least
resistance is afforded by the surrounding tissues. Pus often
accumulates within the cavity of the joint, and the suppuration
is accompanied with much constitutional disturbance; or the
matter may be effused into the bursae, into the surrounding
cellular tissue, or into that beneath the tendinous sheaths of
the muscles in the neighborhood. After a time the capsular
ligament ulcerates, the pus is evacuated, and caries of the bone
is added to the already alarming disease.
It has been a matter of some difference of opinion, whether
in this affection there is enlargement of the articulating extremities of bone.  It is probable, that, in the first stages of the
disease, they are seldom or ever affected; but, as abnormal action increases, inflammation and ulceration of the osseous parts
ensue.  Frequently the knee is the seat of the disease; and
when this articulation is affected, the lymphatic glands in the
groin become sympathetically enlarged. The same fact may
be noticed when the swelling occurs in the elbow joint, in
which instance the axillary glands participate.
i For an interesting cure of AMorbus Coxarius, see Jeanes' Practice of
Medicine, p. 58.




FUNGUS ARTICULORUM.                       421
When the patient has suffered for a considerable time, hectic
supervenes, with its alarming train of symptoms, which are always aggravated after the opening of the abscess. Emaciation,
excessive debility, loss of appetite, night sweats, and diarrhoea
are also present. In some cases health is restored, and the
disease abates spontaneously; in others, complete cures are
effected by careful and judicious treatment. A method of resolution resorted to by nature is anchylosis, which may be either
ligamentous or osseous. New bone is deposited, whereby the
ulcers become as it were cicatrized, and the articulating extremities are joined by firm bony union.  The process of ossification is assisted by the effusion of lymph, and consequent thickening and induration of the ligamentous substance exterior to
the joint. By such means the parts are retained in exact apposition, and the calcareous matter is regularly deposited, as in
fractures retained in situ by the application of splints.
This disease, however, may again recur, and both ligamentous and osseous formation be destroyed by the ulcerative process. In many cases, however, the anchylosis remains permanent.
Treatment.-According to Hartmann, silic. is the principal
medicine in the treatment of fungus articulorum.  He recommends it to be repeated every eight (lays If it should not
effect a cure, the following should be employed (one dose every
week): /lnt.-crud, petrol., iod., clem., or sulph.
In the first stages of the disease, when there is inflammation
of the synovial membrane, acon., bell., mez., nit.-ac., phosph.ac., lyc., sulph., or calcarea, should be employed. When the
pulpy fungus makes its appearance, phosph., thuja, caust., or
sepia may be indicated. In the event of suppuration, silic.,
hepar, mere., or calend. should be remembered.
If the swelling is shining, white, soft, and doughy, puls. is
to be prescribed. In many cases iodine is useful, and may be
employed in alternation with puls. When the swelling is red
and very painful, bryonia would perhaps be more appropriate;
when there is serous infiltrations, ledum, calc., iodium, mere.,
or sulph. may be required.




422                 ANCHYLOS I S.
Of the imperfectness of the above treatment the author is
fully aware; but it should not create surprise, when the present unscientific arrangement of our Materia Medica is remembered. So long as catalogues of disjointed symptoms, recorded
with total neglect of the order of occurrence, and with entire
disregard of all pathological inquiry, have to be examined; and
when, together with these circumstances, the void in our literature, occasioned by the absence of recorded surgical diseases,
treated in accordance with the law of Hahnemann, is recollected, any result less defective could not be anticipated. We
are happy, however, to remark in this place, that such impediments to the advancement of true science will, in a short period
of time, be removed in a great measure, by the publication of a
complete Materia Medica by our English brethren, in which
symptoms will be arranged in connection with those diseases
with which they are most frequently associated.
Section 4. —.Jnchylosis.
By the term anchylosis is understood, an intimate union of
two or more bones, which were naturally connected by means
of a joint. All articulations originally designed for motion,
may become anchylosed. Conner describes a remarkable case
of this disease, in which there was general anchylosis of all the
bones in the body; and a still more curious case is recorded of
a child, only twenty-three months old, whose articulations were
universally affected.
Anchylosis may be spurious, ligamentous, or bony. In the
first case, when the joint is diseased, the extensor muscles become emaciated; the flexors are rigid, and may also be atrophied; and there is thickening of the synovial membrane,
together with contraction of ligaments. This variety often
follows acute synovitis, and should be considered as rather a
favorable termination of that disease. In ligamentous anchylosis, the union is effected by means of the union of the articu



TREATMENT  OF ANCHYLOSIS.                  423
lar surface by ligaments, and follows often upon disease of the
cartilage and compound dislocation. Bony anchylosis is produced by the formation of ossific matter within the cavity of a
joint, uniting the extremities of the bones. The symptoms that
accompany the disease have been already adverted to in the
chapter upon Morbus Coxarius.
Treatment.-In the first two varieties of anchylosis, much
service may be rendered by passive movement of the joint,
together with friction of the joint, and the internal administration of graph., rhod., rhus-tox., sepia, or sulph., and, in some
instances, chain., bry., lyc., and staphys.; and probably by the
early use of these remedial agents, together with passive movement of the joint, the disease may be cured. When we have
reason to believe that bony union is about to occur, phosph.,
phosph.-ac., mez., nit.-ac., silic., staphys., and sulph. may be
employed with advantage. When rigidity of muscles and ligaments produce immobility of the joint, bry., rhus-tox., ruta,
lyc., sulph. should be employed. The patient may also be
placed in an anaesthetic condition, from the inhalation of ether,
and the limb flexed and extended, even if considerable effort is
required. If these means fail, they may be of the utmost service after subcutaneous division of ligaments, which operation
has been performed with considerable success. In bony anchylosis excision of the joint may be resorted to; and from the testimony recorded in favor of such mechanical aid, we are led
to infer that the operation may be as successful as the generality of such as are now practised among modern surgeons.
Excision or resection of joints is not only practised in anchylosis, but also in articular caries, and may be resorted to in
either of these diseases, provided all other remedial measures
have failed. The operation is one of modern times, although
it was practised first in France, and with considerable success
by Moreau (father and son); but, either from prejudice, or
tenacious adherence to established routine, it was some time
before it became known among surgeons in England. Sir
Philip Crampton practised it once in Ireland, but his example
was not followed by others of the profession.




424        ECPHYMA CARTILAGINEUM.
In 1828, Mr. Syme, of Edinburgh, was bold enough to perform the operation on his own responsibility; and, in 1831, he
published a treatise upon the subject. However, the surgical
faculty did not appear to follow Mr. Syme's method, and
mainly on account (according to the latter gentleman's own
words*O "of the principles of its performance being overlooked." These consist mainly in the mode of making the incision, and cutting off the extremities of the bone.
The division of the integument should be free, and in the
form of the letter H, the same as that originally practised by
Moreau. When the flaps are raised and dissected back, the
articulating extremities of the bone are sufficiently exposed,
and should be cut off in portions, in order to avoid the risk
which would be incurred by severing a nerve; which, if any
are exposed, should be pushed aside, before proceeding with
the operation. After the removal of a sufficient portion of the
articulation, the wound closes neatly by the aid of sutures and
adhesive straps.
It may be well to observe here, that these remarks are especially applicable to excision of the elbow joint; but there can
be no doubt that similar methods may be resorted to in other
cases, although operations on the coxo femoral articulation are
attended with great difficulty and danger.
Section 5.-Ecphyma Cartilagineum; or MJovable Cartilage.
Foreign bodies, resembling pieces of cartilage, are occasionally met with, in the various articulations of the body. They
vary in number-from one to twenty-seven have been found
in the same joint; and in size, from that of a lentil to that of a
large kidney-bean. Their shape is quite as variable as their
bulk —sometimes they are round or oval, or they may be
* Vide London Lancet, May, 1855, p. 393. "Mr. Syme on Clinical
Surgery."




MOVABLE CARTILAGE.                      425
smooth or irregular. Those resembling in appearance ordinary cartilage, consist chiefly of albumen; while those that are
of a firmer construction contain a considerable proportion of
phosphate of lime.  The knee joint is their most frequent
location.
The etiology of this affection is very obscure; and, although
many opinions have been advanced, as yet little positive information concerning the origin and growth of these extraneous
bodies has been ascertained. However, certain it is that they
commence as pendulous growths upon the synovial membrane;
that the capsular ligament is distended with increased accumulation of synovia; that they increase in size; and, that they
more or less impede motion. They appear after swelling of a
joint, occasioned by a blow or fall; or they may arise without
any assignable cause. In either case, their presence is known
by the pain which is experienced by the patient, and by the
tumefaction of the part, which increases during rest, but subsides during moderate exercise. Authors formerly supposed
that these foreign substances were portions of articular cartilage, which from time to time had been torn away by external
injury.  This, however, was disproved by Morgagni; who,
from frequent experiment, found the cartilage of the joint entire
and perfectly healthy in those subjects in whose articulations
these movable bodies were met with in the greatest number.
It often happens that, after a time, the pedicle, which connects these abnormal formations to the synovial membrane, is
ruptured; and, in such cases, they pass from one part of the
joint to the other, and sometimes cause excruciating pain, by
becoming impacted between the articular extremities of the
bones. In the knee joint, they are very liable to fix themselves
between the posterior face of the patella and the pulley-like
surface of the femur. In some situations, the foreign substance
can readily be detected beneath the integument; and Dessault
mentions a case, in which they could be seized and twisted
with the fingers.
Treatment.-We know of no medicine that is homceopathic
to this affection. Indeed, from the position they occupy as




426           MOVABLE CARTILAGE.
foreign bodies, and their formation, as it were, sui generis, it
would seem that they were rather without the sphere of medicinal or vital action. Strictly surgical means are the only resort.
Surgeons have advised to force the cartilaginous formation to a
part of the capsule, where it will not interfere with the motion
of the joint, and there to retain it by bandages, straps, &c., to
endeavor to excite adhesive inflammation; however, such result
can scarcely ever be attained, and therefore operation must be
had recourse to. The patient, however, before proceeding with
any such means, should be candidly informed of the danger incurred in opening the cavity of the joint; should be told of the
ratio of successful performances of operation; and should be allowed to determine what course to be pursued. If he consents
to the operation, it should be performed in the following manner -
The patient having been placed on a mattress, or table, with
the leg extended in such a manner that the integuments of the
joint may be relaxed, the surgeon should search for the foreign
body, and having found it, should bring it to the inner side of
the patella, and retain it in that position. The integument immediately over it should then be drawn as tense as possible
with the finger and thumb (this may be accomplished with the
left hand of the surgeon, or by an assistant), and with a single
incision the skin should be divided. The foreign body can then
readily be pressed through the opening, and the wound immediately closed, to prevent the admission of air. If there is any
connection with the surrounding parts, they may be divided
with scissors or a sharp-pointed knife. Forceps, fingers, or
any instrument likely to bruise the joint, should never be
used.
The pain of this operation is trifling, unless a branch of the
internal saphena nerve happen to be divided. The wound may
be closed with isinglass plaster, and compresses moistened with
solution of arnica or calendula applied. It is after the operation that medicinal treatment is most important. To prevent
inflammation of the synovial membrane, it would be well to
immediately administer a dose of aconite; or, if other symp



DISEASES OF THE BURSIE.                  427
toms are present, those medicines already mentioned in the
treatment of synovitis must be employed. After the wound
has healed, spurious anchylosis may follow, which may be relieved by the administration of arm., thus, bry., or caust., together with moderate motion, which should be daily increased.
If the patient recover with partial stiffness of a joint, the operation may be considered as successful.
Fleshy and gristly tumors may produce the symptoms as related of movable cartilage-the treatment is the same.
Wounds of the joints may generally be known by the escape
of the synovial fluid, which commonly appears as small, oily
globules.  The desideratum in the treatment is to prevent inflammation of the synovial membrane (see synovitis). Immediately after the receipt of the injury, the parts should be
brought in apposition, the joint placed in a splint and perfect
rest enjoined. If the cavity of the joint is exposed, and cannot
be covered by integument; if the general health of the patient
is bad; the question of amputation must be seriously considered.
Section 6.-Diseases of the Bursae.
The bursae are lined by a membrane, resembling the synovial
in function, appearance, and disease; they are frequently the
seat of inflammatory action, which in the generality of instances
is of short duration, and terminates in an increased accumulation of the secreted fluid. The abnormal action may be either
acute or chronic, and may take place in those bursie situated
over the patella, olecranon, inner side of the head of the tibia,
the angle of the scapula, or about the carpal articulations.
When the inflammation is acute the pain is severe, and there
is much swelling and fever. The affection may be distinguished
from inflammation of the synovial membrane by the superficiality and regularity of the tumefaction. Occasionally the action terminates in suppuration; pus being effused to a greater or




428         DISEASES OF THE BURS2E.
less amount within the cavity. The affection is frequently encountered among servants; and inflammation of the bursae of
the knee joint is found particularly among females, who, from
resting upon their knees while performing household duties,
irritate the bursae; hence the term house-maid's knee. However, those in the higher walks of life are not exempt from the
disease. Chronic enlargement of the bursae on the metatarsal joint
of the great toe is also frequently met with, especially among
those advanced in years, causing some deformity, and at times
considerable pain; to this affection the term bunion is applied.
Treatment.-The medicines for inflamed bursae are, acon.,
bell., graph., hepar, iod., led., merc., thus, sulph..Acon. and bell. are particularly adapted to the affection
termed house-maid's knee, when the pain is excessive, and the
fever considerable. When there is swelling of the part, and
lancinating pains, these frequently arrest the affection, without
the employment of other medicines. After the more violent
inflammatory symptoms have been subdued, iod., ledum., or
arnica, will in many instances remove the remaining swelling;
a bandage should also be tightly bound around the joint. J/rnica is particularly useful when the swelling and pain result
either from a blow or constant friction of the part; ledum. also
is recommended for such a condition, when there is considerable fever, with preponderance of the chilly stage; graph. may
be employed when there is chronic enlargement of the bursae,
with redness of the surrounding parts, with swelling of the toes,
with itching; agaricus is very serviceable to allay the latter
symptom.
Hepar and mnerc., or silic., should be used when there is tendency to suppuration; when there are shooting pains bry. or
lyc. may prove serviceable.
The bursae may also be punctured, and the effused fluid
pressed out. The instrument should be finely pointed, of good
material, and should contain a groove, the sides of which should
have cutting edges. Sometimes considerable pressure is required to force the instrument through the walls of the bursae;
and to prevent the instrument from snapping, steady pressure
should be used.




DEFORMITY  OF THE JOINTS.                 429
Section 7.-Deformity of the Joints.
All the joints of the body are more or less liable to deformity,
or derangement of their articular surfaces.  Distortion of the
neck, torticollis, wry neck,* arises from a variety of causes.
The head may be retained in an unnatural position for a long
time by glandular swellings; or by rigidity, or spasmodic action, or both, of the sterno-mastoid muscle; the head in such
instances is much displaced, and the neck is twisted. The head
may be either bent forward or turned to one side; usually,
however, the chin looks towards the shoulder of the side opposite to the offending muscle.  Induration of muscular fibre and
tendons of the cervical region, curvature and other diseases of
the osseous system, and rheumatism  and other inflammatory
affections may also produce torticollis. In like manner, the
shoulders may be either preternaturally elevated or depressed.
Round shoulders, as they are termed, are exceedingly common,
and arise from the habit acquired by children of throwing their
arms forward and supporting them  on the front of the chest.
Curvatures of the spine are frequent among boys and girls who
are growing, and proceed from indulgence in unnatural positions. The bones or joints of the lower extremities are frequently deformed, and may be inclined either inwards or outwards; in the former case the patient is said to be knockkneed, in the latter bow-legged.
But the most important deformity is that which is denominated talipes or club-foot, the description and treatment of
which, however, will be treated of in the following section.
Treatment. —If toiticollis arise from improper positions assumed by the patient, braces or other mechanical means to prevent the indulgence in the pernicious habit must be employed.
If the inclination of the head is caused by glandular swellings,
the medicines that are suitable for such indurations will probably rectify the evil.  Among these may be rhus, carbo-an., or
conjurn.
* See Liston's Elements of Surgery, p. 314.




430         DEFORMITY OF THE JOINTS.
If wry-neck is occasioned by rheumatic or other inflammatory affections, it may be advantageously treated with bry.,
puls., bell., acon., &c. For pains as if the cervical vertebrae
were dislocated, which often are felt in the affected part, bry.,
nux-vom. and cinnabar may be suitable. For the contraction
of single tendons of the cervical muscles, natrum-muriat., rhustox., stram., hyos., dulc., zincum, selen., or arsenicum, appear
to be appropriate medicines.
For permanent spastic rigidity of the muscles, tenotomy will
sooner or later have to be employed;* and that not merely on
account of the deformity, but to avoid a more serious evilcurvature of the spine-which often supervenes, and which
may, if unchecked, become both extensive and confirmed. The
tenotomy needle is inserted obliquely, at the origin of the muscle from the sternum and clavicle; the division is effected by
cutting either from without inwards, or in the opposite direction, as circumstances may seem to require; great care being of
course taken not to injure the important parts which lie immediately behind the muscle. To insure safety in this respect, it
may be well, in some cases, to puncture with the ordinary
tenotomy needle, or knife, and then, withdrawing this, to substitute an instrument with a probe point, wherewith to effect
the muscle's section. Sometimes it may be sufficient to cut one
origin only; but, usually, division of both heads is essential.
By resilience of the extremities, restoration of the normal state
is at once produced; and this is maintained by suitable bandaging, if need be, until consolidation of the divided parts occur,
with the due amount of elongation.
If sufficient force and steadiness cannot be gained by simple
bandaging, Jarg's apparatus may be used. This consists of a
pair of leather stays, and of a band fillet, which encircles the
head; on the centre of the fore part of the stays, is a kind of
pulley, or grooved wheel, which can be turned round with a
The following description of the operation is taken from Miller's Practice of Surgery, p. 253, to which is added the method of application of
JSrg's apparatus for torticollis, from Samuel Cooper's First Lines.




TALIPES.                        431
key in one direction, but not in the other, in consequence of becoming fixed by means of a spring. From this pulley or wheel
proceeds a band up the neck to the fillet on the patient's head,
to which it is fastened directly behind the ear, close to the
mastoid process. The band lies in the same direction as the
sterno-cleido-mastoideus muscle, and when drawn towards the
breast, by means of the wheel, produces the same effect as
would arise from an increase in the action of that muscle.  In
short, it pulls the mastoid process downwards and forwards towards the sternum, counteracts the opposite muscle of the same
name, and rectifies the position of the head. Professor J6rg
makes his patient wear this apparatus day and night.
Section 8.-Talipes.*
By this term is understood the deformity of club-foot; generally congenital, yet not unfrequently acquired. The original
development of the bones is not faulty; but their displacement
is gradually effected, by a predominance of action in certain muscles; such predominance being dependent, either on
spasm of those which so act, or in want of action in those
which ought to be their antagonists. There is no actual dislocation of the tarsal bones; there is merely gradual change in
their relative positions.
There are several varieties of this deformity.
I. Talipes Equinus.-The muscles of the calf are contracted;
the tendo achillis is rigid; the patient steps on the toes without
bringing the heel to the ground; the foot is, in other respects,
well-formed; but the extensor tendons being on the stretch,
there is a turning up of the toes, independently of that which
is caused by pressure in progression.
II. Talipes Varus.-This is the most common variety; consisting of extension, adduction, and rotation of the foot-the
* The following section is taken mostly from Miller's Practice of Surgery,
pp. 675-678.




432         TREATMENT  OF TALIPES.
rotation being analogous to supination of the hand. The muscles of the calf and the adductors of the foot are contracted;
the heel is drawn up; the toes turn inward; the outer edge of
the foot rests on the ground; and, in progression weight is
borne on the outside of the foot and on the outer ankle, where
adventitious bursae usually form of some size. The toes are
extended as in the former case.
III. Talipes Valgus is the reverse of the preceding. There
are abduction, rotation, and partial flexion of the foot; the
rotation being analogous to pronation of the hand. The front
of the foot is raised from the ground; and the patient rests on
the inside of the instep, and on the inner ankle. The tendons
of the peronei muscles are chiefly to blame.
IV. Talipes Calcaneus. The muscles in front of the leg are
contracted; the foot is extremely flexed; and, in progression,
the heel alone touches the ground.
One foot, or both, may be affected by Talipes. In the
former case, the affected limb is found thinner, and more
flabby than the other; and, sometimes, by arrest of development, it is shortened as well as weak. The mode of progression is painful and imperfect, and, not unfrequently, contraction takes place at the knee, to a greater or less extent.
Spurious Talipes is said to occur, when displacement of the
foot takes place by muscular change or integumental contraction, following on burns, extensive suppurations, ulcers, &c.
Treatment.-In the minor cases, which occur in children,
mechanical means — early employed, skilfully adapted, and
duly persevered with-are alone sufficient to effect a normal
relation of parts. Many such cases occur; and it is quite unnecessary to subject the little patients to the pain of tenotoiny..JVatr.-muriat., rhus-tox., ruta, con., and caust. are servicable
medicines, when the deformity is occasioned by contraction of
the tendons.  JVit.-ac. and silic. may be employed, when cicatrices give rise to the deformity-they are particularly indicated
when there is pain in the contracted integument during damp
weather. Carbo.-veg. should also be remembered for such
symptoms.




TREATMENT OF TALIPES.                     433.N'ux., graph., dulc., colch., may also in many cases, be indicated.
The selection of the dilution of the medicine employed must
rest with the practitioner. The age of the patient, the constitution, the duration and intensity of the affection require to be
carefully considered, and the potency accordingly chosen —either
from among the triturations and lower dilutions, or from the
higher dynamizations.
Tenotomy is had recourse to, when structural shortening of
muscle, of tendon, or of both, has occurred; and when the obstacles to replacement cannot otherwise be overcome. A large
number of cases are so circumstanced. The operations, however, are but part of the remedial means; and will certainly
fail, unless suitable apparatus be afterwards employed, skilfully
and sedulously. Instead of waiting for reunion of the tendons, and then extending their new bond of union, painfully and
slowly, it is better to effect the required change of relative position immediately after section, leaving the interspace to be
filled up by new matter. In the congenital form, the operation
may be had recourse to about the twelfth or fourteenth month,
when the patient is just beginning to walk; the mechanical and
general remedial means having been in use previously. Extreme cases in the elderly should be regarded as irremediable.
Tenotomy will fail to effect a cure; and may do harm, for a
time at least, by impairing very seriously the acquired usefulness of the limbs.
In talipes equinus, division of the tendo achillis is usually
sufficient. In talipes varus, division of this tendon may suffice,
along with the use of mechanical aid. But, very frequently, it
is also necessary to divide the tibialus posticus and flexor longus
pollicis. In confirmed cases, the tibialis anticus and extensor
proprius pollicis must be added to the list. In talipes vulgus,
the peronei are divided along with the tendo achillis. In
talipes calcaneus, the tibialis anticus is cut, along with the extensors of the toes.
The tendo achillis is divided a little above its insertion into
the calcaneum.  The patient having been placed in a prone
28




434          TREATMENT  OF TALIPES.
position, the limb steadied, and the foot bent, a tenotomy knife
or needle is introduced obliquely; and, by bringing its edge or
point on the rigid tendon, the fibres are cut from without inwards; an assistant flexing the foot forcibly, so as to assist in
the disruption.
This having been completed, the instrument is withdrawn,
and a compress is applied to the aperture. Or division may be
reversed —from within outwards; but there is thus a risk of accidentally wounding the integument. The tibialis posticus may be
divided, either above the ankle, or near its insertion into the
navicular bone. The tibialis anticus is divided in front of the
ankle, from below outwards, so as to save the joint.  The
flexor longus pollicis is divided, where it is felt tense, in the
sole of the foot.  Sometimes it is expedient to divide the
plantar fascia also, from below outwards, to save the important textures beneath. The peroneus longus and peroneus brevis
may be divided above the external malleolus, or near their
points of insertion; the rest, at such points as circumstances
may render apparently most suitable. As a general rule, in
such operations the knife is moved away from, not towards,
arteries and nerves.
It is not improbable that, occasionally, reunion of the divided
tendon does not take place, but that a new attachment is
formed. Obviously, section of tendon should be avoided within
thecae; as, in such a locality, there is but little capability of
the expected plastic exudation.
The mechanical apparatus need not be described. Many
varieties are in use, the simplest usually the best. For the
talipes equinus and the talipes varus-the two most common
varieties —the indications are simple, and may be easily followed: flexion of the foot, by acting on the ankle; and restoration of the normal position of the foot, as regards rotation and
abduction, by acting on the foot itself.




DISEASES OF THE ARTERIES.                   435
CHAPTER XXV.
INJURIES AND DISEASES OF THE BLOOD VESSELS.
Section 1.-Diseases of the.frteries.
THE arteries are liable to inflammation, suppuration, and
ulceration; their texture also may be altered by the formation
of calcareous concretion.  The internal coat is more subject to
inflammation than either the middle or external, as is evinced
by the effusion of lymph, which is often poured out in large
quantity upon the inner surface of an artery, in consequence of
inflammation of contiguous parts from the application of ligatures, from wounds, and from the pressure of tumors.  Chronic
inflammation often precedes or follows calcareous deposition;
although arterial integument resists for a long time the ulcerative process, it is liable eventually to be destroyed, though
this generally takes place on account of improper ligation.
But the most frequent disease of the arteries which is encountered, is the degeneration of tissue and the deposition of calcareous matter.  To a greater or less extent this disease is present in the arterial system of those advanced in age, and for the
same reason that fragilitas ossium is more common among those
at the same period of life.
Treatment.-Tn the treatment of inflammation of the arteries,
the medicines exhibited will frequently arrest the disease in its
first stages, and thus the sequele will be prevented. The principal medicines are aconite, bell., cham.; also in some cases arnica, ars., carb.-veg., lyc., puls., and sepia.  Perhaps the best
medicines for the deposition of calcareous matter within the
arterial coats, are lyc., calc., graph., silicea, and sulphur. In
the treatment of these affections, the practitioner should regard
with particular attention the predisposing and exciting causes
of the disease, whether these be constitutional or local.




436                    ANEURISM.
Section 2.-d-neurism.
Sir Charles Bell* defines aneurism as a pulsating tumor,
formed of arterial blood; but Mr. Miller, with his usual preciseness, writes, that by the term aneurism is understood a pulsating tumor, composed of a cyst, which is filled with blood,
partly fluid and partly coagulated, and whose cavity communicates with the arterial canal.t
Aneurisms have been variously divided, viz.: external, internal, spontaneous, traumatic, true, false, circumscribed, diffused,
dissecting, aneurismal varix, and aneurism by anastomosis. According to Sir Astley Cooper, there are three forms.
Aneurism situated upon the surface of the body (external
aneurism).
This latter presents itself as a small tumor, pulsating very
strongly, containing only fluid blood, of which it can be readily
emptied if pressure be made near the distended artery on the
cardiac side. Little pain is experienced at this time, excepting
cramps, which may occur in the limb below the situation of the
aneurism. In a more advanced stage, the tumor is larger, more
solid, and cannot be completely emptied as in the former case,
the blood being partly coagulated in the interior of the sac,
which is much thickened. The circulation in the surrounding
parts is retarded, and pain is experienced when pressure is
made upon the tumor; the pulsation is distinct, but not so well
marked as in the first period of the affection. In the third
stage, the tumor is larger and more solid, pulsation is indistinct, and the sac is filled with layers of fibrinous matter, and
contains but little fluid blood. There is pain and inconvenience when moving the limb, which becomes cedematous and
deprived of sensation from pressure upon the nerves.
Internal aneurism occupies the cavity of the abdomen, chest,
and cranium, and the diagnosis is frequently difficult.t
C*. Bell's Operative Surgery.
t Miller's Principles of Surgery, p. 551.
$ Hasting's Practice of Surgery, p. 351.




ANEURISM.                       437
True aneurism, or when the sac is composed of all the arterial coats, may occur by dilatation, by dilatation and rupture,
and by rupture.
Aneurism by dilatation is most frequent in the aorta. The
coats of the vessel do not give way, but are gradually and
evenly distended; the integrity and the continuity of the tunics
remaining entire, which can be distinctly traced, particularly
after maceration.
The dilatation may be cylindroid, fusiform, or sacciform.
In the first instance, the expansion is abrupt and uniform; in
the second-as the derivation of the word would lead us to suppose-the enlargement is spindle-shaped; and in the third, the
dilatation is partial, and the hollow swelling that results is said
to be sacciform.
Dilatation and rupture of the arterial tunics do not occur at
the same time.  In the first instance, the abnormal cavity is
formed by dilatation, and after a time the internal and middle
coats are ruptured, either by muscular exertion or ulceration.
The external coat expands, and receives strength from organized fibrinous deposit, afforded by effused blood.
Aneurism by rupture generally arises from sudden muscular
exertion, the internal and middle coats give way by laceration,
and aneurismal formation speedily follows.
When blood passes between the tunics of an artery, separating or dissecting the one from the other, the aneurism is termed
dissecting. In this instance, the inner coat may remain entire,
or both the inner and external tunic preserve their continuity.
An aneurism is said to be pedunculated, when the sac is connected with the artery by means of a narrow neck. A limited
aneurism is one in which it is bound within the limits of a proper cyst; and diffuse aneurism is formed by the blood escaping
from a wound in an artery into the surrounding celluar texture.
In false aneurism the cyst is not composed of any of the
arterial coats, but consists entirely of tissues exterior or adjoining the vessel. It may result from wounds, lacerations,
ulceration external to the vessel, &c. According to Mr. Liston,




438                   A N E EU R I S M.
"false aneurism is the most common form of disease following
accidental wounds of the artery at the bend of the arm; the vein
is stretched over the fore part of the sac, compressed, and perhaps obliterated. The cicatrix appears stretched and thin on
the surface of the tumor, and there is sometimes a degree of
blue discoloration around it.  The progress of the tumor is
steady and uninterrupted, until operative procedure is resorted
to."
A varicose aneurism is where a vein and artery have been
punctured at the same time and place, and a false aneurism
formed between them, communicating with both vessels.
AJneurism by anastomosis was first particularly noticed by
Mr. John Bell,* who writes:
" The tumor is a congeries of active vessels, and the cellular
substance through which these vessels are expanded resembles
the cellular part of the penis, the gills of a turkey-cock, or the
substance of the placenta, spleen, or womb." In the early
stage of the disease, the skin assumes a mottled appearance, apparently arising from small sacs of blood distributed
throughout the tumor. Frequently this affection is closely
allied to vascular spots, termed ncevi materni, that are quite
often met with on the head and other parts of new-born children.
In the incipient stage of aneurism, the tumor is small and
free from pain, by pressure readily disappears, but returns immediately after compression is removed. The skin for a considerable period of time retains its normal color, but as the
swelling augments, it becomes pale and cedematous. The pulsation in the tumor is greater during the early than in the advanced stage, which circumstance is explained by the formation
of coagula in the sac. If the tumor acquires a large bulk, the
integument covering it becomes livid and painful, cracks, and
through the fissures a bloody serum exudes, ulceration follows,
which extending to the sac opens a communication with its
cavity, from which issues in a stream fluid blood, mixed with
* Principles of Surgery, vol. i., p. 456.




ANEURISM.                        439
coagula. As the ulcerative process extends, the opening increases in size, and the hemorrhage becomes more and more
frequent, and if not arrested, destroys the patient.
Aneurisms are more frequent among males than among
females, and seldom occur before the period of puberty. The
predisposing causes of the disease are principally degeneration
of the arterial coats, which may be either steatomatous or
earthy. The exciting causes, are muscular exertion or mental
emotion, besides certain occupations that favor the disease.
In some instances, there is steatomatous degeneration of the
whole arterial system. Patients so affected, are said to labor
under the aneurismal diathesis.
The diagnosis of aneurism is a very important point to be
understood; a subject that has already been alluded to when
treating of abscess.*
Treatment.-In simple navi, or small aneurisms by anastomosis, it will be well to have recourse to medicinal agents before
subjecting the patient to an operation. The medicines mentioned are more or less empirical, and the practitioner therefore
has only the very vague index of clinical experience to point to
a choice. In one case, in which an infant was afflicted with
several nawvi-materni, after the exhibition of caust., suppuration
was observed to be going on in one of the tumors. However,
the child was removed from the city, and no further information
has as yet been received. Should beneficial results accrue from
the further administration of the medicine, the profession will
be acquainted with the same through the medium of some homceopathic periodical.
Hartmann writes,t "if the arterial capillaries are involved, we
may have recourse to sulph., bell., lyc., if the venous, the principal medicines are, sulph., phosph., nux-vom., puls., and
carbo-veg., the latter particularly is indicated when there are
bright-red, round, flat aneurisms, by anastomoses, bleeding
profusely from the slightest injury. Calc.-carb., hepar, petro.,
silic., and sulph.-ac., may in some cases be called for." He also
* See page 147-148.         f Diseases of Children, p. 61.




440          TREATMENT OF ANEURISM.
writes-" There seems to be some resemblance between the
nwevus vasculosus and acne rosacea, and it may therefore be
advisable to try, if otherwise proper, such medicines as rhustox., kreas., carb.-an., ars., ruta, led., aur.-mur., sep., &c."
If medicinal means do not remove the naevus, recourse may
be had to vaccination; the virus to be inserted on the top of
the tumor, precisely in the same manner as in ordinary vaccination; or several needles armed with ligatures may be passed
through the aneurism, the threads then divided close to the eyes
of the needles, and the free ends tightly secured, the result of
which, of course, will be the destruction and sloughing away
in a few days of the morbid formation.
A more certain arrest of the diseased action is oftentimes accomplished by moistening the threads with nitric acid. The
application likewise of nitric acid to the surface of the tumor,
and repeated occasionally, has likewise effected a cure.
The cure of aneurism may be spontaneous,* occasioned by
pressure on the cardiac side of the tumor; by occlusion of the
aperture of communication; by inflammation and gangrene of
the cyst; by the aneurism becoming diffuse, or by obliteration
of the artery on the distal aspect.  These occurrences are,
however, comparatively rare, and in the majority of cases surgical treatment is indispensable to cure the disease. There are
several methods of treatment. Ligatures may be used and
may be applied at the cardiac side of the tumor, as practised by
Mr. Hunter, or as it is designated the Hunterian site; or the
reverse of this operation, that of Brasdor, ligating the artery
at the distal aspect.  Further directions for the ligation of
arteries have already been considered.t
Pressure is also a means of cure, and there are two methods
for its employment; first,J by retarding the aneurismal flow,
and favoring consolidation, or else aiding the textures which
* Dr. Gibson writes that he has never known but one spontaneous cure of
aneurism by anastomosis. Institutes and Practice of Surgery, vol. ii., p. 150.
t See page 137-146.
t See Miller's Principles of Surgery, p. 581.




TREATMENT OF ANEURISM.                      441
overlay the aneurism, and which are as it were continually
striving to keep it down and repress its growth. The one
method diminishes the expansive power from within, the other
increases the repressive power from without. In former times
the pressure exerted was continuous and severe; lately, however, it has been found that by using compression, at intervals,
and not severe, a stimulus as it were is given, whereby an action is established in the part which may result in an arrest of
the disease. The pressure is made at the Hunterian site by
the instrument of Signoroni,* at a point where the coats of the
vessel may be expected to be sound, and therefore not liable to
ulcerate from slight causes. The pressure is maintained until
it becomes inconvenient to the patient, when it should be lessened for a time and afterwards increased. It is preferable to
employ two instruments, so that while one is slackened the
other can be tightened, and vice versa. Throughout the whole
period of treatment, not only by pressure but by ligature, absolute rest is necessary, while the limb below the compressed
point should be equally supported, lest cedema and congestion
supervene. The application of galvanism by acupuncture; or
galvano-puncture, has been productive of good results in certain cases. This method of cure was proposed by Mr. B.
Phillips in 1832, and is performed by introducing acupuncture
needles, partly coated with gum-lac varnish,t to protect the
ordinary textures which they have to traverse, and having inserted them within the tumor, and retarded temporarily the aneurismal circulation by means of pressure, the galvanic current is
set on, of such strength as the patient is able to bear, anaesthesia being employed or not, as circumstances may require.
By such means coagulation has been effected and aneurisms
cured.
The treatment of aneurism by injections of the perchloride of
iron has lately excited much interest among surgeons. Dr.
Pravazt first introduced the practice, and it has been since used
F See page 125.    t Miller's Principles of Surgery, p. 587.
f London Lancet, 1854.




442                 1NJURIES AND
by many surgeons with varied success. Its failure in some instances has been attributed to the fact, that either too much or
too little of the perchloride was injected; the quantity of fluid
to be used not having been specified. The effect is generally
the immediate formation of a clot in the sac-arrest of pulsations and finally obliteration of the trunk of the vessel.
The (langers attendant upon this practice should receive
serious consideration.  Fever results, and formation of pus in
the artery has taken place.
Excessive injection excites acute inflammation of the sac,
followed by ulceration and expulsion of the clot; the essential
part of the operation consists in so managing that there should
be slow resorption of the foreign matter introduced within the
tumor.
Pravaz remarked that in the case of an aneurismn the size of
a pigeon's egg, he would not inject more than four or five
drops of the perchloride, and that he would repeat the operation, should the pulsations in the tumor not cease after a certain time.
The danger, however, in all the cases related is perhaps
greater than that attendant upon the old method of ligature.
Section 3.-Injuries and Diseases of the Veins.
Wounds of the Veins. —The veins are frequently wounded
during the performance of operations, but the hemorrhage can
generally be arrested by properly applied pressure; in some instances, however-though the proceeding, if possible, should
be avoided-cases may occur in which ligatures become absolutely necessary.
Inflammation of the Veins.-Phlebitis may be either acute
or chronic, the former may terminate fatally if not arrested;
the latter is not dangerous, and generally affects varicose veins
of the lower extremities. In acute phlebitis the countenance
of the patient expresses anxiety and depression of spirits, there




DISEASES OF THE VEINS.                     443
are repeated rigors, dry, brown, or blackish tongue, cadaverous
skin, great prostration, pulse rapid and weak, muttering delirium, and vomiting of bile.
Consecutive abscess is said to be a characteristic termination
of acute phlebitis; excessive pain may be experienced in any of
the joints, which is rapidly succeeded by a copious formation of
pus; purulent formation may, after this, speedily collect in other
parts of the body.
Treatment.-The treatment of acute phlebitis is somewhat
difficult, which in many instancess is owing to the disjointed
character of the homeopathic Materia Medica. However, from
the presenting symptoms, particularly in the first stages of the
affection, when the fever is high, with a quick, full pulse, dry,
furred tongue, &c., aconite should be employed.
If after a time the brain appears to participate in the disease,
belladonna is indicated; but the medicine that is best adapted
to inflammation of the veins is pulsatilla, which may be alternated with aconite or belladonna in the first stages of the inflammatory process; but when the tongue becomes dry, brown,
and cracked, when the patient is much prostrated, with burning thirst, and hot, dry skin, arsenicum is distinctly required.
Carbo-veg. may be prescribed for a somewhat similar group of
symptoms, and perhaps would be a preferable medicine, when
the action of the arterial system has been almost entirely overpowered, and venous congestion is indicated by a blue tinge of
the skin over the whole surface of the body, attended with
fearful anguish about the heart, and icy coldness of the surface.
If suppuration threaten, or if it has actually occurred, and
the amount of purulent secretion is considerable, silicea should
be administered, or the case may strongly call for hepar, merc.sol., or sulphur.
For chronic phlebitis, besides the medicines just mentioned,
arn., chain., lyc., nux-vom., spig., or zincum, may be demanded.
Varix.-The term varix designates a hypertrophied condition of the veins, in which they are divided into irregular
pouches, the valves not being able to sustain the reflux column of




444          DISEASES OF THE VEINS.
blood. Deep-seated, as well as superficial veins, are frequently
rendered varicose by undue muscular action, by interruption of
the circulation from ligatures, by the pressure of tumors, and
by the gravid uterus. The veins of the upper extremities are
rarely affected by hypertrophy, while those of the lower, especially the saphenae and their branches, are very liable to the
disease. In the commencement, numerous small circumscribed
swellings are observed, but after a time, the venous trunks and
branches appear enlarged throughout their whole extent; sometimes they are knotted or doubled upon each other, and these
gyrations are particularly conspicuous in the neighborhood of
the valves.*
Treatment.-Great advantage may be derived from allowing
the patient to encase the limb in an elastic stocking, which is
constructed especially for the treatment of varicose veins;t this
should be constantly worn, and at the same time medicines
should be internally administered, which are chiefly agaric.,
ars., particularly when the veins are of a livid color, and attended with severe burning pains; bell., when erisypelatous
inflammation surrounds the varices; carbo-veg., graph., lyc.,
puls.; the latter is perhaps the most efficacious medicine when
there is considerable inflammation, excessive pain, and swelling, and when the limb assumes a livid hue; arnica is a valuable medicine in the treatment of this affection; it is particularly useful when the patient is obliged to maintain an erect
posture for a length of time, or when the veins have become
diseased in consequence of wounds, blows, &c.; very beneficial
results have been obtained by the exhibition of arnica and pulsatilla in alternation, a dose every night.  Hamamelis virginiana has been highly recommended by Dr. Okie of Providence,
in the treatment of this affection. It has been used with beneficial effect both as an external application and as an internal
medicine.
If this treatment fail to produce the desired effect, the surgeon may have recourse to an operation, although we believe
* Gibson's Institutes and Practice of Surgery, vol. ii., p. 166.
t Vide page 185. Treatment of Varicose Ulcers.




WOUNDS OF THE SCALP.                    445
that as the science of true medicine progresses a resort to the
knife for the treatment of varicose veins will be abandoned.
From the amount of successful experience which we possess in
the treatment of this disease, this assertion is very confidently
advanced.
Sir Benjamin Brodie thus writes-" For this operation I have
generally employed a narrow, sharp-pointed bistoury, slightly
curved, with its cutting edge on the convex side. Having then
ascertained the precise situation of the veins, or cluster of veins,
from which the distress of the patient appears principally to
arise, I introduce the point of the bistoury through the skin on
one side of the varix, and pass it on between the skin and the
vein with one of the flat surfaces turned forwards, and the other
backwards, until it reaches the opposite side. I then turn the
cutting edge of the bistoury backwards, and, in withdrawing
the instrument, the division of the varix is effected. The patient
experiences pain, which is occasionally severe, but which subsides in the course of a short time. There is always hemorrhage,
which will be often profuse if neglected, but which is readily
stopped by moderate pressure, made by means of a compress
and bandage correctly applied."
CHAPTER XXVI.
INJURIES AND DISEASES OF THE HEAD
Section. I. —Wounds of the Scalp.
MR. POTT has observed that though the scalp be called the
common integument of the head, yet from its structure, connections, and uses, injuries inflicted upon it by external violence,
become of much more consequence than those of other parts of
the body. It is a well known fact that wounds, however slight,
when inflicted on the head, are very liable to be followed by




446           wOUNDS oF THE SCALP.
inflammation and suppuration either within or without the cranium. In some instances the lips of the wound will unite
readily, and little inconvenience result; in others, however, adhesion will take place only at certain points, while suppuration
will occur at others; this is particularly noticed in contused
wounds, in which the integument has immediately been destroyed by the violence of the injury, or in cases in which the
scalp has suffered considerable laceration.
Small wounds, that is, such as are caused by instruments or
bodies which pierce or puncture, rather than cut, are in general
more liable to become inflamed, and are known to be productive of greater constitutional disturbance than those which are
of a greater extent.
If the wound affect the cellular membrane only, and has not
reached the aponeurosis or pericranium, the inflammation and
tumefaction involve the whole head and face; the latter frequently assuming a jaundiced hue, and being covered with
small bull]e containing a yellow serum.
Treatment. —If a blow on the head has caused extravasation
of blood beneath the scalp, and if there be visible increase of
the accumulation of fluid, the surgeon may suspect that an
artery has been divided; in this case the course of the vessel,
if possible, should be ascertained, and pressure made in order to
arrest the hemorrhage; after which, compresses saturated with
a solution of arnica should be applied to the contused part. If
the scalp be nearly or quite detached, it should be carefully
washed and replaced as nearly in situ as possible, and the aqua
calendula be used as a lotion; the parts should then be brought
together with adhesive straps, and a bandage lightly placed
around the cranium; sutures in the generality of instances
should be dispensed wvith, as the punctures that are made by
the needle are liable to become the seat of inflammatory action.
If erysipelatous inflammation supervene, bell. may be administered internally, or thus radicans; the latter exerts a powerfully
beneficial action over erysipelas of the scalp. If the fever be
high, aconite and bell. may be administered, in accordance with
symptoms that have already been mentioned in various places
in this work.




CONCUSSION  OF THE  BRAIN.                   447
Should symptoms of effusion within the cavity of the cranium
be present, arn., bell., hell., cup., or zincuzm are the most appropriate medicines. If suppuration ensue beneath the scalp or occipito-frontalis muscle, the pus should be evacuated by early incision, and calend., hepar, merc., or silicea should be exhibited.
If extravasated blood be noticed beneath the scalp, there is no
need of incision, for by enjoining perfect rest, with the employment of arnica externally and internally, absorption of the clot
will in all probability take place.
Section 2.-Concussion of the Brain.
According to Mr. Abernethy,* concussion of the brain may
be divided into three stages.  The first is that of insensibility
and derangement of the bodily powers, which immediately succeed the accident. While in this condition the patient is insensible to injury, pulse intermitting, extremities cold, and
breathing difficult, but in the generality of instances without
stertor. This stage has but a short duration, and is succeeded
by the second, in which the symptoms gradually disappearing,
the pulse and respiration become more natural, and though not
entirely normal, are sufficient to diffuse warmth throughout the
extreme parts of the body, and to maintain life. As the effects
of the concussion still diminish, the capability of exerting the
mind becomes increased, the patient can reply to questions, and
refers the chief cause of his sufferings to the head. As long as
stupor remains, inflammatory action appears to be moderate,
and as the former abates, the latter increases; and this constitutes the third and most important stage of concussion. Death,
however, sometimes instantaneously supervenes, from cessation
of the heart's action.
Treatment. —The medicine that is most essentially serviceable in the treatment of concussion, is arnica; and its early
* Essay on Diseases of the Head.




448        COMPRESSION  OF THE BRAIN.
administration, if the injury be not extremely severe, will not
only prevent many of the evil consequences that may result,
but by its influence upon the vessels may limit extravasation
of blood within the cavity of the cranium. If the injury be
severe, and there is extreme restlessness and jactitation of the
muscles, quick, small pulse, rigors, and delirium, bell. must be
employed. If there is jerking of the tendons of the extremities
or clenched hands, foam at the mouth, stram. will be of service.
If the patient rolls the head from side to side, and there is much
oppression, stertorous breathing, hiccup, etc., hyos. is indicated.
The medicines that are homeopathic to irritation, and which
should be employed at the commencement of the third stage,
are ignatia and cicuta virosa.* It would perhaps be the better
practice, when the cause of the affection is considered, to alternate arnica with other medicines which the symptoms may render most applicable. AIconite should not be forgotten, when
after the injury the mental faculties of the patient appear considerably impaired, as inability to think, weakness of memory,
vertigo on raising the head, blackness before the eyes, nausea,
and sometimes vomiting; when the latter symptom is prominent, and the matter ejected is blackish or brownish, with prostration of the vital powers, ars. should be employed.
Section 3.-Compression of the Brain.
Mr. Pott remarks, "The shock which the head sometimes
receives by falls from on high, or by strokes from ponderous
bodies, does not unfrequently cause a breach in some of the
vessels, either of the brain or its meninges; and thereby occasions extravasation of the circulating fluids. This extravasation may be the only complaint produced by the accident; or
it may be joined with, or added to, a fracture of the skull. But
this is not all, for it may be produced, not only when the era* For more particular indications for the employment of Cicuta, vide
p. 117.




COMPRESSION  OF THE  BRAIN.                 449
nium is unhurt by the blow, but even when no violence of any
kind has been offered to or received by the head."
It seldom happens that mere depression of the bones of the
cranium, unconnected with other injury, produces such aggravated symptoms as those which characterize compression of the
brain, for according to Dr. Gibson,* the records of surgery furnish numerous examples of perfect recovery after the most extensive depressions, from which the patients sustained but little
inconvenience, and for the relief of which no operations were
performed. On the other hand cases have occasionally occurred
in which from depression of both tables of the skull, or from
extensive fracture of the inner table, the most urgent symptoms
have resulted, but have been speedily relieved upon elevating
the bone to its natural level.
The symptoms of compression resemble those of apoplexy.
If the cerebral functions cease totally or partially in consequence of the pressure of extravasated blood upon the brain,
the symptoms of nervous apoplexy or paralysis are present,
which in many respects closely resemble those produced by violent concussion. The patient is extremely pale, with pulse
feeble and irregular, and the whole body appears totally paralyzed; vomiting sometimes occurs. In some instances, after
such a condition has existed for a time, the pulse becomes fuller,
the face assumes a more natural color, or becomes very red,
and all other symptoms of hyperemia make their appearance,
precisely as after concussion.
In other cases the patient is deprived of consciousness or
sensation, is totally or partially paralyzed, feces and urine pass
off involuntarily, or the latter may be retained: the breathing
is stertorous, the pulse is hard, full and slow, the eyelids droop
as if paralyzed, the mouth is drawn to the side, and the eyes
are staring and protruded, with insensible and often dilated
pupils. In many cases the patient vomits, and the face looks
livid and turgescent.  Pus, as coagula formed by extravasated
blood, may also produce compression. Suppuration, however,
* Institutes and Practice of Surgery, vol. ii. p. 183.
29




450       TREATMENT OF COMPRESSION.
does not immediately follow an injury of the skull, and often
proceeds from irritation occasioned by the shattered fragments
of the internal table.
Treatment. —The first act of the surgeon, when called to a
patient suffering from compression of the brain, is to administer
a dose of arnica. This medicine is now employed by many of
the most distinguished surgeons in the treatment of this particular variety of injury, but none of them (we refer to allopaths)
acknowledge their indebtedness to Hahnemann for the introduction of this important remedial agent. If symptoms are present that in a measure call for the exhibition of other medicines,
they may be administered in alternation with arnica.
Veratrum should be employed when there is coldness of the
whole person, with distorted and protruded eyes, disfigured
countenance, flabby muscles, trismus, and imperceptible breathing.  Coffea by the mouth and anus has frequently succeeded in
relieving such symptoms.
~conite is an important medicine in the treatment of compression, and belladonna has frequently produced the most
desirable results.
Coffea is an excellent palliative, but must always be succeeded
by other more appropriate medicines.  Opium  also, restores
the reactive power of the organism, and is indicated when there
is stupor, with coma, stertorous breathing, red, bloated face,
constant motion of the lips, full slow pulse, and frequent profuse sweat.
Lauroc., hyos., stram., merc., plumb., and iodine, are useful
medicines; the latter, especially when there are violent pulsations of the whole body, with anguish and dyspncea. Other
remedial agents may also be called for, but want of space will
not permit their insertion in this place.  Full details may be
learned from  the various works upon the Materia Medica.
When this treatment does not relieve the patient, and there is
reason to believe that the brain is still oppressed by a coagulum, the trephine must be resorted to, and the coagulum
removed.
If after injury inflicted upon the skull, a depression is ob



TREATMENT  OF  COMPRESSION.                    451
served, and there are but slight symptoms of compression, the
surgeon must remember that fragments of bone, though at first
producing little irritation, may after a time create the inflammatory process, which may terminate in suppuration, and thus
the most disastrous consequences may ensue. The question of
operation in this, as in all other cases, requires serious consideration.
The trephine is a circular saw, moved by a light and rapid
movement of the hand, whereby a portion of the skull is separated, and may be removed.* Dr. Gibsont says, that the object of the surgeon in applying the trephine, is either to make
an opening for the removal of coagulated blood, or for the introduction of the elevator beneath a depressed bone.  Very
frequently it happens that there is a sufficient space between the
edges of the fragments of a bone to insinuate the elevator, and
with it restore the depressed portion to its natural level. When
the operation is undertaken for the elevation of depressed bone
it is seldom necessary to remove an entire circle, as all that is
required is sufficient space for raising the depressed portion and
removing fragments, if need be. This can in many cases be
accomplished by fixing the centre pin of the trephine on the
brink of the sound bone, and so removing by the saw only a
segment of a circle.
The spinal cord is also subject to compression and concussion
from blows or other injuries. In compression and concussion
the symptoms are similar to those of compression of the brain,
paralysis being most prominent. If dislocation or fracture give
rise to the compression, the proper treatment will be found in
that portion of this work which is devoted to those subjects.
If inflammation produce the disease, the student may refer to
any work on the practice of medicine. The prognosis in such
cases is generally unfavorable.
* Miller's Practice of Surgery, p. 66.
t Institutes and Practice of Surgery, vol. ii., p. 188.




452            DISEASES OF THE  EYE.
CHAPTER XXVII.
DISEASES OF THE  EYE.
THE class of diseases which is the subject of the following
chapter is too often superficially noticed by the student, indeed the study of affections of the eye is frequently altogether
omitted.  This is to be the more regretted in consequence of the
very great importance which attaches to the subject, as well
as the frequency with which the organ of vision is attacked
with some one or other variety of the diseases to which its exposed situation, as well as its complex anatomical structure,
render it liable.
A distinguished physician recommends all students to inquire
particularly into diseases of the eye, as many affections in
miniature may thus be observed. The stages of inflammation
can readily be noticed; suppuration is manifested by the formation of a yellowish, or in some instances a milk-white fluid
in the chambers of the eye.
A dark red color of the parts with swelling affords an instance
of extravasation, as is witnessed after injuries, or in scurvy or
fevers of a typhoid character. The yellow appearance of the
conjunctiva in jaundice, exhibits the same pathological condition as is noticed in the skin of patients suffering with that
affection. The peculiar inflammation, which is supposed to
constitute rheumatism, is seen in a slight injection of the minute
vessels beneath the conjunctiva.  Erysipelas, a variety of inflammation, frequently attacks the eyelids.
Tumors of various formation, the result of the inflammatory
process, are also frequently met with in the organ of vision.
Medullary sarcoma in its first stages produces a red, gray or
turbid appearance in the posterior chamber of the eye which
advances with the progress of the disease.
Morbid structures behind the ball, occasion its protrusion,
thereby altering its position. Encysted tumors of the lachry



DISEASES  Or THE  EYE.                   453
mal glands, fatty and other degenerations, osteo sarcoma,
aneurism and exostosis, which may arise in the maxillary nasal
and cerebral cavities, also cause increased convexity of the
organ.
A moderate protrusion which arises quickly, exhibits hyperaemia of all or part of the structures within the orbit.
Inflammation of the iris is known by exudations of lymph,
on it and within the pupil, sometimes accompanied with yellow
specks.
If the iris presents a dirty grayish appearance, and is covered
with small red or yellowish-gray elevations, syphilis may be
suspected.
When the iris is attacked with arthritic inflammation, it presents an ashen gray, leaden hue, having lost its distinctive
appearance.
Besides these morbid conditions, there are deviations from
the normal functions of the eye, which are often important indices to the physician. If the eye gradually becomes sunken
or hollow, the surgeon may suspect atrophy of the parts posterior to the eyeball: such occurs in phthisis, and may be considered as an unfavorable sign; long fasting may also engender
retraction of the ball, or it may be owing to the smaller amount
of fluids contained in the vessels, as is the case in cholera,
violent diarrhcea, or after repeated venesection.
In these instances if both eyes are affected, the prognosis
cannot be regarded as otherwise than unfavorable.
When extravasation is the result of injury, or of great bodily
exertion, the symptom is not very unfavorable, but if such appearance is noticed during severe internal inflammation, the
most unfortunate results may be anticipated.
In diseases of the brain the size and form of the pupil afford
important indications.
A dilated pupil, if not the effect of cataract, or of obstructed
entrance to the rays of light, denotes cerebral irritation, which
latter may be symptomatic of gastric disturbance.
Dilatation of the aperture is likewise noticed, when pressure




454           DISEASES OF THE EYE.
on the brain is occasioned by extravasation of blood, inflammation, effusion of serum, and by narcotic poisons.
When soporose conditions are present with the dilatation, the
prognosis may be considered as unfavorable.
Permanent expansion of the pupil may be congenital, or
occasioned by iritis.
In syphilis the iris may be dislocated, upwards and inwards.
At the commencement of violent diseases, such as affections
of the heart, &c., the lustre of the eye is impaired. In gangrene, typhus fever, and Asiatic cholera, the eyes appear to be
covered with a fine powder, and are of a dull dirty color.
In paralysis of the muscles of the organ of vision, the eyeball is immovable, which may also be present in effusion on the
brain, or in apoplexy.
Turning up of the eyes, except in sleep and in amaurosis, is
an evidence of great debility.
Extremely frequent movements is a sign of clonic spasm, or
occurs when the mind is vigorously employed, or it may be
present in acute affections of the brain, when it indicates apoplexy, or it is noticed in general spasm, delirium, variola, and
at the crisis of diseases.
Squinting or strabismus indicates encephalitis, apoplexy, or
hydrocephalus. If it occurs in hydrophobia and typhoid fevers,
it may be regarded as an unfavorable symptom, unless crisis is
about being established, when the unnatural appearance is of
less import: if it be connected with epilepsy, hysteria, or
verminous affections, it is not important.
By a single look or glance, the attentive observer may derive
much information. A wild or rolling eye denotes irritation or
inflammation of the brain; an anxious expression may indicate
disease of the heart; a timid look is often connected with hysteria and hypochondriasis, and is also observed at the commencement of many acute diseases.
Despair, when exhibited by the eye, is indicative of violent
inflammation of the abdomen, or of softening of the stomach,
and is likewise frequently seen in Asiatic cholera.
Temporary stop of vision may be occasioned by diseases of




DISEASES OF THE EYE.                     455
the brain and optic nerves, by tumors of the encephalon, exostoses, inflammation of the investing membrane of the optic
nerve, and in some acute diseases; deprivation of sight may also
be occasioned by irritation of the intestinal canal, by morbid
alterations in the liver an(l spleen, and by intermittent fevers.
Permanent dimness of vision may arise from inflammation of
the retina, from extravasations in the chambers of the eye,
paralysis or alteration of the structure of the parts, or from
pressure on the optic nerves.
In diseases of the retina optical illusions are frequent, objects
are seen in unnatural positions, and colors cannot be distinguished; lights, sparks, or fiery balls seeming to appear before
the eyes, are indications of irritation of the retina, congestion
of the eye, or of internal ophthalmitis; such optical deceptions
are also present in inflammation of the brain and its membranes,
in amaurosis, apoplexy, and epistaxis.
If the cornea or crystalline lens is diseased, or there is irritation or inflammation of the retina and surrounding parts, congestion of the brain or irritability of the nerves, the patient
complains of dark specks or moats, of a larger or smaller size,
floating in the surrounding air.
This subject might still be extended, but to pursue it more
in detail, would somewhat encroach upon the limited space
generally allowed for the consideration of such minutiae in
works of this description; but a knowledge of the few facts
and illustrations that have been selected, may in a measure exemplify to the student the importance of minute observation
in the establishment of both diagnosis and prognosis.
In a few preliminary remarks to an excellent treatise, "On
the Homceopathic Treatment of Diseases of the Eye," Dr.
Dudgeon writes: " The eye symptoms recorded in our Materia
Medica are sadly defective in clearness of description.  The
particular seat of the objective and subjective symptoms is very
seldom noted.'Inflammation of the eye,' is often the vague
term used to denote the appearance observed; or if with greater
pretensions to accuracy, we have sometimes'inflammation of
the white of the eye,' whether that be of the conjunctiva or




456               O P T HALMITIS AND
sclerotic, we are left to guess. An equal vagueness is observable in the details of most of the subjective symptoms. Again
the clinical records in many cases are as ill described as the
pathogenetic symptoms of the remedies; and it would be
often hard to say what was the real disease the practitioner
treated."* With the hope that some of the obstacles to the
successful homceopathic treatment of ophthalmic surgery, may
be overcome, the medicines that are best adapted to each particular affection of the eye will be mentioned, in connection
with the description of the disease; and to enable the student
to select the appropriate remedial agent with less labor and
greater precision, the symptoms of those medicines that possess
the most powerful action on the organ of vision, will be appended to the end of the chapter.
Section 1.-Ophthalmitis and Catarrhal Ophthalmia.
Ophthalmia is a generic term —particular names being given
to the different parts of the eye which may be affected. When
all the tissues are involved at the same time, the term ophthalmitis is given, to which belong the usual symptoms of inflammation; heat, pain, redness, swelling (diminished or increased),
secretion of tears, to which is superadded great sensibility to
light (or photophobia). The commencement of the attack is indicated by a stiffness in the movements of the eyeball, with dryness and heat, together with redness, which may sometimes be
observed in the sclerotic coat.
There is also an itching in the eyelids, or a sensation as if
sand or small particles of some foreign substance had accidentally lodged under the eyelids. As the disease advances, the
lachrymal glands secrete very freely, the tears being often extremely acrid. These, in consequence of the swollen condition
of the puncta lachrymalia, cannot escape through their natural
* British Journal of tIomceopathy, vol. vi. p. 191.




CATARRHAL OPTHALMIA.                      457
channels, and running over the cheeks occasion much smarting
and inflammation. The conjunctiva of the lids is of a deep red
color, and where it passes over the eye itself, sometimes projects like a wall around the cornea, and in very aggravated
cases presses apart the eyelids, presenting the appearance of
a fungous mass. (To express great turgescence of the conjunctiva, the term  chemosis is used.  German writers, however,
understand by this appellation not only turgescence, but a very
highly colored redness, with intense pain.)
The conjunctiva scleroticae is so covered with red vessels, that
the white color of the eye is lost. By pressing upon the conjunctiva, if the inflamed vessels be movable, the diagnosis of
conjunctival inflammation is made. As the disease advances
the pain increases, becomes burning, throbbing, and lancinating,
darting through the eyeball into the head; the eye also feeling
so much increased in size, that it seems as though it would burst
or be protruded from its socket. There is likewise intolerance
of light, and usually all the symptoms are aggravated towards
evening.
In the last stage of ophthalmia, the conjunctiva secretes
mucus, and often in such large quantities, that the disease resembles a genuine blenorrhcea, the secretion being purulent in
appearance. This mucus, together with the exudation from
the meibomian glands, often collects, and hardens about the
eyelashes, occasioning nocturnal agglutination.
Should the abnormal action advance still onward, and exhibit its worst possible phase, the other tissues then participate
in the disease, suppuration ensues, the humors of the eye are
evacuated through an ulcerated opening, and blindness results.
Sometimes phlyctenae make their appearance, for the most
part on the edge of the cornea —these become small ulcers. In
other cases, a large portion of the conjunctiva becomes thickened or ulcerated.
If the ophthalmitis be violent in degree, or progresses to an
advanced stage, the symptoms continuing severe, the constitution participates in the derangement, and febrile symptoms more
or less violent are developed; the pulse becoming frequent and
hard, the tongue coated, and the appetite destroyed.




458               OPTHALMITIS AND
The causes of ophthalmitis are such as produce inflammation
in other parts of the body.  Sudden changes of temperature
acting either upon the eye itself, or the body generally; exposure to cold after the body has been very much heated (hence
individuals exposed to such sudden withdrawals of heat, are
often attacked with it-workmen in glass foundries, cooks,
bakers, and smiths); acrid vapors coming in contact with the
eye, from mercury, lead, sulphur, arsenic, mineral acids, and
such like; too long-continued exertion of the eye, reading
small type, microscopic examinations, reflection from snow in
the bright sunlight, foreign bodies lodged in the eye or under
the eyelids.* A vitiated state of the atmosphere also produces
ophthalmia, being occasioned by such a cause in overcrowded
places of public resort, as well as from the glare of light usual
in such places.
Ophthalmitis is also occasionally produced by the presence
of insects, especially of the pediculus ferox pubis, attaching
itself to the roots of the hair of the eyebrows and eyelashes, instances of which are mentioned by Scarpa and Beer. Injuries
also produce the disease, as blows, wounds, &c. Inflammation
of the brain likewise causes it; the morbid action being propagated along the tunics which envelop the optic nerve. The
reverse also happens; the inflammation extending itself from
the eye to the brain.
Itching is indicative of conjunctivitis. Burning is also another symptom, as likewise smarting, which perhaps depends
on the conjunctiva being deprived of its epithelial covering.
The sensation as of sand and dust in the eye is often experienced, and also belongs to conjunctival inflammation. There
are likewise raw, corrosive, gnawing, and burning pains, which
may be caused by an altered state of the lachrymal secretion,
or the conversion into a fatty acid of the fat globules which are
found in tears.
* Such bodies may remain for a long time within the eye, without occasioning any inconvenience, after the irritation occasioned by their introduction subsides. Pieces of iron are often seen imbedded in the eyes of smiths,
and minute portions of wood in those of carpenters, &c.




CATARRHAL OPHTHALMIA.                     459
In the more acute forms of ophthalmia, aconite is very decidedly indicated.  The symptoms which solicit it are, dryness,
especially of the upper lids, with pressure on the eyeball;
smarting, itching, and burning-the latter sometimes being experienced in one, then in the other eye; sensitiveness to the
open air; redness of the conjunctiva; photophobia; lachrymation; chemosis.  In the inflammation induced by the application of acrid substances, by burns and wounds, this medicine
has proved very efficient.
A few globules of the 6th attenuation, dissolved in eight tablespoonsful of water, of which solution a tablespoonful may be
administered every six, eight, or twelve hours, until the symptoms are alleviated; it may be then altogether omitted, or
given at longer intervals, should the progress of improvement
again appear arrested.
Catarrhal ophthalmia may be diagnosed, if, together with
the itching, burning, smarting, and lachrymation, the palpebral
conjunctiva is found covered \aith fine striae of a vermillion red,
somewhat relaxed and enlarged in volume; or the redness of the
conjunctiva may present a dingy hue, inflammation may commence at the canthi, the cornea be less transparent, with burning
and sensation of pressure in the eyes, as from sand. To these
symptoms may be added, considerable secretion of mucus, with
phlyctenae, and particularly a white space of about two lines in
diameter, which completely circumscribes the cornea. The
latter appearance may be thus accounted for: There is a regular distribution of blood vessels, which, converging from the
circumference of the orbit towards the centre of the eye, bifurcate and terminate in fine points about a line or a line and a
half from the cornea, thus leaving the space alluded to destitute of any visible anastomosing branches.
Catarrhal ophthalmia, in some instances, has been known to
be contagious, and is generally occasioned by damp and cold
weather; it is often epidemic, and of more frequent occurrence
in Europe than in this country. The tears are very acrid, and
excoriate the parts over which they pass, and the caruncula
are the seat of very severe pain.




460             OPHTHALMITIS AND
In the early stages, when there is no lachrymation, and a
sensation of pressure is experienced when moving the lids, together with agglutination and catarrhal fever, cham. should be
prescribed.
If dryness occur, with a high stage of inflammation of the
conjunctiva, with congestion to the head, together with acrid,
thin coryza, dry, hacking cough, and ordinary catarrhal symptoms, belladonna is indicated. It is also called for if the conjunctiva is swollen, and also the eyelids; if there is great sensibility to light, and dimness of vision. Also if the coryza
produces excoriation and pimples under the nose, from its
acridity, a few globules of the 6th dilution, dissolved in six
tablespoonsful of water, is sometimes sufficient to effect a cure.
At the expiration of twelve hours, should not a favorable effect
have been produced, the dose may be repeated.
Euphrasia is indicated, if there is much pressure and redness, with profuse discharge of acrid tears, with excessive
coryza and cephalalgia. The sensation of sand under the
eyelids is also experienced, which sensation is owing either to
distension of the vessels, a vesicle or phlyctana, or an ulcer.
It is also serviceable, if both eyelids are agglutinated and much
swollen, with a bloody viscid discharge; if the margins of the
eyelids are moist and ulcerated; frequent blinking and great
sensitiveness to light. A solution of a few globules of one of
the lower dilutions, repeated at several hours' interval, may be
directed.
Hempel alleges that, for catarrhal ophthalmia, aconite is a
most valuable medicine, and says that even in mismanaged
cases, with ulceration of the conjunctiva, deep-seated aching
and sore pain in the eyeball, boring or sharp aching in the
frontal sinuses, even if fever be not present, this medicine is of
great service. If the inflammation is less marked, but there is
severe pain in the eyes, much lachrymation, photophobia, with
fluent coryza, ignatia is indicated.
arsenic, besides exercising a powerful action upon the sclerotic and choroid coats, is very beneficial in inflammation of the
conjunctiva. The symptoms which require its use, are violent




CATARRHAL OPHTHALMIA.                    461
and intense redness of the membrane, with congestion of the
vessels; swelling of the eyelids; a profuse flow of acrid tears;
nightly agglutination; great photophobia; aggravation of pain
from exposure to light, and a feeling as though sand were
lodged in the eyes.
According to Dr. Dudgeon, when the affection is recent, in
the first stage, and the chief symptoms are dryness; itching or
smarting sensation in the eyes and lids; sensation as though a
foreign body were lodged in the eye; frequent winking and occasional discharge of tears, but little secretion of mucus; sulphur, in almost any dilution, suffices to effect a rapid cure.
When the inflammation is intense, the mucous secretion excessive, the redness of the eye considerable, and the caruncula
particularly inflamed, argent-nit. will prove specific.
When the meibomian glands are much affected, and the
edges of the lids are red and swollen, the secretions forming
deep yellow crusts upon the eyelashes at night, mercurius and
hepar may be administered. When the symptoms are exacerbated towards evening, puls. may be found useful. Dulcamara
has been recommended when the symptoms are slight, and the
attack has been produced by exposure to cold and wet.
Knorre found digitalis useful, when the affection of the eye
occurred after the sudden suppression of coryza. Kali-bichrom.
should also be remembered, when the disease has become chronic, and there is profuse yellowish secretion. JMerc., hepar,
euphr., arsen., puls., sulph., are frequently indicated. When
the caruncula and general conjunctiva are the seat of the chronic mucous affection, argent-nit., lyc., zinc., rhus-tox., or bry.,
should be employed. When there is a tendency to the formation of pustules, vesicles, and indolent ulceration, euph., ars.,
sulph., coloc., merc., or silic., may be exhibited.
The sensitiveness to light (photophobia) accompanying pure
catarrhal ophthalmia is seldom important, but when it exists to
any degree, and fails to yield to other remedial agents, con. or
bell. will almost certainly procure relief.*
There are other medicines which may in some cases be called
* See Peters' Diseases of the Eye, p. 49.




462          PURULENT  OPHTHALMIA.
for, among which are caust., digit., phosph., nux-vom., sepia,
silic., zinc., the selection of which will depend upon the group
of symptoms which the individual cases exhibit.
Section 2.-Purulent Ophthalmia.
Purulent Ophthalmia. —This variety of ophthalmia has received various names, in accordlance with the nature of the secretion which accompanies it.  As the disease most frequently
is met with in infants, the term  ophthalmia neonatorum has
likewise been given it; and, as its characters are strikingly defined and developed in them, the best description of the disease
can be given from its progress in such cases.
Sometimes it appears immediately at birth-sometimes three,
six, or ten days after; at others, when the child is three or four
months old. For one person affected above three months,
twenty at least are subject to it under that age.
It commences with some redlness of the palpebral conjunctiva, accompanied with a slight discharge of puriform-looking
secretion, and intolerance of light. At this period of the disease, the conjunctiva covering the eyeball is not inflamed: an
adult will complain of itching, or the sensation as if a grain of
sand were within the eye. As the disease advances, these
symptoms become aggravated, there is great difficulty in separating the lids; the discharge, which was thin, whitish, and
small in quantity, becomes viscid and of a yellowish or grayish
color, resembling pus.  The palpebral conjunctiva is much
swollen and reddened; and this swelling increases to such a
degree as to prevent the raising of the upper lid, and is so protruded as to cover entirely the lower palpebra. The surgeon,
in examining the eye when in this condition, must be cautious
lest during the struggles of the child the upper lid be everted,
to reduce which is very difficult, and sometimes impossible.
The external surface of the palpebra reddens and swells,
which redness and swelling spread to the cheeks and face, sometimes assuming a livid hue-accompanying these local symp



PURULENT  OPHTHALMIA.                     463
toms there is pain, which extends into the head, temples, or
deep within the brain, with the sensation of the eye being too
large for the orbit.  Sometimes hemorrhage takes place from
the eye before the muco-purulent secretion occurs; when such
takes place, an amelioration of all the symptoms ensues. In
consequence of the swelling of the conjunctiva the cornea appears
imbedded in the eye, and very often only its centre can be distinguished, and if an incrustation of dried matter attaches to
it, suppuration of the cornea appears to have taken place.  If
the disease advances the corneal conjunctiva becomes affected,
and the cornea itself becomes opaque, either impairing or destroying vision; further progress results in suppuration and
bursting of the coat with an escape of the humors of the eye.
Before this rupture of the cornea takes place, ulcers more or
less deep are to be seen, which working entirely through, occasion that variety of staphyloma called mulberry, frofri its granulated structure and peculiar color.  The cornea now either
cicatrizes, losing its convexity and transparency, or the whole
eye suppurates.  This description applies to the disease in its
most aggravated form; fortunately, however, the result is not
often so disastrous-the symptoms, under judicious treatment,
are arrested, and the disease is entirely subdued. This disease,
with the results just described, accords in many respects with
that of the celebrated Egyptian ophthalmy-though differing
from the latter in attacking weak cachectic individuals.
Children, as before observed, are most liable to be attacked
with purulent ophthalmia, especially those badly fed and clothed.
The disease frequently prevails in lying-in and foundling hospitals. The chief cause has been supposed to be morbid vaginal
secretions. Authorities however of weight, imagine it owing
to the sudden exposure of the eyes at birth to light; the former
supposition is much more probable.
Treatnent.-If the affection is slight, frequent washing with
a clean sponge dipped in warm water will be sufficient. If the
symptoms increase, aconite every four hours may be given, to
be followed up by euphrasia. The symptoms calling for the
administration of the latter, being a copious secretion of tears




464          PURULENT OPHTHALMIA.
and mucus, and when the conjunctival and sclerotic coats are
both much inflamed with small ulcers around the circumference
of the cornea, together with cephalalgia, profuse coryza, and
evening exacerbations.
Ignatia is to be had recourse to when there is less inflammation than demands euphrasia but severe aching in the eyes,
lachrymation, dimness of vision, and fluent coryza.
Belladonna should be directed when there is dryness of the
eyes with a high degree of conjunctival and sclerotic inflammation, with determination of blood to the head, and more
urgently if there is profuse excoriating coryza, with a dry,
hacking, short or spasmodic cough..Arsenic is advantageously used in some stages of purulent
ophthalmia, especially when the pains are very violent and
burning, and there is a secretion of an acrid serous naturean intermittent character will also recommend its use.
After the disease is subdued there often remains a soreness
and redness of the margins of the eyelids, increased or renewed
by changes of weather, for which nux-vomica is the proper
medicine; a dose should be administered at bed-time, and repeated every night, until relief is afforded; and as individuals
accustomed to indulge in alcoholic or vinous drinks are liable
to such sequelae, which are generally accompanied with headache, eight or ten ordinary sized globules of the medicine in a
tablespoonful of water may be prescribed.
If diarrhcea, intertrigo-miliary eruption, flaccidity of the
muscles, and restlessness attend, chamomilla is the proper
remedy, which may be succeeded by belladonna. If the infant
is at the breast, the diet of the nurse requires attention, and it
will generally be found that either bry., nux-vom., or puls.,
are indicated. Constitutional symptoms are most frequently
met by merc.-sol. or sulph. Euphorbium may be used when
there is severe ulceration of both lids, with violent itching and
irritation, but with rather pale swelling and profuse secretion
of pus.
We know of a case of a most aggravated nature cured by
repeated and steadily continued doses of calcarea carbonica.




PURULENT  OPHTHALMIA.                      465
There may in some instances local applications be required.
Among old school practitioners solutions of alum, sulphate of
copper, nitrate of silver, and oil of turpentine, have been recommended. These, according to Peters, are quite homceopathic enough, " but," says he, " a weak solution of tartaremetic is still more so, and in a few cases I have found it the
most useful one; it is decidedly homceopathic to pustular, purulent, and suppurative inflammation; has a well-earned old and
new school reputation against inflammation in general, and is
certainly not more irritating than turpentine and nitrate of silver, which have been found very useful. Still, I prefer, as a
general rule, a solution of kali-chlor., kali-carb., or kali-hydriod., to be used several times a day for three days; these, although they will not decidedly check the profuse purulent discharge, will alter its character, render it less noxious, thick and
purulent."  Dr. Peters then mentions, that out of over forty
cases of purulent ophthalmia in children, treated by himself and
colleague, Dr. W. S. Stewart, at the Home for the Friendless,
not a single eye was lost, though in some instances the disease
was obstinate, and the progress of cure protracted.
There are other medicines homceopathic to this disease,
among which are rhus., clem., mez., cann., hepar, &c.
The sequeke of purulent ophthalmia have been arranged in
the following manner:
1st. Sloughing of the cornea, especially when the swelling of
the conjunctiva of the ball and the chemosis are very great.
2d. Bursting of the cornea. In some instances there is no perceptible change in the cornea previous to the rupture; but in
others, a small line across the coat is observed, which gradually
increases until the cornea not only becomes opaque, but projects
in an irregular cone, finally a paroxysm of excruciating pain is
suddenly terminated by a sensation of something giving way;
a little hot fluid runs down the cheek, and great relief is experienced. 3d. Suppuration of the cornea. 4th. Ulceration of
the cornea.  5th. Interstitial deposits, forming opacities in
every degree, from the thinnest film to the most dense leucoma.
6th. Opacity of the cornea from cicatrization of ulcers. 7th.
30




466        GONORR H  A L O P HTHALMIA.
Prolapsus of the iris. 8th. Adhesion of the iris to the cornea.
9th. Loosening, sponginess, vascularity, and thickening of the
mucous membrane covering the cornea, with enlargement of its
blood-vessels, and more or less diminution of its transparency.
This change occurs in various degrees, from slight vascularity
to pannus. 10th. Staphyloma, general or partial; and dropsical enlargement of the ball of the eye or collapse of its tunics.*
Section 3.-Gonorrhceal Ophthalmia.
Gonorrhceal ophthalmia somewhat resembles the purulent
variety, and is occasioned either by the direct application of
gonorrhceal matter, or by metastasis. The mucous membrane
of the eyeball and lids is the seat of violent inflammation,
and there is a profuse discharge of purulent matter, resembling
that which issues from the urethra in gonorrhcea. This variety
of ophthalmia is said to be the most violent and destructive to
which the eye is subject. It often destroys the sight in a short
period of time, and frequently when the patient applies for relief the disease is so far advanced that the organ is irreparably
injured.
In this affection there is a great degree of vascular congestion, chemosis, excessive tumefaction of the conjunctiva, and
palpebrae. In the first stage, which is generally short, the
inflammation is confined to the conjunctiva, and the usual
symptoms of such pathological condition are present —soreness, stiffness, photophobia, &c.  After a time, however,
the disease extends to the cornea, and the patient experiences
severe, often excruciating pain in the orbit and head, which is
aggravated by exposure to light; there are also constitutional
symptoms present-shivering, fever, delirium, &c. If the disease still advance, the inflammation extends from the mucous
membrane to the cornea and globe of the eye; the tumefaction
of the orbicular conjunctiva is often so great that it laps
* Quoted by Peters from Lawrence on Diseases of the Eye.




GONORRH(EAL OPHTHALMIA.                       467
the cornea, effusion takes place in the lids, and the swelling
may be so great that it is impossible to obtain a view of the
cornea; this tumefaction declines after a time, and both eyelids may become everted, the convex edge of the tarsal cartilage being pushed forwards by the swollen conjunctiva. The
effects of gonorrhoeal ophthalmia are as follows-suppuration,
ulceration, and sloughing of the cornea, interstitial deposit,
escape of the humors, obliteration of the anterior chamber, staphyloma, prolapsus iridis, corneal opacity, and obliteration of
the pupil.
Three distinct forms of ophthalmic inflammation occur in
conjunction with, or dependent on, gonorrhcea, viz., acute inflammation of the conjuctiva; mild inflammation of that membrane; inflammation of the sclerotic coat, sometimes extending
to the iris.*
Treatment.-As the same tissues are affected in the first
stages of gonorrhieal ophthalmia, as are primarily involved in
ophthalmia neonatorum, the medicines that are adapted to the
one disease are in a measure suited to the other. The great activity of the inflammation, and the more intense febrile disturbance accompanying it, render the employmentt of aconite indispensable at the commencement of the disease, and the most
striking beneficial results are said to have followed its administration.
JIrg.-nit., sulph., mer., chain., puls., thus, and, perhaps,
ignat. or bry. may be indicated.
When the tissues that are more deeply seated become involved, when the pains are pressive, and there is throbbing in
the eye, bell. should be employed. This medicine may also be
used in alternation with aconite../]rsenicum is indicated when the pains are severe, occurring
in paroxysms, when there are violent stabbings in the eye; the
eyeball feeling like a coal of fire. Dr. Dudgeon recommends
* See IIastings' Practice of Surgery, p. 442.
f Dudgeon on Diseases of the Eye. British Journal of Homeeopathy, vol.
vii., p. 4.




468       GONO RRHCEE AL OPHTHALMIA.
highly a solution of nitrate of silver as homeopathic to gonorrhoeal ophthalmia, as well as to the severe forms of ophthalmiac
catarrhales. The solution he recommends is composedl of from
two to four grains of arg.-nit. to an ounce of distilled water;
a small quantity of this solution is carefully introduced beneath the eyelids with a camel's hair brush once a day, every
two, three, or four days, according to the severity of the
symptoms.
Although we have mentioned the treatment by local application of a solution of nitrate of silver, as recommended by Dr.
Dudgeon, we by no means agree with that gentleman as to its
necessity or superior efficacy. On the contrary, we believe,
and the conviction is the result of much personal knowledge,
that by the internal exhibition of the appropriate medicines
cures are more prompt and certain. The attenuations likewise
being high rather than low. The same remark we would apply
to nearly every instance of external application, with a view to
medicinal action, mentioned throughout this volume.
Besides this topical application, he has derived advantage
from the local use of weak solutions of euphrasia, arsenicum,
rhus and mercurius. On this subject Dr. Dudgeon writes that,
judging by analogy, equal advantage might be derived from
the local use of the other medicines in these local diseases. He
says, further-" The mode in which I usually employ the remedies locally, is to mix a drop or two of the mother tincture, or
of the 1st, 2d, 3d, or 4th dilution, or of the dilution taken by
the patient internally, with a teacupful of water, to be applied
one, two, or three times a-day to the eye with a soft rag.
Tussilago petasites is said by Dr. Rosenberg to have proved
effectual in gonorrhceal ophthalmia; but Dr. Dudgeon remarks
that the case given by the former in illustration of the virtues
of tussilago, was not a genuine ophthalmia gonorrhoica, but a
species of blephar-ophthalmia, with scrofulous or other dyscrasic complication..Scid-nit. is useful when the anterior chamber looks as
though filled with a dirty looking pus, and the whole eye appears to threaten disorganization.  If symptoms of iritis de



SYPHILITIC  OPHITHALMIA.                   469
velop themselves, aconite in alternation with merc.-corr.-sub.
are said to be invaluable agents.*
Section 4.-Syphilitic Ophthalmia.
This affection is intermediate between secondary and tertiary
syphilis, By Ricord it is supposed to belong to the former,
and Gollmann coincides in this opinion.
The iris is the primary seat of the disease, although, if the
symptoms are violent, the other tissues of the eye may be involved; in most cases but one eye is affected, and the organ
affected presents many of the properties and appearances of
common iritis. When syphilitic ophthalmia is accompanied
with sclerotical injection, the latter is said to depend upon an
accidental rheumatic complication; however, sometimes among
the anatomical signs of ophthalmia syphilitica is noticed a zone
of violet red, from a line to a line and a half in width, of uniform tint, and in which cannot be observed any distinct vessels.
This zone is called the dyscrasic circle. In the commencement
of the disease the iris becomes duller, and presents a grayish
appearance, the radii being more or less effaced; the small
circle of this membrane is livid or copper-colored; its tissue is
tumefied, and forms an elevated ring composed of thick, downy
flakes. The pupil is more or less contracted, and assumes an
irregular, or angular shape; the cornea is somewhat dimmed,
and on its inner surface careful examination detects small fasiculi
of congested vessels; the tunica albuginea is of a rose-color,
which at its juncture with the cornea is converted into a darkred hue.  As the disease advances the iris becomes more discolored, its surface is covered with exudation, its free margin
is tumefied, and upon its anterior surface there are elevations of
a yellowish or gray tinge. The pupil at length becomes perfectly immovable; pedunculated excrescences, termed condylo" See Gollmann's Diseases of the Urinary and Sexual Organs, p. 77.




470         SYPHILITIC  OPHTHALMIA.
mata of the iris, sprout from the membrane, and adhesion takes
place between the iris and the lenticular capsule. In such cases
the pupil still remains open, and presents a gray instead of its
usual black appearance. At the bottom of the anterior chamber,
through the dim cornea, a more or less elevated layer of pus,
sometimes mixed with extravasated blood, can be perceived.
The patient experiences in the suborbital region of the affected
side violent constrictive, boring pains, which radiate sometimes
to the neighboring regions of the head, are increased towards
evening, most violent at midnight, and abate towards morning.
The visual faculty is more or less altered, by reason of the
intensity of the inflammation, and of the plastic exudations
formed in the pupillary opening. Photophobia is never present
in true syphilitic ophthalmia, and when the symptom is noticed,
other complications are the cause of its appearance.
The terminations of the disease are, resolution, condyloma of
the iris, exudation within the pupil, or obliteration of this
aperture.
This variety of ophthalmia, although it is sometimes met
with alone, is generally accompanied with other symptoms of
secondary syphilis; such as eruptions of the skin, ulceration of
the fauces, pains in the periosteum, &c.
In the treatment of this specific disease,* the desideratum to
be attained is to arrest the further progress of the syphilitic process, and to prevent the permanent or temporary loss of vision
that may be occasioned by the closure of the pupil or adhesion
of the iris from an effusion of lymph. The medicine which the
experience of our allopathic brethren has shown to possess specific virtues in this opthalmia, is, as is well known, mercurius;
and this is the only substance with which we are acquainted,
that possesses the power of producing iritis and inflammation
of the membrane of Descemet. But it so happens that the disease is usually encountered, when the violence of the inflammatory process within the iris threatens a closure or obliteration
of the pupil-an evil which may be prevented by producing
* See British Journal of Homceopathy, vol. vii., p. 23.




RHEUMATIC OPHTHALMIA.                     471
artificial dilatation of that orifice, by bell. or hyos.  But these
medicines have not, according to experience, proved useful in
checking the syphilitic process, and therefore the main reliance
must still be placed in mercurius.
A resort to the external application of belladonna or
hyoscyamus in a concentrated form to dilate the pupil, is equivalent to a mechanical force, the object being to irritate muscular fibre into unnatural contraction-very different from
exhibiting an infinitesimal dose to produce curative action.
In the more chronic stages of the disease, advantage will be
derived from the use of sulph., hepar, puls., and perhaps nit.ac. When condylomata appear in the iris, thuja, nit.-acid, and
in some cases caust. and sepia may be employed.
When abscess forms in the iris, hepar, merc., silic., and
sulph. are valuable medicines.
For the chancrous ulceration that sometimes attacks the cornea; besides mercurius, arsen. and calc. should not be forgotten.
In those cases in which mercury has been abused, nit.-ac.,
hepar, sulph., mez., and dulc. will prove useful.
Colchicum will be of service when there is an exudation of
lymph, or the inflammation is of a very chronic character.
Section 5.-Rheumatic Ophthalmia, or Sclerotitis.
Rheumatic ophthalmia is seated in the serous and fibrous
membranes of the eye, and although generally complicated
with other rheumatic affections, may exist independently of
such diathesis. This disease commences with a violent stitch
in the eye, and with a sensation as though some extraneous
matter had suddenly and accidentally been introduced between
the lids; red vessels can be observed in the sclerotic, which
are either in converging patches, situated near the tendon of a
muscle, or in the form of radii, which extend more or less per



472                 SCL E R 0 T I T I S.
fectly around the cornea, terminating at its edge, or in some instances, running a short distance into it.
There may be some conjunctival inflammation; and, when
such is the case, a net-work of larger vessels anastomosing
over the immovable pinkish-colored fine injection of the sclerotica can be perceived.
The palpebral conjunctiva generally escapes implication.
The pains are tearing, shooting, aching, throbbing, and deep
seated; extending round the orbit, over the brow, in the temple, cheek, and side of the nose; the eye feels stiff, immovable, and painful, if motion is essayed; there is also photophobia. Cold and wet increase the symptoms, which are most
severe from sunset till midnight. Phlyctenae, ulcers, and abscesses may form; and, if the inflammation extends to the anterior capsule of the lens, the latter becomes dim, and resembles
the appearances presented in cataract.  The inflammation,
though rarely, extends to the retina. If the membrane of the
aqueous humor is affected, there may be a fine circle of vessels
on the inside of the cornea; and if the secretion of the aqueous
humor is increased, the cornea bulges outwards.
When the latter is the chief seat of the inflammatory process,
the red vessels may be seen to extend to its centre; white or
bluish spots are formed by exudation, which are to be distinguished from other affections of the corneal conjunctiva, by examining the eye from the side. The entire cornea may become
opaque, and maculae may form. This state of things is accompanied with almost intolerable pain.
The disease may continue from two to six weeks; or, becoming chronic, may last for years, with intermissions of longer
or shorter duration.
If the inflammation is slight at the commencement, pulsatilla will relieve the pain. For the inflammation itself bryonia
should be given.
If the inflammation and pain are excessive, acon. should
be prescribed, especially at the beginning of the attack, if the
sclerotica is red, with a burning pressure, protruded eyes, and
cutting pains.




ARTHRITIC OPHTHALMIA.                     473
Clematis erecta is indicated, if the eyelids are glued together
in the morning, with burning and lachrymation increased in the
open air; and if the iris should likewise be inflamed.
If there be sudden dartings through the ball of the eye, and
rending, boring pains in the orbit and frontal sinuses, and adjacent parts, with a bright red weblike arrangement of the red
vessels of the sclerotica, with copious secretion of tears and
dim-sightedness, mercurius-sol. is the remedy.
If the photophobia lessens, but the pains, especially of the
head and face, increase, euphrasia has proved very effectual.
Caust., calc.-carb., or sudph. will generally be required for the
remaining symptoms.
For the stiffness of the eye and great pain during movement,
spig., bry., and rhus may be employed. If the pain extends
into the head, spig., bell., merc., coloc. should be remembered.
When the morbid process has extended to the iris, bell., merc.,
or sulph. will be found useful. When the rheumatic is complicated with catarrhal ophthalmia, those medicines should be selected which possess a marked action upon the conjunctiva, as
well as on the more deeply seated structures-among which are
ars., bry., calc., hepar, merc., puls., and sulph.
Section 6. —A/rthritic Ophthalmia.
Arthritic ophthalmia, or the venous or varicose ophthalmia
of some authors, is often seen in persons who, so far from having
indulged luxuriously, are poor, and badly nourished; the distinctive term gouty ophthalmia is not well chosen.
The disease commences with a prickling sensation in the
eye; a feeling as if a hair were drawn over it, with formication
in the orbital region, together with a sensation of coldness in
the parts; pains then follow of a boring, digging kind, in the
orbit or bones of the cranium; there is likewise numbness in the
forehead, eyelids, surface of the eye, and corresponding side of




474                TREATMENT OF
the head. Photophobia though present, does not exist in as
aggravated degree as is noticed in rheumatic sclerotitis. The
vision is not much impaired so long as the inflammation occupies the conjunctiva, but as the zone of congested vessels forms
around the cornea, the bottom of the eye becomes greenish, the
sight becomes dim, and total blindness may ensue. The terminations of the disease are resolution, deep ulceration of the
cornea, glaucoma, exudation in the pupil and obliteration of its
opening.
The conjunctival injection is composed of large, distinct, and
nearly varicose vessels, which pass under the conjunctiva of the
lids, and ramify by bifurcation. When arthritic ophthalmia is
the sequence of ophthalmia catarrhalis, the injection of the
conjunctiva presents often only the characteristics of the latter,
with this difference, however, that the vessels are of a deeper
color, intermixed and larger. In the sclerotica there exists a
deeper colored circle of vessels than is noticed in the rheumatic
variety, but the appearance which chiefly characterizes the
venous injection, is the presence of a whitish blue ring, surrounding the cornea, which latter may become the seat of effusion or of circumscribed ulceration in more advanced stages of
the disease; the ulcer is of irregular form, with abrupt uneven
edges, and covered with a grayish matter. As the iris becomes
involved it changes color and appears to be deprived of its
pigment, assuming a marbled aspect, and is spotted with
patches, more or less large, of a bluish gray or pearly hue.
The membrane loses its fibrinous structure, the pupil is dilated,
immovable, and perpendicularly or transversely oval; or it may
become irregular and contracted on account of adhesions which
are formed between its margin and the anterior crystalline
membrane. Arthritic ophthalmia is constantly accompanied
with inflammation or congestion of the choroid, which is manifested by the injection of the external membranes of the eye.
The secretion is often of an acrid and corrosive nature, the mucus sometimes resembling a whitish foam, (arthritic foam,) which
collects in the angles or in the folds of the conjunctiva..Jcon. and bell. are prominent medicines in the commence



ARTHRITIC OPHTHALMIA.                     475
ment of the attack, when inflammatory symptoms are strongly
marked, with lachrymation and considerable pain.
Colocynth should be directed if the pains are of a burning,
cutting kind, and there is also pressing and tearing pain, directing itself to the forehead, and extending also to the root
of the nose: these symptoms compelling the patient, from their
intensity, to a constant change of position.
For the internal inflammation and that of the retina which
frequently accompanies the disease, belladonna is the remedy,
especially when the eyeballs feel as if they would be torn from
the sockets, or pressed into the head; with aching pain above the
eyes; with muscae volitantes, with bright fiery borders and flashes
and sparks before the eyes-and this medicine should be continued should the coroid, iris and scleorotica be inflamed and
the pupil indented and dilated
Spigelia is adapted when the deeper-seated tissues are
affected; when the pain is digging, boring, and sticking, with
a direction to the inner angle of the eye: the eyeballs feeling
enlarged, with a wreath of red vessels around the cornea, with
a narrow white band between; (an important diagnostic sign
to which allusion has already been made when giving the detail of symptoms). This medicine is also indicated when the
eyeball is covered with enlarged blood-vessels, and if the eyes
for an instant are opened the pain becomes almost insufferable;
flashes of light before the eyes.
Sulphur, a remedy so efficient in all cases of arthritis may
be prescribed very advantageously in arthritic ophthalmia,
more especially immmediately after aconite.
Digitalis, when there is horrible pain in the eyeball if
touched, acrid tears, the lachrymation being greater in a room
than in the open air, sensation of weakness in the eyes with
agglutination in the morning-together with the objective
symptoms already stated as characterizing the disease.
Hepar-sulph., rhus-tox., phosph., caust., natr., mur., china, sepia, puls, and other medicines are sometimes required.




476         VARIOLOUS OPHTHALMIA.
Section 7.-Erysipelatous. Ophthalmia.
Erysipelatous ophthalmia frequently accompanies, or is the result of an extensive erysipelas of the face; the pain is sometimes
considerable, and is occasioned by the pressure of the ocular conjunctiva against the palpebrae, there may also be experienced
a sensation of tension, or there is itching and prickling in the
eye. There is neither photophobia nor alteration of vision.
The disease is principally seated in the ocular conjunctiva, or
sometimes may extend to surrounding cellular tissue, particularly that of the eyelids, causing considerable tumefaction.
The injection of the vessels of the conjunctiva is confluent,
the membrane swells, assumes a pale-yellow color, becomes relaxed, and presents somewhat the appearance of infiltration;
the sclerotica is often entirely concealed by the swelling of the
subconjunctival cellular tissue, and the choroid and iris preserve
their integrity. The mucous secretion is scarcely augmented,
and there is no epiphora.
Treatment.-This disease is generally subdued by the exhibition of bell., or thus; in other cases, when the affection has
assumed a more chronic type, sulph., graph., or hepar, may
prove serviceable.
Section 8.-VT'ariolous Ophthalmia.
The integument of the eyelids, and portions of the conjunctiva, are the seat of this variety of ophthalmia. The variolous
pustules may be numerous on the external surface of the eyelids,
and there may be inflammation and swelling of the surrounding
parts. A sensation of tension or of the presence of gravel or
sand, with lancinating pain, generally announces the appearance
of the exanthema, and the sufferings are proportionate to the
extent of tissues involved, as is also the trouble of vision, and
obscuration of the cornea; photophobia is very great, and the
tears are burning. If the disease be not arrested, suppuration




SC R O FULOUS OPHT H ALMIA.                477
of the cornea may ensue, terminating in the total destruction
of the latter; or chronic conjunctivitis and blepharitis may supervene. Falling of the eyelashes, trichiasis, ectropion, ertropion, obliteration of the lachrymal sac, and blenorrhcea, may
also be mentioned as sequents of this variety of ophthalmia.
The pustules that are developed upon the conjunctiva are
small, yellowish, and elevated above the level of the membrane.
The sclerotica is the seat of vivid injection, andt if the cornea
is also affected, this membrane becomes the seat of suppurative
points which are at first whitish, afterwards yellow, finally extend, and destruction of the part may result.  The iris and
choroid may be secondarily affected.
Treatment.-The danger attendant upon variolous ophthalmia, is not great when the affection is treated according to the
homceopathic law, as the primary disease is generally so much
modified, that the danger of the attendant ophthalmia is also
diminished in proportion. The medicines that are best adapted
are acon., bell., hepar., puls., strai., sulph., and variolin.
Dr. Dudgeon records a case* in which the latter medicine
effected a permanent cure, after a diminution of the inflammation, and photophobia had been effected by other remedial
agents mentioned.
Section 9.-Scrofulous Ophthalmia.
Ophthalmia scrofulosa, or scrofulous ophthalmia, is generally a conjunctivitis. It has been called by some phlyctenular
ophthalmia, from vesicles or phlyctenoe being associated with
it. The redness is not very intense. A bundle of enlarged
vessels runs from an angle of the eye to the cornea; or it may
be scattered pretty generally over the conjunctiva, its course
being directed to the cornea. The intolerance of light being, in
some instances, very great, though unaccompanied with pain;
* British Journal of Homeopathy, vol. vii., p. 27.




47S                TREATMENT OF
the patient is compelled to keep the lids almost closed, and to
remain in a darkened room.
As the disease advances the sclerotic may participate, and
red vessels pass over the circumference of the cornea, and at
their terminations a small vesicle may be perceived, which at
first contains a transparent, then a milky fluid. These vesicles
are often seen on the cornea, but generally they are not found
beyond its border. These after a time burst, and become
ulcers of a whitish appearance, which have a strong bias to extend towards the centre of the eye, by involving the parts in
that direction; they are also accompanied with much pain.
Though the vesicles which form on the sclerotica are larger,
they are of less import than those of the cornea. These phlyctenae may be resolved without ulceration, and when such termination is accomplished, there remains a slight speck, which
designates the spot they occupied; the cicatrix, however,
which remains, should ulceration have ensued, is more reluctant
in its departure, or may remain during life. The phlyctenoe
produce the sensation of a foreign body under the lid.
The pain that accompanies scrofulous ophthalmia is severe,
and the patient is sometimes awakened at midnight with acute
stabbing pain in the ulcer, or in the surrounding parts. There
is either a secretion of clear, acrid tears, or of a white, thin
mucus, which corrodes the cheeks. The pains in the eyeball
are shooting and burning. All the symptoms are worse during
the day, but diminish in such a remarkable manner towards
evening, that the patient can frequently open the eyes without
inconvenience, and no signs of inflammation can be perceived.
In this disease the palpebral conjunctiva is inflamed, as are
also the meibomian glands; the edges of the eyelids swell and
become red, and the eyelashes fall out. The lachrymal sac is
also frequently implicated.
Vision  is not much  affected;  there being  sometimes,
however, the appearance of mist before the eyes. When the
cornea and deeper seated tissues become involved, the imperfection of sight is increased.
Scrofulous ophthalmia is generally accompanied with other




SCROFULOUS OPHTHALMIA.                    479
manifestations of a strumous habit, such as cutaneous eruptions,
lymphatic ulcers, glandular engorgements, or affections of the
osseous system. In children relapses are apt to occur, the disease varying in activity at different periods.
Treatment.-In the commencement of the attack, when there
are aching, stinging pains in the eyes, with redness, intolerance
of light, corroding tears, and secretion of much mucus, puls. is
indicated. With such symptoms, and the disease decidedly
aggravated in the morning, nux-vom. has been productive of
much benefit. For symptoms somewhat similar, euphras. is
likewise called for.
sJrsen. is indicated, when the eyelids are swollen, their edges
reddened, and there is profuse secretion firom the meibomian
glands; when the cornea is dim, with opaque spots on its outer
edge, with deep ulcers about its circumference; when the
puncta lachrymalia are swollen and inflamed; when there is
copious lachrymation, and piercing, burning pains, with violent
stitches in the eyes.
Hepar is among the best remedies for the disease-it is advantageous at any period. Hartmann recommends two or
three grains of the 2d or 3d trituration as a dose, two or three
times a day.
The alternate use of calc.-carb. and sulph. has been followed
by the happiest results.  Calc.-carb. one day, and sulph. the
next: the 2d or 3d trituration, two or three grains of either, to
be administered morning and evening at a dose. It is alleged,
that the disease, though of years continuance, has been cured
by these means in one or two weeks.
When the bundles of red vessels are numerous, extending
themselves into the cornea, and the phlyctenae or ulcers are
present, bell. may be given with great benefit. Also when a
painful pressure is experienced when turning up the eyes, and
when the symptoms are increased by cold and damp.
Calc.-carb. is to be selected, if there be a sensation as though
a foreign body had got into the eye; pressure inward, especially in the evening; acrid tears, and secretion of mucus.
When there is present at the same time with the ophthalmia




480            IRITIC OPHTHALMIA.
scrofulosa herpetic eruptions on the face, rhus-tox. should be directed.
Conium is a powerful agent in the treatment of scrofulous
ophthalmia, particularly when there is great photophobia, dimness of the cornea, redness of the eyelids, with profuse discharge
of mucus and tears; sensation as though the eyes would be
pressed from their sockets.
MJerc-sol. and merc.-corr.-sub., are both useful preparations
in the treatment of this disease; the latter is particularly indicate(l when there is spasmodic closure and swelling of the lids,
discharge of thick pus and mucus from the eyes, the cornea
covered with red vessels, also with ulcers, which threaten perforation, &c.  The alternation of arsenicum and euphrasia has
effected a cure of ophthalmia scrofulosa. Cann., caust., dig.,
nit.-acid., puls., sep., silic. or sulphur may in some cases be
required. The disease, however, not being local, will often
resist all efforts for a considerable period; though it may be
relieved or even be made to disappear, it will from time to time
recur, until by appropriate treatment it has been eradicated
from the system.
Section 10.-Iritis. —Iritic Ophthalmia.
The iris is capable of taking on inflammatory action of itself.
It is distinguished by a severe lancinating pain extending from
the eyebrow to the orbit, from thence backward to the optic
nerve, and into the cranium; there is also great intolerance of
light, and many red vessels are apparent on the sclerotic coat,
especially near the cornea, the conjunctiva not being inflamed.
The iris loses its lustre and becomes of a reddish or greenish
hue; upon its surface, also, red vessels may be perceived; the
pupil contracts, becomes irregular, and is turned backwards.
The inflammation generally terminates in effusion, and spots of
coagulable lymph may be deposited upon the iris, on one side
of the pupil, the remainder of the opening being left unaltered;




IRITIC OPHTHALMIA.                     481
this condition is termed by surgeons " imperfect closure of the
pupil," (atresia iridis imperfecta,) and is always attended by
more or less impairment of vision.
When considerable effusion has taken place into the posterior
chamber, the plastic material becomes organized into a dense
opaque substance, to which the entire circumference of pupil is
closely fixed, the opening itself being greatly contracted, or
entirely closed.  By this complete " obliteration of the pupil"
(atresia iridis perfecta) the communication between the two
chambers is destroyed, while the passage of light into the eye
is almost wholly intercepted, being accompanied with a corresponding loss of sight.
The usual causes of inflammation occasion the disease; also
wounds produced by operations for cataract; exposure to a
bright light; syphilis or abuse of mercury.
In the early stage aconite should be employed to reduce the
inflammation. The medicine is to be prescribed in a tolerably
low dilution, and frequently repeated; if, however, there is
much pain in the forehead and occiput, bell. is clearly indicated.
These medicines, however, may be given in alternation; the
latter to be used in cases, even should the pupil be contracted
or less dilatable than natural. When there is aching pain in
the head, with great dryness and pressure, with immovable
contraction of the pupil and frequent scintillations, cina. has
great influence upon the disease.
If the vision is very much impaired mer.-corr.-sub. is to be
directed. Plumbum rapidly absorbs the effused lymph.
In iritis produced by the abuse of mercury clematis has been
used with advantage-also in scrofulous individuals.
In arthritic iritis, with inflamed cornea and sclerotica, intolerance of light, lancinating pains, and contracted pupil, cocculus
should be selected.
If there is lancinating pains in the orbit also, cocculus is still
further indicated.  Staphys., bry., lyc., calc.-carb., and conium,
are also suited to this kind of iritis. For iritis from abuse of
mercury, hepar-sulph. stands foremost in the list of medicines.
If the above treatment fail and the pupil is completely ob31




482              ARTIFI CIAL PUPIL.
literated, the surgeon can have recourse to an operation which
may restore sight to the patient, by means of an artificial pupil.
The considerations which should influence the operator, before
the knife is called into requisition, are of importance, and demand some notice in this place, although the minutiae cannot be
entered into as fully as would be quite satisfactory were sufficient space allowed.
Concerning the admissibility of making an artificial pupil,
when one eye is free from disease, many discussions have arisen,
and different conclusions arrived at.  On this subject Mr. Walton writes*-" My own opinion is against operating, as a rule,
so long as one eye is efficient, for in all probability the vision
that may be restored to the faulty eye will not be equal to that
of the other, which will continue to be used alone. A more
forcible objection, however, is that as a new pupil cannot be
made to correspond to the natural one, there will most probably
be confusion of sight, double vision or squint.
"When the true tissue of the cornea has been lost, and its
place supplied by a *cicatrix, an operation is contra-indicated,
although there may be a part of the cicatrix nearly transparent;
for the iris is necessarily incorporated with the new material.
An operation is also contra-indicated when the iris is adherent
to the corneal tissue.  An iris that has lost its characteristic
fibrous appearance and lustre, and bulges forward, affords but
a doubtful prospect of success, from the tendency there is for
the breach that is made in it to close by adhesive inflammation."
A long interval should be allowed to elapse after the cessation of the disease that has caused the obliteration before
attempting an operation.  "If the original disease has long
passed away, and a fair.trial has been given to means calculated
to subdue inflammation, -if the health is good, and the eye is
free from irritability, and there is much encouragement from the
soundness of the retina, I do not hesitate to operate.
" An eye that has seemed to be in an almost hopeless condition directly after the subside nce of the disease that has rendered
*1 Vide Walton's Operative Ophthalmic Surgery, p. 549.




ARTIFICIAL PUPIL.                     483
its pupil useless, may, on the restoration of the general health,
improve considerably, and be brought into a proper state for
successful operation."   There are  additional considerations
which the practitioner, before attempting the formation of artificial pupil, would certainly consider, as well as the size and
construction of instruments employed, together with other
minutia of the operation.
The method of operating is a revival of Chesselden's, by Sir
William Adams-Chesselden being the first surgeon who suggested and performed the operation. The directions of Sir
William Adams are viz.: " The patient being seated as in the
operation for cataract, and the eye rendered steady by a gentle
pressure with the concave speculum placed under the upper eyelid, the artificial pupil knife should be introduced through the
coats of the eye, about a line behind the iris, with its cutting
edge turned backwards instead of downwards. The point is
next brought forward through the iris, somewhat more than a
line from its temporal ciliary attachment, and cautiously carried through the anterior chamber until it has nearly reached
the inner edge of that membrane, when it should be almost
withdrawn out of the eye, making a gentle pressure with the
curved part of the cutting edge of the instrument against the
iris in the line of its transverse diameter. If in the first attempt
the division of the fibres of the iris is not sufficiently extensive,
the point of the knife is to be again carried forward and similarly withdrawn, until the incision is of a proper length, when
the radiated fibres will immediately contract, and an opening of
a large sore will be formed. After the operation is thus completed, the eye should be covered over with a plaster of simple
ointment, spread on lint, and the patient put to bed with his
head raised high.
If the obliterated pupil should be combined with an opaque
lens or capsule —which can be seen behind the pupil, of a
whitish or bluish appearance-the surgeon when dividing the
iris should cut or tear up the lens, capsule, or both, and push
them forward through the pupil, which they will contribute to
keep expanded.




484             PSORO P H T H A L M I A 
By Wenzel, Guerin, Azalini, Beer, Reissinger, and others,
modifications have been made in the method of operating, and
with much success; but to detail the method of procedure in each
would occupy more time and space than can be here allowed.
The iris may also be prolapsed (procidentia iridis) through
a wound or ulcer of the cornea. The pain of this disease is
excessive, and there is much photophobia; the pupil becomes
irregular in shape, though generally of an oval figure. Sometimes
there are several projections of the iris, each through a separate
orifice in the cornea. After a time adhesions take place between the cornea and iris, and the part of the iris beyond the
cornea may become dry or hard, or it may slough away.
If the occurrence follows a wound of the cornea the surgeon
must immediately replace the iris; if it passes through an ulcer
of the cornea, the ulcer must first be healed before the iris can
be retained in its natural position. The application of a solution of nitrate of silver upon a fine camel's hair brush, or a
solid piece of the nitrate shaved down to a very fine point, and
the edges of the ulcer gently touched, has been found to be a
successful mode of treatment.  The  morbid sensibility of
the iris is'also allayed by the caustic, and the projecting and
superfluous portion of the membrane may also be destroyed by
its application.
It may be well to remark here that the nitrate of silver is
much more preferable than the vegetable caustic or potassa, the
former confining its action to the parts to which it is applied,
the latter diffusing itself to adjacent parts and rapidly destroying animal fibre.
Section 11..-Psorophthalmia.
The above term is used to designate an inflammation or
ulceration of the eyelids. Other names have been applied to
the disease, such as ophthalmia tarsi, lippitudo, tinea ciliaris,
&c.




TREATMENT OF PSOROPHTHALMIA.    485
The inflammation first appears on the margin of the lids,
the tarsal cartilages and glands-the adjoining mucous membrane of the parts being often involved, the disease extends
along the conjunctiva to the globe of the eye, attended with
pruritus, redness, and sometimes severe pain. The roots of the
eyelashes at first become stiff and dry, but as the disease advances they are moistened by increased secretion. The meibomian glands always participate more or less in the affection,
and no longer pour out the mild and unctuous fluid which is
destined to lubricate the lids, but their secretion is suspended,
so that during the night the eyelids are glued together by the
increased conjunctival discharge.* The inflammatory action
may terminate in suppuration, followed by ulceration of the
tarsi, which sometimes creates considerable deformity.
When pustules form on the margin of the lids, especially
about the roots of the eyelashes, the term tinea ciliaris designates the affection. These ulcers break and discharge a yellowish matter, which concretes in the form of yellowish brown
scabs. As this disease is seated along the roots of the ciliae,
their growth is affected and their direction altered.
Treatment.-Dr. Peters, in writing on this affection, remarks,
that a large portion of the treatment falls to the share of the
patient or his attendants. The lids if possible should always
be prevented from becoming agglutinated at night, and if this
cannot be effected, they never should be separated in the morning, until the matter by which they are glued together has been
completely softened. By forcing the lids roughly asunder, the
irritation is constantly enhanced, and the discharge daily aggravated; tepid milk or water should be used, or the agglutinated
lashes should be anointed with olive oil, or some other simple
unguent (simple cerate or fresh lard is better). The margins of
the lids should be carefully examined with a magnifying glass,
and all inverted lashes carefully extracted; by such means a
great degree of inflammation may be prevented, and the cure
be more readily accomplished.
* See Peters on Diseases of the Eye, p. 10.




486             HYDROPHT HALMIA.
Boraz is homceopathically indicated when the eyes become
agglutinated at night with hard, dry gum../lumina may also
be employed for such condition, and may be rendered preferable
by the presence of other symptoms.
/Jrg.-nit., amm.-m.ur., carb.-an., may also be called for.
One of the chief remedies for psorophthalmia, and one which
has been productive of most beneficial results, is euphrasia.
In many cases its exhibition is sufficient to effect a cure without
the administration of any other remedial agent. Abundant experience in relation to its action when there is " inflammation
and ulceration of the margins of the eyelids," was furnished to
the author, while physician to the Philadelphia Homceopathic
Dispensary.
Kreas. is recommended for chronic swelling of the margin of
the lids.
Eupat., spig., merc., and clematis may also be required, and
in obstinate cases calc. or sulph. may be productive of beneficial
results.
Section 12.-Hydrophthalmia.
This affection has been described under different names, as
hydrops oculi, hydrophthalmus, dropsy of the eye. It is a partial or general enlargement of the globe of the eye, caused by
increase in the quantity of the humors, or by the effusion of an
aqueous fluid. The water may be effused either into the anterior or posterior chamber of the eye, and if much protrusion
take place from an increased accumulation of water, there is
much pain both in the eye and head; vision is impaired; the
iris trembles when the patient moves the head, and the aqueous
humor becomes turbid. This condition is attended with the
same inconveniences as are experienced in staphyloma, and is
accompanied with equal or greater deformity. By the enlargement and irregular figure of the globe, which continually presses
upon the lids, and irritation of the latter is frequently the
result.




HY  DR   PHT H A L MI A.             487
Of this disease Scarpa says-" The generality of surgeons
teach that the immediate cause of the dropsy of the eye is
sometimes the increase of the vitreous, at other times of the
aqueous humor. In all the cases of dropsy of the eye which I
have operated upon, or have examined in the dead body, in
different stages of the disease, I have constantly found the
vitreous humor, accordingly as the disease was inveterate or
recent, more or less disorganized, and in a state of dissolution;
nor have I been able in any instance to distinguish, on account
of the increased quantity, which of these two humors, vitreous
or aqueous, had the greater share in the formation of the
disease."*
Treatment. —When vision is: almost or entirely destroyed,
and the eye projects beyond the lids, it is proper to evacuate
the water, which may be done with a common lancet or couching needle. When the water collects, the operation may be
again repeated. The evacuation of the effused fluid is resorted
to to prevent irritation and suppuration.
Before, however, having recourse to the mechanical treatment, there are many articles of the Materia Medica, the administration of which offer a more than reasonable hope of
removing the water by absorption. Should the disease occur
after debilitating losses china, ferrum, merc., and sulph., might
correspond to the presenting symptoms; if from a repercussion
of an eruption, dig., hell., rhus-tox., and sulph., should be remembered.
Jirs., bry., kali-carb., phosph., and samb., would also offer
themselves for consideration.
If these medicines do not succeed in removing the disease,
the operation for the radical cure of staphyloma must be performed; the after deformity being remedied by an artificial
eye.
* Hastings' Practice of Surgery, p. 451.




488         PTERYGIUM, OR EYE WING.
Section 13.-Pterygium, or Eye Wing.
This affection derives its name from the supposed resemblance
of the abnormal growth to the wing of an insect. Authors
have divided it into four varieties, viz. cellular, vascular, fatty,
and fleshy; but, according to Walton,* pathology warrants no
such arrangement, while distinction for the sake of description
is useless. The disease is not uncommon, and consists in a
thin, triangular, membranous expansion of the conjunctiva, and
of the subconjunctival cellular tissue, increased in vascularity,
and presenting various appearances in regard to thickness and
color.
The disease generally commences at the inner canthus, with
the base of the abnormal growth connected with the semilunar
fold and caruncle from which it appears to grow. In very rare
instances the base may be at the cornea.  A  bifurcated
pterygium has been described by Weller.
The affection is more common in some localities than in
others; warm climates being said to be more favorable to the
propagation of the disorder than those of a colder temperature.
It is a singular fact that pterygium  scarcely ever passes beyond the centre of the cornea.
Treatment.-The only medicine that is mentioned as suitable
to this affection is arg-nit.  Probably thuj., caust., or sep.,
might be of some service. Excision is frequently resorted to
by surgeons of the present day, and the operation is said to be
quite successful; however, it should never be attempted, unless
the abnormal structure encroach upon the cornea, and threatens
to obscure vision.
There are two modes of operating for pterygium. One consists (the lids in both cases being separated by the fingers or
speculum) in elevating the thickened tissue by means of small
forceps, then dissecting it all or in part away by scissors or
knife. The second operation consists in elevating the pteryV* ide A Treatise on Operative Ophthalmic Surgery, by II. Haynes
Walton, p. 288.




DISEASES OF THE CORNEA.                     489
gium, as in the former case, and passing a knife or scissors perpendicularly through it, thus dividing it into two parts; then
by introducing the sharp point of a pencil of nitrate of silver
and cauterizing the cut surfaces, reunion is prevented; the
thickened membrane is then absorbed, or at least the advance
of its growth over the cornea is arrested.*
Section 14. —Diseases of the Cornea.
The cornea is variously affected by diseased action; when
inflammation attacks it, the term ceratitis indicates the affection. In this latter there is not much redness, and the cornea
being possessed of little sensibility the pain is not severe, but an
increased secretion of tears and intolerance of light are always
present. The cornea assumes a dingy, faint, and dim appearance, which dimness varies in degree and extent of surface,
giving rise to several morbid appearances, to which different
names have been assigned; the translucency itself being occasioned by a deposit of lymph between the lamellae of the cornea.  If the inflammation is severe the effusion is greater, and
a pseudo membrane is formed; or the cellular structure between
the corneal layers may entirely be absorbed, and a direct union
of the parts be the result.  Should this take place, the whole
texture of the membrane is entirely altered.
In simple opacity the dimness is diffused, and is gradually
lost in the more transparent portions of the cornea; it is generally directly beneath the conjunctiva, its situation being readily
detected by examination of the eye laterally with a magnifying
glass. The iris and pupil may both be perceived through the
opacity, and vision is but slightly impaired.
AJlbugo, according to its cause, varies both in color and form.
It is always the consequence of a wound or ulcer, hence its name
cicatrix. The pupil may be very much distorted in consequence of
* Vide Hastings' Practice of Surgery, p. 447.




490                 TREATMENT OF
being attached to the cornea at the albugo; or the former may
be covered with cicatrices, having its color and form both destroyed thereby.
Leucoma is a circumscribed opacity, of a white or pearl color.
If situated beneath the conjunctiva, it will present a dull or
leaden aspect; if deeper seated within the cornea, its appearance is polished or shining; and if directly in front of the pupil,
vision may be either entirely or partially destroyed, in proportion as the opacity obstructs the admission of a portion, or of
all the rays of light.  In some instances, before the disease has
reached an advanced stage, the patient possesses the faculty of
seeing during the evening and night, although deprived of sight
during the day —this is in consequence of the pupil dilating, and
permitting the passage of a greater number of visual rays.
Pannus is an opaque and vascular condition of the anterior
membrane of the cornea. The appearance presented by an eye
affected with this disease, resembles that of a piece of cloth or
rag covering the cornea; hence the name.
Corneal opacities are caused by the application of corrosive
or acrid substances to the eye, wounds, &c.; and are likewise
owing to constitutional affections, such as rheumatism, gout,
scrofula, &c.
Treatment. —If the inflammation has been induced by mechanical injury, the use of arnica, internally and externally,
should immediately be had recourse to. A few drops of the
tinctae. arnicae, diluted with a fluid ounce of water, should be
applied upon linen cloths to the injury, and the 6th attenuation
-fifteen or twenty globules dissolved in fgvj of water-of
which solution a tablespoonful should be given every four
hours. The tincture for internal exhibition being made from
the root only, is a different preparation from that which is
obtained from the stems, leaves and flowers of the plant, used
for external application. This is a difference which should
be carefully borne in mind in practice.  Calendula officinalis,
which has been found so beneficial in lacerated wounds, may
prove very advantageous.
The steady and long-continued use of iodine will often re



DISEASES OF THE CORNEA.                   491
move opacities of the cornea.  One drop of the tincture in a
tumbler of water (f~viij), a dessertspoonful every evening; or
a grain of hydriodate of potassa in f.~vj of water (dose the
same) may be given.  These medicines will be found efficacious, especially in persons of a scrofulous habit.
The tincture, diluted with water, may likewise be applied by
means of a camel's hair pencil to the opacity, to facilitate absorption-one drop diluted is the proper strength when thus
applied.
Among the medicines to be administered, lepar is highly recommended-a dose of the 2d or 3d trituration to be used at
bedtime.
Cannabis is also held in high estimation by some homceopathic physicians. It may be used both as an external application and as an internal medicine. It is said to have proved of
great benefit in pannus.
Euphrasia may be employed, when there is opacity or
cloudiness of the cornea. Spig., bell., puls., and calcarea are
also medicines which may be used in this affection-the latter
is especially serviceable in children, and has proved effectual
without the exhibition of other remedial agents. A few globules dissolved in a teaspoonful of water, and administered
every third or fourth night, may lessen the opacity in a short
time; after which, the interval between the doses should be of
much longer duration.
JMag.-mur. and nitric-acid are efficacious medicines, when
the corneal opacity presents a decidedly whitish hue, arising
from traumatic or arthritic ophthalmia; when there is itching
and burning in the eyes and eyelids, dilated pupils and photophobia.
Sep., ol. jec. asc., and some other medicines, have also been
used and recommended.
The cornea is also liable to ulceration: it may be superficial,
directly under the conjunctiva, deeper seated, or in the cellular
structure between the lamelle. It is frequently met with;
it often follows ophthalmia, or arises from the application of
corrosive substances to the eye. The ulceration may be con



492         DISEASES OF THE  CORNEA.
fined to the conjunctiva only, where it covers the cornea, and
may be seen by viewing the eye laterally. Opacity in these
cases does not always follow, in consequence of a thin, shining
crust forming upon the exposed surface, which arrests the disease. If, however, the ulceration follows purulent ophthalmia,
it commences externally, and often extends itself into the anterior chamber.
If the centre of the sclerotica be the site of the ulcerative
process, it will resemble a collection of matter in the substance
of the cornea, whence it either advances to form an external solution of continuity, or penetrates the anterior chamber, causing
hypopion. This latter disease will hereafter be alluded to.
In ulceration of the cornea the pain is less than that of the
inflammation which generally precedes it. Sometimes, however, it is complained of as being as sharp as though a needle
were thrust through the eye; movement of the eyelids and
light increase the sufferings. Around the ulcer there is usually
a slight cloudiness, and in certain cases vessels may be seen
coming from the conjunctiva (vascular ulcer of the cornea).
When the ulcer heals these vessels disappear, the cicatrix being
always partially absorbed.
If the ulcerative process is accompanied with inflammation of
the sclerotica and conjunctiva, those medicines must be used
which have already been mentioned in the treatment of inflammation of those tunics.  In obstinate ulcerations the most successful allopathic treatment has been, and is, to apply a solution
of the the nitras. argenti (lunar caustic), of the strength of four
or six grains to an ounce of distilled water, with a camel-hair
pencil-this is to be used, should the ulcer remain transparent,
or show no disposition to cicatrize. When a deposition of new
matter is perceived undergoing a vascular organization, and the
ulcer cleans, its application should either be less frequent or
omitted. Dr. Gibson advises the caustic to be lightly applied
till an eschar forms, and when this drops off, which it does in
twelve or eighteen hours, to reapply the solution, taking care
to wash away any superfluous caustic from the eye or eyelids.




HYPOPION.                         493
If the stitches are very violent, and the pain much increased
by moving the lids, or there be a sensation as if red-hot needles
were passed into the eye, the pains very much aggravated by
light, or a sensation of sand being lodged in the eye, arsenicum
is the proper remedy. It is also indicated by throbbing accompanying the stitches, together with dark redness of the vessels,
with cedematous swelling of the lids, and especially should
these symptoms arise in gouty or rheumatic individuals.
Calcarea carbonica is indicated, if with the photophobia there
is a dtesire to press in the eyes for relief; also itching, especially
in the evening, and burning when the lids are closed; also
lachrymation, sometimes of a smarting fluid, particularly in
scrofulous individuals, anal in those who are of frail constitution
with an impoverished nutrition; and especially in very young
children, of a scrofulous diathesis, with muscular and nervous
weakness, disposed to inordinate discharges from the mucous
surfaces.
Belladonna, if the ulceration commence in the cellular structure connecting the lamellke; when, in closing the eyes, a deep
aching pain is experienced; dryness and burning; likewise with
pain in the orbits.
Sepia is a very effectual medicine in the treatment of those
ulcers which are vascular: merc., hepar, euphra., puls., silic.,
have likewise been employed.  Thuja especially, in the 30th
dilution, together with cann., in the same potency, are recorded as having been productive of most happy results.*
Section 15,.-Hypopion.
Violent and deeply seated ophthalmia may terminate in the
formation of pus within the anterior or posterior chambers of
the eye, constituting the disease called hypopion. The matter
" See a paper on Vascular Tumor of the Cornea, by J. J. Drysdale, M. D.
British Journal of Homoeopathy, vol. vii., p. 244.




494                  HY Po PI O"N.
secreted being heavier than the, aqueous humor, sinks to the
bottom of the anterior chamber, where it can be observed, and
frequently presents the appearance of a yellowv crescent-shaped
spot, which gradually increases until the whole cavity may be
filled; there is much photophobia and other symptoms of ophthalmia experienced, which, however, in some instances may
gradually subside, and the pus be absorbed; or the matter may
remain for many weeks mixed with the aqueous humor, which
it renders turbid. The affection generally terminates unfortunately, in consequence of the humors of the eye being discharged through an ulcerated opening or slough.
Treatment.-The object will be to subdue the inflammation
which accompanies the disease, the reduction of which will
either lessen the quantity of pus or promote its absorption.
The medicines to accomplish which will be among those
already detailed for the different forms of ophthalmia, some
one or other of which will accord with the symptoms which
present themselves in connection with hypopion.
The custom formerly resorted to by surgeons of perforating
the cornea, to allow the exit of pus, is at the present era entirely exploded-for matter is rapidly absorbed, so soon as the
inflammatory process is arrested. The distinguished oculist
Beer, when appealing to his former experience with regard to
the evacuation of the purulent secretion by means of openings,
thus wrote:
"Any one who has successfully and completely cured by incisions so many cases as I have, will not think it worth while
to hear, or read, and much less to refute such objections."
Subsequent experience entirely changed his opinion, and in another work he writes: "That when matter showvs itself in the
anterior chamber, the surgeon must on no account think of
opening the cornea, for the eye will certainly be much injured."*
The medicines that have proved remedies for hypopion, are
arsen., euphra., hepar, merc.-sol., merc.-corr.-sub., and sulph.
* Peters on Diseases of the Eye, p. 107.




STAPHYLOMA.                        495./rsenicum, 4, every four hours, cured entirely in fourteen
days a violent inflammation of the eye, with effusion of pus into
the anterior chamber. Several cases have been cured by hepar,
merc., and merc.-corr.-sub. The two latter, when the formation of pus followed upon rheumatic and scrofulous ophthalmia.
Sulph., according to Rummnel, accomplishes extraordinary results in hypopion, even when it arises from gonorrhceal ophthalmia.*
Section 16.-Staphyloma.
Staphyloma is an affection of the cornea, in which the latter
is destroyed either partially or in toto, and its place supplied
by a projecting opaque substance.
Mr. Jones' explanation of the pathology of this disease,t
appears to be correct according to Walton. The former gentleman affirms, that staphyloma is not a bulging of the cornea,
as is generally taught; and he explains its formation by pointing out the fact, that when the iris is exposed by the loss of
the cornea, it becomes covered by an opaque firm tissue, resembling that of a cicatrix, which is incorporated at the base of
the tumor with the cornea, constituting a partial staphyloma,
which consists of protruded iris, covered by new tissue, intended to supply the loss of corneal substance; and he remarks,
that the formation of a total staphyloma is precisely the same,
the degree only differing, and the form of the tumor depending
on the extent to which the cornea has been destroyed. This
has been confirmed in a dissection by Mr. Bowman, the results
of which are briefly given in his lectures on the parts concerned
in the operations on the eye.
Accompanying the staphylomatous state, there are occasionally changes in the crystalline lens, whereby it is ossified or
rendered cretaceous; and although it is not possible to know
when it is so changed, or to be able to refer with precision
* Loc. cit.         t London Medical Gazette, vol. xxi., p. 847.




496        TREATMENT OF STAPHYLOMA.
to any set of symptoms indicative of those alterations, proof is
not wanting that a calcareous lens is prejudicial, acting as a
foreign body within the eye.
There may be greater opacity in some portions of the cornea
than in others, the sight being either partially impaired or completely destroyed.
Treatment.-In the commencement of the disease, when inflammatory symptoms are present, with their usual concomitant
sensations, the exhibition of acon., bell., euphra., hepar, merc.,
or suiph. may not only subdue the inflammation, but prevent
the appearance of staphyloma.
Many other symptoms in staphyloma are found in connection
with affections of thie eye already treated, to which reference
must be made for detailed treatment.
When the affection has reached its acme, and the opaque
firm tissue has been formed, operations have been resorted to
with success.
The most convenient method of removing complete staphyloma is thus mentioned by Mr. Walton:*
The operator should stand behind the patient, and raise the
upper lid; "and, after an assistant has transfixed the staphyloma with a curved needle, or seized it with a hook, the required portion is cut away with a scalpel. It may look neater
for the operator to entrust the lids to an assistant, while he
pierces the staphyloma; but then the assistant would most
likely press too much on the globe, and squeeze out its contents. Care should be taken, in case the lens is in its place
and healthy, to avoid injuring the capsule with the instrument
that transfixes the staphyloma. I recommend this, because I
am in the habit of leaving the lens; some surgeons, however,
always remove it, under any condition, lest it should become
the seat of calcareous matter, and if examples of such occurrence can be adduced, the rule for the removal should be absolute.
"After the operation the lids should be closed directly, and
* Operative Ophthalmic Surgery, p. 353.




CATARACT.                         497
cold water" (or solution of arnica) "applied by means of bits
of rag, for some time after, as a safeguard against bleeding, and
the patient should be watched for several hours, that such occurrence may be promptly met, for it is prone to occur; and
from neglect I have known a child nearly bleed to death. The
operation is very painful, far exceeding what would be expected;
and the collection of blood within the remaining tunics of the
globe, over which we have no control, may cause prolonged
suffering."
For many distressing symptoms which take place after operations upon the eye, the./sarum Europaeum has not only a
close correspondence, but is asserted to possess a strong elective medicinal affinity for the organ. In a dilute form it may
be applied externally, while at the same time it must be internally administered.
Section 17.-Cataract.
By the term cataract is understood a partial or general opacity of the crystalline lens, of its capsule, or of the morganian
fluid, either separately or conjointly, with a corresponding
diminution of sight.  The opacity may be within the lens or
capsule, or without the lens and its investing membrane; when
in the latter location it is owing to the presence of blood, pus,
or some other foreign matter within the pupil, and is denominated a spurious cataract; when in the former; (within the lens
or capsule,) it is called a true cataract, cataracta vera, of which
there are four varieties, viz., lenticular, capsular, capsulolenticular and morganian.
The formation of a cataract is generally slow, requiring
weeks, months, or years for its complete development. It may
appear in one eye, or in both; but when the former is the case,
the other eye is generally affected either sooner or later.  The
diagnosis between cataract and amaurosis is very necessary, and
is correctly reached by the due appreciation of the appearances
presented by each of these affections.  In cataract, all objects
32




498                   CATARACT.
appear to be encompassed with a cloud or mist, especially those
that are white. When looking into the eye through the pupil,
an opacity may be seen in the centre of the opening, and as the
dimness of vision increases, a blackish ring, which is the shadow of the iris reflected upon the lens, is perceived around the
pupilary aperture: this appearance is more perceptible in light
than in dark colored eyes. In the commencement of the disease, the opacity being seated in the centre of the lens, objects
directly in front of the individual cannot be observed, while
those laterally situated are capable of being seen. Early in the
morning, or in the evening, in consequence of the lesser degree
of light, the pupil dilates, and the rays passing into the interior chamber of the eye, around and beyond the part which is
opaque, vision is considerably improved. The flame of a lamp
appears as though surrounded with a white circle, which widens
as the distance from the light is increased. In a more advanced stage of the disease, the idea of the distance of the flame
can only be conjectured, it being very indistinctly seen. The
movements of the iris are not affected by incipient cataract.
In amaurosis, the cloudiness is perceived at a greater distance behind the pupil, is of a reddish or greenish hue, and appears concave; the pupil is angular or dilated, and the cornea
is less bright and clear than in a healthy state; the dimness
of vision is notvaried by the degree of light. Violent mental
emotion, stimulating drinks or food, will improve for a short
time the visual function; while it will be impaired by depressing passions, watching, or fatigue. The flame of a lamp or
candle, instead of being encompassed with a white halo as in
cataract, is surrounded with a circle of variegated colors. In
cataract, convex glasses assist; in amaurosis, their use does
not facilitate vision.
On examining the eye, if a cataract is present, the pupilwhich naturally is black —appears gray or white, except in the
instance of black cataract. The catoptric examination affords
unerring diagnostic signs of cataract.
The late Professor Sanson began to observe in 1836, and
pointed out to his clinical class, in 1837, that when a candle is




CATARACT.                         499
placed before the eye of an amaurotic patient, whose pupil is
dilated, three images of the flame can always be distinguished,
succeeding one another from before, backwards. The first, or
anterior one, which is the brightest, is erect; the second, or
middle one, which is less bright, is reversed; and the third,
or posterior one, is much fainter than the other two, and is
erect like the first one. M. Sanson and his pupils arrived at
the same results, and ascertained that the anterior erect image
is produced by the cornea; that the middle reversed one is
owing to the posterior segment of the crystalline capsule;
while the posterior erect image arises from the anterior segment of the same capsule. Opacity of the cornea destroys all
three images. Opacity of the anterior capsule destroys the two
posterior images. Opacity of the posterior capsule prevents
the production of the reversed image.
In other words, when there is a posterior capsular cataract,
we cannot see the middle or reversed image; in anterior capsular cataract, the anterior erect image is alone visible; and so
it is in capsulo-lenticular cataract. The experiments of M.
Pasquet, combined with these, have confirmed the conclusion,
that a cataract, even at its commencement, can always be distinguished from amaurosis and glaucoma. For since in glaucoma and amaurosis, the alteration does not affect the crystalline apparatus, the three images of the flame still remain.*
The causes of cataract are often very obscure. Persons exposed to the glare of fires-as men working in furnaces, glasshouses, &c.-are often its subjects. It is supposed sometimes
to have an hereditary origin. External violence may also produce it, or it may arise from metastasis of scabies (itch), suppressed hemorrhoids, syphilis, or gout. Intense heat frequently
and constantly applied to the eye, or the very constant use of
the visual organ, may produce the disease; hence students,
artizans, &c., are frequently affected. Statistics of three hundred cases show, that three-fourths of that number had been
persons long exposed to the sun, in a stooping posture; the
* Clymer's Medical Examiner, July 15, 1845, p. 142.




500                   CATARACT.
eyes being thus subjected to the sun's reflections from the
soil.
The proximate cause of cataract has been considered to be
an inflammation of the lens, or of its capsule; in proof of which
oculists have asserted, that by microscopic examination red
vessels can be distinctly seen in the substance of the lens. Dr.
Jacobs,* however, in his work on "Inflammation of the Eyeball," remarks, that he could not detect them in the lens, but
has seen them in the cornea. There has been considerable discussion among oculists regarding the preiexistence of inflammation being necessary to the formation of cataract, which it is
unnecessary to detail here.
Cataract occurring in aged individuals has been reasonably
ascribed to a rigidity and consequent obstruction of circulation;
and it is asserted that, from the same cause, the cornea in old
persons is affected with what is denominated arcus senilis.
Many varieties of cataract are mentioned by surgical writers,
a few of which may be pointed out, viz.:
Lenticular cataract is generally hard and firm, though it has
been classified into hard and soft.  The darker the color, the
harder is the cataract; the grayer its appearance, the softer its
consistence.  Lenticular cataract is sometimes radiated, the
opacity appearing in streaks or radii, with comparatively
transparent interstices; the radii generally beginning in the
circumference of the lens, the reverse of the ordinary form of
opacity, which commences in the centre.
The milky or fluid cataract presents the appearance of the
conversion of the lens into a whitish or other kind of fluid.
When the substance is a medium between hard and fluid, the
term  caseous, or soft cataract, is used-the lens in this latter
variety is much enlarged.
In morganian cataract there is an opacity of the fluid situated between the lens and its capsule. Its existence without a
further extension of morbid change, is denied by many authors.
It is hardly possible for it to exist alone for any length of time.
* Walton's Operative Ophthalmic Surgery, p. 385.




CATARACT.                         501
Cataracta capsularis, or opacity of the capsule of the lens,
has been divi(led into anterior capsular, posterior capsular, and
complete capsular cataract.
In anterior capsular cataract, the opacity, which is whitish
and glistening, is noticed on a level with the pupillary margin
of the iris. The capsule cannot become extensively involved,
without the lens also being affected.
Posterior capsular cataract can be recognized, by the opacity
being seen at a distance behind the pupil, the anterior portion of membrane retaining its transparency. The opacity
has not the white or glistening color which distinguishes the
anterior variety, and is concave.
When the capsular cataract is complete the whole membrane
is involved. If the anterior part of the capsule have become
opaque, it will prevent the diagnosis being easily arrived at;
which can only be certainly ascertained in the early stages of
the disease, when the anterior capsule is but slightly affected.
It often happens, that the lens participates in the disease, constituting capsulo lenticular cataract, which is frequently met
with.  In the latter form a variety of appearances are present,
to which the older writers gave different appellations, in accordance with the fancied resemblance of the opacity to some
object-as cataracta stellata, pyramidal, or disseminated cataract.* Another variety is the arborescens of Richter, which is
always the result of violence, which has separated and lodged
upon the capsule a portion of the tapetum of the uvea. At
first this can scarcely be perceived; but inflammation coming
on, the uvea is united to the capsule, the iris is sluggish, and
the lens finally becomes opaque.
It is impossible to explain, in the present state of our knowledge, the causes of these varieties; but, that they are occasioned by essentially different morbid actions, will not be questioned. They cannot be supposed the result of the same kind
of inflammation or morbid processes.
* For an interesting account of peculiar appearances presented in Cataract, see Medical Examiner, April 1843, p. 72.




502                TREATMENT OF
Treatment.-Before proceeding to the considerations connected with the operation, and the different methods of relieving the patient by means of the knife, mention will be made of
those remedial agents that have been found instrumental in
curing the disease. Allopathic medicine repudiates the idea of
curing afully developed cataract. Quite an authoritative author
observes: "That cataract has often been checked in its progress
by the administration of remedies adapted to correct that peculiar diathesis of the system from which it has originated; but
there is no single instance on record where the disease can be
said to have been cured, or, in other words, where the opaque
lens has again become transparent by such means."
At one time certain medicines were much in vogue, among
which were puls., bell., merc., &c.; and that they obtained
considerable reputation, could only have been from cures having been effected by their use; and their failure since must be
attributed to a want of knowledge in their selection, or their
imperfect administration as to dose and repetition even when
adapted to the cases.
The passing of galvanism through the opaque lens has instantaneously caused the disappearance of cataract; and its
transmission through a transparent one has produced the affection-a beautiful illustration of the law, "similia similibus
curanter."
In selecting a medicine for the relief of this disease, the first
consideration must have reference to the diathesis of the individual, and the endeavor should be made to ascertain, if possible, the connection which may exist between it and the local
affection. Should scrofula be detected, sulphur immediately
suggests itself, and we find upon inquiry that this mineral substance has materially contributed to cure the disease.
Puls. presents much claim to attention; and, as noticed
already, old school practitioners have employed it. We know
of an instance in which cataract was cured by its continued exhibition for eight months, at intervals first of forty-eight hours,
and afterwards, when the action of the medicine was decidedly
established, every four or five days. A few globules of the 6th




CATARACT.                       503
or 7th attenuation, dissolved in a small quantity of water, was
the prescription employed.
Another case is recorded to have been cured by pulsatilla,
the cause of the disease being supposed to have been suppressed
scabies. Cann. was also used after the puls., to complete the
cure.
The capsulo lenticular variety has been cured with the decillionth of carbonate of magnesia, followed by cann. A cure
likewise of lenticular cataract by puls., and cann.; opium also
having been used. Sulph. and caust. also are asserted to have
cured.
For cataract produced by a wound, cann. has successfully
been administered.
For traumatic cataract, conium is much extolled.
The other medicines recommended are, con., phosph., silic.,
euphra., ruta, nit.-ac., digit., hyos., chelid., carb.-baryt., and
ammonia murias.
In the treatment of disease of this kind much patience is required on the part of both physician and patient, as a favorable
change in by far the greater number of cases can only be anticipated by a regular and long continued use of the means prescribed.
The administration of medicines failing in the removal of the
opacity, the last resource is a surgical operation; the propriety
of which must be determined by the consideration of a variety
of circumstances. Among those which either forbid its performance or render the result doubtful are; when a violent
pain in the head has preceded the formation of the cataract;
under which circumstance the disease is said almost invariably
to have returned after an operation.  (Would not the cure of
the headache by homceopathic treatment have prevented the
formation of the cataract?)  If the patient is much affected
with rheumatism of the joints, or of the eye, and especially if
the arthritic affection is not present in the spring or autumn,
at which period the individual had usually suffered.
When the patient has suffered from severe ophthalmia —or
when a particular diathesis, as scrofula, is present; when there




504                TREATMENT OF
is a disposition to erysipelas of the face; when the patient has
suffered from frequent convulsions-epileptic or others, especially in early life-and when different degrees of light cannot
be appreciated.
If the cataract appears in hysterical and hypochondriacal individuals, or if complications exist-as glaucoma, amaurosis,
&c. From these various considerations, therefore, it is apparent
that an operation should not be resorted to, without much
reflection.
The several conditions of lenticular cataract require different
operations.* The hard cataract should be extracted, that is,
removed from the eye, or displaced by being pressed into the
vitreous humor, though considerable time may elapse before
absorption takes place. Soft cataract, though allowed to remain in its position, should be sufficiently lacerated or broken,
in order that absorption may remove it, the softer textures
readily yielding to the process. Capsular cataract must be
removed from the eye, although there are exceptions, in which
laceration or division may suffice.
Cataract is not a disease of emergency, for which operative
surgery must be immediately resorted to; therefore, all circumstances connected with the use of the knife in order to restore
sight to the afflicted individual, should be carefully considered.
A successful result, according to the justly distinguished
Scarpa, may be anticipated when the cataract is simple or unconnected with any other disease of the eyeball. In subjects
not unhealthy or decrepid, and in whom the opacity has been
gradually formed, not from external violence or frequent ophthalmia, and where there has not been oft repeated cephalalgia,
an operation may be performed. When the pupil dilates and
contracts freely and has preserved its circular figure; when the
patient can distinguish between light and darkness, and when
the pupil dilates to that degree which it generally does in a
moderate light.
* Vide Walton's Operative Ophthalmic Surgery, p. 408.




CATARACT.                       505
Before operating, the patient should be in a perfectly healthy
condition, and should have for some time lived moderately, in
order to prevent all tendency to an excited state of the system.
For the purpose of dilating the pupil, the extract of belladonna
mixed with a sufficient quantity of lard to the consistency of
an ointment, must be rubbed upon the forehead, over the eye,
upon the temples, and under the eye, a half or three quarters of
an hour before the operation. Stramonium and hyosciamus have
also been used for the same purpose, and in like manner.
If both eyes are affected, and concomitant circumstances are
favorable, the operation may be performed upon both at the
same time.
Several different operations may be performed for the relief
of cataract-extraction, which was introduced by Davel, a
French surgeon; couching or depression, which method was
employed and described by Celsus; reclination, which is a
modern variety of depression, and solution or absorption; by
the latter is understood the breaking up of the substance of the
lens, and bringing it into the anterior chamber of the eye, there
to be absorbed by the aqueous humor; the term keratonyxis
has also been applied to this operation, which may be either
anterior or posterior, according as the needle passes into the
eye, through the cornea or sclerotica.
In operating for extraction, the patient should be seated on a
low chair or stool, and the upper eyelid raised by the fingers
of an assistant, whilst the operator depresses the lower; or the
lids may be separated by a speculum. The surgeon then directs
the patient to roll the eye to the internal canthus, and having
taken the cataract knife, enters it at the external side, about a
quarter or half a line anterior to the junction of the cornea with
the sclerotica, above the middle of the cornea, and pushes the
instrument forwards until it emerges at the inner margin of the
cornea, (see fig. 87,) and by being carried forwards, cuts itself
out, thus making a section of the cornea, the aqueous humor
discharges itself through the opening, after which the lids
should be closed for a few moments. The next step in the
operation is to separate the lids, raise the corneal flap, and




506        TREATMENT OF CATARACT.
Fig. 87.
divide the capsule of the lens in its centre with the point of a
needle; the lens then gradually approaches the surface, and passes
out through the corneal opening; if, however, it remain in
situ, gentle pressure on the ball of the eye will suffice to dislodge it; the cornea is then adjusted and the lids closed by a
loose bandage.
Should inflammation occur after the operation, the remedies
should be selected that correspond with the symptoms which
present themselves. These symptoms and the medicines for
their removal will be found by referring to the chapter on
ophthalmia.
The only medicine omitted at that time, and which especially
demands notice here, is the.Ssarum Europteum, which relieves
the darting pains so apt to occur in irritable temperaments after
operations upon the eye.
The operation of couching or depression is performed in the
following manner: The patient should be seated as before mentioned, and the surgeon, holding the couching needle as a pen,
passes it through the sclerotica, at the external angle of the
eye, about two lines posterior to the iris, (see fig. 88.) The
needle must then be pushed forwards until its point is distinctly
seen in the pupil, anterior to the lens; the anterior capsule
should then be carefully but freely opened with the point of
the instrument, and the lens pressed downwards and backwards,
until it is lodged in the bottom of the vitreous humor; the
needle is then carefully withdrawn and the eye closed. The
operation of reclination is performed in a similar manner, ex



GLAUCOMA.                        507
Fig. 88.
cept that the lens is merely reclined, by pressing upon its upper
edge, and forcing it below the axis of vision..Jbsorption or solution is performed with an instrument similar to that used in couching; the anterior operation is performed, after having placed the patient in the position already
mentioned, by inserting the needle about a line anterior to the
union of the cornea with the sclerotica, and pushing it forward
through the pupil; the capsule and crystalline lens are thus
broken up, and the fragments deposited in the aqueous humor,
from which they are afterwards removed by absorption. The
posterior operation is distinguished from the anterior by the
surgeon entering the needle through the sclerotica in the same
manner as directed for couching. The latter is the method
generally preferred. Several weeks may elapse before the lens
and capsule are entirely removed by the process of absorption,
and in some instances the operation may have to be repeated
several times before a cure is effected.
Section 18.-Glaucoma.
Among the older pathologists, this word was used synonymously with cataract, but it is now ordinarily applied to an
opacity of the vitreous humor. It first appears as a slight
opacity far within the eye, which increases and approaches
nearer and nearer the pupil, which no longer exhibits its black




508        TREATMENT  OF GLAUCOMA.
shining lustre, but displays a sea-green color, and becomes
oval, its longest diameter being the transverse.  The vision
from being impaired is finally lost, and there is pain in and
around the eye, in the side of the face, in the orbit, and extending into the brain; the pain is increased by the warmth of the
bed, and relieved if the patient rises and breathes a more moderate atmosphere. The pain lessens as the glaucoma increases,
and the crystalline lens after a time assumes the same green
color as the vitreous humor. As the lens enlarges, the anterior
chamber is destroyed, the iris is either thrown forward on the
cornea or is seen forming a narrow ring around its circumference.
This disease is often connected with a gouty diathesis; also
with morbid conditions of the liver or some of the abdominal
viscera. It has been known to succeed the rapid healing of a
chronic ulceration of the extremities.
If the eye presents a similar appearance to that sometimes
observed in persons advanced in years, or from a diminished
secretion of the pigmentum nigrum, it may be distinguished in
such instances from glaucoma by the fact of vision not being
impaired.
Pathologists have not been able to ascertain positively whether the seat of the disease be the septa of the hyaloidea, or
the fluid within their cells, or both.
Treatment. —The disease when fully formed is considered
incurable.  To arrest it, allopathic practice consists in local
and general bleeding, purgatives, epispastics to the temples or
behind the ears, and warm aromatic applications to the eyes.
Phosphorus is the only homceopathic medicine which appears
to be recommended for this disease. It is stated to have cured
it. If phosphorus has cured it, the belief cannot but be entertained that were opportunities afforded for the exhibition of
those agents which we know produce powerful action upon the
eye, this affection might be removed from the catalogue of incurable diseases.




AMAUROSIS.                        509
Section 19. —-.maurosis-Gutta Serena.
The above terms are applied to an insensible condition of
either the retina or optic nerve. The disease may be either
primary or secondary, and its first symptoms are defects of
vision, as seeing only portions of objects which are presented
to view; words, syllables, or whole lines, are wanting when
reading, and the individual is compelled to move the head before the vision can recover the lost portions. Sometimes an
object is seen in one position, and if removed it is lost to the
view; at others, everything appears surrounded by a circle of
variegated colors, or covered with gauze or network; or black
spots, or moats, muscee volitantes, visus muscarium, appear
flitting before the eyes.
The patient cannot bear a bright light —and to some amaurotics all colors appear a shade darker, or they are crooked and
distorted, or all objects may appear of the same hue. Double
vision also sometimes exists. The disease may come on slowly
or suddenly, and may be owing to the gastric irritation of
worms, to other irritating matters in the stomach or bowels, or
to repressed cutaneous disease. It sometimes exhibits an intermittent character, appearing every second, third or fourth day,
or at intervals of months. The dimness of vision it occasions
may be experienced either during the day or night; the former
being designated hemeralopia, the latter nyctalopia. When
amaurosis exists as a purely local affection it may be complicated with other diseases of the eye, or it may be associated
with organic diseases of the abdomen, brain and cranium; it
sometimes occurs during pregnancy.
When the disease is present the pupil generally remains permanently dilated, or in some instances very much contracted,or it may be irregular, or angular in shape, and of a grayish
or dark green hue, resembling the humors of the eye of a horse.
Often when looking into the eye a splendid disc of a white or
greenish yellow tint a little to the side of the visual axis may
be perceived. The pupil likewise generally is drawn to the in



510       TREATMENT OF AMAUROSIS.
ternal and upper portion of the eye. The iris is sluggish, or
very irritable, and there is pain in the supercilia and temples,
shooting into the orbit, or the sufferings may be intermittent;
as the disorder progresses these pains lessen, the eye feeling
swollen and dry. If the affection is connected with a paralytic condition, there is ringing in the ears, pulsation in the
brain, tottering gait, difficulty in moving, vertigo, and flushed
face-complication exists which renders the prognosis unfavorable. The disease attacks for the most part persons of middle
age, although it is often met with in youth; persons with dark
eyes are supposed to be most liable to the affection.
The causes of amaurosis are steady application of the eye
upon minute objects-hence in tailors, clerks, and students it is
frequently encountered; looking upon the sun and moon; reflected light from snow and sand, likewise produce it: hence in
northern regions, as well as in very warm climates, it is not
unfrequent. Long confinement in dark chambers or cells, depressing passions-typhoid fevers, excessive venery, onanism,
suppuration from extensive ulcers, profuse salivation-hemorrhagia, cholera, dysentery-narcotics, as belladonna, hyosciamus,
opium, stramonium —mineral substances, as arsenic, lead, &c.,
are also causes. The absence of the pigmentum nigrum, and
blows upon the eyebrow, are also enumerated as causing the
affection; in the latter case the injury done to the frontal nerve
is supposed by sympathy to affect the retina; and from the
latter cause the ainaurosis is long in its development.
If the disease has suddenly occurred, a more favorable prognosis may be made, than when it is of gradual development.
If the figure and structure of the eye are altered, the affection
has been considered incurable. If it appear in one eye and no
cause can be assigned for it, it will in all probability attack the
other organ of vision. The condition of the pupil will not
enable us to form a satisfactory opinion, for it may possess the
power of contraction and dilatation in incurable cases, and be
very slugglish and immovable in others, that are capable of
permanent relief. When amaurosis does not exist to any considerable degree it may disappear after an eruption has invaded




TREATMENT OF AMAUROSIS.                    511
some part of the body, or upon the formation of abscesses, or
the recurrence of menstrual or hemorrhoidal discharges.
When dependent upon gastric irritation the prognosis is most
favorable.
Very many of the medicines in the Homceopathic Materia
Medica are recommended.
For the incipient stage a case is related to have been cured,
in which there was no sight in the left eye; dimness of vision
of the right eye; eyelids red and swollen, and a discharge of pus
from the right eye, with the following medicines: calc. carb.
12, silic. 18, acid-nit., phosph., petrol., caust., silic. again,
and ending with causticum.
Bella. with the aid of puls., when there is frequent double
sight with muscae volitantes, also when there is mistiness befor the sight, dilated pupils, and an ability to see duiing the
day only. Bella. also is indicated when gastralgia is present, and when a sense of pressure and sensibility to light is
experienced, and when the patient sees all objects as through
a mist,
Cinchona cured the disease in the case of an intemperate
man, who at a short distance from an object could but perceive
its outlines; a printed page appeared as a black surface with
white borders; pupils dilated; interior of the eye appearing
smoky.
JMerc. Incipient amaurosis, muscae volitantes, photophobia,
temporary blindness, and lachrymation; the latter symptom was
cured by euphras.
Phosph. Almost perfect inability to read, and as little
ability to distinguish objects.
Ruta. Incipient amaurosis, diminished power of vision,
objects near encompassed with mist, those remote undistinguishable.
In a case of hemeralopia, bell., hyos., puls. and verat. Puls.
was very serviceable in a case when there was deficient menstruation, and the hemeralopia accompanied by a sensation as
if the eyes were firmly bound by a handkerchief.




512           FISTULA LACH RYMALIS.
Verat. was of much use when the hemeralopia was complicated with diarrhcea, which was aggravated at night.*
Sulph. When, with other symptoms, there was a sensation of
a little piece of feather below the upper eyelid.t
Section 20.-Fistula Lachrymalis.
Permanent obstruction of the nasal duct may be occasioned
either by acute or chronic inflammation, by extension of disease
from the nose, either syphilitic or other, by caries or exostosis
of the surrounding bone, or from morbid formations originating
in the nose or antrum. In persons of a scrofulous diathesis,
affected with inflammation of the Shneiderian membrane, the
disease is frequently met with, and is occasioned by the abnormal process extending itself to the lining of the lachrymal sac.
In the first stages of the disease, there may be considerable
pain, extending down to the nasal bones, but after a time, more
acute sufferings abate, but the patient is greatly troubled by
the passage of the tears over the cheek, the discharge of the
lachrvwlB secretion through the nose being either totally or
partially obstructed.
Treatment. —Under allopathic treatment, according to the
best authority, fistula lachrymalis cannot be relieved by the
internal action of remedial agents; by homceopathic treatment,
however, the affection has been entirely cured. The medicines
that are most serviceable in the treatment are calc., carb.,
caust., nit-ac., natr., stann., silic., sulph. In such diseases as
the one now under consideration, it is necessary that the medicine be well selected, persevered in, and administered in the
correct dynamization.
Calc. carb. effected three complete cures, two of which were
* For the above, vide Jeanes' Homneopathic Practice, p. 197.
t Vide Guide to the Practice of Homoeopathy, by Edward Hamilton,
M.D., p. 3. London, 1844.




TUMORS OF THE EYELIDS.                     513
accomplished by the 30th dilution, one by the 200th potency;
we know of others in which the result was similar from the 7th
attenuation. JV'atrurn was successful in one case, as was also
stann., silic. and sulph.*
The operation for removal of obstruction of the nasal duct,
consists in passing a narrow bistoury into the canal, introducing
the point of the instrument just below the orbicularis palpebrarum muscle; then by pressing it downwards, backwards and
inwards, it will enter the duct, the remaining obstruction of
which must be cleared by a probe; a silver, or as some prefer,
a catgut style, with an expanded head, and of sufficient length
to reach from the internal canthus to the termination of the
duct, must then be inserted in the wound and allowed to remain
for a considerable time, in some instances it is recommended to
be worn permanently.
Section 21.-Tumors of the Eyelids.
Tumors, varying in size from a pea to that of a large bean,
are frequently seated beneath the conjunctiva, or in the substance of the eyelid. They are generally soft, devoid of pain
and roll under the finger.  When the tumor has attained a
considerable growth it is liable to interfere with vision, or produce eversion or other diseases of the eyelids. These abnormal
growths may be either horny, resembling warts, glandiform,
steatomatous, vesicular, &c.
Treatment.-Horny excrescences on the lids are said to consist of inspissated sebaceous matter.  The medicines for their
removal are antim.-crud., calc., caust., sab., thuj.
For glandiform  tumors the medicines recommended are
chiefly calc., thuj. and merc.
Steatomatous tumors have been cured by carb.-an., calc. and
particularly thuj.
* See Peters on Diseases of the Eye.
33




514                   ST R ABISM US.
The medicines that should be employed in vesicular tumors
are canth., euphorb., mez., or rthus.
For encysted tumors on the eyelids, baryta, sepia or silex.
For scirrhoid indurations, con., baryta-mur., iod.-pot., iod.hydrarg., and thuja, deserve attention.
If these medicines fail, operations should be performed. If
the tumor is situated immediately beneath the conjunctiva it
must be removed by incision from the inner side of the lid, but
when it is deeply seated in the substance of the orbicular
muscle, or lies exterior to it, the incision should be made
through the lid from its outer side, parallel with the edge of
the eyelid; the tumor may then readily be seized with a hook,
and removed with a few touches of the scalpel. The lips of
the wound if external, must be brought together and retained
in situ with strips of plaster, but if the incision has been made
upon the conjunctival surface, no dressing is required.  Should
inflammation supervene, asarum, arn., acon., or bell. may be
called for.
Section 22.-Strabisnius.
By strabismus is understood an affection of the eye, in which
the ball is drawn from the centre of the orbit towards the internal canthus, accompanied sometimes with defective vision.
Treatment.-If strabismus be the result of irritation of the
brain or optic nerve, it may be removed by coff., ign., bell.,
hyos., stram., zinc., or other medicines.  If, however, the deformity be owing, which is generally the case, to a permanent
contraction of the internal rectus, an operation must be resorted
to, which is simple, easily performed, and generally succeeds,
both in correcting the deformity and improving the vision.
The patient should look outwards, and have the eyelids separated by the fingers of an assistant, or by a speculum; the
best instrument for this purpose is the spring-wire speculum,
although Pellier's elevator answers very well.  Then with the




ECTROPIUM.                       515
double hook catch the eye about midway between the edge of
the cornea and canthus; raise the conjunctiva at the canthus
by a pair of forceps, and with the curved scissors divide it as
well as the cellular tissue beneath; take then the blunt hook
and pass it under the tendon of the muscle, raise this on the
hook and divide it with the scissors; the moment the blunt
hook is passed under the tendon of the muscle, the double hook
may be taken away. The tendon being divided, the operation
is finished; yet sometimes the eye has still an inclination inwards, even after the tendon has been divided-this is owing
to the intermuscular fascia. The blunt hook must be placed
under this fascia, which is to be divided to the requisite extent;
care being taken not to cut through too much, else there will
be reversion of the eye.
The operation finished, which occupies but two or three
minutes, the eye should be dressed with a piece of lint and bandage, to keep out light and place the eye at rest. If inflammation threaten, it must be combated by appropriate means; but
this seldom occurs. There is sometimes, after the operation, a
small tumor or exuberant granulations, which spring forth from
the incision, occupying the corner of the eye; these are removed by the exhibition of silex., ars., petrol., and graph.
There is also, after the operation, a certain degree of double
vision, which is owing to objects being presented to eyes of
different powers and adjustments; this passes off after a time.
It often happens that the eye looks a little goggled, from the
bulging out of the inner side of the ball. The operation for
deformity or false direction, in every other case, is performed in
like manner with the one already described, and needs, therefore, no especial notice.
Section 23.-Ectropium.
The term ectropium signifies a turning out or eversion of the
eyelid; it is the reverse of entropium, and, according to Walton, is not only of more rare occurrence, but also is less severe




516       TR EATMENT OF ECTROPIUM.
in its effects. In ordinary cases but one lid is affected, and the
patient is much inconvenienced by the flow of the lachrymal
secretion over the cheek; when both lids are everted, there is
considerable danger of inflammation attacking the globe of
the eye from the absence of the necessary secretion.  Ectropium may be either temporary or permanent. In the former
variety it is occasioned by inflammation of the eye, particularly
purulent ophthalmia; the latter may also arise from the same
cause, or may be the result of wounds, burns, or other injury
inflicted upon the eyelids. The constant exposure of the mucous membrane of the eye, when the disease is permanent, often
causes inflammation and thickening of the external tunic, which
may finally degenerate into a smooth cuticular enlargement
near the margin of the lid —to such affection the term fleshy
ectropium (ectropium sarcomatostm) is applied.
Treatment. —When ectropium threatens from severe ophthalmia, the medicine must be carefully selected in accordance with
the existing symptoms.
When the eversion arises from excoriation and contraction of
the skin of the eyelid, together with a sarcomatous state of the
conjunctiva (ectropium  sarcomatosum), caust., thuj., silic.,
phosph., or calc. should be employed.
If the disease follow suppuration, ars., merc., hepar, silic.
must be remembered.
If inflammation and swelling of the lids are present, together
with the eversion, bell., puls., euphra., bary.-mur., &c., should
be exhibited.
The debility of the orbicular muscle, occasioned by chronic
inflammation, may be remedied by the administration of ang.,
nux., thus, caust., or arn. If disease and contraction of the
cartilage have given rise to the deformity, ars., mez., merc.,
ruta, silic., or sulph. are applicable.
If remedial measures are not sufficient, recourse must be had
to mechanical means; by which the lid may, in a measure at
least, be restored to its natural position. When the eversion is
considerable, and has been present for a length of time, the
tarsus having become elongated and changed in figure, that it




ENTROPIUM.                      517
can no longer accommodate itself to the convexity of the globe,
a portion of the lid should be removed by an incision like the
letter V. The operation may be performed with scissors or
knife, and the lips of the wound having been carefully brought
together, should be retained by the twisted or interrupted
suture.
Dieffenbach's operation is performed as follows: An incision
is made through the skin and orbicularis muscle, beginning two
or three lines from one angle, and ending at the same distance
from the other. Each end of the incision should be about a
line from the margin of the lid, and the middle of the division
two or three lines-the small flap of skin thus made is turned
up. The incision should then be continued to the conjunctiva,
which should be divided to the extent of the external wound.
The external edge of the divided conjunctiva should next,
with forceps, be drawn to the wound of the integuments,
which must now be united by sutures passing through the
conjunctiva as well as the skin. Considerable traction is thus
applied to the ciliary margin of the everted lid, which is drawn
into its natural position.
Dr. Jaeger's operation consists in passing a sharp-pointed
double-edged knife through the conjunctival surface near the
inner angle of the eye, and bringing it out through the skin on
the cheek; it must then be carried on transversely through the
outer angle. The detached lid must now be fixed accurately
and firmly in contact with the globe, while the integuments of
the cheek must be drawn up towards the eye, and retained in
that position by adhesive straps, compresses, and bandages.
This operation can be performed on either eyelid.
Section 24.-Entropium.
This is an affection in which not only the eyelashes, but also
the margin of the eyelid are turned inwards towards the ball of
the eye, and is attended with the unpleasant consequences of




518        TREATMENT OF ENTROPIUIM.
trichiasis in an aggravated form. It may be either temporary
or permanent. In the former instance, it is the result of inflammatory cedema of the eyelid; the tumefied conjunctiva, according to Littell,* pressing on the orbital edge of the tarsus, whilst
its ciliary margin is turned inwards by the action of the orbicularis. This variety seldom lasts over twelve or twenty-four
hours. Permanent entropium is most frequently met with in
the upper lid, and is generally the result of protracted ophthalmia tarsi, psorophthalmia, or other chronic diseases of the eye;
or it may depend on excessive development and spasmodic action of the orbicularis and tensor tarsi muscles.
Treatment.-Dr. Dudgeon has the credit of being the first
to propose homeopathic treatment for the cure of entropium.
He suggests borax as applicable to some forms of catarrhal
and senile ophthalmia, particularly when accompanied with
entropium. The indications for this medicine are chiefly itching and burning in the eye, with agglutination of the lids at
night and derangement of the eyelashes, which have a tendency
to turn in.t
In the temporary form of the affection inversion should be
opposed by means of a strip of adhesive plaster, fastened at one
end to the inverted lid, whilst the other is attached to some
part of the face, so that sufficient traction may be exerted to
remedy the deformity, until its cause has been removed by
medicines principally directed towards the removal of the inflammation and tumefaction.
Permanent entropium is not so readily remedied; and it is
generally found that operative interference is required. If,
however, the affection appears to depend on a vitiated action
of the tensor tarsi and orbicularis muscles, beneficial effect may
be derived from the administration of nux., ignat., or ang.; or,
in other instances, by the external and internal use of bell.,
strai., or conium.
Several operations have been practiced for the removal of
* Littell on Diseases of the Eye, p. 95.
f Peters on Diseases of the Eye, p. 39.




HORDEOLUM.                       519
this deformity. The most common method consists in the removal of an elliptical piece of the integument of the eyelid. A
careful examination is necessary, in the first instance, to determine how much is to be removed in order to rectify the position
of the lid, and yet avoid taking away an unnecessary amount,
and thus perhaps produce an opposite condition of the parts or
ectropium. When this has been determined, a fold of the skin
should be taken up between the blades of suitable forceps, and
removetl by means of a knife or scissors; the edges of the
wound  should then be united with sutures, and adhesion
follows.
Mr. Tyrrell recommends that the lid should be merely
divided at its centre, by a single perpendicular incision. The
pressure caused by the contracted cartilage is thus relieved;
and as the wound, shaped like an inverted V, becomes filled
with granulations, little deformity results. This operation,
however, is only applicable when the disease arises from a contracted state of the tarsal cartilage.
The operation of Professor Jaeger, of Vienna, is a very effectual method of removing the deformity. A smooth, slightly
concave piece of horn, adapted to the lid, is introduced under
it as a means of extension and support, though the part to be
removed may be drawn outwards by forceps; a horizontal incision is then made through the skin and orbicularis muscle, a
line and a half from the ciliary margin, and carried to each extremity of the inverted portion. The part thus marked out is
to be carefully dissected off by repeated short strokes of the
knife, carried obliquely, so as to include the bulbs of the inverted lashes and leave the mucous surface entire.
Section 25.-Hordeolum —Stye.
By the term hordeolum is understood a red, painful, and inflamed tumor, involving one or more of the meibomian glands.
It bears, in many respects, a strong similarity to the common




520                     PTOSIS.
furuncle, and is usually seated near the inner angle of the lower
eyelid. The affection is one of very common occurrence, and
is attributed by some to a deranged condition of the gastric
functions. In many individuals, especially young females,
there appears to exist a predisposition to the formation of
styes.
Treatment.-Puls. is not only a specific for this affection,
but also is a prophylactic.
In several cases where styes frequently occurred, they
shortly disappeared after this medicine was prescribed; and
by persisting in its use-about two doses of the 6th dilution
-the return of the affection was prevented.
Ferrum should be given when there is redness and swelling
of the lids, with burning in the eyes and agglutination of the
lids.
Phosph. is said to be best adapted when the hordeola
appear upon the lower lids; when there is photophobia, discharge of acrid tears, with ulceration of the internal angles of
the eye.
Rhus may be employed when the eyes secrete much mucus,
and the styes are large.
Sepia is an excellent medicine, and is of great service when
suppuration progresses slowly-for the latter condition hepar
and nterc.; and when the hordeola frequently return, the 30th
dilution is recommended.  Staphys. and sulph. may also be
applicable in some cases.
Section 26.-Ptosis, &c.
Lapsus palpebrae superioris, or blepharo-ptosis, are terms,
together with ptosis, which are used by surgeons to designate
a falling of the upper eyelid, with partial or complete want of
power to elevate it. In this affection, if the eyelid be lifted, it
slowly falls again over the eye. It may arise from wounds or
disease involving the muscles or nerves.




TREATMENT OF PTOSIS.                   521
Treatment.-Dr. Peters recommends for this disease ars.,
plumb., nux., ign., ang. Other medicines are bell., cham., crocus, hepar, hyos., viol.-odor.
Trichiasis denotes an unnatural direction of the eyelashes,
in which they turn inwards and press against the eyeball. By
the term  distichiasis is understood an affection in which the
misdirected eyelashes are in a separate row from others, which
remain properly directed.
Treatment.-The medicines best adapted to the treatment of
trichiasis are bor. and puls. In many instances it is necessary
to extract the offending eyelashes with small forceps, and after
their removal to administer the appropriate medicine to prevent the return of the affection.
Foreign bodies in the Eye.-Various substances may become
lodged between the eyelids, or may pass into or through the
cornea. Pieces of wood, steel, or hot iron often penetrate the
surface of the cornea, producing considerable inflammation.
Lime, also, is sometimes accidentally projected into the eye;
and, if the substance is pure, it is very destructive to the cornea, destroying its transparency and creating violent inflammation of the conjunctiva.
Treatment.-The first desideratum in the treatment is the
removal of the extraneous matter from the eye, which may be
effected by the forceps, by paper rolled with a pointed extremity, or by the point of an ordinary quill toothpick.
When glass or other substances have deeply penetrated the
cornea, it may be necessary to make a section of that membrane
with the cataract knife, in order to remove the foreign body,
after which a weak lotion of arnica may be applied externally,
and the same medicine internally administered.
AJngustura has been recommended, to be employed in like
manner; coniurm may also be useful. If inflammation of the
conjunctiva supervene, those medicines must be employed
which have already been mentioned when recording the different varieties of ophthalmia,




522                      o T I T I S.
CHAPTER XXVIII.
INJURIES AND DISEASES OF THE EAR.
Section 1.- Otitis.
THE mucous membrane and other textures of the ear may be
attacked by acute inflammation, and to such the term otitis is
applied. External otitis generally occurs in children, from exposure to cold; while the internal variety may arise from some
constitutional vice, or may be caused by severe injury to the
part. The inflammatory process extends from the external
ear, or from the nares and fauces, along the Eustachian tube
to the tympanum.  The disease generally commences with
ringing and buzzing in the ear, which in some instances is very
troublesome, and impairs the hearing. In most cases the pain
is of a lancinating character, extending to the more internal
structure of the parts, and sometimes even to the alveolar
sockets. There is slight fever, unless the inflammatory process has reached a high point and is about to terminate in suppuration, and infiltration of the surrounding textures; when
together with much fever, there is excruciating pain, restlessness and delirium. Sometimes a number of purulent vesicles
are seen in the meatus auditorius.
If the inflammation should penetrate to the tympanum or
inner ear, (internal otitis,) there is deep-seated intolerable pain,
throbbing, well marked inflammatory fever, which is generally
followed by suppuration (abscess of the ear); this is an event
which, from its consequences, may be considered as extremely
dangerous, and when it is about to occur, the lancinations become less, and the pain, though intense, is duller in character.
After a time the tympanum ulcerates, and a copious purulent
secretion is suddenly discharged. Suppuration in the organ of
hearing often follows eruptive diseases, and either one or both
ears may continue to discharge for a long time; if this be the
case, and if it is accompanied by inflammatory symptoms, open



TREATMENT OF OTITIS.                     523
ings may form over the mastoid process, communicating with
the cells, and these are often connected with abscess betwixt
the dura mater and pars petrosa of the temporal bone. Formations of pus in the middle lobe of the cerebrum, or in the
cerebellum, are sometimes evacuated through the meatus auditorius. In all cases, but in the last more particularly, the
patient suffers extremely when the discharge is suppressed, and
is again relieved immediately by its reappearance.
Treatment.-The chief medicines for otitis are bell., merc.,
nux-vom., puls., and sulphur; or in other cases, borax, bry.,
calc.-carb., cham., &c.
Pulsatilla is a specific remedy in most cases of otitis; its
effects in some instances are truly surprising, as exhibited by
almost immediate amelioration of the violent symptoms, after
the administration of a few globules of the medicine. It is
particularly indicated when there is heat, redness, and painful
swelling of the outer and inner ear, with buzzing and tingling,
with discharge of pus.
Belladonna is indicated when the inflammatory symptoms
are of the higher grade, when there are lancinating pains extending from the upper jaw to the internal ear, with stitches in
the parotid gland, tingling, roaring, and tearing in the external
parts, from above downwards; deafness and inflammatory
swelling of the parotid gland..Mercurius should be employed when there are tearing and
sticking pains in the ear, with sensation of extreme coldness, or
as if ice had lodged in the part, together with buzzing, ringing,
and pulsative pains, with discharge of pus. This medicine is
also recommended for abscess of the mastoid cells..JNux-vomica corresponds when the inflammation has even
extended to the parotid gland; when there is tingling and
hissing in the ears, with lancinations from within outward, particularly in the evening, and when the patient is of a dyspeptic
habit.
Many other medicines for the treatment of this affection
can readily be found in the Repertory and Materia Medica, to
which the student is directed for further information upon the




524                   o T O R R H CE A.
subject. It may be well, however, to remark in this place, that
when the mastoid process has become involved, and suppuration has occurred within its cells, that besides the medicines
already specified, hepar, silicea, mez., nit.-ac., and sepia, are
appropriate.
Section 2.-Otorrhcea.
By this term  is understood a puriform  discharge from the
ear, generally preceded by symptoms of acute or chronic otitis,
or dependent upon sub-acute inflammation resulting from exanthemata.
Scrofulous children are mostly subject to this disease. The
ear should be examined carefully with a speculum, and if the
continuity of the tympanum be found unbroken, the affection
may be considered as comparatively simple; but if the membrane has lost its integrity, or has been partially destroyed by
abnormal action, the prognosis is decidedly unfavorable.
Treatment.-For catarrhal or mucous otorrhcea, the medicines best adapted are bell., calc., carb.-veg., hepar, merc, nat.mur., puls., silicea, and sulphur. It may be well here to
recommend to the notice of the profession a medicine which
appears to have been little employed in the treatment of purulent otorrhcea. In the majority of instances we have found
that bovista more speedily and more radically cured the affection than other remedial agents.  Cases of this description, that
had resisted for years all efforts directed to suppress the discharge, yielded to one or two doses of the sixth attenuation of
this medicine.
Otorrhcea resulting from exanthemata is best combated by
bell., carb.-veg., colch., hep., and lycopod. If the disease arise
in consequence of abuse of mercury, aurum, asa., hep., nit.-ac.,
sil., and sulph.; and if accompanied by caries of the ossicula
auditoria, aurum, mez., phos., nat.-mur., silicea, and sulphur.
For scrofulous otorrhcea, with ulceration of the concha, hepar,
lyc., merc., puls., sulph., and thus.  When there is hemor



OT A L G I A.                   525
rhage'from the ear, the medicines recommended are bry., cicuta,
graph, merc., petrol., puls., and rhus.
Section 3.-Otalgia.
This is a neuralgic affection of the ear, constituting true earache. It may be connected with an irritation of the fauces
and mouth, but in the generality of instances, the affection
cannot be traced to any other disease.  It is frequently occasioned by exposure to cold, wounds, &c.
Treatment.-The chief medicines for the relief of this affection are bell., chainm., merc., spig., puls., sulph., and in some
instances arn., china, dulc., hepar, nux-vom., platina.
Belladonna is indicated when there is tearing and shooting
pains extending into the throat, with twitting, roaring, or humming in the ear; when there is excessive sensibility to the least
noise, accompanied with painful affection of the eyes and face,
with congestion of blood to the head.
Chamomilla should be employed when there is cutting as
from knives, extending into the lobes of the ear, dryness of the
parts, with sensation of stoppage; the least noise renders the
pain insupportable; the patient is also restless, ill-humored,
and disposed to be offended at trifles.
JMercurius is indicated when there is a sensation of cold in
the ears, with aggravation of the pains in the warmth of the
bed; inflammatory redness of the ear, discharge of cerumen,
and profuse perspiration, from which no relief is experienced.
Pulsatilla is a very important medicine in the treatment of
otalgia, and is indicated when there is redness and swelling of
the lobes of the ear, with sensation as if something were endeavoring to pass out through the ear, with tearing pains on
the whole side of the head; it is especially suited to persons of
a mild disposition, females and children.
Spigelia when there are drawing and shooting pains extending to the bones of the face, or when there is a sensation as if
something were lodged in the ear.




526                   DEAFNESS.
Sulphur is homceopathic when there is drawing and tearing,
particularly if the left ear be affected with humming, whizzing,
or cracking, or with tearing pains that extend into the head..Irnica is the proper medicine when the disease arises from
external injury, or when there is a return of the sufferings from
the slightest cause, with internal heat and great sensitiveness to
noise.
China when the pains are aggravated by contact, and manifest themselves rather externally than internally, accompanied
with shooting and tinkling in the parts.
JV'ux-vomica may be employed when there are tearing or
shooting pains, particularly aggravated in the morning, which
extend into the forehead and temples, with tearing in the bones
of the face.
Platina is appropriate when there are violent spasmodic
shocks, with roaring or thundering in the ears, which feel cold.
Section 4.-Deafness.
Deafness may proceed from affections already named, as well
as from a variety of other causes.  The first care of the surgeon, when called to attend to such cases, should be to examine carefully the external and internal ear by means of a
speculum. Accumulation of cerumen, which has become inspissated within the meatus, is a frequent cause of deafness; or
the defect in hearing may be produced by deficient secretion of
cerumen. Disease of the mucous membrane lining the ear,
causing induration and thickness, may also give rise to the
affection. Diseases of the membrana tympani, the Eustachian
tube, of the brain, of the auditory nerve, repercussion of eruptions, or congestion to the head, also occasion the disease.
Treatment.-When the surgeon has reason to believe that
the dysecoia proceeds from congestion, or determination of
blood to the head, the medicines required are bell., aurum,
graph., nier.-sol., phosph., and silicea. If the defect in hearing
originate from nervous diseases, caust., petrol., phosph:., phosph.



TREATMENT OF DEAFNESS.                      527
ac., and spigelia, may be indicated, and in some cases, anacard.,
mur.-ac., verat., &c. When caused by suppression of discharge, bell., hepar, ledum., mer.-sol., and puls.. If the deafness arise from deficiency of ceruminous secretion, carbo-veg.
and graph. are the principal medicines.  If accumulation of
inspissated cerumen has given rise to dysecoia, conium, selen.,
sil., and zinc., should be employed; in very many cases, the
patient can be relieved, by moistening the indurated secretion
several times during the day, and particularly at night when
the patient retires, with a few drops of glycerine, which, softening the hardened cerumen, allows it to be readily removed by
means of a simple probe, or the handle of a director.
The more precise indications for the administration of medicines are as follows: Calcarea, when there is constant dryness
of the ear, or else purulent discharge, pressive pain in the forehead, with humming, roaring, and tinkling in the ears, with
throbbing and heat.
Causticurn when there is a sensation of obstruction in the
ears, with humming and roaring in the head, loud vibration of
all sounds, and even of the patient's voice, with oterrhcea; it
is also applicable when there are rheumatic pains in the ears
and limbs, with extraordinary sensitiveness to cold winds, &c.
Graphites is indicated by great dryness in the ears; the difficulty of hearing is somewhat alleviated by motion in a carriage; humming or a noise as of thunder in the ears, especially
at night, or a sensation as if air penetrated to the Eustachian
tube; this medicine should also be remembered when there are
herpes or scabs around the ears, or the patient suffers from
other cutaneous affections.
Ledunm is especially useful after a suppression of otorrhcea
from a cold, when there is a sensation of stoppage and humming
in the ears, confusion and giddiness of the head, with sensation
of torpor of the integument.
JMercurius-sol. is a very important medicine in the treatment
of deaflness, and is indicated when every sound reverberates in
the ear, with tinkling, roaring, or humming, which is worse in
the evening, when there is sensation of coldness in the ear, dis



528          CONGENITAL OCCLUSION.
charge of cerumen, or purulent otorrhcea, with ulceration of
the parts.
NVitric-acid must be employed when there is great dryness
in the ear, with cracking, and particularly when the affection is
accompanied with scorbutic symptoms.
Petroleum is an excellent medicine when there is troublesome
dryness of the internal ear, or discharge of blood and pus;
when there is a sound of tinkling or rolling in the ear; when
the patient is affected with herpes or other eruptive diseases.
Phosphorus should be employed when there is difficulty in
hearing sounds, especially that of the human voice, with excessive reverberation of all sounds, and especially of words; congestion of blood to the ears, with throbbing and pulsation.
Pulsatilla is homceopathic when the deafness is occasioned
by the presence of hard and black cerumen, or when the secretion is too profuse and liquid, and there is humming, tinkling,
and roaring in the ears. This medicine is especially suitable
to persons of a mild disposition, or women disposed to leucorrhcea or other uterine disorders.
Silicea is the medicine when there is obstruction of the ears,
which is dissipated by blowing the nose, or when the deafness
alternates with excessive acuteness of hearing.
Sulphur when there is difficulty of hearing, especially the
human voice, aggravated when eating or blowing the nose;
when there is a sense of gurgling or fluctuation in the ears, as
if caused by water; when there is disposition to catarrh and
mucous discharges. Space will not permit further detail in the
treatment of deafness; for more particular information on this
subject, however, the student should consult the Repertory
and Materia Medica.
Section 5.-Congenital Occlusion of the Meatus and other.Affections.
The ear though fully developed at birth may be covered by
integument, causing either partial or total deafness. In such




POLYPUS OF THE EAR*                    529
cases a simple incision relieves the patient; care, however,
should be observed in dressing the wound after operating; and
lint or other extraneous matter be inserted between the lips of
the wound, to prevent adhesion; if this be neglected, the defect
will not be removed, indeed, from the contraction of the parts,
it may be more permanent than previous to the operation. If
the covering of the meatus is thick, fleshy or cartilaginous, the
obstruction should be removed by careful dissection. Some
individuals, though born without the external ear, have been
known to possess the sense of hearing. In such cases it is
presumed that sound is conducted along the bones of the cranium to the internal ear, which is perfectly constructed.
Hypertrophy of the A.turicle.-Hypertrophy of the whole
auricle, though of rare occurrence, is occasionally encountered
by the surgeon; partial hypertrophy, affecting one lobe only, is
frequently met with,* a!nd chiefly in women. If excessive and
irksome to the patient, from its unseemliness, the redundancy
should be removed by the knife.
Polypus of the Ear.-The sense of hearing is sometimes obstructed by the presence of polypi, which may be either soft
and pulpy, resembling the mucous polypus that affects the
nose, or firm and fleshy,t like the solid polypus of the vagina;
both varieties are simple in structure and tendency.
Treatment.-The medicines that have been chiefly recommended for polypus in the ear are calcarea, carbo-an., and staphysagria. The polypus may be removed by mechanical
means, in the following manner: The tumor should be grasped
as close to its pedicle as possible, with delicate forceps; when
the pain and bleeding have subsided, if any portions of the
tumor remain, either of the above medicines may be administered, or others which may be called for by existing symptoms.
If otitis supervene, the treatment already has been mentioned.
* Miller's Practice of Surgery, p. 243.
t Hastings' Practice of Surgery, p. 419.
34




530  PERFORATION OF THE MEMBRANA TYMPANI.
Section 6.-Perforation of the JMembrana Tympani.
Perforation of the membrana tympani is not frequently required; it is deemed advisable when atmospheric air is prevented entering the cavity of the tympanum, from obstruction
of the Eustachian tube.
The performance likewise of the operation is rendered necessary when the cavity of the tympanum is obstructed by extravasated blood from wounds, &c.
The object to be accomplished is not only to make an aperture in the membrane, but also to render it permanently pervious, and thus afford entrance to the accustomed supply of
atmospheric air in the middle ear. The best instrument for
accomplishing such an end, is that of Fabricci. "It consists
of a canula, into which slides a spiral wire, somewhat resembling that of a corkscrew. It is to be used in the following
manner: Pass the canula with the spiral Wire down upon the
inferior part of the membrana tympani (so as not to interfere
with the manubrium of the malleus), retain it there with the
left hand, being careful not to press too firmly on the membrane; then, with the right hand, take hold of the small
handle which revolves the spiral wire, and turn it from right
to left, being what is usually called turning the wrong way.
The instant the membrane is perforated, a peculiar sensation is
imparted to the operator. The wire is now no longer to be
turned, though by its handle the instrument is to be retained
in its situation; then gently revolve the canula, which has
a cutting edge, from left to right, when a circular portion of
the membrana tympani, corresponding to the diameter of the
canula, will be cut out, and at the same time drawn into the
canula and held fast by the spiral wire."*  Or, instead of this
instrument, a trocar, with volute and sharpened sides, may be
used. The punctured portion may be excised, by rapidly turning the instrument upon the membrane.
* Williams on the Ear, p. 204.




O     Z  NA.                   531'CHAPTER XXIX.
DISEASES OF THE NOSE.
Section 1.-Ozoena.
THis affection consists in a troublesome ulceration of the
lining membrane of the nostrils, attended with fetid purulent
discharge. Occasionally it is followed by destruction of the
nasal cartilages, and by caries of the nasal bones. In some
instances the senses of smell and taste are entirely destroyed.
Though the origin of the disease is somewhat obscure, yet
there is reason to believe that, in most instances, it is connected
with the primary or secondary forms of syphilis; and in others
with the purely scrofulous diathesis. The most disagreeable
feature of the affection is the accumulation of inspissated mucus, or incrustations, within the nasal cavities, which sometimes
form in such considerable quantity as to entirely close the passages. After ulceration is fairly established, not only is the
cartilaginous septum affected, but the ethmoid, the spongy, and
other bones of the nose; and, in the worst cases —particularly
when there is complication with syphilitic or mercurial disease
-even the palate and superior maxillary bones exfoliate, and
in consequence of such ravages the contour of the nose is
destroyed, and an otherwise frightful deformity of the face
results.
Treatment.-The remedies which have chiefly been employed
in this affection are: alumina, teucrium, puls., sulph., calc., or
magnes.-mur., bryonia, bell., lycopod., nat.-mur., and causticum
in the first stage, whilst there is yet merely mucous obstruction.
In the second stage, when the secretion has been transformed into
pus and the nasal bones are affected, with fetid odor from the
nose and loss of smell, mercurius and aurum are to be administered. These may be followed, if required, in ozcena scrofulosa
by sulph., sil., acid-nit., phosph., conium, or kali-bich. In
syphilitic ozoena, mercurius constitutes the principal remedy;




532                 POLYPUS NASI.
if, however, the patient has previously been subjected to an injurious course of treatment with this medicine, aurum is to be
preferred, and succeeded, if it be found requisite, by acid-nit.,
hepar, asafaetida, conium, or thuja.
The following are the more particular indications for the administration of the medicines..fllumina. Constant discharge from the nose of a thick, yellow, fetid matter, especially in the morning; at the same time
anorexia, with obstinate obstruction of the nose.
Jqurum. A thick, yellow, half-watery, half-dry discharge is
blown from the nose; fetid odor from the nose; loss of smell,
especially in ozcena syphilitica, with discharge of bloody pus;
yellow, ichorous crust over the aloe nasi; the nose, forehead,
and upper part of the face red and swollen.
JMagnes.-mur. Ozcena benigna; soreness in the inner part of
the nose; yellow crust on the nose; discharge of a yellow
ichorous matter; redness and soreness of the upper lip, and
swelling of the lower part of the nose.
JMercurius is indicated, especially in syphilitic ozcena;
swelling of whole nose, the nasal bones themselves being enlarged; dryness of nose, with yellow discharge and fetid smell.
This medicine is also suited to ozcena scrofulosa.
Pulsatilla must be employed when there is discharge of yellowish, green, ichorous matter, with fetid odor; the nose
swollen. This medicine is also serviceable when the disease
attacks females, with retarded menstrual discharge or leucorrhoea.
Section 2.-Polypus Jasi.
A polypus of the nose may arise from any portion of the
Schneiderian membrane, but it originates most frequently from
either the superior or inferior spongy bones. Occasionally the
seat of the tumor is so high, that instead of falling towards the
anterior nares, it takes a backward direction, hanging behind




TREATMENT OF POLYPUS NASI.                    533
the palate, and sometimes even reaching the pharynx. It is
most commonly pyriform, narrow at its base and expanding
below, though this depends much upon the natural form of the
cavity in which it is situated; sometimes the base of the tumor
is exceedingly large. Either one or both nostrils may be
affected, and when the latter is the case, the patient breathes
with much difficulty and with a peculiar rattling noise; and in
(lamp weather the tumors often project beyond the exterior of
the nostrils, but assume their former position upon the reappearance of dry weather.
The consistence'of nasal polypi is not less variable than their
form.  In some instances they are solid, fleshy, and firm;
whilst in others they are extremely soft and tender, liable to be
torn upon the slightest touch-most of them are extremely vascular, and if not handled with care, bleed profusely. No age
or sex is exempt from the affection; which sometimes assumes
a malignant form, and at others destroys life, producing by its
pressure caries of the ethmoid and spongy bones, inflammation
of the brain, &c.
Treatment.-The medicines which have proved most efficacious in this disease, are ca lc.-carb., teucrium, sulphur, and
phosph.; * puls., silicea, staph., carbo-an., and sepia may also
be called for in some cases. Sometimes it is necessary, when
medicines cannot effect a cure, to remove the polypus by mechanical means: this may be done in a variety of ways, but in
most cases the use of the forceps is preferable. These should
be stronger than the ordinary dressing forceps, well serrated
and slightly curved. The patient is seated on a low chair, before a powerful light, with the head moderately thrown back
and firmly supported; the surgeon then carefully introduces
the instrument with its blades expanded, grasps the tumor
firmly at its root, and then by twisting rather than pulling removes it. A copious flow of blood generally follows, but the
" For several interesting cases of polypi nasi, cured by the three former
of these medicines, see British Journal of Homceopathy, vol. viii., p. 283;
and vol. x., p. 484.




534                  H A R E- L I P.
forceps should again be introduced, until not a vestige of the
polypus remains; the best criterion of the operation being complete is, that the patient can breathe freely through the nostrils.
Care must be taken not to use unnecessary violence, as in some
instances the ethmoid bone has been broken up, and other serious
mischief resulted.
Excision and the ligature have also been recommended by
some writers, for the removal of these troublesome tumors-the
former when it is of large size, and arises from a broad base;
the latter when it arises by a narrow neck, and hangs beyond
the posterior nares. The hemorrhage which results may be
arrested by the administration of one or more of the medicines
mentioned under epistaxis; or, if these should fail, a plug of
lint may be introduced into the nasal cavity.
CHAPTER XXX.
DISEASES OF THE MOUTH.
Section 1.-Hare-Lip —Labium Leporinum.
By the term hare-lip is understood a congenital malformation of the upper lip, the deformed part being supposed to bear
a resemblance to the natural development of the hare. The
deformity may exist either singly or doubly, and is frequently
complicated with deformity of the alveoli, causing irregularity
and projection of the teeth, or with cleft or fissure of the hard
and soft palates.
Simple hare-lip consists of a fissure extending through the
whole thickness of the labium, situate on either side of the
mesial line, and partially or totally dividing the lip. The deformity is great, even when the affection occurs simply and
singly, and the functions of the parts are necessarily much interfered with.




TREATMENT OF HARE-LIP.                    535
Treatment.-An operation must be resorted to, the object of
which is to approximate the edges of the fissure accurately at
every point, and secure union by adhesion. Although this
operation has been repeatedly performed a few days after
birth, yet probably the most preferable period is after the child
has passed its second year; for at this time the process of dentition has generally been accomplished, and there is greater
tolerance of pain and less loss of blood.
Operation. —The arms and legs having been completely
confined by means of bandages or cloths, the child is held on
the lap of a nurse or assistant, with its head secured between
the knees of the surgeon, who is seated on a chair in front of
the patient and nurse. The free margin of the lip, on one side
of the fissure, is first taken hold of and put on the stretch,
when a straight and narrow sharp-pointed bistoury is inserted
at the upper or nasal angle of the deficiency, and carried down
its whole length, removing a strip sufficiently wide to leave a
smooth, flat surface for union. The opposite margin of the fissure is then treeted in the same manner. Hemorrhage from
the superior coronary arteries sometimes is very profuse; but a
ligature is never required, the flow of blood being readily
arrested by pinching or twisting the bleeding vessels with forceps. The lips of the wound should then be carefully brought
together, and accurately adjusted in every particular; a harelip pin, or an ordinary sewing needle, is then passed through
both sides of the lip, penetrating at least two-thirds of its
thickness, and entering and emerging about a quarter of an
inch from its cut edges. The first pin should be placed near
the margin of the lip, to hold it in accurate adjustment, when
the twisted suture of unwaxed silk-ligature should be passed
several times around this pin, in the form of a figure 8. A
second pin should then be passed above the first, andl the
suture applied in a similar manner; and the ligature may be
carried from one pin to the other, care being taken not to
pucker the lip. Two pins generally suffice, although if the
length of the wound should require it, more may be inserted.




536  MALFORMATION OF THE FRPENUM  LINGUE.
Mr. Fergusson * recommends very highly an instrument
which he almost invariably employs, for assisting the action of
the sutures in maintaining close approximation. It consists of a
semicircular spring, padded at both extremities; the latter are
applied to the cheeks in such a manner, as to relieve the
needles of the strain which would otherwise be imposed on
them.  The instrument is maintained in its proper position by
means of straps or bandages passed over the cranium.
When double hare-lip exists, there is a fissure extending
from  each nostril, with an intermediate structure, which is
either fully or partially developed; the cleft in these cases is
usually complete.
Treatment. — The operation for double hare-lip does not
differ in principle from that in the preceding variety, the ordinary incisions being made to each fissure. The pin should be
passed through the three flaps, piercing the central portion of
each, and emerging a quarter of an inch beyond the farthest
incision.
Complication exists more frequently in the double than in
the single form. Fissure may exist in the hard and soft
palates, or the gum and teeth may project between the clefts.
The abnormal condition of the palate does not interfere with
the operation on the lip; but the traction which is necessary to
bring the parts together may have a beneficial effect in diminishing the palatine chasm. In cases in which the alveoli and
teeth protrude, these must be removed.
Section 2. —Jalformation of the Frcennum Linguc.
It sometimes happens, though by no means so frequently as
is imagined, that children are born with the fruenum of the
tongue so short, that they are unable to raise the organ to the
palate, and consequently sucking is materially impeded. This
* Practical Surgery, 1853.




RANULA.                        537
condition is made apparent by raising the point of the tongue
with a spatula. If the surgeon should fail in this attempt, and
the tongue appear, upon examining it laterally, to be unnaturally confined, little doubt can remain of the frawnum being
defective.
Treatment.-This complaint is readily removed by means of
an operation, which, however, trifling though it may be considered, is one which should not be lightly performed, nor upon
every ordinary occasion. Petit relates two instances, in which
death followed from the frienum being so much loosened as to
permit the tongue to fall backwards into the pharynx, thereby
occasioning suffocation; and other cases are recorded of fatal
hemorrhage following the operation, from wounds of the ranine
arteries and veins.
A pair of probe-pointed scissors are used for the operation.
The tongue should be pressed upwards, by means of the index
and middle fingers of the left hand, and the fraenum should then
be divided in its transparent portion as far as may be deemed
absolutely necessary; at the same time taking care to direct
the points of the instrument downwards, keeping as close to
the lower jaw as possible, that the arteries and veins may be
avoided. If carefully performed, there is scarely any hemorrhage attending the operation; but, if hemorrhage should result, it may be arrested by applying small pieces of sponge, a
solution of alum, gun-cotton, or some other styptic.
Section 3.-Ranula.
By the term ranula is understood an obstruction of one or
more of the ducts of the sublingual glands, giving rise to the
formation of a semi-pellucid tumor, supposed by the older anatomists to resemble the belly of a frog, hence the name. The
swelling may attain a considerable size, interfere with deglutition, or even displace the teeth; the tumor is cystic, and is
generally filled with saliva, though sometimes it contains a




538                 TONSILLITIS.
fluid resembling albumen. It arises from a natural imperfection, or adhesion of the duct, or from the lodgment of calculous
concretion within its passage. This disease chiefly affects children.
Treatment. —The medicines which have been found most
successful in relieving this affection, are merc.-sol., calc., and
thuja. MJlercurius should be employed when there is an excessive secretion of saliva, with soreness of the surrounding gums,
and there is disposition to profuse sweat, the sufferings being
aggravated at night.
Calcarea-carb. is an excellent medicine, and is particularly
adapted to children affected with scrofulosis; when there is
violent burning in the buccal cavity, with difficulty of speech.
Thuja should be employed, when the tumor is transparent,
jelly-like, blue-red, or gray; and when the disease is accompanied with soreness of the whole palate, and with swelling of the
salivary glands.
Other medicines are petrol., puls., silicea, strai., staph., and
sulphur.
Section 4.-Tonsillitis, or Cynanche Tonsillaris.
This term denotes an inflammatory affection of the fauces,
chiefly resident in and around the tonsils. It is ordinarily the
result of atmospheric exposure, and is characterized by swelling and redness of the back part of the throat, accompanied
with difficulty of swallowing, impeded respiration, difficult
articulation, marked alteration of the voice, fever, and other
ordinary constitutional accompaniments, according to the intensity of the inflammatory action. As the local affection progresses, the foregoing symptoms become aggravated, and
suppuration ensues, constituting abscess of the tonsils. The
affection occasionally, though rarely, is dangerous, if not properly treated. In its simple form it becomes of moment should
it assume a putrid type, as in such instances the attendant




TREATMENT  OF TONSILLITIS.                    539
fever is of a typhoid character; from which circumstance a
peculiar constitutional tendency may be inferred.
In scrofulous constitutions, chronic enlargement, or hypertrophy of the gland, frequently follows inflammation; in such
a condition there is considerable dryness in the throat, which is
worse in the morning on waking, together with a sensation of
scraping in the parts, and the patients often are obliged to
sleep with the mouth open; the vocal cords are frequently involved, causing alteration of the voice. Suffocation has occurred in inveterate cases of the disease.
Treatment.-The principal medicines for cynanche tonsillaris
are acon., bell., merc.-sol., merc.-subl., hepar-sulph., chainm.,
ars., ignatia, nit.-ac., nux-vom., baryta, silicea, and sulphur.
In the first stages of the disease, when the patient is troubled
with an undue secretion of saliva, inducing constant and painful deglutition, and when the inflammation is accompanied by
synochal fever, aconite should be prescribed. After the fever
has been subdued, bell. is particularly efficacious, and frequently
in alternation with aconite rapidly cures the affection. It is
especially indicated by the following symptoms: Phlegmonous
redness of the tonsil, with shooting pains during deglutition,
sensation as if the fauces were spasmodically constricted, with
slimy white mucus on the throat and tongue.
JMercurius-sol., or viv., is required when there is much swelling of the glands, profuse secretion of saliva, deglutition much
impeded; or should suppuration unfortunately have ensued,
when there is throbbing and shooting in the gland, and small
ulcers appear, which are isolated and round, with a tendency
to become indolent in character.
Cham. may prove useful in mild cases of cynanche, when
there are stinging pains in the part, with great restlessness at
night.
Ignatia is called for when there is soreness during deglutition,
with a sensation of a lump in the throat, shootings into the
ears when not swallowing, and greater difficulty experienced
in swallowing liquids than solids.
When the disease appears in persons who are affected with




540       TREATMENT OF TONSILLITIS.
dyspepsia, nux-vom. should be employed, particularly when
there exists a feeling of excoriation in the throat, and there is
a sensation of constriction during deglutition.
Hepar may be employed together with sulph. Silic. or
sulph. promote granulation and cicatrization after the discharge
of pus.
In chronic enlargement and induration of the amygdalae, the
medicines are chiefly bell., baryta-c., merc., silic., sulph., or sep.,
puls., ars., nit.-ac., &c.  Chronic enlargement of the tonsils is
a disease which for successful treatment requires the utmost
patience and unwearying perseverance, not only of the practitioner but also of the patient.  The medicines must be well
selected, administered in not too low a potency, and at considerable intervals; at the same time it is of great importance
that the patient should strictly observe the proper dietetic
rules, and avoid exposure to a damp and cloudy atmosphere.
It may confidently be asserted that from the negligence of
patients, and the want of perseverance of practitioners, many
cases quite curable are abandoned as hopeless.
In some instances, however, it may be advisable to excise
one or both tonsils.  The instrument usually employed for this
purpose is that of Fahnestock; although some practitioners
prefer merely a tenaculum and scissors or scalpel.  In the annexed plate is a representation of an instrument invented by
Dr. Francis Sims —late Professor of Surgery in the Homceopathic Medical College-which, from the simplicity of its
mechanism, its strength, and its easy application, is preferable
to any other. It meets every indication for the complete excision of the offending part. It was first made by direction of
Dr. Sims by Mr. Jacob H. Gemrig, surgical instrument maker,
No. 43 South Eighth Street, Philadelphia.
The following is the description of the tonsil and uvula
scissors (see fig. 89). The instrument is eight inches in length,
with the cutting edges of the blades concave, in order to prevent the escape of the part to be excised, thereby avoiding the
necessity of a second cut. The length from the pivot to the
point is two inches (see fig. 90). Three inches from the points,




TREATMENT  OF TONSILLITIS.                     541
Fig. 89.
or one inch below the pivot, the instrument is curved at an
angle of about twenty degrees, in order to throw the hand of
Fig. 90.*
the operator aside, and prevent its obstructing a view of the
part to be removed.  On the outer side of the blades is
placed a pair of jaws armed with six teeth, three in either
jaw; these fit in corresponding holes drilled in either jaw;
thus effectually preventing the excised part falling into the
patient's throat; the blades and their jaws work on the same
pivot, so that their relative position to each other remains
always the same.
* Fig. 90 is a full sized representation of a portion of the instrument.




542       STRICTURE OF THE (ESOPHAGUS.
CHAPTER XXXI.
DlSEASES Ot THE NECK.
Section 1. —Stricture of the (Esophagus.
SPASM of the oesophagus, or spasmodic stricture, is an affection which occurs at intervals; the patient suddenly finding
himself incapable of swallowing, and at the same time experiencing a sensation of choking in the throat. In organic or
permanent stricture, the obstruction to deglutition is always
the same, and the bougie meets with resistance when it is
passed into the throat, differing in this respect from spasmodic
stricture, in which the instrument can be passed through the
contracted parts with slight pressure. The affection is said to
be dependent upon a prostrated condition of the body, or from
disease. There are cases on record, which disappeared upon
the removal of hemorrhoids.
Treatment of spasmodic stricture. This affection, if not depending upon incurable disease, can be totally removed, indeed
it can be palliated in every instance, as has been already mentioned when speaking of hydrophobia.  The chief medicines
are bell., hyos., strata., or verat., or in certain cases con., lyc.,
merc., nux-vom., &c. For the indications of these medicines
the student must refer to the Materia Medica.
Permanent stricture of the esophagus consists of a thickening of the mucous or sub-mucous coats of the tube, the result
of inflammation or other cause. Females are said to be more
liable to the affection than males. The constriction is generally situated near the termination of the pharynx. The advance of the disease is very gradual, and the patient for years
may complain of some difficulty in swallowing, which from
some exciting cause increases, is attended by considerable pain,
and occasionally aggravated by spasm. There may be pain in
the throat, which extends to the head, or there may be stitches
from the chest to the shoulders. When a bougie is introduced,




STRICTURE  OF THE M SOPHAGUS.                      543
considerable pain is experienced, and when the instrument is
withdrawn, upon its surface can be found the marks of stricture.
This affection may terminate fatally from  starvation, by irritation causing inflammation or ulceration of the lungs.
Treatment.-The medicines that appear to be best adapted
to the treatment of this disease are bell., hyos., and conium.
These remedial agents, judging from their pathogeneses, would
be the most appropriate, indeed the latter two (hyos., con.) are
highly recommended even by allopathic authority; others, however, may be required, among which are lyc., nux., stram., acidsulph., verat., &c. Should the administration of these alone
fail to relieve the patient, they may be employed together with
the use of the bougie, which instrument should be curved to
correspond to the passage.  The patient should be directed to
throw his head well back, and to swallow while the surgeon
introduces the bougie, which should be warmed, and passed
steadily and gradually from the posterior part of the pharynx
to the seat of stricture. The instrument is to remain a short
time within the oesophagus, and the operation repeated once or
twice a day, or at longer or shorter intervals, according to the
judgment of the surgeon.
The best method of treating stricture of the cesophagus is
that introduced by Jameson, who used eight or ten separate
probangs, each consisting of a stick of whalebone, having
affixed to one of its extremities a spindle-shaped piece of ivory.
The instrument first introduced is small, but, after the stricture
has been removed sufficiently to readily admit the passage of
the probang, a larger size must be selected. The operation
must be frequently repeated, each time using a larger sized
probang than formerly, until the obstruction is removed.*
*- The following is a case of stricture of the cesophagus cured by Dr.
Jameson's probangs, by the late C. B. Matthews, M. D., Professor of Mlateria Medica and Therapeutics in the Ilomoeopathic Medical College of
Pennsylvania. It is quoted from a letter of the above named gentleman
to Dr. Sims, late Professor of Surgery in the same Institution.
" Miss -, aged about 18, applied to me about the year 1829. She
was unable to swallow anything except fluids, and those in small amount.




544    FOREIGN BODIES IN THE (ESOPHAGUS.
Section 2.-Foreign Bodies in the (Esophagus.
Extraneous matter frequently lodges in the oesophagus; particularly articles of food, portions of which, from hurry or voraciousness in swallowing, are impacted generally in the superior
portion of the tube; such articles, in most instances, are beef,
gristle, tripe, cheese, &c.  On other occasions the patient is
choked firom having accidentally swallowed articles carelessly
placed in the mouth, as coins, pins, needles, &c. Death has
ensued from such accidents.
Treatment.-The  foreign  substance in  many instances is
lodged between the thyroid cartilage and the cornua of the os
hyoides; in this situation, if the body be large, it may be
reached and extracted with the finger; if small, as a fish bone,
pin or needle, forceps should be employed. Sometimes by
tickling the fauces with a feather, or by exciting vomiting by
emetics, the irritating substance can be expelled.  Curved and
other forceps have been employed, but when the surgeon is suddenly called to a patient, who is in imminent danger of suffocation, these instruments may not be at hand, and the delay
occasioned in procuring them may prove fatal to the sufferer.
In such instances, the handle of a spoon, the finger, or other
convenient article, should be selected, and the foreign substance
either dislodged, withdrawn, or, if the article be digestible, forced
into the stomach.  The ordinary probang —a whale-bone rod,
She had been treated by Dr. George M'Clellan by means of a flexible sound
of block tin, without benefit. I began using the smallest sized probang
and Bell's sound, which passed with difficulty, but continuing it several
days, it passed easily several times backwards and forwards, through the
stricture. I followed with the next size in the same manner, using each
four or five days, or until it passed easily, thus continuing up to the fifth,
or largest size. This occupied four weeks, or more, at the end of which
period I was convinced the stricture was subdued, but the patient was
afraid to swallow solids; I obtained a piece of meat of ordinary size, say
seven-eighths of an inch cube, and made her swallow it in my presencethis broke the charm, and she could swallow well ever after. I have seen
this woman this autumn, (1850,) and she remains perfectly free from her
stricture. "




EXTRANEOUS BODIES IN THE LARYNX.   545
with a round piece of sponge attached to one end, and a blunt
hook to the other-is the instrument used by surgeons for this
purpose. After the extraneous matter has been dislodged, the
patient should gargle the throat frequently with a weak solution of tinct. arnicae, and the same medicine should be administered internally.
Section 3.-Extraneous Bodies in the Larynx and Trachea.
During the act of deglutition, articles of food instead of
passing into the cesophagus are diverted from their natural
course and thrown into the glottis; producing instantaneous
violent cough, and labored respiration, and if the substance
remain in the glottis, death, from suffocation, speedily follows.
In the majority of instances, however, the body passes into the
trachea, or else is'forced into the laryngeal pouches, in which
situation it has been known to remain for a considerable timein some instances for years-without producing any very serious
consequences; in many cases, however, the presence of the
foreign body excites constant irritation, and if not removed
death may supervene.
Treatment. —The surgeon seldom succeeds in extracting by
forceps, &c., extraneous bodies, which have become impacted
within the larynx, the operation of laryngotomy or tracheotomy
being required for their removal. The former is thus performed:" The patient being laid on a table, with his head supporte(l by a pillow, and thrown moderately backward, the surgeon after having found the membranous space situated between
the thyroid and cricoid cartilages, makes a perpendicular incision, about an inch in lenoth, through the integuments, platysma myoides, and between the sterno-thyroidei and sternohyodei muscles. Vessels that may be (livided are next carefully
secured, and the bleeding having entirely ceased, it only remains
e See Gibson's Institutes and Practice of Surgery, vol. ii., p. 335.
35




546                BRONCHOCELE.
to push the knife through the crico-thyroid membrane, when
the extraneous substance will be immediately thrown out, or be
visible at the wound, if the body be too large for spontaneous
expulsion, in which case the incision should be prolonged upwards, by separating from each other the two lateral parts of
the thyroid cartilage. After the substance has been removed,
the wound may be drawn together with adhesive straps, and
permitted to heal.
When tracheotomy is necessary, the surgeon makes an incision from below the cricoid cartilage, and extends it through
the skin and platysma-myoides nearly as far as the sternum.
The sterno-hyoidei and sterno-thyroidei muscles are next carefully pushed aside, until the surface of the trachea is cleared,
and when all hemorrhage has ceased two or three of the rings
of the trachea may be divided by a perpendicular incision.
Section 4. —Bronchocele-Go~itre.
An enlargement of one or both lobes of the thyroid gland,
constitutes the disease known by the name of goitre. The
affection usually occupies one lobe of the thyroid gland; but
as the tumor increases the other lobe becomes involved. The
swelling may continue stationary for a length of time, and indeed never attain considerable size; but in other instances its
magnitude is enormous. Other tumors of the neck may be
mistaken for goitre, but the latter may readily be diagnosed,
by directing the patient to irritate the action of swallowing,
and if the tumor follows the motions of the larynx and trachea,
and at the same time occupies the natural situation of the thyroid gland, there can be very little doubt of its nature. The
causes of the disease have not been as yet satisfactorily explained. By many it is supposed, though erroneously, to be of
a scrofulous nature.  Unwholesome diet, intermittent fevers,
and the drinking of snow water, have been imagined by others
to give rise to it; but all these causes are extremely hypothetical.




HYDROTHORAX.                        547
Treatment.-The principal medicine in the treatment of this
disease is iodine, which has been used by allopathic practitioners from a remote date, but with inconsiderable success
from its improper administration; indeed, in many instances, the
drug, instead of ameliorating, aggravated the affection. The
iod. should be used in the 30th potency, and, according to Mr.
Cameron,* repeated every second day.
JVNatr.-carb., repeated a few times, has relieved a globular
and somewhat indurated enlargement of the upper part of the
thyroid gland. In another case calc.-carb. afforded speedy
relief. Staphys. together with lyc. has also been of great
service. Spongia is also a medicine of great power in effecting
relief, if it does not cure the disease.
CHAPTER XXXII.
DISEASES OF THE THORAX.
Section 1.-Hydrothorax-Emphysema-and Empyema.
BY the term hydrothorax is understood an accumulation of
fluid in the cavity of the chest; empyema may also be included
in this definition; but generally by the latter term surgeons
understand a collection of pus within the thorax. In this place
hydrothorax is applied to an accumulation of serous fluid in
one or both plural cavities. In the incipient stage the symptoms. are very uncertain, and may be mistaken for those of
affections of the lungs, heart, &c. There is transitory oppression of the chest, after exercise, talking or ascending an eminence, with increased dyspncea in the evening. This condition
* Vide a very interesting and highly important paper on Bronchocele, by
H. Cameron, Esq., M. R. C. S. E. British Journal of Ilomceopathy, vol.
iii., p. 469.




548      TREATMENT  OF HYDROTHORAX.
may pass away with expectoration or profuse sweat; but it is
very liable to return, particularly in the warm season. The
difficulty of breathing increases, the patient is unable to lie
down on account of the gravitation of the fluid within the
chest; there is palpitation of the heart, livid countenance, disturbed sleep, and dullness on percussion. If the effusion is on
one side only, the patient lies most comfortably on that which
is affected. The above symptoms are paroxysmal, in time
sopor and insensibility supervene. There is often cough, with
extreme irritation of the chest. Where the percussion sound is
faint the respiratory murmur disappears; and when there is
much effusion bronchial respiration is sometimes heard. The
vibrations of the thorax when talking are feeble or entirely
absent.
It is important that the practitioner should remember, that
the diaphragm, liver and spleen, are often forced downward
into the abdominal cavity, presenting appearances very analogous to those observed in ascites.
Persons of advanced age, with weak lungs, occasioned by
frequently returning catarrhs, are peculiarly liable to this affection. Malformations of the thorax, curvatures of the vertebral
column, and deformities of the ribs and sternum, also engender
the disease.
Treatment.-./rs.-alb. is one of the principal medicines; it
corresponds to many of the symptoms, particularly the dyspncea, and torturing feeling of suffocation.  Other indications
which call for its exhibition are the complete prostration of the
patient and burning thirst, together with nocturnal exacerbations.
Ipecac., pulsatilla, and ignatia, may also, in some cases, be
called for. Scilla is an efficient medicine when there is constant cough, with expectoration and dyspncea. When there
are rheumatic and constrictive pains in the chest, palpitation of
the heart, restlessness and excessive anxiety, carbo-veg. is indicated, particularly when the disease arises from excessive loss
of animal fluids.
Lycopodiutm  should be prescribed when together with the




TREATMENT OF HYDROTHORAX.                      549
dyspnoea there is excessive palpitation of the heart, occurring
principally after a meal, with cold feet. Hartmann* states
that he has cured hydrothorax with am.-carb., one dose every
four days.
Other medicines are bry., china, colch., dig., hell., kalicarb., spigelia, and sometimes stannum and dulcamara.
Frequently by the exhibition of these medicines the disease
is arrested.
To evacuate the fluid the operation of paracentesis thoracis
is had recourse to, and which is thus performed: An incision
into the chest is made, with a knife, and a canula passed into
the opening; or a trocar may be thrust directly into the cavity,
the stilet withdrawn, and the canula allowed to remain. In
this operation care should be taken while passing the instrument within the cavity, that the lung be not irritated, else
troublesome cough will be the consequence; the part selected
for the operation should be as dependent as possible, and the
patient placed with the face up, and the head and shoulders
thrown back. Whichever method of operation is resorted to,
the instrument should be made to pass in close proximity with
the superior edge of the sixth or seventh rib, to avoid wounding the intercostal artery which courses along the inferior margin of the bone. The opening should be valvular, in order to
prevent the passage of air into the cavity; this can readily be
effected by drawing tense the integument over the place of
entrance, and it will be found that when the instrument is withdrawn the skin will roll over the aperture, thus forming an
integumental valve.
Empyema.-Empyema is a collection of pus within the
cavity of the thorax; it may be the result of acute inflammation, whether traumatic or idiopathic. The symptoms are
similar to those of hydrothorax.
In the treatment of this affection the operation described
above (paracentesis thoracis) may be performed. But the formation of pus may be prevented, in some instances, by the
* Chronic Diseases, vol. i., p. 194.




550          INJURIES OF THE CHEST.
administration of medicine, by which the inflammation will be
subdued, and consequently suppuration prevented.
Emphysema, or a collection of air within the pleura, may
be caused by wounds of the lungs, fractures of the ribs, and
penetrating wounds of the chest. According to Hastings,*
" There is absence of respiratory murmur upon the affected
side, where it is caused by wound of the lungs, with an exceedingly clear sound on percussion, with immobility of the ribs;
in the sound side there is puerile respiration. Where the injury is dependent upon the bursting of an abscess, a metallic
tinkling is audible, and upon directing the patient to cough, a
drop of fluid falls from the orifice in the lung and drops to the
bottom of the chest with this peculiar sound; or if the chest be
shaken, the fluid can be heard to splash."
If from the collection of air suffocation is threatened, and
medicinal treatment prove of no avail, the same operation as
is recommended for empyema and hydrothorax may be performed.
Section 2.-Injuries of the Chest.
In wounds of the lungs great danger is to be apprehended
from inflammation, suppuration, or hemorrhage. The patient
generally experiences, when afflicted with such injury, great
dyspncea, with a sense of suffocation. Arterial blood, mixed
occasionally with clots, is expectorated, or if the wound be
extensive, there may be profuse hemorrhage from the mouth.
Inflammation always supervenes, and unless the abnormal process be prevented, profuse suppuration, hectic, and debility
result.
Treatment.-If the external opening be large, and the lung
protrude, it should be returned by gentle pressure, and retained
within the cavity by means of bandages and compresses. It is
* Practice of Surgery, p. 248.




INJURIES  OF THE CHEST.                  551
very important that the latter be moistened with a solution
of arnica, as by such application bleeding may be restrained,
inflammation prevented, and the healing process advanced; the
internal administration of the same medicine, perhaps in alternation with aconite, if the fever be intense, would materially
assist in accomplishing the same favorable result.
If the intercostal artery has been wounded, it must be
ligated, even though extension of incision be necessary. If extraneous matter have lodged within the lung or surrounding
textures, it should be gently removed, otherwise profuse suppuration may follow, and the patient be destroyed. Secondary
hemorrhage may be arrested by means of the internal administration of aconite, arnica, crocus, diadema, phosphorus, and in
some instances bryonia; the latter particularly is applicable,
when, together with the cough, there is expectoration of bloodstreaked mucus, with stitching or sticking pains, especially
when the pleura is also attacked by the inflammatory process.
Phosphorus is an important medicine, when, after granulation
has commenced, there is threatened inflammation of the parenchyma of the lung, with prostration, and dullness on percussion.
The external wound should be closed with lint, plaster, and
bandage, the patient kept perfectly quiet in a well ventilated
apartment, and all causes of excitement studiously avoided.
In simple contusion a bandage should be placed around the
chest, arnica administered internally and externally, and inflammation of the contents of the thorax combated by those
means already adverted to.




5.52      WOUNDS OF THE ABDOMEN.
CHAPTER XXXIII.
INJURIES AND DISEASES OF THE ABDOMEN.
Section 1.-Wounds of the Abdominal Viscera.
WOUNDS of the abdominal viscera have generally been considered as perilous as those of other parts of the body; the
danger, however, must obviously depend on the organ that is
wounded, and the extent of the injury inflicted. Superficial
wounds of the abdominal muscles, or their integuments, are
seldom of much consequence, and should be treated according
to common principles. When the wound is penetrating and
extends deeply into the cavity, the peritoneum is involved.
Inflammation of this membrane constitutes the chief source
of danger in all wounds of the abdomen. But though this
membrane is so liable to inflammatory action, cases have
occurred in which balls, swords, or bayonets have passed entirely through the abdomen, transfixing the peritoneum, and
several convolutions of intestine, without proving fatal, and
giving rise to but few untoward symptoms.
The most certain sign that an intestine is wounded, is a discharge of blood from the anus, or of faeces, bile, or food from
the wound; the absence of such signs, however, is no proof
that the viscera are intact.
Wounds of the duodenum are much more dangerous than
those of the larger intestines, as there is greater difficulty in
nourishing the patient, and more risk of effusion.
Wounds of the stomach may be known by the seat of injury,
great depression, vomiting of blood, and by the matter that
escapes. In wounds of the intestines, faces sometimes are extravasated into the peritoneal sac, giving rise to excruciating
pain. In these wounds, the danger always is imminent..
Wounds of the substance of the liver are almost certainly
fatal, from the great vascularity of the organ. From slight
injury of this viscus, patients, however, often recover.
Wounds of the kidneys may be suspected from the position




INJURIES OF THE ABDOMEN.                   553
and direction of the injury, and a discharge of bloody urine;
this accident is dangerous from three causes —hemorrhage, inflammation, and profuse and continued suppuration.
Treatment of wounds of the abdomen.-When the surgeon is
called upon to treat a wound of the abdomen, probing should
be dispensed with as much as possible —such examinations
made thoughtlessly, are productive of great mischief. If an
intestine protrude, it should be replaced; or, if this is impracticable on account of the distension of the gut with flatus, etc.,
a dose of nux-vomica should be prescribed; or, if there is considerable vomiting, and cold, clammy skin, and great prostration, a dose or two of veratrum in alternation with the nux.
When the distension abates, and vomiting and other symptoms
are relieved, the intestine should be returned, and the lips of the
wound brought together and retained by adhesive straps. If,
from the extent of the injury, straps are not sufficient, a suture
may be required, although it is better, if possible, to avoid its
use.
If there is no solution of continuity of the external parietes,
and the peritoneum has sustained injury from external violence,
arnica should be prescribed internally, and at the same time a
diluted tincture of the medicine should be externally applied.
If either from blows or from wounds the symptoms of peritoneal
inflammation arise-which are, painful tension and tumefaction
of the abdomen, with excessive sensibility to touch, and frequently ischuria and constipation-aconite, bell., bry. should be
employed, in accordance with the presenting symptoms. JV'uxvom. is the proper medicine when there is painful sensibility and
distension of the abdomen, with vomiting and other symptoms
of gastric derangement, together with ischuria..Mercurius should be employed when there is quick, weak
pulse, nocturnal sweats, and prostration.
When the features are collapsed, and there is rapid sinking
of the vital energies, and if the inflammation appear to have
extended to the upper portion of the alimentary canal, with
vomiting of blackish matter, arsenicumn is plainly indicated; in
other instances, carbo.-veg. is equally demanded.




554    ABSCESS OF ABDOMINAL PARIETES.
If the kidney is the seat of injury, the wound should be
treated in accordance with principles already laid down; and
the inflammation of the gland combated with the means
employed in the treatment of nephritis.
If the intestine or part of the stomach that protrudes from
the wound is divided, it is recommended by surgeons to sew up
the wound with a fine needle and silk; in the performance of
which, care should be taken to bring the edges together in such
a manner, that the two surfaces of the outer or serous membrane be opposed to each other, as adhesion does not take
place between mucous surfaces.
An artificial anus not unfrequently follows gunshot wounds
of the intestines; or it may be the sequence of a penetrating
wound, an abscess, or ulceration.  "In all examples of this
description I have seen," writes Dr. Gibson,* "spontaneous
cures have taken place, after the contents of the bowels have
been discharged, for several weeks, through the fistulous opening."
The consequences of artificial anus are both dangerous and
revolting-dangerous, since the patient may suffer from inanition; revolting, from the constant escape of fecal matter and
flatus.
The principal medicines in this affection are, calcarea, causticum, phosph., silic., and sulph.
When, as a consequence of wound or contusion, abscess of
the abdominal parietes takes place, the location of the secreted
matter is generally between the layers of tissues constituting
the walls of the abdomen. In the first stages of this affection
a hard and painful tumor is observed, which increases in size,
becomes softer, and, in some instances, fluctuation may be distinctly felt.
Treatment.-If the surgeon is aware that suppuration may
ensue-in the abdominal parietes, by properly directed treatment,
as previously mentioned,t the tumor may be discussed; if, how* Institutes and Practice of Surgery, vol. i., p. 185.
t Chapter ix., p. 146.




TUMORS OF THE ABDOMEN.                    555
ever, suppuration is the result of a wound, a free incision should
be made as soon as possible; indeed, some surgeons recommend that an opening be made with a knife in the most prominent part of the tumor, before the inflammatory process terminates in suppuration, and thus avoid the great danger of the
contents of the abscess being emptied into the cavity of the
abdomen, and often as a further result, ulceration of the intestines.
Section 2.-Tumors of the A.bdomen.
Tumors of the abdominal parietes demand great attention,
lest by their enlargement they extend to the deeper layers and
involve the peritoneum. Tumors composed of adipose tissue
are more frequently found in this locality than in any other, and
in the generality of instances are easily removed by the knife.
Ovarian tumors are more frequently met with than any other
within the cavity of the abdomen, and though generally cystic,
may be of compact structure. In the commencement of the disease there is a sensation of pressure and heaviness experienced
at the junction of the horizontal ramus of the pubic bone and
the'crest of the ilium, with a sensation of numbness in the
affected side; a tumor is then observed, which gradually increases, and the patient experiences a sensation as if a globular
or cold body were falling from one side of the abdomen to the
other. By an examination, per vaginam, fluctuation can be
perceived, and the uterus is felt pushed to the opposite side.
Treatment.-If the inflammation of the ovaries is attended
with a high degree of fever, aconite is necessary. When there
is induration of the ovaries, with ulceration, bell., china, canth.,
calc.-carb., and platina have been found more or less successful.
When the ovaries are swollen from inflammation, which has
been caused by excessive venery or onanism, china, nux-vom.,
or staphys. should be employed. Platina is an excellent medicine when there is considerable pain, which is of a bruised character, and when there is a continual irritation of the internal
genitals, accompanied with nymphomania.




556                    A SCITES.
AJmbra., canth., puls., and antim.-crud. are also recommended for the treatment of ovarian induration and inflammation. There is a medicine that has lately been proved,
which exercises a powerful influence upon the ovaries, particularly when the tumor formed is of a cystic character; this is
apis mellifica.  Under its use, we have known an ovarian
tumor, of years' standing, to have entirely disappeared; and
appended to the proving of the medicine can be found several
interesting cases of ovarian disease successfully treated. The
doses of this medicine should not be too frequently repeated,
aggravation instead of amelioration thereby being produced.
Other medicines for ovarian dropsy are ars., prunus, iod.,
sulph., hell., graph., hepar, silex., &c.
In many instances, however, these medicines only produce a
palliation of the symptoms, and the operation of tapping must
be resorted to. It is performed in the same manner and with
the same instruments as will be mentioned when treating of
ascites.
Section 3. —2Jscites.
By ascites is understood a dropsical effusion in the cavity of
the peritoneum; it may be complicated with hydrothorax, or
general anasarca. Dypsncea, cough, dryness of the skin, diminished secretion of urine, loss of appetite, constipation of the
bowels, and prostration of strength, are symptoms which are
generally present in the commencement of the affection; these
are succeeded by general fullness of the abdomen, and by a
sense of fluctuation easily recognized by percussion, which
should be performed by pressing one hand on the side of the
abdomen, and striking it with the other.
The causes of ascites generally are disease of the viscera of
the abdomen, particularly of the liver, pancreas, spleen, &c.
In some instances, a very large amount of fluid collects in the
cavity of the peritoneum.
The prognosis in this affection depends upon the nature of




TREATMENT  OF AS CITES.                   557
the case, and the age and temperament of the patient. When
combined with organic disease of the abdominal viscera, or
when occurring in individuals of a sickly constitution, or in
persons of advanced age, apprehensions may be entertained of
an unfavorable termination.
Treatment. —The principal medicines in the treatment of
ascites, are ars., bry., china, hell., ledum, lyc., merc.-sol.,
sulph.
In some instances, in the first stages of the disease, aconite
is useful to allay vascular excitement; after which hellebore
should be prescribed, if there is a tendency to torpor, prostration, extremely scanty secretion of urine, with shooting pains in
the extremities.
Jrsenicum is indicated when there is extreme debility, and in
cases connected with organic affection of the abdominal or thoracic organs; when the patient emaciates, and there is stiffness and immobility of the limbs, with aggravation of the sufferings at night.
China should be employed when the disease can be traced to
losses of the animal fluids; when there is paleness of the skin,
short cough, with expectoration.
If there is excessive nausea, palpitation of the heart, &c.,
digitalis should be employed. A dingy and livid complexion
points to ferr.-acet.
JMercurius is the appropriate medicine, when there is disorganization of the abdominal glandular system, with occasional
paroxysms of pain, &c.
Other medicines are euphorb., solanum, kali-carb., conium,
sulph., iod., zincum, apocy-cann., ol. tereb.
The operation of paracentesis abdominis is frequently called
for in the advanced stages of the disease, to palliate the sufferings of the patient. It is performed in the following manner:
The patient is seated on the side of the bed, or on a chairthe bladder having been previously evacuated —and a broad
bandage placed around the abdomen in the following manner:
its middle should be on the anterior wall of the abdomen, and
its ends should be of sufficient length to be brought around the




558                     HERNIA.
body and firmly held by an assistant. In the centre of this
band, in the lower part of the abdomen, and directly opposite
the linea alba, an opening should be made, sufficiently large to
admit of the introduction of the trocar, which with its canula
should be thrust through the abdominal parietes at the point
aforesaid, in an oblique direction; and, after it has pierced
through the integuments, the trocar should be withdrawn,
allowing the canula to remain, through which the fluid generally passes in a continued stream.  If the intestine or omentum obstructs the passage of the fluid, it should be gently
removed by the introduction of a probe through the canula;
and if, after a considerable portion of the water has been withdrawn, the stream lessens, the bandage may be tightened by
traction made upon its extremities, which compressing the abdominal parietes, forces out the remaining fluid.
Care, however, is necessary in the performance of this operation, that the evacuation of the abnormal secretion be not too
speedily effected, lest the patient, already somewhat debilitated
by the evacuation of so large an amount of fluid, incur great
risk from extreme prostration; indeed, in most instances, when
the water has been withdrawn slowly, towards the end of the
operation a feeling of faintness is experienced, to relieve which,
a small quantity of brandy and water is required, after which
china and arsenicum may be administered.
CHAPTER XXIV.
H E R N I A — R U PT U RE.
BY the term hernia is understood a protrusion from within an
internal cavity, of part of the contents of that cavity. But the
term is usually limited to the most frequent form of such protrusion, namely, that from the cavity of the abdomen; and of this
hernia there are varieties, according to the site of protrusion.




H E R NIA.                      559
They are designated as inguinal and ventro-inguinal, femoral,
umbilical, phrenic, perineal, vaginal, labial, obturatorial, ischiatic.
They vary according to the anatomical relation of their parts,
as, for example, congenital, infantile; and again, according to
the parts protruded, as enterocele, if the intestine alone be displaced; if the omentum, epiplocele; and if both, entero-epiplocele; and further, other varieties depend on the pathological
condition of parts-reducible, irreducible, incarcerated, and
strangulated.*
The causes of hernia are predisposing and exciting: among
these may be mentioned, severe exercise on foot or on horseback, lifting heavy weights, playing on wind instruments, long
continued exertion of the abdominal muscles, natural want of
closeness of development of the abdominal parietes, costiveness,
strictures of the urethra, booping cough, parturition, &c.
In consequence of laceration, or separation of fibres, the disease may occur suddenly; or the protrusion may appear and
gradually increase, where the tendons are naturally weak or
deficient.
Hernia, ordinarily, is a soft tumor,t situated at one of the
abdominal openings, which enlarges upon coughing and exertion of the abdominal muscles; if the protrusion be intestine,
it may be returned to the abdominal cavity by pressure, retiring
with a gurgling sound. But hernia may be mistaken for other
diseases; it is necessary, therefore, to use much care in diagnosis. Hydrocele simulates hernia, but differs from it in being
more or less translucent. Hernia is almost invariably opaque;
the only exception being in case of descent of a large fold of
intestine, distended alone by gas, and covered by thin integument. In hydrocele the tumor is constant, and undiminished
by pressure; hernia is always varying more or less in size, and
can generally be made to disappear by pressure. In hydrocele,
a part of the cord can be felt distinct from the tumor, at its
* Miller's Practice of Surgery, p. 386.
t Hastings' Practice of Surgery, p. 263.




560                     HERNIA.
apex; in hernia, the cord is never distinctly felt in any part.
Hydrocele, unless congenital, does not enlarge upon or feel the
impulse of coughing, or exertion of the muscles of the abdomen.
In hydrocele, the testicle can scarcely be felt, if at all; in hernia, it can be felt distinct and separate from the tumor, at the
lower part of the scrotum. The history of the two diseases
differs also: the hernial tumor appears suddenly, is developed
above, and descends; hydrocele forms gradually, and is developed from below upwards. But these two diseases sometimes
coixist. In hydrocele of the cord, the tumor is circumscribed,
leaving a portion of the cord clearly to be felt above and below
the tumor, and has most of the other distinguishing signs of
hydrocele. But when that portion of the cord within the inguinal canal is the site of such serous effusion, the difficulty of
diagnosis is great, for the tumor may be made to disappear
upon pressure. Cirsocele may be distinguished from hernia by
the non-reducibility of the swelling, and its characteristic form,
which is like a bunch of earth-worms.  Yet it is like hernia, in
(liminishing during recumbency and under pressure; the tumor
returns upon assuming the erect posture, even though the abdominal ring may be closed by pressure of the thumb. But
when the enlarged veins occupy the upper part of the cord and
inguinal canal, with an accumulation of serum, the diagnosis is
extremely difficult.
The enlargement of the veins of the cord often facilitate
hernial protrusion. Bubo, from its history, from the sensation
detected by the fingers, and progress of development, differs
essentially from hernia; but there may be enlargement of the
inguinal glands occurring at the same time, with either femoral
or inguinal protrusion.
Descent of the testicle, in some cases, being  unusually
late, may be arrested in the inguinal canal, thus causing
a painful swelling, presenting appearances somewhat similar to those of hernia; but a distinction may be drawn by the
absence of the testicle from the scrotum, and by the characteristic pain produced by pressure. From sarcocele hernia may
be ascertained by the history of the disease, its negative signs




REDUCIBLE  HERNIA.                      561
when coughing, and freedom of the cord, except in some cases
of malignant disease. Psoas abscess, though simulating femoral hernia, may be known by the history of the case, by evidences of spinal disease, by the distinct fluctuation in the
swelling, and by the site of the abscess, which is generally exterior to that of hernial protrusion. Varix of the femoral vein,
when projecting through the saphenic opening, may be mistaken for femoral hernia, but correct diagnosis may be arrived
at by placing the patient in the recumbent posture, and having
reduced the tumor by pressure, allow him to rise: If the case
be one of hernia, the pressure prevents a return of the tumor,
but if it be varix the swelling quickly reappears.
Reducible* hernia may be distinguished from other varieties
of the disease by the following symptoms: The tumor descends
in the erect, and retires within the abdomen during the recumbent position, or when pressure is made upon it. If the sac
should contain intestine, a peculiar rumbling or gurgling noise
will be heard, both by the surgeon and patient, at the moment
the gut slips into the abdomen. The tumor also of hernia possesses a tense, elastic feel. Omentum, on the contrary, communicates to the finger a doughy sensation, and is with greater
difficulty restored to the abdomen. Besides these indications,
a reducible hernia may be recognized from  other diseases by
the circumstance of its being larger after a meal than when the
stomach and intestines are empty, and by an impulse being
communicated from the tumor to the surgeon's finger when the
patient is directed to cough. If suffered to increase, a reducible
hernia may in time become enormously large, and the patient
not only experiences great disorder of the digestive organs, but
he is always liable to a strangulation of the gut.
By an irreducible hernia is understood a protrusion of the
gut which cannot be re(luced, and is permanently fixed in the
extra-abdominal position. This state of things may be causedt
1. By adhesion of the sac, on its external aspect, to the parts
- Vide Gibson's Institutes and Practice of Surgery, vol. ii., p. 369.
t MIiller's Practice of Surgery, p. 361.
36




662            IRREDUCIBLE  HERNIA.
into which it has been protruded; and by adhesion of its internal surface to the hernial contents. 2. By the nature of the
protrusion, which may become too large to repass the orifice
through which it has emerged, and by displacement of the subadjacent areolar tissue. 3. By contraction of the abdominal
cavity.
Irreducible herniae are of course exposed to all the consequences of external injury and violence;* hence various cases
are recorded,t in which the protruded bowel has been ruptured
by blows, falls, &c.
The symptoms of strangulated hernia are, in the majority of
instances, so well expressed as to allow of easy recognition;
yet it occasionally happens that the disease is confounded with
ileus and other intestinal affections. According to Pott,t the
swelling in the groin or scrotum resists the impression of the
fingers; if the hernia be of the intestinal variety, it is generally
painful to the touch, and the pain is increased by coughing,
sneezing, or standing upright. These are the very first symptoms, which, if not relieved, are soon followed by others, viz.:
sickness of the stomach, frequent retching, stoppage of alvine
discharges per rectum, frequent, hard pulse, fever, &c. After
a time the tumor becomes harder and more tender to the touch,
the pulse more frequent, the peritoneum inflames, and the abdomen becomes extremely tender to pressure. If the strangulation
be not relieved, vomiting of bile, mixed sometimes with fawces,
occurs, the tumor inflames upon its surface, hiccup sets in,
and the patient is covered with a cold perspiration. As the
last stage approaches, pain ceases, and in some instances the
spirits of the patient are heightened, and he entertains hopes of
recovery; however, ulceration and gangrene of the protruded
intestine take place, and death soon follows.
An incarcerated hernia is one in which the protruded portions of the abdominal contents are retained in their abnormal
situation, without strangulation or the occurrence of the inflam* Lawrence on Ruptures.
t Vide Sir A. Cooper on Hernia, Part II. Scarpa on Ruptures, p. 310.
t Pott on Ruptures.




GENERAL TREATMENT OF HERNIA.  563
matory process.  Generation of gases, accumulation of fluid
and solid contents, &c., &c., may prevent reduction.
General Treatment of Hernia.-For reducible hernia an appropriate truss should, as soon as possible, be applied. The
best method of fitting a patient with a truss, according to Dr.
Gibson,* is to try a number of instruments, and select the one
that most readily adapts itself to the abdominal and pelvic inequalities; of course such an one will be worn with the least
inconvenience. Many of the great variety of trusses that are
at present offered to the public, by those who have made the
subject a particular study, are well adapted to retain the protruded intestines within the parietes of the abdomen. A wellcontrived truss should, as has been already observed, fit accurately to those parts of the body to which it is applied, should
cause no inconvenience by unequal pressure, and in addition
should, by its lightness, no way impede the motions of the
wearer.
It is in the treatment of strangulated and incarcerated hernia
that homceopathy has been found to possess powerful remedial
action. By the judicious employment of a few of its medicines, the knife may be in many instances dispensed with, and
the peril which in all instances attaches to the operation need
not be encountered. Mr. Yeldham writest —" But although
the superiority of the homceopathic treatment of hernia, as distinguishing it from that of the old school, will be found to
reside chiefly in its power of preventing those accessory symptoms on which the danger of the displacement depends, its influence will not stop here. A careful survey of the allopathic
mode of treating strangulated hernia, together with the results
of homceopathic experience, limited though it be, warrant us
in asserting that many cases, now submitted to the knife, would
yield to a more rational and scientific management. In contemplating the teachings of the allopathic school on this subject,
one is struck with the want of precision in their rules of pro" Gibson's Institutes and Practice of Surgery, vol. ii., p. 374.
t British Journal of Ilomceopathy, vol. viii., p. 309.




564     GENERAL  TREATMENT  OF HERNIA.
cedure. They appear to be constantly wavering between the
fear, on the one hand, of operating too early, and therefore unnecessarily, and on tme other, the danger of a too protracted
and often fatal delay."
Mr. Yeldham further remarks*" Putting out of the question division of the stricture by the bistouiry, I cannot but consider the allopathic mode of treating strangulated hernia in
other respects as highly unscientific and objectionable. In
order to overcome the tension of the stricture, and relieve the
swelling and congestion of the strictured part, it is customary
to bleed the patient in the arm, put him into a warm bath,
give anodynes, &c..... If they succeed, all well and'good;
but supposing, as too frequently happens, that the result is not
so fortunate, and that after all the knife is the only alternative,
in what a condition does it find the patient! what front can he
oppose to the dangers of a hazardous operation? Previous to
those operations that admit of delay, it is customary to place
the patient under a preparatory course of medical and dietetic
treatment, in order to bring the system into as favorable a state
as possible, to bear the shock of the operation, to meet successfully any untoward accident that may attend upon or result
from it, and to carry on afterwards the process of reparation.
The urgent nature of strangulated hernia precludes the possibility of this salutary preparation; but that, surely, is no
reason why the unhappy condition of the patient should be
rendered still more hopeless by the adoption of such measures
as may effectually rob him of his best and only prospect of
safety! This is the rock on which the allopathist splits-his
weak point in the treatment of hernia.
The medicines that are best adapted to the treatment of
hernia are, aconite, nux-vom., sulph.-ac., opium, and lycopod.;
and in some instances ars,, thus., sulph., and veratrum.
A.conite should be employed when there is inflammation
of the affected part, with excessive sensibility to the touch,
accompanied by considerable fever, and quick, hard, full pulse;
it is also indicated when there is bilious vomiting, cold and
# Loc. cit.




GENERAL TREATMENT OF HERNIA.   565
clammy sweat, and violent burning pain in the abdomen; the
dose should be repeated every half hour until symptoms of
amelioration present themselves, after which the intervals of
repetition should be considerably lengthened.
JVux-vomica, for its specific action, is however the most
important medicine in the treatment of this morbid condition,
and is to be preferred when respiration is laborious and oppressed,
when the tumor is sensitive to pressure, but not in so great a
degree as when aconite is called for; when there is bitter vomiting, and when the strangulation has been occasioned from errors
in diet, or exposure to cold.
Perhaps the safer method of treatment in the generality of
instances-unless the particular indications for the administration of a single medicine are very prominent-would be to exhibit aconite and nux in alternation.
According to Hartmann sulph.-ac. is a specific not only
for certain cases of hernia, but also for the chronic diathesis
which leads to intestinal protrusion.
If the above medicines do not produce the desired effect, and
there is cold, moist skin, coldness of the extremities and profuse vomiting, veratrum should be administered; and if after a
few doses of this medicine relief is not procured, and there is
vomiting even of fawcal matter, with hard distended abdomen,
and a somewhat comatose condition, opium may be exhibited.
Dr. Laurie, in his Homceopathic Practice of Physic,* has inserted some very practical remarks of M. Traub, on the homceopathic treatment of incarcerated hernia. The latter gentleman
from his own experience, recommends most highly nux-vom.,
sulph.-ac., lyc., bell.; and moreover remarks concerning aconite,
that although it does not offer in the series of symptoms that it
is capable of producing, those which accompany the formation
and incarceration of a hernia, yet it cannot be dispensed with
as an appropriate or intermediate auxiliary remedy, in certain
forms of incarcerated ruptures, on account of the unlimited influence which it exercises upon the vascular, and chiefly upon
* Page 503.




566   GENERAL TREATMENT OF HERNIA.
the capillary system; and accordingly not only comprises among
its symptoms the type of inflammatory fever, but also the type
of acute local inflammation. Further, 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 frighted-states of mind which we not unfrequently meet with in persons affected with incarcerated hernia.
M. Traub also mentions three varieties of incarceration.
In the first, the rupture is of recent occurrence; or one that
had formerly existed, has suddenly become incarcerated; in
which case the rupture is small, and the symptoms appear suddenly and with great intensity. They consist in a pinching or
squeezing and pressive sensation in the region of the rupture;
violent dragging pain with periodical tearing, and spasmodic
constriction in the abdomen; nausea, inclination to vomit, and
actual vomiting of an acrid mucus; obstruction, with frequent
inclination for stool. Most of these symptoms are increased by
the slightest pressure on the rupture, as also by movement.
JVNux-vom. corresponds with the' symptoms of this form of incarceration, and according to the above authority, a dose consisting of ten or fifteen globules of one of the higher potencies,
frequently ameliorates the symptoms; if, at the same time that
relief is afforded, a sensation of movement takes place in the
rupture, or if a gurgling noise be heard, a remission of the incarcerating muscular contraction, and a speedy replacement,
without 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 integuments become very
sensitive to the slightest touch;. or if the heat in the affected
parts increase, and thus betoken an increased determination
of blood to those 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, aconite
should be administered; and an hour afterwards, nux-vom. (in
a lower dilution than in the first instance) should be had recourse to.




GENERAL TREATMENT OF HERNIA.  567
The second variety of incarceration generally appears somewhat suddenly, and the rupture is small; there is a tearing,
dragging pain, which is often the most prominent symptom,
and is experienced both in the rupture itself and in the whole
abdomen; there are also fugitive stitches in the region of the
hernia, and the symptoms return periodically-disappearing
almost entirely for a time. The patient is much exhausted
during the remissions, he complains of a general sensation of
cold; the abdomen is much distended by flatus; and after a
continued desire to vomit, the patient eventually throws off an
acrid tasting fluid. There is also a very urgent inclination for
stool, but no evacuation takes place.
In this form of incarceration, likewise, nux-vom. is an excellent medicine; but lyc. vies with it in efficacy. According to
Traub, these may be administered in alternation. If, however,
the symptoms appear in a crural rupture; if the patient is a
female; and if, moreover, the individual is of a mild, yielding
disposition, lyc. is to preferred. If throbbing, burning, and
other symptoms, indicating acon., become predominant, of
course that medicine should be administered.
The third form of incarceration occurs chiefly in aged persons, and in ruptures of long standing, and generally appears
insiduously. It betrays itself at first by a distressing, pinching,
and constrictive sensation in the region of the rupture, by uneasiness and fullness in the abdomen, and by periodical sickness
and constipation. The hernia is not very painful to the touch,
and the incarcerated part is not so tense and hard as in the two
preceding forms, but feels more doughy. This strangulation
may exist for days, without any perceptible increase in the
concomitant symptoms; gradually, however, twitchings and
pinchings, combined with periodic, 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.
With this form also two medicines concur, and the one is
again nux-vom., which competes here with sulph.-acid for the




568                      TAXIS.
rank of preeminence. If the patient is of a sanguineo-choleric
temperament, which, however, is but seldom the case, nux, in
a low dilution, may be administered; and, should the removal
of the incarceration not be effected in twelve hours, sulph.-ac.
must be exhibited.
The operations for the different varieties of hernia will be
mentioned in the following sections:
Among the means, however, to remedy strangulated or incarcerated hernia which present themselves, the taxis stands
prominently forward as so natural a mechanical means for
overcoming a mechanical difficulty, that it should at once be
attempted.
By taxis is understood the endeavor to reduce a hernia by
the hands.* The operation consists in varied endeavors to
return the protruded intestine to its natural position within the
abdomen. The patient is generally placed in a recumbent posture. When the case is an inguinal or femoral hernia, the pelvis should be placed higher than the shoulders, and, if possible,
the patient should avoid straining, coughing, and every exertion of the abdominal muscles.
Mr. Lawrence, concerning the treatment of ruptures, has
written some applicable remarks, which are here inserted at
length.
"( The position of the patient must also be regulated with a
view to the opening, through which the parts have descended.
Hence, in inguinal and crural hernia, the thigh should be bent
and rolled inwards, in order to relax the tendon of the external
oblique muscle. It is also recommended to elevate the shoulders slightly, as well as the pelvis. This brings the trunk into
a curved state, and completely relaxes the abdominal muscles.
Since the position now described is the most favorable to the
return of the protruded parts, it should be continued, as nearly
as circumstances will admit, until the rupture is replaced.
When things are thus prepared, the surgeon begins his attempt
by a gentle pressure on the tumor, which may be gradually ina Vide Dorsey's Elements of Surgery, vol. ii., p. 57.




TAXIS.                      569
creased, but should not be carried to such an extent as to cause
pain. Violence cannot indeed be beneficial, as it is more likely
to press the parts in a mass against the ring, and thereby bruise
and injure them, than to urge them through the opening. Numerous instances are recorded, in which this unscientific roughness has produced the most injurious consequences. Suppuration
of the omentum, and gangrene or rupture of the intestine, have
been its more immediate or remote consequences; and the danger of the subsequent operation must be greatly increased, if the
attempts at reduction are ineffectual.
"We usually grasp the tumor with one hand, while the
other is placed at the aperture, where it may be employed in
facilitating the entrance of the parts, and in keeping up those
which have already been returned. Success will often be
obtained by exerting a general pressure on the whole surface
of the swelling; in which method both bands must be employed, in order to subject the entire tumor to the action of the
force. This method is strongly recommended by Petit.
" The pressure should be exerted according to the course in
which the parts have been protruded. Thus the contents of a
bubonocele pass obliquely downwards and inwards; those of a
femoral rupture downwards, and then forwards; yet we should
not confine ourselves entirely to such a kind of pressure as the
course of the hernia would suggest, bdt in failure of those
attempts, make other trials in different directions. The following manmuvre will sometimes succeed in a bubonocele or
scrotal hernia, after the more ordinary methods have failed,
particularly in cases where the strangulation seems to have
been caused by an accumulation of fwecal matter. Let the surgeon embrace the neck of the swelling, close to the tendon,
with the finger and thumb of one hand, and carry them down
with a moderate pressure, so as to remove the contents from
the portion next to the ring; this will reduce the size of that
part, which he may then attempt to pass into the ring with the
other hand. Indeed, since the obstacle exists at the mouth of
the sac, reduction will in general be more easily effected by
pressing the upper part of the tumor towards the ring, than by
exerting a general pressure over the whole swelling.




570           VARIETIES OF HERNIA.
" The return of a piece of intestine is generally preceded by
a peculiar noise, caused by the passage of air through the strictured part. It recedes at first gradually, and then slips up
suddenly. The omentum goes up slowly to the very last portion, which must be actually pushed through the opening."
If the taxis should not succeed at first, it may often be successfully repeated after the exhibition of nux-vom.
Section 1. —Varieties of Hernia.
By inguinal hernia is understood that variety of protrusion
of intestine, which passes through one or both abdominal rings.
There are six investing tunics to an inguinal hernia. 1st. The
integument. 2d. Superficial fascia, composed of several layers. 3d. The intercolumnar fascia. 4th. Cremaster muscle.
5th. Fascia propria. 6th. The hernial sac.
There are several varieties of inguinal hernia, viz.: oblique,
direct, congenital, and encysted; of these, the oblique is of most
frequent occurrence. It follows the course of the spermatic
cord, and commences at the internal abdominal ring, passes
into the inguinal canal, where it receives the name of bubonoFig. 91.      cele; and, continuing its course, passes
through the external abdominal ring, and
descends to the labium  in the female,
constituting  labial hernia; and into
the scrotum  of the male (see fig. 91),
when it is termed oscheocele, or scrotal
hernia.
Direct or ventro-inguinal hernia is not
covered by the cremaster muscle, because
the protrusion does not follow the course
-i  of the spermatic cord, but passes through
the tendons of the internal oblique and
transversalis muscles, opposite the external abdominal ring. Sometimes the




CRURAL HERNIA.                        571
tendon is not ruptured, but merely distended and pushed along
in front of the gut, thus becoming one of the investing fasciae of
the hernia. In this variety of rupture, the epigastric artery is
upon the outer side of the neck of the sac.
Congenital hernia occurs soon after birth. At this time the
intestine or omentum passes out of the abdomen, accompanies
the testicle in its descent, and becomes lodged in the pouch of
peritoneum which forms the tunica vaginalis testis, before its
communication with the general peritoneal cavity has become
obliterated. The sac of this hernia is therefore formed by the
tunica vaginalis, having all the other coverings of the oblique
variety.
Encysted, or hernia infantilis, is a variety of the congenital,
but is more complicated than the latter, because it has as it
were two sacs. The communication between the cavity of the
tunica vaginalis and that of the abdomen is closed at its upper
part; but the former is unusually large, and continues high on
the cord, containing more or less serous fluid. Behind this a
hernia descends, invested by the ordinary peritoneal sac.
Femoral or crural hernia.-At the point where the femoral
vessels emerge from the abdomen, the mouth of their sheath is
wide and loose, and a space is left between them and the os
pubis; this is the femoral ring; and through this aperture the
intestine protrudes in crural hernia. (See Fig. 92.)
It has the os pubis behind, Gimbernat's ligament on the
inner side, the femoral vein exteriorly, and Poupart's ligament
in front. To prevent the ready descent of the intestine into
the femoral ring, the latter is filled with loose fibrous tissue
enclosing lymphatic glands. When, therefore, the protrusion
takes place, this fibrous lamina is forced before the intestine
along the crural canal, forming one of the coverings of the
hernial sac, and has received the name of septum crurale.
The crural canal, therefore, is merely the sheath of the
femoral vessels, derived from the fasciae lining the anterior and
posterior parietes of the lower abdomen. When, therefore, the
hernial tumor reaches the termination of the crural canal, in
the fossa ovalis, its further descent is prevented; and the dis



572                CRURAL HERNIA.
Fg. 92.
tended sac is found to consist of the following layers: 1. The
skin. 2. The superficial fascia. 3. The cribriform fascia. 4. The
sheath of the vessels. 5. The septum crurale; and 6. The peritoneal sac.
Crural hernia may be distinguished from psoas abscess by
the latter being generally more external, by its yielding a
sensation of fluctuation, not being tympanitic, and generally
accompanied by disease of the spine. Bubo, and other tumors
of the groin, sometimes simulate crural hernia, but they may be
recognized by not being accompanied with general disturbance
of the abdomen. If, however, with swelling, &c. symptoms
of strangulation are present, the tumor may be cut down upon,
and its true character ascertained.
Ufmbilical hernia is a protrusion of the intestine at or near
the umbilicus, and generally occurs in infants, and females who
have borne children.
In obturator hernia the gut passes through the obturator
foramen.  Ischiatic hernia protrudes through the  ischiatic
notch.
By ventral hernia is understood the passage of the intestine
through the parietes of the abdomen, at other points than
those already mentioned.
Perineal, vaginal, labial or pudendal hernia, are of comparatively rare occurrence. Their names designate the parts into
which the intestine protrudes.




OPERATIONS FOR HERNIA.                    573
WVhen there is a separation or rupture of the fibres of the
diaphragm, occasioned by a fall, or blow upon the abdomen,
through the fissure a hernia may protrude into the cavity of the
thorax. The term diaphragmatic hernia designates such condition.
Section 2.-Operations for Hernia.
In strangulated oblique inguinal hernia,* the most frequent
form of the disease, the operation consists in placing the patient
on his back, upon a convenient bed or table, with his thighs
separated and flexed, his feet resting upon chairs.  The surgeon places himself between the thighs of the patient; then
picking up the skin over the hernial tumor between his fingers,
making a fold of it, he passes a scalpel through the base of this
fold and cuts upwards, managing the integuments and knife in
such a way, that by this means he will have made an incision
about three inches, or at most, four inches, long. No case of
hernia, however large, requires a longer incision. This incision
should have its upper edge at the neck of the tumor, and extend
down on the body of the hernia. (See dotted line in fig. 93.)
This is an excellent rule for division of the integuments in most
operations, and should always be adopted where there is not
good reason for omitting it, since it divides in an instant the
skin and subcutaneous cellular tissue.  This being done, we
come to the superficial fascia, which should be pinched up by the
forceps, and a small transverse cut made through it by the
scalpel, into which the grooved director must be passed and
carried along in the direction of the first incision; the point of
the scalpel then carried along the director divides the fascia;
the cremaster muscle and fascia propria are to be treated in the
same way; the sac then appears, and this is to be managed the
same as the fascia, using great caution not to take up the omen* The above methods of operating for strangulated inguinal and femoral
hernia are taken from Hastings' Practice of Surgery.




574          OPERATIONS FOR HERNIA.
Fig. 93.
tum or intestine in the forceps along with it. When the sac is
divided, a quantity of fluid sometimes escapes.  At this stage
of the operation, we have the intestine, or the omentum, or
both before us. The intestine should be examined well to see
that it is sound, before being returned to the abdomen; if mortified points or spots be found upon its surface, or if it have been
wounded by the knife, these spots should be included in a ligature, both ends of which must be cut short off, and the intestine returned in this way to the abdomen. These ligatures'are
soon enclosed by deposit of fibrin, and they gradually ulcerate
through into the canal, and are discharged per anum in the
form of loops, whilst the intestine is repaired from without by
the organized fibrin deposit. If the intestine be completely
mortified, (which is the case when the operation has been too
long delayed,) then it cannot be returned, and it is necessary to
form an artificial anus. For this purpose it will be necessary
to relieve the stricture and retain the intestines at the groin, at
the same time administering hepar., merc., or silic. to favor
separation of the mortified part. This may afterwards be cured
either by Dupuytren's or Dr. Physick's operation. The former
consists in the application of the enterotome, a peculiar forcep,
constructed for the occasion. With this the two sides of the
intestine, which lie together, are pinched, and the instrument
left until by ulceration it comes away, or sufficient irritation




OPERATIONS F'OR HERNIA.                   567
has been excited by it. Dr. Physick's plan has been considered
preferable. This consists in passing a ligature, by means of an
armed needle, through the contiguous sides of the intestines as
they lie side by side. The ligature should be passed at least
an inch from the extremities of the intestines, and then tied
rather loosely, otherwise great pain will be occasioned; after
about three weeks, the ligature has ulcerated out, the sides of'
the intestines are fast glued by adhesion, and the faeces pass
per anum. A compress and truss are applied to the opening in
the groin, and caust., calc., phosph. or silic. exhibited to promote the healing process, which however, in the generality of
cases, is somewhat protracted.
If, however, upon examination the gut be found healthy,
(which will be known by its color being natural, or darkened
but slightly,) then the forefinger must be carried up between the
sac and the intestine to discover the seat of the stricture; which
will be in one of three spots: these are the neck of the hernial
sac, the external abdominal ring, or the internal ring. The
same exploratioi serves to discover whether it is an oblique or
direct inguinal hernia, by finding the situation of the epigastric
artery, which in the former lies inside of the neck of the sac,
in the latter it is on the outside of it, and can readily be felt
pulsating. In old inguinal hernias, this is often the only means
we have of telling which of the two forms it is.
Having ascertained the point of stricture, all is ready for the
insertion of the knife. This should be a probe-pointed bistoury,
(Fig. 94,) or scalpel, having only about half an inch of cutting
edge, commencing near the point. The ordinary probe, or
Fig. 94.
blunt-pointed knife, may be covered by a bandage from the
heel down, leaving only half an inch of cutting edge exposed.




576         OPERATIONS FOR HERNIA.
While the nail of the forefinger of the left hand is kept under
the point of stricture, (Fig. 95,) push the knife, with its side
Fig. 95.
I, 
lying on the finger, (Fig. 96,) along it, until it is introduced
into the neck of the sac under the stricture. When the edge is
Fig. 96.
under this point, it should be turned directly upwards, and a
slight incision made; it rarely ever requires more than a slight
touch of the edge of the knife, against the tightened band which
strangles the intestine, to suffice for its liberation. The stricture removed, the intestine and omenturn must be carefully
returned to the cavity of the abdomen, the wound brought together by adhesive straps, and dil. tinctae arnicce applied
during the cure. Absolute rest is demanded, and the adminis



OPERATIONS FOR  HERNIA.                     577
tration of a tepid water enema must prevent constipation.
After the part has healed, a proper truss must be applied.
In the operation for direct inguinal hernia, the only difference is in the number of tunics covering the hernial sac; this
variety being deficient in the coating of the cremaster muscle.
But any numerical arrangement of tunics in these operations
must always lead to disappointment and perplexity, if they be
expected and looked for. In old hernia, for instance, the fasciae
are all thickened and increased, so that no certain number of
coverings can be found shutting in a hernial tumor; therefore,
the only good rule for operation in this disease is to proceed
carefully, dividing everything that intervenes between the operator and the hernial sac (which can always be recognized from
the superincumbent tissues); this gained, all uncertainty is at
an end.
In femoral hernia, Sir Astley Cooper operates by making an
incision in the form  of an inverted L.  Mr. Liston makes an
incision parallel to and directly over Poupart's ligament; from
the centre of this an incision is carried down over the tumor;
the length and manner of incision being the same as in the
former case.
Other surgeons employ, with equal propriety, a perpendicular incision directly over the tumor, beginning at Poupart's
ligament: this makes a smaller external wound, and as the only
object is to approach the strictured point, the smaller the opening necessary to accomplish this object, the better.
The integuments being divided by either of these incisions,
the superficial fascia must then be raised and divided as already
described; we next come to the fascia propria, which must be
raised in like manner, and the hernial sac is brought into view.
This, as well as its contents, must be treated in the manner
directed for inguinal hernia.
The point of stricture in femoral hernia may either be the
neck of the sac, the cribriform Jfscia, the falciform process of
the fasciafemoris, the femoral ring, or HIey's or Gimbermat's
ligament. The latter is most frequently the seat of stricture.
After the place of stricture has been correctly ascertained, the
37




578                PROLAPSUS AN1.
forefinger of the left hand is thrust into the neck of the sac
and the stricture, and the same operation performed as has been
mentioned for inguinal hernia.
The mechanical treatment of umbilical hernia of children is
as follows:* The protrusion is returned within the abdomen,
and compression is made by means of a conical pad —such as a
piece of cork, covered with wadding or soft leather —which is
made to occupy the space usually filled by the protrusion, and
is retained in its place by strips of adhesive plaster; the integument is closed over it in a fold; and the whole may be secured
by a circular bandage. This simple contrivance is more effectual than any truss or belt, being much less likely to slip; and
it has the equally important advantage of not acting as an excitant of protrusion elsewhere. In the adult the case is not so
easily managed. The tumor is larger and less repressible. A
corresponding compress is necessary, secured either by a belt
or by the spring of a truss; its use is merely palliative. When
strangulation occurs relief is obtained in the ordinary manner,
either by'recourse to medicine, the taxis, or operation.
The other varieties of hernia that have been mentioned are
of very rare occurrence, but the principles of treatment are the
same.
CHAPTER XXXV.
I)SEASES OF THE RECTUM.
Section 1. —Prolapsus ARni.
A PROTRUSION of a portion of the rectum, or of its internal
coat, from the anus, is denominated a prolapsus, or procidentia
ani.  In some cases a considerable portion of the rectum
protrudes.
* Miller's Practice of Surgery, p. 409.




TREATMENT OF PROLAPSUS ANI.    579
The causes of the complaint are such as tend to weaken the
action of the muscles which support the intestine, and violent
exertions of the rectum in consequence of certain irritations.
The frequent use of cathartics, especially those which contain
aloes —the presence of ascarides in the lower portion of the
alimentary canal-habitual costiveness, and hemorrhoids, all
occasionally produce prolapsus ani. Cases are on record in
which the affection was engendered by the tenesmus attending
dysentery.
In some instances the intestine remains a considerable length
of time unreduced without any ill consequences, but more commonly it swells and inflames very speedily.
Treatment.-WVhen called to a person suffering from a prolapsed rectum, the surgeon should immediately attempt reduction. This is readily accomplished by grasping the displaced
gut, having first smeared the protruded part with fresh lard or
simple cerate, and pressing upon it inwards and upwards. It
will slowly, or in some instances quickly, return to its natural
position. If a larger portion have escaped, as sometimes happens, especially in females rather advanced in life, a smooth
towel folded cone-like, and well greased, must be placed against
the central and most dependent part, and pressure then made
firmly and steadily upwards —from time to time it may be necessary also to press inwards and upwards upon the circumference of the intestine. If, however, the, surgeon be not called
until the protruded intestine is swollen and painful, an immediate attempt at reduction may prove abortive; therefore a dose
of ignatia or nutx-vomica should be administered, and the
patient placed at perfect rest.  These medicines, possessing a
powerful influence over the intestinal canal, will probably relieve the patient in a short time, when the part may be returned
to its normal condition, in the manner above mentioned. The
vapor of hot water retards rather than facilitates reduction.
This complaint is, unfortunately, very apt to recur; to prevent
which the proper means should be used-among which are,
that the patient be strictly prohibited overloading his stomach,
and that his diet should consist of the plainest aliment. Dr.




580                H      IEM O RRHOID S.
Physick succeeded in completely curing some cases of prolapsus
ani, by confining his patients exclusively to a diet of rye mush
and sugar; and the same means have proved equally beneficial
in the hands of other practitioners.
There have been many bandages and contrivances invented
to prevent the recurrence of prolapsus ani, but they generally
fail in accomplishing the desired end, which latter is much
more certainly attained by the administration of appropriate
medicines, and rigid dietetic observances.
The principal medicaments are, ign., nux-vom., merc., sulph.,
or ars., caic., lyc., raft., sepia.
For the particular symptoms indicating a choice of the above,
the Materia Medica must be consulted.
Section 2. -Hamorrhoids.
Haemorrhoids, or piles, according to Druitt,* are small
tumors situated near the anus. They commence as varicose
enlargements of some of the haemorrhoidal veins, the irritation
of which causes various morbid changes in the mucous membrane and cellular tissue adjoining. The general division of
hremorrhoids is into internal and external; the former are firm
tumors, varying in size, of a reddish-brown color when indolent, but dark or bright red when inflamed; great inconvenience
is occasioned by their protrusion, which slight movement is
liable to induce, and they are exceedingly liable to bleed. The
external are hard tumors at the margin of the anus, covered
with skin and mucous membrane, or are formed of oblong
ridges of skin external to the sphincter; these do not bleed,
and from this circumstance are termed mariscme, or blind piles.
Piles when indolent produce no great inconvenience, except
that resulting from their bulk and situation; when inflamed,
however, they occasion pain, heat, itching, fullness and tension
* Modern Surgery, p. 447.




TREATMENT  OF H-EMORR HOIDS.    581
about the anus, with sensation as if a foreign body were in the
rectum, with more or less bleeding. In violent cases irritation
of the bladder, frequent micturition, pain in the back, and
aching in the loins, are also experienced.
Treatment.-The medicines that are best adapted to the
treatment of this affection are as follows:.Rconite, though not a specific, is exceedingly useful when
the hLemorrhoidal tumors are highly congested or inflamed,
giving rise to symptoms of general vascular excitement; after
which the most appropriate medicine should be administered.
The most efficient medicine in the treatment of either variety of
piles is nux-vomica, particularly in individuals leading a sedentary life, when there is shooting, burning, and itching in the
tumors, bruised pain in the loins, difficult urination, constipation, colic, and other symptoms of gastric disturbance.
Jrsenicum should be employed when there is itching and
burning in the tumors, with stinging pain in the (lay time, particularly when walking.
Belladonna when there are sudden lancinations in the rectum, pain in the back, and difficulty in voiding urine.
Lycopodium when the hbemorrhoidal affection is chronic,
attended with congestion to the head, constipation, painful protrusion, and acrid discharge; palpitation of the heart during
digestion.
Pulsatilla- when there are discharges of blood and mucus,
accompanied with smarting and sense of excoriation.
Causticum when there are large and painful tumors, with
stinging and burning and excessive itching of the anus day and
night.
Platina when there is frequent inclination to go to stool,
creeping, itching and piercing in the anus, succeeded by general shuddering, and a feeling of weakness in the abdomen..lntim.-crud. discharge of blood and mucus at every stool,
followed by severe colic, burning at the anus, and acrid discharge, particularly at night.
If the haemorrhoids are attended with excessive colic, colocynth is an excellent medicine. Sulphur may follow the ad



582              FISTULA  IN  ANO.
ministration of nfux; hepar, and belladonna symptoms often present; thus is useful after the latter, to relieve the severe aching
in the back.
Other very important remedial agents are, cap., calc.-carb.,
chin., merc., ipecac., &c.
Section 3.-Fistula in A8no.
When an abscess forms in the cellular membrane surrounding
the rectum, or about the verge of the anus, and leaves, after its
contents are discharged, one or more small openings communicating with its cavity, the disease is denominated fistula in ano.
Other appellations have also been employed, expressive of the
particular situation of the fistulous orifice and the extent of the
disease.
If the fistula opens upon the surface of the integument, it is
called an external fistula; if it communicates with the rectum,
and not with the integuments, an internal fistula; and if the sinus
open internally through the rectum and externally through the
skin, a complete fistula.
The formation of a fistula in ano is often denoted by rigors,
painful swelling about the ischium or perinmeum, difficulty of
passing urine, and by irritation in the rectum and neck of the
bladder.  During the progress of the disease, the patient in
many instances suffers extremely; at other times, however, the
abscess forms and breaks almost without his being aware of its
existence.  Generally the abscess communicates with the integuments by a single opening, but occasionally there are three
or four.
In healthy constitutions the abscess does not differ from that
met with in other parts of the cellular tissue, but in consumptive and scrofulous subjects the disease often assumes a different
character. The surface of the integuments is covered with an
erysipelatous inflammation, the constitutional symptoms are
considerable, the matter is discharged in small quantity, and




FISTULA IN ANO.                      583
from a sloughy, ill-conditioned opening, or from a ragged, unhealthy surface.
The cause of fistula in ano cannot be always satisfactorily
ascertained.  Sometimes it arises from  irritation about the
rectum; from local injury; from the lodgment of undissolved
articles of food taken into the stomach, and passed through the
intestine as far as the rectum (for example, small bones of fish
or fowls); severe and long-continued exercise, particularly on
horseback; haemorrhoids, &c.
Treatment. —When the inflammation is erysipelatous, and
spreads rapidly, bell. or rhus may be prescribed. Silic. is a
very important medicine, not only in the commencement of the
affection, but also when the fistula is fully established. In the
former case, if the abscess has not discharged, and the cellular
membrane be found in the sloughy state, a free incision should
be made, to permit the escape of the purulent secretion. If
healthy action does not display itself, ars. and china must be
prescribed.
JlIerc., sulph., silic., hepar, or calc.-carb. must be exhibited,
if incarnation proceed imperfectly. If the constitution of the
jatient is impaired before operation is thought of, appropriate
Medicines must be administered, to eradicate any disease that
may be present. In cases where the fistula has not been subje(ted to homceopathic treatment from the commencement,
merc. or silic. may be given. Hepar may be required after
nerc., when the fistula is extensive; and phosph. after silic.,
where there is complication with disease of the lungs. When
the digestive apparatus is impaired, calc., nux, merc., and silic.
mill prove valuable medicines.
Caust. is very important in cases of long standing, and in
alternation with silic. we have known a fistula in ano to be
heiled.
If, however, after a patient trial of the means above mentioled, the disease remain uncfianged, recourse must be had to
the knife, as a last resort. The operation must be performed
in toe following manner: The patient being placed upon his
face and knees, the pelvis elevated, with the thighs sepa



~584              FISTULA  IN  ANO.
rated —or upon his back, with the thighs separated and
flexed upon the abdomen —the surgeon, oiling the forefinger
of the left hand, passes it up the rectum; a narrow probepointed scalpel or bistoury (see fig. 97) is passed up the fistula,
Fig. 97.
until it comes in contact with the finger. If the intestine be
not perforated by the disease, the surgeon must make an opening into it by the edge of the knife, and pass it into the cavity
of the intestine; the end of the finger is then firmly fixed upon
the probe point of the knife, and by drawing both outwards,
the sphincter muscle and all the intervening tissues are divided.
A better and easier mode of performing the operation, is by
passing a grooved director through the fistula, against or
into the intestine.  Then pass into the rectum a smooth, round
stick, resembling a rectum  bougie, the size of the thumb; the
stick having a groove on one side as wide as the finger. Th's
being passed up and held firmly by an assistant, the surgemn
takes the director, already introduced, and impinges Its
extremity firmly against the groove in the stick.  He now
takes a sharp-pointed knife, and runs it forcibly down the
groove in the director, and when it comes in contact with th(
rectum stick, cuts outwardly against this, and thus divides thL
fistula at one sweep. This operation is performed in a shorte'
time than the one previously mentioned, with much less pain lo
the patient, and greater convenience to the surgeon.
Many of the French surgeons, after dividing the fistula, dssect out its walls-thus cutting out a tube of the indurated soft
parts.
In whatever way the operation is performed, after the fistula
is divided, lint is to be pushed into the wound, to insur( its
closing from the bottom by granulations; which, as the healing




TUMORS IN THE RECTUIM.                    585
process progresses, push the lint before them.  The patient
must be kept at rest; and, if there be any constitutional excitement, it may be allayed by aconite and bella. in alternation,
after which silicea and sulphur may be exhibited, to hasten
granulation.
There is one point that should not be overlooked in this
operation. When passing a probe into the fistula, the instrument should be carefully used, lest it perforate the walls
of the sinus, and pass into the cellular texture of the perineum.
Deep cutting in this region may be productive of the most
serious results; and, as the cure of the disease does not call for
any such risk, it should never be encountered.  The service
required of the knife, is the division of the sphincter muscle;
and, to accomplish this object, an incision an inch, or an inch
and a half, in depth, is all-sufficient, and should never be exceeded.
Section 4.-Tumors  within the Rectum-Stricture of the
Rectum —Fissures of the  n.tns —Pruritus sini.
Tumors within the Rectum. —Various abnormal growths
have been found within the rectum, and according to their bulk,
or specific character, excite more or less irritation, inflammation, diarrhcea, &c. There are cases on record* of enormous
tumors of the lower intestine, involving the whole circle of the
anus, and extending beyond it many inches.
Treatment. —The best medicines for such tumors are caust.,
coniur, calc.-carb., lyc., phos., sepia, sulph. and thuja; others,
however, may be employed according to the presenting symptoms; when these fail, resort may be had to an operation.
If the tumor originate by a narrow pedicle, and admits of
motion, it may be pulled down by the forceps, and a ligature
applied to its neck. If, however, the abnormal formation is
large, it should be drawn down as low as possible with the for* Vide Mr. John Bell's Principles of Surgery, vol. iii., p. 188.




586        STRICTURE  OF THE RECTU1[M.
ceps, and several needles armed with ligatures must be passed
through its base, and their ends firmly tied; circulation thus
being arrested, sloughing will result.
Stricture of the Rectum.-The rectum is sometimes the seat
of stricture, which may be either spasmodic or permanent; the
former is caused, in many instances, by improper or unwholesome articles of food taken into the stomach, which passing
undigested through the alimentary canal, excite irritation, which
gives rise to the spasm. Permanent stricture generally originates from chronic inflammation of the lining membrane of the
intestine, causing thikening and contraction of the part or deposit of sub-mucous cellular tissue. In these diseases there is
great pain and difficulty in voiding the faeces, which are passed
in narrow flattened fragments, or if fluid, are ejected with considerable force.  The stricture may be felt in some instances
per anum, by the finger; in others, however, when the stricture is higher up, an instrument must be used. The digestive
organs become impaired, dilatation takes place above the seat
of stricture, which may result in ulceration of the intestine; in
such cases prognosis is exceedingly unfavorable.
Treatment.-In spasmodic stricture nux vom. is the principal
remedy, and will often relieve the affection if the patient observe the strictest dietetic rules.  Jlrsenicum, bell., hyos.,
sulph.-ac., and verat., may also be called for.
In permanent stricture ars., bell., canth., colch., ignatia, nuxvom., lyc., merc., sulph. may be indicated, and together with
the administration of the most appropriate, the bougie must be
employed.. The instrument should be soft and at first introduced once in three or four days, and allowed to remain as long
as the patient is able to bear it. After a time a larger sized
bougie should be used, and introduced more frequently; in
some instances, where there is great constriction and the smaller
sized bougies cannot be introduced with facility, it is necessary
to divide the stricture with a probe-pointed bistoury, passed
into the intestine upon the forefinger.
Fissures and Ulcers of the.Anus. —The verge of the anus
and the mucous coat of the bowel are often the seat of fissures




PRURITUS ANI.                        587
which are exceedingly troublesome, and arise from a chap or
other trivial cause. Persons afflicted with dyspepsia are often
subject to this troublesome disorder.
Treatment.-The medicines that relieve the patient most
speedily, are graphites and nitric acid; indeed, we have known
fissures that have resisted other treatment for a considerable
time, yield readily to the action of these remedial agents, especially the latter.
Dr. Perry* has written a valuable article on this subject, and
the following are the results of his experience: The chief medicines for this painful affection are nit.-ac. and ignatia; next in
order are plumb., sulph., ars., nat.-mur., phos., and sepia;
lastly, caust., sil., nux-vom., thuja., tabac gratio., and mez.;
petrol. is also an important medicine.
Itching of the anus is a very troublesome and inconvenient
affection. Frequently it is an attendant upon verminous diseases, or in other cases it may be purely idiopathic. In most
instances it is attended with other symptoms, as burning, tingling, &c.
Treatment.-All stimulating ointments, plasters, &c., should
positively be prohibited, as in the generality of cases they aggravate rather than ameliorate the pruritus, or convert a simple
into a troublesome and sometimes painful affection.
Where there is excessive itching of the anus, a few doses of
causticum may entirely subdue this unpleasant symptom. If
there is burning pain, alumina and capsicum frequently relieve
it.  When it occurs during the night, iod.; during stool, terebinth; after evacuation, antim-tart. or strontia.  Burning,
itching  and smarting in the anus, is cured by antim-crud.;
burning, itching, and tingling, by colchicum; and itching,
smarting, soreness and burning, with sensation as if tumors
would form, by nit.-ac.  Platina is homceopathic when there
is frequent creeping, with tenesmus, as if diarrhcea would set-in,
particularly in the evening before going to sleep.
v Journal de la Societ6 Gallicane, quoted by British Journal of Homceopathy, vol. viii., p. 541.




58S                   HYDROCELE.
Kali-carb. relieves a stinging, tearing, and cutting, also an
itching and burning in the antis. CWhen there is itching, with
sensation of contraction of the anus, plumb.  For the itching
dependent upon verminous affections the medicines adapted
to those diseases of course should be employed.
CHAPTER XXXVI.
DISEASES OF THE TESTICLE AND PENIS.
Section 1.-Hydrocele.
THE tunica vaginalis testis secretes, in its natural state, a
limpid fluid, which lubricates its internal surface and that of the
tunica albuginea; and whenever this fluid, from any cause, is
secreted in an undue proportion, it distends the tunica vaginalis, giving rise to a tumor of the scrotum, which is termed
hydrocele.
Hydrocele is a disease of not infrequent occurrence; it is
incidental to the young as well as to the old; though most
commonly a local disorder, it is at times combined with a hydropic condition of the system. The causes which give rise to
this disease are not well known.* It is probable that the accumulation is the result of excited action in the parts, for its
origin is most frequently attributable to external injury-blows
or bruises, followed by rapid swelling, which, after a time, subsides, leaving, perhaps, some enlargement of the testicle, or of
the more superficial tissues, and succeeded by the gradual appearance of the disease in question. It is also owing sometimes to inflammation of the testis, and is frequently combined
with stricture of the urethra, or local irritation along its course.
Dr. Physick succeeded in curing a case of this disease by dilating
" See Listoen's Elements of Surgery, p. 415.




H YDROCELE.                        589
the stricture with a bougie.  When the communication between
the cavity of the abdomen and the tunica vaginalis is not closed
as it should be at the usual period of time, the fluid descends
from the cavity of the abdomen into the cavity of the tunic,
forming what is (denominated a congenital hydrocele.
This affection is sometimes conjoined with sarcocele, or
chronic enlargement; in which case it is termed hydro-sarcocele.  It is very important to distinguish between these two
diseases; and this distinction may be readily made, by attending
to the following circumstances: In sarcocele, the tumor is oval
and flattened; it may attain a considerable size, without, however, ascending so near to the external abdominal ring as does
a large hydrocele. In sarcocele there is a space between the
tumor and the abdominal ring, whereas, generally, there is none
in a large hydrocele. The tumor may also be known by its
weight and opacity. In hydrocele the swelling commences at
the bottom  and is generally confined to one side.  At first the
tumor is flaccid, and the testicle may readily be distinguished; but as it increases in size it becomes firm and incompressible, and the testicle can scarcely be felt. The swelling
assumes a pyriform shape, the corrugations of the scrotum disappear, and the raphe is displaced to the opposite side; generally there is little or no pain or inflammation, and no alteration
of color. When inflammation, however, precedes this (lisease,
there is pain, swelling, and hardness. The swelling is translucent, and on placing a lighted candle on one side of the scrotum, the light can be discerned through it. In some cases, however, the tunica vaginalis becomes thicker and harder, the fluid
is opaque and dark colored, thereby obstructing the passage of
the rays of light.  Under these circumstances there would be
no transparency.
Sometimes an accumulation of fluid takes place in the tunica
vaginalis of the spermatic cordt, forming an encysted hydrocele
of the cord.  This variety occurs more frequently in children
than in adults.  The fluid is thin and clear, and contained in a
distinct cyst, of a smooth, shining, serous appearance internally;
this cyst may be either an unobliterated portion of the congeni



~590       TREATMENT  OF HYDROCELE.
tal spermatic structure, or composed of thickened and condensed
cellular tissue, strengthened exteriorly by the expansion of the
cremaster muscle.  This variety of the disease may be confounded with hernia, from which it is very necessary to distinguish it.  In hydrocele of the cord the accumulation takes
place gradually, unattended with pain, and is always below the
external abdominal ring.  When the patient coughs there is no
impetus communicated to the finger, and the tumor is not capable of being returned into the cavity of the abdomen; whilst
in hernia, the swelling takes place suddenly, after some violent
effort, attended with pain; and the peculiar impetus is communicated from the tumor when the patient coughs, and it may
generally be returned by pressure into the abdomen. It sometimes happens, however, that both these affections coexist in
the same individual, and in such cases the diagnosis is very
difficult.
Of itself, hydrocele is not a dangerous disease. Persons may
have it for years, and yet be firee from pain; but, if the swelling increase to a great size, pains in the spermatic cord and
renal region may be experienced. On account of the enormous
size of the effusion, the penis becomes much retracted, and
sexual intercourse is rendered impossible. The discharge of
urine may be interfered with, and the emission of semen is likewise impeded.
Treatment.-Hydrocele, especially that of children, is an
affection very amenable to homceopathic remedies; and a full
trial should be given to them, before resorting to an operation.
The medicines which have proved most effectual in the treatment of this affection, are as follows: calc.-carb., conium, dig.,
dulc., graph., iodium, merc.-sol., puls., rhod., sil., sulph.
Of these, calcarea should chiefly be relied upon, where there
is a scrofulous taint pervading the constitution, and the reproductive system is depressed, as indicated by loss of appetite,
debility, emaciation, dryness of the skin.
Conium is particularly suitable, when the affection can be
traced to mechanical injuries, contusions, &c.
Digitalis is useful, if there is a constant desire to pass water,




TREAT IMENT  OF HIYDROCELE.                    591
and is particularly suitable when children are the subjects of
the affection.
Dulcamara, when it arises from a cold, suppression of tetters,
suppression of a momentary or habitual sweat by exposure to a
draught of air, dampness, &c.
Iodium is a valuable remedy in hydrocele, and is particularly
adapted to a general scrofulous taint, characterized by glandular swellings and emaciation.
Rhododendron has been highly recommended in this affection.
In a case of several years' standing, where there was no disease
of the testes or spermatic cord, it effected a permanent cure in
a few months.
Graphites and pulsatilla are of the highest importance, and
have the most marked symptoms of hydrocele in their pathogenesis.*
Should this treatment prove unavailing after a fair trial,
an operation must be resorted to; which consists in withdrawing the serum, and injecting a stimulant fluid instead,
whereby an acute congestion may be established, whose resolution, when complete, shall have the effect of restoring the normal balance between exhalation and absorption.
When this is contemplated, a round trocar and canula are
to be used. The patient is placed in the erect posture, with
the thighs separated; the surgeon then takes the scrotum and
posterior part of the tumor in his left hand, rendering it tense
and prominent in front; the instrument is then entered at the
lower and anterior part of the tumor, passing obliquely upwards and backwards (see fig. 98), so as to avoid wounding
the testicle, yet at the same time taking care that the obliquity.is not such as endangers separation of the coverings of the sac,
and non-entrance into the sac itself.
The stilet being withdrawn, the canula remains; this should
* For a very interesting account of hydrocele successfully treated by
homceopathic medicines, and particularly concerning the action of graphites in this affection, see a paper by Dr. Black, in the British Journal of
Homoeopathy, vol. vii., p. 525.




592       TREATMENT OF HYDROCELE.
be pushed well into the cavity. The serum having then been
withdrawn, a caoutchouc bottle, with stop-cock and nozzle, is
Fig. 98.           adapted to the canula-or a
syringe may be employed,
and  the  cavity  partially
filled with some stimulant
fluid. Port wine undiluted,
or two parts of wine to one
of water, used to be much
employed.  Now, the favor~j;'~:1 a{ite injection is iodine, in solution-one part of the tinc7'~":~:~~   /ture to three of water.  Or,
a small quantity of pure tincture of iodine having been
thrown in, may be permitted
to remain permanently in the
sac, disappearing ultimately
by absorption. If the dilute injection be used, three or four
ounces are injected, and temporarily retained.
After waiting a few minutes, the patient will experience pain
in the testicle, shooting up the cord into the loins, and a sensation of faintness will probably ensue. Then the fluid is allowed
to drain away, and the patient is put to bed with the scrotum
supported. In a few hours after the parts become much swollen, when aconite and arnica have to be administered; the
swelling usually subsides in two or three days, when a cure
may be anticipated.
Before injecting any stimulant, it is necessary that the surgeon satisfy himself that the point of the canula is fully within
the cavity of the tunica vaginalis; otherwise the injection
would pass into the areolar tissue of the scrotum, which would
be foilowed by ulceration, sloughing, and severe constitutional disturbance.




H EM AT O C EL E.                  593
Section 2.-Haematocele.
By this term is understood an accumulation of blood in one
of three localities —the areolar tissue of the scrotum, the areolar tissue of the cord, and the tunica vaginalis.  It may be
either of spontaneous occurrence, or the consequence of external injury.
When it attacks the scrotum it is the result of a bruise or
oblique wound; the scrotum becomes swollen, and assumes a
blackish hue, like that of urinous infiltration; the swelling has
a doughy feel, and at one or more points where the cells are
broken down and much blood has collected, fluctuation is perceived more or less distinctly. Haematocele of the cord arises
from the giving way of a spermatic vein, from external injury,
or great bodily exertion, when extravasation into the areolar
tissue will result, forming a tense, discolored tumor. Haematoceie of the tunica vaginalis is the most common variety; and
to it, in strict accuracy, the terni may be limited. The blood
is extravasated into the cavity of the tunica, and may be associated with hydrocele, from a wound of the testicle in tapping,
or by a blow or other external injury, or by the spontaneous
giving way of a blood vessel-a hydrocele may at any time be
converted into hamatocele, the diagnostic marks of hydrocele
thereby being lost. The tumor suddenly increases in size, and
is the seat of pain; and when handled is found heavier and less
fluctuating than before. The blood, if in small quantity, becomes diffused in the serous fluid; when copious, a portion
coagulates, and assumes the fibrinous arrangement. This, acting as a foreign substance, may excite inflammatory action; and
suppuration may take place, with much increase of swelling
an(l pain.
Treatment. —The treatment of this affection, when unconnected with hydrocele, is as follows: When the accompanying
inflammation assumes a high grade, a few doses of aconite
should be administered in the first instance; and when it results
from a contusion, or any other mechanical injury, arnica or
conium should be given internally, and applied to the affected
38




594                  SARCOCELE.
parts as a lotion; pulsatilla also may prove availing in such
cases; and nux-vom., thus, sulph., or zinc., may also be found
efficient. The use of the knife is not necessary unless suppuration has unfortunately occurred.  When the  extravasation
supervenes on hydrocele, and the medicines mentioned for that
affection prove unavailing, simple tapping is in the first instance
to be had recourse to. To inject then, however, would be productive of evil rather than good result. The fluid is allowed
to collect again, and tapping is repeated, and when, after
several withdrawals, the fluid is found once more to be of the
same character as in simple hydrocele, then injection may be
resorted to with safety, and with much probability of successprovided the testicle be sound. In confirmed cases, however,
and more especially when suppuration is already threatened,
the only means of obtaining a radical cure, is by free incision;
laying the cavity fully open, turning out the coagula, and
obtaining closure of the wound by granulation; care being taken
during the performance of the operation, to avoid wounding
the testicle.
Section 3. —Sarcocele.
Chronic inflammation of the testicle, or, as it is termed, sarcocele, may result from acute orchitis imperfectly resolved, or
the action may be chronic from the commencement of the disease. It may be either primary or secondary, that is, it may
occur as an independent affection, or as a concomitant result of
gonorrhcea; it not unfrequently results from disease of the urethra, and in some instances the affection may be traced to
syphilis.  The tumefaction extends from the epididymis, which
is usually the primary seat of the disorder, and gradually involves the whole testicle, which presents the appearance of an
inelastic, uniform tumor, which is usually of an oval form, and
seldom exceeds two or three times the bulk of the healthy gland.
The accompanying uneasiness is slight, is more severe at night




V A R'I C o C E L E.               595
than during the day, and, as the disease advances, the characteristic sensibility of the organ to pressure is lost. Occasionally
the disease, in its latter stages, is accompanied with a degree of
effusion within the tunica vaginalis, constituting what is termed
hydro-sarcocele. Upon examination more or less yellow solid
lymph is found interspersed throughout the substance of the
testicle, extending into the vas deferens, and, according to Mr.
Curling, deposited in the tubuli semeniferi. By the smoothness and uniformity of the swelling, its gradual progress, and
the absence of glandular enlargement, the affection may be
distinguished from malignant disease of the testicle.
Treatment. —Rest and a recumbent posture are necessary in
the first instance; and in a mild form of the disease, or at its
commencement, resolution may be effected by means of the following medicines: aurum, clematis, lycopodium, agnus castus,
graphites, rhododendron, and sulphur.
When the disease has a syphilitic origin, a careful investigation, and an accurate knowledge of the character of the syphilitic affection from  its commencement, are required.  Calc.carb., carbo-veg., aurum, kcali-carb., lycopodium, spongia,
merc.-sol., acid-nit., clematis, mezereum, &c., are indicated in
this form of the disease; but other medicines may be required.
Graphites, lycopodium, oleander, and belladonna, are recommended if the disease is complicated with a general scrofulous
condition, chronic eruptions, glandular enlargements, &c.
Where the tumor, in an advanced stage, gives evidence of
the supervention of a malignant condition, arsenicumn, clematis,
diadema, carbo-veg., and thuja, may possibly arrest the progress of the disorder, though in the majority of such instances,
the use of the knife can scarcely be avoided.
Section 4.-Varicocele.
Varicocele, circocele, or spermatocele, express a varicose
condition of the veins of the scrotum, or spermatic cord. Usu



596       TREATMENT OF VARICOCELE.
ally the latter is affected. It commonly commences close to
the testis, and extends upwards towards the abdominal ring.
It is caused by obstruction to the return of blood, the dependent nature of the part predisposing to the affection. Laborious
and constant exercise in the upright position, constipation, corpulence, the wearing of tight belts, or trusses, tumors, or whatever affects the upward flow of blood, gives rise to the disease.
It is much more frequently observed on the left than on the
right side, in consequence of the spermatic vein of that side
having a longer and more tortuous course, and consequently
having to support a greater column of blood than that of the
right, and its being much more liable to compression, by accumulation of fiecal matter in the sigmoid flexure of the colon.
The affection is chiefly met with amongst young, vigorous, unmarried men, who have led exemplary lives. The whole of
the cord appears to consist of knotty and tortuous veins, which
feel like a bundle or congeries of earth-worms twisted upon
each other; it is sensitive to the touch, creates a feeling of
weight in the scrotum and loins, and often a degree of numbness in the thighs. It may be distinguished from hernia in the
following manner: After the patient has been placed in a recumbent posture, and the swelling reduced by compression of
the scrotum, the fingers' are then pressed on the upper part of
the abdominal ring, and the patient is directed to rise; if it be
circocele, the swelling will reappear in increased size, from the
obstruction offered by the pressure, to the return of blood; but
if hernia be present, the recurrence of the tumor cannot take
place so long as the pressure is continued.
Treatment.-The radical cure of this affection by means of
homeopathic medicines is attended with much difficulty, and
in many instances palliative relief is all that can be obtained.
Pulsatilla and arnica are the most useful medicines; the treatment may be commenced with puls., and the testes should be
supported by means of a suspensory bandage, or bag truss,
made of silk net-work. When the affection has been occasioned by a blow, or other external injury, or by pressure from
the pad of a truss, arnica should be applied in the form of a




P H IMOSIS.                     597
lotion. JNVux-vom. is suitable when constipation exists, and
puls. is found inadequate; sulphur will sometimes prove useful
after nux; and arsenic and carbo-veg. may be selected when
burning pains are experienced in the tumor: graph., lyc., and
sepia may also be found useful in some cases. But when the
symptoms do not yield to these medicines, and the tumor is
large and painful, and there is danger of the testicle becoming
atrophied in consequence of the pressure, the varicose veins
should be removed. These may be compressed by suture applied by needles passed beneath them, as in ordinary varix,
care being taken to exclude the vas deferens and the spermatic artery.  Obstruction of the  duct is tantamount to
castration, and obliteration of the artery can hardly fail to be
followed by atrophy of the testicle. Professor Pancoast's
operation consists in passing an armed needle behind the veins,
excluding always the nerves and vas deferens; the needle is
removed, leaving the ligature behind the veins; it is then
passed, unarmed, through the same orifices in the scrotum, but
in front of the spermatic veins; the loop of the ligature is then
passed over one end of the needle, and over the other end the
ligature is tied as tightly as possible, so as to completely strangulate the veins. The ligature may be removed in eleven days.
Inflammation, consequent upon the performance of these operations, is to be combated by the appropriate medicines mentioned under the treatment of wounds.
Section 5.-Phimosis.
Phimosis signifies a preternatural constriction of the edge of
the prepuce in front of the orifice of the urethra. The prepuce
occupies its natural relative situation, but great difficulty is
experienced in uncovering the glans, and frequently this is impossible.
There are two varieties of this affection, the natural or congenital, and the preternatural or acquired. The former exists




598                    P H I MO S I S.
at birth; but the latter may occur at any period of life, and is
most frequently the result of an acute inflammatory process following external injury; or of the cicatrization of an ulcer or
wound; or is sympathetic with gonorrhcea, balanitis, or venereal sores.
Congenital phimosis is by no means an uncommon affection,
and will be met with in two or three varieties.  Sometimes,
though rarely, the prepuce is imperforate, and consequently the
urine, not being emitted, collects between the glans and prepuce, forming a large bag or tumor.
Another variety is that in which an opening exists at the
extremity of the prepuce, which, however, is not sufficiently
large to allow the urine to escape with the same rapidity as it
issues firom the urethra; consequently it collects under the prepuce, and distending the latter to a great size, is then forced off
gradually, in a fine stream and to a great distance. If the disease continues in this state for several years, pus, and even
calculi, may collect within the cavity of the distended prepuce,
keeping up a constant irritation.
In the majority of instances, however, there is no impediment to the flow of urine, and no extraordinary elongation of
the prepuce, yet it is so closely contracted at its orifice as to
prevent the exposure of the glans. This gives rise to many
inconveniences. A whitish, sebaceous matter collects in large
quantity between the glans and prepuce, exciting great irritation; and inflammation sometimes ensuing, adhesion takes place
between the glans and prepuce, only to be relieved by painful
dissection.
In after life, the praeputial contraction may have the same
effect as a tight stricture of the urethra; causing first irritability of the genito-urinary system, afterwards organic change,
stricture of the urethra, alteration of the coats of the bladder,
dilatation of the ureters, and finally renal disease.  Should the
patient, at an advanced age, have escaped these dangers, ulceration is apt to take place at the contracted part; or a cancerous
condition may ensue, which, involving the glans and body of
the penis, demands amputation; for in nine cases out of twelve




TREATMENT  OF PHIMOSIS.                    599
in which Mr. Hey* had occasion to amputate the penis for cancerous disease, the patients were affected with natural phimosis.
It is expedient, therefore, on many accounts, to remove this
source of evil as early as possible.
Preternatural or acquired phimosis may be either acute or
chronic. In the acute variety, the areolar tissue becomes infiltrated with serum; the swelling thus caused, prevents the
glans from being uncovered in the usual way; and discharge
accumulating, aggravates the disorder. The chronic form may
result from gradual increase of original malformation, or, as
before stated, may be occasioned by the cicatrization of a
wound or ulcer.
Treatment.-In the acute variety of acquired phimosis the
difficulty may be relieved by a well-directed horneopathic
treatment; thus obviating the necessity of an operation.
The remedies most appropriate for this affection are as follows: Ilcon., arnm, bell., bry., calc., camph., cann., canth.,
caps., cinnab., hepar, merc., rhus-t., thuja, sepia, sulph., and
viola-tric.
When the inflammation has been produced by constant friction, or any other mechanical cause, arnica should be employed
both internally and in the form of a lotion. If, however, the
inflammatory action should be very violent, a dose or two of
aconite is advisable, to be followed by arn. If no beneficial
effect appears to result from the use of the latter remedy,
calend., rhus, or puls., may be administered. When the disease has been caused by uncleanliness, aconite should be employed, if there is a high degree of inflammatory action, to be
followed by merc. or sulph. When the affection is accompanied
with suppuration, merc., caps., or hepar, may effect a cure;
and when induration of the affected part, and surrounding integument, supervenes, sepia and sulphur are the most appropriate medicines. When gangrene threatens, or when it has
actually commenced, particularly if the disease is associated
* Practical Observations in Surgery.




600          TREATMENT OF PHIMOSIS.
with gonorrhcea, ars. is highly recommended.* When young
children are the subjects of this affection, acon., merc., calc., and
sulph., are most suitable. When this difficulty arises from
syphilitic causes, the homceopathic remedies with which it
should be treated are, merc.-sol., rhus-t., thuja, cann., cinnab.,
sulph., and v'iola-tric.  Balanorrhcea generally accompanies
this variety of phimosis; indeed, some authors state this to be
always the case; and when the above-mentioned remedies are
insufficient to effect a cure, it may be necessary to make slight
incisions into the prepuce, for the purpose of allowing the
secreted pus to escape.t
The congenital and chronic variety of acquired phimosis,
however, can seldom be relieved without recourse being had to
an operation; which may be performed by several different
methods.
When natural phimosis, existing at birth is complete, an
immediate operation is required to save the patient's life; generally puncture with an ordinary lancet in the most prominent
portion of the tumor, will be sufficient, as the stream  of urine
will afterwards prevent the closure of the wound.
When the orifice of the prepuce is not entirely closed, but
merely contracted, a simple and very suitable method of operating is that recommended by Mr. Liston;t which consists in
passing a grooved director, open at the end and well oiled,
under the prepuce, alongside of the fraenum, taking care that it
is not passed into the urethra.  A sharp-pointed knife is passed
along the groove, and emerges at its extremity; then with one
sweep the prepuce is divided. If the edge of the prepuce is
thickened, it should be seized between the blades of the forceps,
and be shaved off.  Several fine sutures will now be necessary
to prevent the separation of the integument and mucous membrane, in order that they may unite by adhesion.
In phimosis the stricture is caused by contraction and rigidity
- For an interesting account of several cases of this nature, effectually
treated by arsenicum, vide British Journal of IIomceopathy, vol. iv., p. 265.
1- Gollmann's Diseases of the Urinary and Sexual Organs, p. 64.
i Elements of Surgery, p. 410.




P A R A P H I M OSIS.                601
of the internal membrane of the prepuce, the external portion consisting of cellular tissue and skin, remaining generally
sufficiently loose and yielding. Hence the constriction may be
relieved by dividing merely the internal lamina. This operation
may be effected, in cases in which the phimosis is not very
complete and rigid, by drawing back the external portion of the
prepuce as far as practicable, until the tense ring of the inner
prepuce, which forms the stricture, is exposed, and then dividing the latter with a bistoury or pair of scissors, at one or more
points, sufficiently to permit of the free motion of the prepuce
over the glans.*
Another very neat operation is that of Cullerier. It is
applicable to those cases of phimosis, in which the integuments
appear to be not much condensed or indurated; but in which
the stricture is due chiefly to the more unyielding mucous membrane. The instrument employed is a pair of small straight
scissors, of which one of the blades is terminated by a little
button, like a probe-pointed bistoury. This blade is passed
between the glans and prepuce, while the sharp-pointed blade
is thrust into the substance of the prepuce, being separated
from the other blade by the mucous membrane; the latter is
then divided a sufficient length to allow  the prepuce to be
drawn back.t  This operation has frequently been performed
by Dr. Peace of this city.1
Section 6. —Paraphimosis.
Paraphimosis is the reverse of phimosis-the prepuce becoming retracted behind the corona glandis, leaving the glans
uncovered; the body of the organ is constricted by the tight
praeputial orifice, and gives rise to unpleasant and sometimes
dangerous consequences. The superficial areolar tissue becomes greatly swollen on either side of the stricture, the glans
* South's Chelius, vol. 2.   t Miller's Practice of Surgery, p. 587.
* For an interesting article on the Operation of Phimosis, vide Med.
Chir. Rev., April 1851, p. 445.




602       TREATMENT OF PARAPHIMOSIS.
also being involved in the tumefaction; and an acute inflammatory process is established under adverse circumstances, the
strangulated parts being obviously ill provided with the power
of resistance or control.
The disease may be either congenital or acquired, though the
latter variety is by far the most common. It may be the result
of a successful retraction of the prepuce, when the patient had
previously been affected with phimosis; but it generally proceeds from inflammation, induced by a syphilitic or gonorrheal
disease. In some instances the swelling and constriction are so
great, that mortification ensues, and the glans, or even the
whole penis, may be lost; this, however, must be considered a
comparatively rare termination. In neglected cases ulceration
of the body of the penis may take place, perforating the urethra
and producing urinary fistula.
Treatment.-In recent cases, before the swelling has attained
any considerable size, reduction is generally practicable. The
patient having been placed in a suitable position, and the parts
well oiled, the surgeon grasps the glans with the fingers of the
right hand, and makes steady pressure thereon, at the same
time pushing it steadily from him; then, with the fingers of the
left hand, he draws forward the constricting portion —the object
being to push the glans, when diminished by pressure, through
the narrow preputial orifice. If this should fail, and there is
still no marked urgency, the penis should be placed in an erect
position, and a stream of cold water poured on the glans for
some time. This may have a happy effect in diminishing the
bulk of the formerly turgid part, and it may be replaced within
the prepuce without much difficulty.
For many of the symptoms connected with paraphimosis,
aconite, cannabis, sabina, and mercurius are the most appropriate medicines; but, should these, together with the above
mentioned means, fail, resort must be had to an operation,
which may be performed by either of the following methods:
The tumefied parts are to be separated by the fingers, and
the strictured band cut through with the sharp point of a knife,
when the prepuce should immediately be drawn forward, so as




CANCER  OF THE PENIS.                    603
to occupy its normal position; this operation is recommended
by Mr. Hunter.  That of Richter consists in raising a fold of
the skin and cutting through it; a director is then pushed beneath the stricture, and the latter is divided by a sharp bistoury,
Section 7.-Cancer of the Penis.
Cancer of the penis is generally of the scirrhus, and very
rarely of the encephaloid variety. The disease generally commences with the appearance of a small warty excrescence or
pimple on the prepuce or glans.  It almost always occurs in
old persons, and may often be traced to the irritation consequent upon phimosis; commencing by ulceration at the praoputial orifice, and from thence extending to the body of the penis.
The glans becomes hardened and enlarged, ulcers of an irritable
appearance penetrate it here and there, the lymphatics on the
dorsum of the penis become swollen and indurated, the glands of
the groin are generally involved, and the discharge from the
sore is fetid and irritating.  The disease follows the ordinary
course of cancer, and, if not arrested, the patient dies-his end
hastened probably by hemorrhage from the ulcer.
Treatment.-The medicines which have been mentioned for
cancer in other parts of the body, may be used in this case; in
a great majority of instances, however, amputation is the only
resort, and this unfortunately is not always successful, as the
disease reappears in the stump, or exhibits itself in the inguinal
glands.
Ricord's method of amputating is preferable, being well calculated to obviate the difficulty generally attendant upon the
operation-namely, tendency to contraction in the orifice of the
urethra.
The procedure is conducted in the following manner:
The penis is put upon the stretch by the left hand, and lopped off at one cut, care being taken to leave integument sufficient to cover the corpora cavernosa; the surgeon then seizing




604                 CASTRATION.
the mucous membrane of the urethra by means of forceps, with
a pair of scissors makes four slight incisions, so as to form four
equal flaps; then using a fine needle armed with a silk ligature,
he unites each flap of membrane to the skin by a suture. The
wound heals by the first intention, adhesions form between the
skin and mucous membrane (these textures becoming continuous), and the cicatrix, then contracting, tends to open the urethra. When micturition is difficult of accomplishment, in consequence of the shortness of the penis, the inconvenience may
be obviated by allowing the patient to urinate through a funnelshaped canula of sufficient length, placed against the pubes.
Section 8.-Castration.
This severe and painful mutilation is occasionally demanded,
and may be performed in the following manner:
The scrotum and groin having been carefully shaved, and
the patient placed in a recumbent position, the surgeon grasps
the tumor behind, in order to render the skin tense.  An incision is then made from the external abdominal ring, reaching
to the bottom of the scrotum; or the scrotum may be gathered
into a fold by the fingers, and transfixed at its base, when a
suitable incision will be made by cutting directly outwards.
The cord having been exposed, is separated from the surrounding textures, and entrusted to the firm grasp of an assistant, to
prevent retraction within the abdominal aperture when divided;
the bistoury is carried behind the cord, which is then cut across,
and the operator seizing its lower portion draws it forward, and
proceeds to dissect out the testicle-a dissection rendered comparatively painless and bloodless, by early section of the cord.
The arteries should then be tied, and the wound kept open
until all bleeding has ceased; the lower portion seldom healing
otherwise than by granulation, need not be closely approximated. Care should be taken, during the operation, not to
wound the septum, and thus expose the sound testicle.




STRICTURE OF THE URETHRA.                     605
The operation may be performed by first separating the testicle from its integuments, before dividing the cord; all fear of
irrepressible hemorrhage by retraction of the vessels may be
avoided, by dissecting up their cremaster envelope for a considerable distance towards the abdominal ring, and passing a
ligature around them before severing the cord.
CHAPTER XXXVII.
DISEASES OF THE URETHRA AND BLADDER.
Section 1. —Stricture of the Urethra.
STRICTURE of the urethra is a complaint more frequently existing than is generally imagined.  There are three varieties of
the affection. 1. Permanent or organic stricture, in which the
urethra is contracted and condensed from chronic inflammation.
2. Spasmodic stricture, arising from spasm of the muscular
fibres which surround the membranous portion; and this is, in
some instances, combined with a degree of true inflammation,
constituting, 3. The inflammatory stricture.*
The symptoms of stricture are generally so well defined, that
the diagnosis of the disease is as near as may be positive. In
its commencement there is a slight uneasiness experienced along
the canal, which is increased by urination, which leaves a tingling sensation; the water is not passed in a perfectly round or
steady stream, but is more or less broken, diverging, or twisted.
The inflammation sometimes extends to the bladder, when, of
course, the symptoms of cystitis are present, as pain in the lumbar region, &c. These progress slowly but steadily, till micturition is extremely painful, the urine only emitted by drops,
attended frequently with ardor urinae.
* Druitt's Modern Surgery, p. 457.




606                 TREATMENT OF
Treatment.-For the above symptoms, or others which may
be present, an appropriate medicine must be selected; which,
although it may not be sufficient to cure the disease, will allay
the more violent inflammatory symptoms, which would render
hazardous the application of instruments.
One method of curing stricture is by dilatation; before commencing which, it is necessary to ascertain the seat of the
obstruction. To accomplish this, some employ a silver catheter; others, a graduated bougie.  Sir C. Bell recommends a
ball-headed probe.  Sir B. Brodie uses a full sized plastic bougie, which is to be softened by rubbing it in the hand, and well
oiled and bent into the form of the urethra.  There are also
instruments made in a conical form, which are objectionable, for
the reason, that when introduced to a certain extent, you are
unable certainly to ascertain whether the pressure conveyed to
the finger is caused by the stricture itself, or the larger portion
of the instrument at the mouth of the urethra.  The most
general form of instrument now used by the best surgeons, is
the gutta percha bougie; but, whatever be the instrument, as
the obstacles to overcome are the same, the greatest caution
should be used in its introduction.
The best method of ascertaining the seat of the stricture, after
having selected a proper instrument, is to place the patient in a
standing position, grasp the glans penis with the ring and little
finger of the left hand, and by gentle traction place the penis in
a horizontal position; then, having smeared well with oil, and
holding the bougie as you would a pen, gently introduce it, by
a slight rotary motion, until it reaches the prostate. When it
reaches the stricture a sensation will be communicated to the
hand, which should be a warning to proceed with increased
gentleness.
There are several obstacles which may impede the course of
the bougie, which it is necessary to mention. It may become
entangled in one of the lacuna, or in some accidental fold of the
urethra. A small and soft instrument may bend, when pressed
against the lower portion of the urethra; or its onward course
may be arrested by a spasmodic contraction of the canal.




STRICTURE OF THE URETHRA.                    607
It is always the better plan to commence with small and soft
bougies; for the stricture may be an old one, narrow and tortuous; and much additional suffering and danger thereby may
be avoided.
Some surgeons recommend a fine catgut bougie-others, a
gum catheter, curved and without the wire.
There is some disadvantage in using these pliable instruments, because, on pressure being exerted, they yield very
easily; but a skillful han(d can readily distinguish between the
giving of the bougie or the narrowing of the canal. If a soft
instrument cannot be introduced, recourse must be had to a
metallic one.
Frequently the obstacle preventing the passage of the bougie
arises from the vital action of the part; this may be overcome
by steady pressure on the instrument, and.care, as it passes
down the urethra, that nothing is lacerated.
We can generally tell whether the bougie has entered the
stricture, by endeavoring to withdraw the instrument. If it
has passed into the contraction, there will be a resisting force.
There has been, by many surgeons, fault found with the term
" dilatation" in reference to strictures. It is argued, and justly
too, if a stricture were merely a muscular contraction, then
the term would be correct; but, as has been before shown, this
is not the case-for there are organic changes which take place.
The passage of the instrument modifies the vital properties of
the part; while the pressure which it exercises on the newly
organized parts induces a tendency to absorption, and gives a
stimulus which enables nature to complete the cure.
The effects of the bougie, or, as it has been well termed, the
"C vital action," are visible from the commencement of the treatment. Hemorrhage is often experienced, and there is almost
always a slight discharge.
But whatever be the kind of instrument employed, long experience has demonstrated, that, with certain exceptions, dilatation is the most safe and effectual method for relieving the
distressing incidents which attend stricture of the urethra.
The mode of dilatation is not by any means to be disre



608      STRICTURE OF THE URETHRA.
garded.  It may be conducted on different principles; it may
be temporary or permanent; or these may be had recourse to
in a gradual or rapid manner.
The size of the instrument, whether it be a plastic bougie or
metallic sound, must be regulated by the presumed diameter of
the contraction; and after having been selected, and introduced
in the manner described, it must be allowed to remain for a
certain time, and withdrawn at stated intervals. The object is
to effect a regular and progressive dilatation of the strictured
part, without inflicting any injury on the tissues, or exciting
any severe irritation in the urethra.  On the first introduction
of the instrument it ought not to remain more than a few
minutes in the urethra; if it has been borne well, it may be
introduced on the following day, and so on, but the best practice is to introduce the bougie every third day at first, and then
gradually shortening the intervals, increase the size of the instrument. All this, however, must be regulated by the effect
produced upon the stream of urine, which indicates the progress
of improvement.
Though dilatation is the safest and most certain, it is nevertheless a tedious method, and hence many surgeons have
attempted to effect dilatation in a more speedy manner.  This
is done by first introducing a bougie of small calibre, quickly
withdrawing it, and then passing others of larger size, until the
patient complains of uneasiness or pain. The same operation
is repeated every day or two. Larger instruments being gradually employed. By the adoption of this method obstinate
strictures have been cured in five or six days.
Permanent dilatation, as its name implies, is effected by leaving
the instrument permanently in the bladder. The treatment
should commence by using a metallic bougie, which should be
allowed to remain in the urethra, from twenty-four to fortyeight hours, and then withdrawn.
Temporary dilatation is the method most frequently employed,
because it is generally the safest and best. Rapid dilatation
may be attempted when the stricture yields readily, or when it
is a matter of great moment to the patient to be speedily
relieved.




FISTULA  IN  PERINEO.                    609
In the treatment of permanent stricture, any disorder of the
general health or of the genital organs must be corrected by
the administration of appropriate medicines, after which the
treatment by dilatation must be resorted to.
Puncturation, or division of the stricture by means of lanceted stilettes, has proved successful in some cases of long
standing in which the stricture was in the anterior part of the
urethra.  If the stricture is situated far back the operation is
dangerous and should not, unless under urgent circumstances,
be attempted.
In cases of rupture of the urethra and extravasation of urine,
the operation of opening the urethra from  the perineum is necessary. The patient should be placed in a position similar to
that directed for the operation of lithotomy-a director passed
into the stricture, the left forefinger introduced into the rectum
in order to feel for the urethra, and serve as a guide to the incisions. The straight bistoury is then to be plunged into the
perineum the depth of an inch, and carried backward until the
stricture is divided.
Section 2.-Fistula in Perineo.
By this term is understood an abnormal communication between an external opening in the perineum and the urethra, by
means of an orifice in the latter.
It is frequently caused by strictures of the urethra, blows,
and other injuries.  In proportion as a stricture increases, the
urethra at the diseased part is diminished, while that portion of
the canal immediately behind the obstruction is enlarged by the
continued propulsion of the urine against it. The irritation
thereby induced engenders the inflammatory process, which
terminates in ulceration; an opening is formed through the
urethra, and communicates with the cellular membranes surrounding it; the presence of the urine excites additional irritation; suppuration results, the pus is discharged, and there
39




610            R ETENTION OF URINE.
remains a fistulous opening, through which the urine constantly
dribbles.
Fistula in the perineum may also sometimes proceed from
rupture of the urethra,* and the urine is instantly diffused into
the loose cellular membrane of the perineum and scrotum,
where it occasions much distension, and excites inflammation
so intense, that in a few hours gangrene and sloughing of the
scrotum may take place, leaving, in many instances, the testicles and urethra bare, and endangering the patient's life.
There is seldom more than one fistulous opening communicating immediately with the urethra, but from it numerous
sinuses generally extend in various directions; and in cases of
long standing it is not unusual to find the cellular membrane of
the scrotum, and all the other parts through which the urine
meanders, greatly condensed and converted into indurated
tumors, upon the surface of which may be found innumerable
small holes that discharge offensive urine and matter-rendering the patient disagreeable to himself and pitiable to his
neighbors.
Treatment.-When a fistula in perineo depends upon a stricture of the urethra, the first care of the surgeon must be to get
rid of the obstruction by means already adverted to; after
which the most appropriate medicines should be administered,
among these are, ars., calc., carb.-an., silic., and sulph.
By such means it will generally be found, that as soon as a
natural outlet is established for the passage of the urine, the
sinuses will heal.
Section 3. —Retention of Urine-Ischuria Vesicalis.
This affection differs materially from suppression of urine.
In the latter, the kidneys do not perform their usual functions,
while in ischuria, the urine is secreted and passes into the blad* Gibson's Institutes and Practice of Surgery, vol. ii., p. 465.




RETENTION  OF URINE.                     611
der, but cannot be ejected from that viscus. There is always
more or less pain in the bladder, which, from distension, is perceptible above the pubes; there is urgent desire to void the
urine, with pain and sickness, and but few drops are emitted.
The disease is generally easily amenable to treatment, but in
some cases it is of a very intractable character.
Treatment.-The chief medicines for this complaint are, acon.,
cann., canth., dulc., merc., nux-vom., op., puls., stram. Others
than the above may be required in particular cases. An empirically applied medicine, but one which relieves spasmodic retention of urine frequently in a short time, is buchu. The
powerful action that this plant is known to exercise upon the
urinary apparatus, should lead to its proving upon the healthy
individual, and there can be but little doubt that it would be a
valuable acquisition to our Materia Medica.
the method of preparing it for administration is as follows:
Place in a large sized tumbler, or other vessel, a small handful
of the leaves of the plant, and pour thereon scalding water;
allow this to remain until it becomes cold-of this infusion administer a dessert spoonful every quarter or half-hour, until the
patient is relieved. The above is an empirical use of the medicine; but a knowledge of the fact may be useful to the practioner in urgent and peculiar cases, when other means have
failed. When the surgeon is called to a case, in which the
patient is suffering intense pain from distension of the bladder,
the catheter should be immediately used. To accomplish its
introduction the patient is first laid on a low bed, couch, or on
the floor, with his shoulders and knees slightly raised; the surgeon then standing on the patient's left side, holds the glans
with the forefinger and thumb of the left hand, and presses it
gently from before backwards, so as to cause the orifice of the
urethra to gape, into which he introduces the catheter. Holdinog the instrument (previously warmed and dipped in oil) in his
right hand, he carries it onwards with a gentle pressure-taking care to stretch the penis sufficiently to prevent the movable
part of the urethra from remaining bent, or being thrown into
folds-until it reaches the angle of the pubes, where the ure



612              URINARY CALCULI.
thra perforates the triangular ligament; the surgeon's right
hand being brought by the course of the instrument nearly over
the anterior part of the crest of the ilium. At this stage of
progress the hold with the left hand is given up, and the right
should move into the mesial line; in other words, the instrument should be brought parallel with the linea alba; next, it
should be raised and made to describe a portion of a circle, of
which the catheter is, as it were, the radius, and then a force
little more than the weight of the instrument will cause the
point to glide into the bladder. In all instances, whether of a
simple nature or attended with difficulty, it is a good general
rule to cause the point to move along the upper surface of the
urethra.*
The following is the method of passing the female catheter:
The forefinger of the left hand should be introduced between
the nymphae and passed down to the urethral orifice, which is
known by a depression, with an elevation on its vaginal aspect.
The catheter should be taken in the right hand, and introduced
along the finger which is at the urethral orifice, into which it
should be inserted, and thence it easily passes within the
bladder.
Section 4.-Urinary Calculi.
Urinary calculi are formed originally in the kidney, from
whence they find their way along the ureters into the bladder,
where, if too large to be passed off through the urethra, they
remain, and serve as nuclei for other depositions.t
Urinary calculi vary considerably in size, form, character,
and chemical composition. They may be composed of lithic
acid, lithate of ammonia, phosphate of magnesia and ammonia,
* Vide Fergusson's Practical Surgery, p. 589.
i For the different Urinary Deposits, and the Diathesis that give rise to
them, see MSiller's Practice of Surgery, pp. 436-458; and for the Chemical
Constituents of Calculi, and their Tests, vide Gardiner's Medical Chemistry.




URINARY  CALCULI.                     613
phosphate of lime, oxylate of lime, triple phosphate of magnesia
and ammonia, and carbonate of lime. Of these, the lithic acid
calculi are by far the most numerous.
Urinary calculi may be contained in the kidney, ureters, bladder, prostate gland, or urethra; but the bladder is their most
common receptacle, in which they may be loose, or may be
contained in cysts formed between the coats of the bladder, the
termination of the ureters, or between the folds of a contracted
bladder; there may be a single calculus, or great numbersupwards of a hundred having been found.
During the passage of a calculus along the ureter, the patient
suffers, in most instances, excruciating pain, has frequent desire
to pass water —a few drops only being emitted at a time, and
that high-colored and sometimes mixed with blood. Fever,
eructation, nausea, vomiting, and spasmodic retraction of the
testicle, are the common accompaniments of the disease.
An encysted stone seldom gives rise to severe symptoms;
but one that lies loose in the bladder, and is liable to move
about, must always excite more or less uneasiness. *
Stone in the bladder is not generally difficult to diagnosticate.
There is irritability of the bladder; frequent and irresistible desire to make water; occasional sudden stoppage of the stream
(luring micturition, by the stone falling upon the orifice of the
urethra, the urine probably flowing again if the patient throw
himself upon his hands and knees, or change his position;
occasional pain in the neck of the bladder, increased after micturition; pain in the glans penis, and if the patient be young,
lie attempts to alleviate it by pulling at the prepuce, which
becomes extremely elongated: but the only sign to be fully
relied upon, is actual contact with the stone, by means of a
sound passed into the bladder; by this medium, both the senses
of touch and hearing may be convinced of the presence of
stone.
The symptoms of stone vary in severity according to its size
* Gibson's Institutes and Practice of Surgery, vol. ii., p. 487.
t See Hastings' Practice of Surgery.




614          STONE IN THE BLADDER.
and roughness, the state of the urine, and the condition of the
bladder, whether healthy or inflamed. These symptoms may
be slight for years; indeed, a little pain and bloody urine, on
micturating after riding, may be the only inconveniences experienced. But after a certain time the bladder suffers just as it
does from any other cause of irritation; the urine deposits a
slight cloud of mucus; the bladder becomes more irritable, and
finally inflames; the urine becomes alkaline, loaded with viscid
mucus and with the triple phosphate and phosphate of lime;
the strength fails, and, after years of suffering, the patient
finally sinks under the irritation. Sir B. Brodie remarks,
"that if the prostate become enlarged, the sufferings from
stone are mitigated; because it is prevented from falling on the
neck of the bladder."
Treatment.-The general diagnostic signs for ascertaining
the presence of stone in the bladder have been given above,
but the positive means for assuring the surgeon that there is
present a calculus in the bladder is by sounding, by which term
is understood the introduction of a solid steel instrument, resembling a catheter in figure, into the bladder, and moving it
about in that viscus until it comes in contact with the stone,
when a peculiar impulse is communicated along the instrument,
or a metallic sound is appreciable to the ear.  Sometimes the
stone cannot be detected; in such cases, by introducing a finger
into the rectum, and pressing the lower part of the bladder upwards, the calculus may be made to touch the sound. When
these means proved unsuccessful, Dr. Physick, of this city,
whose experience in lithotomy was very extensive, was in the
habit of placing the patient nearly upon his head, by which
position the stone was dislodged from the fundus of the bladder
and thrown against the sound.
In sounding for stone, care must be taken lest the student
mistake a stone in the urethra or prostate gland for a calculus
within the bladder.
Extraction by the Urethra.-When a stone is known to have
recently escaped from the urethra into the bladder, the irritability of that organ must be allayed by the administration of




LIT H OTO M Y.                   615
acon., canth., scill., or calc.-carb., nux-vom., opium, puls.,
kali-carb.
The patient* should also drink plentifully, in order that the
bladder may be quite filled. As soon as a desire to pass urine
is experienced, he should be directed to lie on his face, and to
grasp the penis, that the urethra may become distended with
urine; by these means the sudden gush of fluid which will
escape when the grasp is abruptly relinquished will force out
the stone. In some cases the urethra may be dilated by passing bougies. But if this plan succeeds not, Weiss's urethral
forceps should be tried. The patient being placed on his back,
with his pelvis raised, the urine must be drawn off by a catheter, and afterwards five or six ounces of tepid water must be
injected into the bladder. The forceps must then be carefully
introduced and with them the surgeon must feel for the stone,
which, when found, if its size permit, must be gently extracted.
If too large to be removed in this manner, other operations
must be performed; if of a medium  size it may perhaps be
brought to the membranous portion of the urethra, where it
can be extracted by incision. Some calculi, of particular chemical construction, can be removed by injection. Sir B. Brodie
has satisfactorily shown that phosphatic calculi may sometimes
be dissolved by means of injections of very dilute nitric acid
through a double gold catheter.
Section 5. —Lithotomy.
This operation, which has been greatly modified and improved since its first introduction to the notice of the profession,
may be performed in several different modes, denominated the
lateral, high, and bilateral. The first is most commonly employed, and is conducted in the following manner: The bowels
having been previously evacuated, and the urine retained within
* See Druitt's Modern Surgery, p. 485.




616                 L1THOTOMY.
the bladder, the patient is placed upon a table of convenient
height, his hands and feet are approximated and firmly bandaged together, with the knees elevated; a staff, deeply
grooved on its convex and left side, and of sufficient calibre to
fill the urethra, should then be introduced. The knees should
be separated by an assistant on either side, in order that the
perineum, which should be cleanly shaved, may be exposed.
The patient having been brought to the edge of the table, the
surgeon seats himself in front, with his instruments in a convenient place, and the staff, being in contact with the stone, is
brought up under the symphysis pubis, and not pressed downwards upon the rectum, and is then given into the hands of an
assistant, who is directed to hold it vertically, and, at the same
time, guard the scrotum against injury.
An incision of about three inches in length should then be
made, commencing at about an inch behind the scrotum, and
extending downwards and outwards to a point between the
tuber ischii and anus, and even extending further than this.
Various measurements have been given by different surgeons,
regarding the point at which this incision should be commenced,
but, on account of the diversity in size and depth of the perineum in different patients, the surgeon should not depend on
absolute measurement, but rather be guided by circumstances;
he should ascertain the probable size of the prostate gland, by
means of an examination per anum, and then make his incision,
in view of exposing the membranous portion of the urethra,
taking care, at the same time, not to cut the bulb of the corpus
spongiosum lying in front, nor the rectum behind.
The incision having extended through the skin and superficial fascia of the perineum, the transversus perinei muscle and
artery, the lower edge of the triangular ligament, and a few
fibres of the levator ani muscle, will then have to be divided.
By an examination with the finger, the staff may now be felt
in the urethra, which should be opened by a bistoury, when a
flow of urine will immediately result.
The gorget or scalpel should now be introduced into the
wound, and, if the former, its beak must be firmly fixed in the




LITH OTOMY.                      617
groove of the staff, pushed in the direction of the bladder, cutting through its cervix and the prostate gland. The handle of
the instrument, whilst making this thrust, must be depressed,
in order that the rectum may not be wounded. When the
bladder is penetrated, urine gushes out, and the instrument
should be removed carefully, to avoid wounding the pudic
artery; the finger should then be employed for ascertaining
the position and size of the stone, and afterwards a strong pair
of forceps should be introduced into the bladder, and the stone
grasped in such a manner that its short diameter may be presented to the opening, through which it should be removed
carefully and gradually.
If, from the size of the calculus, it be found impossible to
remove it through the first opening, this may be enlarged on
the same, or, if necessary, the other side. After the removal
of the stone, the finger should again be introduced, in order to
ascertain that no more calculi remain.
The bladder having been freed from the presence of all calculi by means of the forceps or syringe, a tube, by which the
urine is to escape, should be passed into the bladder through
the wound. The patient should then be placed in bed with
his knees together, and a small cup or saucer placed in a convenient position for receiving the urine as it escapes from the
tube. In case of wound of the bulb of the corpus spongiosurn,
or of the urethra-bulbar artery, severe hemorrhage may result;
in such cases a ligature should be applied, or, if this is impracticable, the flow of blood may be stopped by compression.
If there be subsequent venous or arterial oozing, the tube
should be removed and the wound stuffed with lint, a catheter
having been passed through the urethra. In cases in which
its removal is not necessitated by hemorrhage, the tube should
be allowed to remain until the wound has granulated around
it, and the urine has recommenced to flow through the urethra.
The high operation is performed by making an incision
through the linea alba, and opening the bladder where it is not
covered by peritoneum. This method is only necessary when
the stone is of enormous size, the prostate gland diseased, or




618                 LITHOTRIPSY.
the space between the tuberosities of the ischia less than
usual.
The recto-vesical operation consists in cutting into the bladder, through the walls of the rectum.
Stone in women is of much less frequent occurrence than in
men, mainly in consequence of the renal calculus being more
readily passed through the urethra. When, however, the calculus is retained in the bladder, and increases in size, it may
be removed either by dilatation of the urethra, or the performance of the lateral operation; in the latter case, the incision
should be made from the orifice of the urethra, and through
the neck of the bladder.
Lithotrity.-The term lithotrity signifies the boring or drilling of the stone, and was most successfully accomplished by
Civiale. His instrument consisted of a straight canula, containing a drill and three claws, which can be protruded after the
instrument has been introduced into the bladder. These claws,
however, are liable to catch in the coats of the bladder, and
the operation has fallen into disuse.
Section 6.-Lithotripsy.
By this is understood the crushing of the stone within the
bladder, and it is preferable to all other methods of disintegration. It can be most successfully employed in cases in which
the patient is an adult, the urethra free from stricture, the bladder void of irritability, and the prostate gland not enlarged.
The mulberry calculus, on account of its hardness, is the most
unfavorable for the performance of lithotripsy.
The instrument most frequently employed is that of Heurteloup, or a modification of it. It consists of two blades, which
are made to slide one upon the other. The instrument is introduced into the bladder as a simple sound or catheter, and
the blades are afterwards expanded, for grasping the stone.
In the original form of the instrument, the male blade was




QUESTION  OF AMPUTATION.                   619
struck with a hammer; now, however, the crtshing force is
exerted by means of a peculiarly adapted screw. The extremities of the instrument are fitted with teeth, for the retention of
the stone after it has been grasped, and fenestrae, or perforations, to allow the escape of the powdered stone or sand.
It is advisable that, previous to the operation, the urethra
be dilated, and the urine should be retained in order that the
bladder may not be in a collapsed condition, and thus endanger
its coats being caught by the instrument.
The patient should lie on a convenient bed or table, with
the pelvis elevated in such a manner as to throw the stone into
the fundus of the bladder. The instrument, having been oiled
and warmed, is then introduced, and, after encountering the
stone and fairly grasping it-an operation which requires skilful manipulation —-the calculus is crushed by slowly and gradually turning the screw. The instrument should then be withdrawn, and after the irritation consequent on its presence has
somewhat subsided, may again be introduced to crush the fragments; thus many introductions of the instrument may be
necessary, before the stone has been broken to sufficiently small
particles to allow of their passage through the urethra.
CHAPTER XXXVIII.
QUESTION OF AMPUTATION.
So long as the destructive effects of injuries and diseases of
the extremities cannot, in every instance, be prevented by the
employment of other means, a necessity for amputation must
continue to exist, and the sacrificing of a branch, as it were,
thereby making use of the only rational means for maintaining
the integrity of the trunk, frequently becomes indispensably
proper. It is, however, the imperative duty of the surgeon




620        QUESTION  OF AMPUT'ATION.
never to have' recourse to this terrible, and sometimes fatal,
operation, without a perfectly clear and fully substantiated conviction of its necessity; it should always be regarded as the
last expedient to which the surgeon should resort, justifiable
only when farther attempt to save the injured or diseased part,
would be fraught with danger to the life of the patient. With
this conviction, it is evident that a precise knowledge of such
cases as demand amputation, as also those in which it should
be dispensed with, and the exact periods at which its performance is most conducive to the welfare of the patient, are considerations demanding the most marked attention.
The various conditions demanding a performance of this operation are as follows: Compound fractures, extensive contused
and lacerated wounds, gangrene and mortification, gun-shot injuries, diseases of the joints, exostosis, and necrosis.
Compound Fractures. —The necessity for amputation in injuries of this nature, does not depend entirely upon the
seriousness of the accident, but also, in a measure, upon other
circumstances, as the condition of the patient, his mode of life,
the facilities for ventilation, &c.  If; however, a compound
fracture occur in which the soft parts have been extensively
involved, and the bones have been so seriously injured that perfect quietude and constant attention are required to afford any
chance of recovery, amputation should, in the generality of
instances, be performed.  On the contrary, when the soft parts
have been less extensively injured, and the bones have been
broken in such a manner that they can readily be readjusted,
and maintained in their proper position; or if but one bone be
involved in the injury, amputation is deemed both unnecessary
and inhuman: accompanying circumstances, however, are to be
considered in concluding for or against amputation.*
-* The circumstances adverse to a favorable prognosis, in cases of compound fracture, are thus detailed by Professor Miller: " Comminution of
the bone, or fracture at several points; extension of the fracture into an
important articulation; an open state of the joints; much bruising and
laceration of the soft parts, rendering extensive sloughing inevitable, with a
risk of gangrene involving the whole limb, and with a certainty of exten



QUESTION  OF AMPUTATIOlN~.                     621
In compound fractures, as Mr. Pott has pointed out,' there
are three distinct periods when it is deemed proper to perform
amputation.
The first of these is, immediately, or as soon as practicable
after the receipt of the injury.  The second, when the bones
continue for a great length of time wxithout imanifesting any disposition to unite; and the discharge from the wound has continued so long, and is so excessive, that the patient's strength
fails, together with general symptoms foreboding dissolution
supervene. And third, when mortification has so completely
involved the soft parts of the inferior portion of the limb, quite
down to the bone, that upon separation of the diseased portions
the bone or bones are left bare in the interspace. The first and
second of these are matters requiring serious consideration. The
last demands scarcely any.
A disposition to mortification is often evinced when fracture
occurs in the middle of a bone; but much more frequently when
any of the large joints are involved; and in many of the abovementioned instances, a decision favorable or adverse to amputation, is really a determination for or against the patient's life.
If, after judicious treatment, throughout every stage, by the
united efforts of medicine and surgery, the sore, instead of
granulating kindly, and contracting daily, does not diminish in
size, has a tawny, spongy surface, discharges a large quantity
of thin sanies; the fractured ends of the bones, instead of tending
to exfoliate, or unite, remain as perfectly loose and ununited as
at first, whilst the patient is deprived of sleep and appetite,
becomes greatly weakened; hectic fever, with a quick, small,
hard pulse, and profuse sweat, contributing at the same time to
bring him to the brink of the grave, notwithstanding all efforts
sive and tedious suppuration following separation of the sloughs; laceration of a large artery, as evinced either by hemorrhage or by rapid formation of a large, bloody swelling; old age; and enfeeblement of the frame
by disease, by privation, by intemperate habits," &c. Principles of Surgery, p. 717.
* Remarks on the Necessity, &c., of Amputation in certain cases. Surgical Works, vol. iii. London, 1808.




622        QUESTION  OF AMPUTATION.
to the contrary: under these circumstances, if amputation be
not performed, what else can rescue the patient'from destruction.
Extensive contused and lacerated Wounds.-These form the
second class of general cases requiring amputation; though,
when not in conjunction with fracture, they seldom render the
operation necessary. But, if a limb is extensively lacerated
and contused, and its principal blood-vessels are injured to so
great an extent, that a continuance of the circulation cannot
reasonably be expected, an immediate removal of the affected
limb is recommended, even though no bone is involved in the
injury; and as all efforts of the surgeon to preserve a limb so
seriously injured generally prove unavailing, and such wounds
are more disposed to assume a gangrenous condition than any
other, the sooner the operation is performed the more favorable
will be the prognosis.
In the preceding varieties of injuries, although amputation
may not always be necessary in the first instance, yet it may
become so  subsequently.  Sometimes mortification  rapidly
takes place, either in consequence of the extreme violence of
the injury, or consecutively, froin greatly excited action going
on in parts whose powers of resistance have been much impaired-or profuse suppuration, with its consequences and
accompanying conditions, ensue, which the system is unable
to resist; in these instances amputation should be resorted to.
When the surgeon has fully resolved upon operating, it is
advisable to wait until reaction has come on, lest the additional
injury should increase the collapse which always follows severe
injuries, and thus increase the danger.* In particular, says
Professor Gibson,t amputation should be avoided so long as
the extremities are cold, the pulse weak and fluttering, the
wound dry, and the powers of life nearly exhausted.
When patients die from a premature operation, it is owing to
the shock communicated to the nervous system before the vital
* Fergusson's Practical Surgery, p. 50.
t Institutes and Practice of Surgery, vol. i., p. 96.




QUESTION  OF AMPUTATION.                     623
energy has rallied sufficiently to encounter so severe a stimulus.
When they die after the full restoration of the circulating system and the establishment of febrile action, then life is assaulted
through the medium of inflammation and high action, and the
operation is almost sure to be followed by gangrene. Each
state, then, it will be seen, is precarious; and it is only by observing a happy medium, that success can be expected to
follow.*
Gangrene and.Mortification.-Gangrene is another cause,
which, when advanced in a certain degree, renders amputation
indispensable.
It sometimes happens, that gangrene appears so extensive in
either the upper or lower extremities, or that mortification has
committed such ravages, as to preclude the hope of saving the
limb or even the life of the patient, if such a source of irritation
is allowed to remain. The surgeon will seldom be performing
his duty, if, in this instance, he leaves the case to the efforts of
nature so entirely as in partial slough; for although experience
proves that a portion of the hand, foot, fore-arm, or leg, may
drop off, or that either member may be separated at its articulation with the trunk, by the process of disjunctive absorption,
it is equally certain that the work is done in a tedious, painful,
and unsatisfactory manner-months sometimes elapsing ere the
parts are entirely separated; and when, at length, this has been
accomplished, months more may pass ere cicatrization takes
place. There cannot be a doubt that the surgeon is justified in
many of these cases, in performing amputation; and the only
difficulty is to determine the proper period for such a procedure.t
Practitioners have entertained very opposite opinions concerning the time when the operation should be performed.
Some declare, that whenever the disorder presents itself, especially if it be the result of external violence, amputation should
immediately be had recourse to, as soon as the disease has began to form, and while it is in the spreading state. Mr. Pott
* Loc. cit.    t Fergusson's System of Practical Surgery, p. 108.




624        QUESTION OF AMPUTATION.
says, that he has often seen the experiment of amputating a
limb, in which gangrene had began to show itself, tried, but
never saw success follow, and it invariably hastened the
patient's death.*
The operation, however, may be postponed too long, and it
is sometimes advisable to amputate to prevent gangrene: thus,
when the limb has been much injured by mechanical or chemical means-in the case of severe compound fracture or burn,
for example-and it is apparent that mortification must ensue,
involving the whole thickness of the limb, of an acute character, tending to spread, and from the first accompanied with the
most formidable constitutional symptoms —amputation is to be
performed above the injured point, as soon as the primary
shock has passed away, and the system rallied so far as to
afford sufficient tolerance of the operation.
In injuries of this nature, when gangrene has set in, delay,
with the object of waiting for the spontaneous line of separation, will be in vain. The gangrene spreads upwards and upwards, with a diffused and streaky margin; typhoid symptoms
grow more and more intense; the trunk is reached, rendering
operative interference hopeless; or, long ere this, the system
has sunk and the patient perished. The only hope of escape is
by early amputation: it is a slender chance, but it is the only
one, and to it the sufferer is entitled.t
When gangrene is acute and humid, dependent on an external cause, and unconnected with a previously existing failure
of system, or organic change in the general limb, amputation is
performed, if at all, during the progress of the disease, without
waiting for a line of demarcation. When it is chronic and dry,
dependent on an internal cause only, or on internal more than
on external cause, and connected with failure of both general
and local power, the line of demarcation is to be awaited, and
the progress of separation cautiously watched; and when de1 Surgical Works, vol. iii.
t Miller's Principles of Surgery, p. 289. Lectures by Tyrrell, vol. i.,
p. 132.




QUESTION OF AMPUTATION.                      625
tachment is far advanced, the surgeon interfering merely for
facilitating and modifying its completion, amputates in the line
of separation.*
When gangrene is an attendant upon one particular cause,
as cold, the line of disjunction is to be awaited; and, as soon
as it has become evident that this is fairly formed, the surgeon
should resort to amputation, which may be performed either at
the point of separation of the dead from the living textures, or
at a distance above, according as the circumstances of the case
may demand.t
Diseases of the Joints.-Scrofulous diseases of the joints, involving the bones, with morbid alteration of the structure of
the adjacent ligaments and cartilages, is another condition in
which amputation may become an absolute necessity.  An unpleasant circumstance attending these affections is, that the
majority of subjects are young children, incapable of determining for themselves.  All efforts at cure sometimes prove unavailing, and operation is the only resort.
It is a highly important fact, that amputation, in these instances, is attended with a greater degree of success when the
disease has considerably advanced, than when undertaken at an
earlier period. This is particularly fortunate, as it affords ample opportunity for the administration of those medicines that
have been mentioned; and thus, perhaps, all necessity for the
operation may be obviated.
Exostoses, under certain circumstances, sometimes occasion a
necessity for amputation; but when they merely produce deformity, without pain or inconvenience from the pressure which
they exert on neighboring parts, the performance of an operation for their removal is not advisable; for, as Boyer has observed,' in a great number of instances, the local affection is
much less to be dreaded than the means used for its removal.
When, however, the tumor becomes hurtful to the health, and
* See Miller's Principles, p. 290.' For Question of Amputation in Gunshot Wounds, vide p. 101.
t Treatise on Surgical Diseases, vol. ii.
40




626        QUESTION  OF AMPUTATION.
its situation permits of a ready removal, this may be done without an entire division of the part on which it is situated; but
frequently its base is so extensive and deeply seated, as to preclude the possibility of a removal by this method. If, in this
case, it is situated on the extremities, and has become insupportable on account of its weight, amputation should be performed
in preference to any operation having in view the saving of the
limb.
Another affection of the osseous system which sometimes
demands the performance of amputation, is necrosis-or the
death of the whole, or a very considerable portion of the bones
of the extremities.
The performance of this operation in these cases, however,
is the exception, not the rule. It may happen, that in acute
necrosis, in the young subject, violent inflammatory action is
followed by severe irritative fever, which latter is quickly succeeded by a formidable hectic, that must evidently be relieved
at all hazards, by a removal of its cause; or, in more chronic
cases, a like summary procedure may be required at a more
distant date, after weeks and even months have elapsed, when
the separation of the sequestrum is far advanced, but not yet
complete, after the system has long resisted the exhausting
burden of irritation and discharge, but when, nevertheless, it
has evidently become unequal to a prolongation of the contest.
On the one hand, the surgeon must beware of sacrificing life
in endeavoring to save a limb; and, on the other, must be
equally careful not to sacrifice a limb in endeavoring to succor
life not yet actually endangered; and, in connection with this
subject, it is important to remember, that necrosis is not
always so extensive as outward appearances would lead one to
suppose.




AMPUTATION OF THE THIGH.                    627
CHAPTER XXXIX.
AMPUTATION.
Section 1. —JAmputation of Lower Extremities.
A.mputation of the Thigh.-This amputation being probably
the most important, and one that is frequently performed, it
will be convenient to describe it first; and to embody in the
description of it such general precepts as are applicable to
other amputations.
In the first place, the surgeon should have his tourniquets,
amputating knives, saws, forceps and tenacula, ligatures, bonenippers, sponges, and curved needles threaded, close at hand
on a tray, arranged in due order; and he should, by personal
examination, be satisfied that everything that can possibly be
required is at hand before he commences.
The next point is, to place the patient in a convenient posture. For amputation of the thigh the patient may be placed
on a bed, or on a table covered with a folded blanket; the
affected leg should project sufficiently over the edge, and
should be supported at the knee by an assistant, who sits on
a low stool in front, and the sound limb should be secured to
one of the legs of the table with a handkerchief.
Measures then must be adopted for compressing the main
artery, and preventing too great loss of blood. This may be
done, either by pressure with the hand or with the tourniquet.
Pressure with the hand on the main arterial trunk, if effected
by an assistant whose steadiness can be trusted, is sufficient in
most cases; and, if the limb is amputated so high up, that the
tourniquet cannot be applied, there is, of course, no choicethe femoral artery must be compressed against the ramus of
the pubes.
This amputation, like others, may be performed in two
ways: either by the circular incision-that is, by cutting
round the limb from without towards the bone; or by the flap




628       AMPUTATION OF THE THIGH.
operation-that is, by transfixing the limb, and then cutting
outwards. The flap operation is, in most instances, chosen by
surgeons of the present day. It certainly can be performed
with much more facility; and it enables the surgeon to select a
flap where he pleases, so that when the flesh on one side of the
limb be destroyed by disease or injury, the end of the stump
may be covered with a flap taken almost entirely from the
sound side, and a greater length of limb may be preserved. It
affords, too, a greater certainty of preserving a sufficiency of
flesh to cover the bone; and it enables the muscles to be more
easily retracted, and the bone exposed for the application of the
saw. It entirely avoids the difficulty, also, which sometimes
occurs in the circular operation, of retracting the skin, when it
has become adherent to the parts beneath. But, as Sir C.
Bell observes, the cardinal rule in all cases is, to save integument enough to cover the muscle, and muscle enough to cover
the bone, and not to scrape off the periosteum. And, if
these things are done, it requires ingenuity to make a bad
stump.
Circular method.-The surgeon stands on the outer side for
the left leg, and on the inner for the right; so that he may use
his left hand to grasp and steady the part which he is to amputate. The artery must be compressed by one of the methods
before described, and an assistant must grasp the limb with
both hands, so as to draw up the skin as high as possible.
Then the surgeon commences by putting his arm under the
thigh, and makes an incision, at one sweep, completely round
the limb, through the skin and adipose structure to the fascia.
The assistant is now to draw the skin further up, the retraction being aided with a few touches of the knife; and then the
knife, being put close to the edge of the retracted skin, is to
divide everything down to the bone, by another clean circular
sweep. The next thing is, to separate the muscles from the
bone for another inch or two with the point of the knife, especially those connected with the linea aspera; and then, the
periosteum having been divided by one more sweep, the retractor-a piece of linen, with a longitudinal slit in it-is put




AMPUTATION  OF THE THI GH.                  629
over the face of the stump, and the muscles are to be drawn up
with it. The bone must now be sawn through.
The heel of the saw should first be put on the bone, and it
should be drawn up, so as to make a groove, before working it
downwards. It should be used very lightly; and the last few
strokes should be extremely short and gentle, that the bone
may not be splintered; if it is, the irregular parts must be removed by nippers.
The femoral artery must now be tied, its orifice being seized
and slightly drawn out by forceps, and afterwards any large
branches that appear in the muscular interstices. Then all
compression should be suddenly withdrawn, that any arteries
liable to bleed may do so, and immediately be tied. Hemorrhage from large veins may be restrained by elevating the
stump, and making compression for a short time with the finger. If, however, nothing else will do, they must be tied.
Obstinate oozing from small vessels should be restrained by
sponging with cold water. Then a light bandage may be
passed round the limb above the stump, and the edges of the
wound should be approximated with a few strips of plaster,
with or without sutures. The edges are to be brought together in a straight line, which may be made either perpendicular or horizontal; the latter, however, being probably the
better plan. The ligatures should be left hanging out in the
interstices of the adhesive straps. The patient should then be
removed to bed, and the stump be supported on a pillow
covered with oil-cloth.  No other application will be needed
save a cloth well saturated with a mixture, viz.:
Arnicae Tincturae: f 3j.
Aquae fluvialis:    Oj.
M.
It may be well to state here, that the above prescription is
sufficiently strong. The use of the pure tincture produces at
times an inflammatory condition, closely resembling erysipelas;
a result which has, in many instances, given rise to very serious
symptoms. The specific action, which is all that is desired, is
fully obtained from the above dilution.




630       AMPUTATION  OF THIE THIGH.
The stump may remain without being disturbed for some
days, the discharge being merely wiped occasionally from its
surface.  But after from four to six days, sooner or later, according to the quantity of the discharge and the feelings of the
patient, the dressings should be changed, the straps taken off
and replaced one by one, with care not to disturb the ligatures;
the hands of an assistant being employed to support the edges,
and prevent their falling asunder. At the subsequent dressings
the points to be attended to are, to renew the light bandage
occasionally, which was passed round the stump soon after the
operation, in order to support the muscles and prevent their retraction; to bring together the edges of the wound with adhehesive straps; to remove the ligatures when loose (that on the
femoral artery should not be disturbed for a fortnight); and to
accelerate cicatrization if the granulations appear languid.
There are a few varieties in the manner of performing this
circular operation, that require a brief notice. Some surgeons,
after having cut through the skin, dissect it from the fascia and
turn it back-a proceeding necessary enough if the operation is
performed (which it never should be) when the cellular tissue
is condensed and adherent. Again, if the patient is very emaciated, the circular incision may be carried down to the bone at
once, without hesitation, because in such patients the muscles
always retract greatly. Sir C. Bell recommends the skin not
to be divided quite circularly, but the knife to be inclined a little, first to one side, then to the other, so as to make two oval
flaps. The same may be done also in dividing the muscles.
He further recommends that the limb should be raised perpendicularly whilst the bone is being sawn, so that the saw may be
worked horizontally; by which means, he says, the bone may
be divided more evenly and much shorter, so that its end will
be no more seen when the stump is depressed.
Flap Operation.-The flaps may be made either from the
inner and outer, or from the anterior and posterior aspect of
the limb. The latter method is the most convenient if the amputation is low down, but the former if it be in the middle or
upper third; because the end of the bone is liable to be tilted




AMPUTAT1ON OF THE THIGH.                      631
forwards by the iliacus and psoas muscles, and to project between the lips of the wound. In performing this operation,
the surgeon, standing as before,* grasps the flesh on the anterior surface of the limb with his left hand, and lifts it from the
bone (Fig. 99); then passes his knife horizontally through it,
carries the point over the bone, and pushes it through the other
Fig. 99.
fthima
side of the limb as low as possible; then makes it cut its way
out upwards and forwards, so as to make the anterior flap.
In amputating the right leg, the knife should be passed in
behind the saphena vein. It is again entered on the inner side
a little below the top of the first incision, passed behind the
bone, brought out at the wound on the outside, and directed so
as to make a posterior flap in the direction of the dotted line.
This should be a very little longer than the anterior, because
the flexor muscles retract more than the extensors, which are
adherent to the bone. Both flaps are now drawn back; the
knife is swept round the bone to divide any remaining muscular
fibres, and the bone is sawn through. In the same manner flaps
may be made from the inner and outer sides of the limb, the
* Mr. Fergusson thinks it more convenient that the surgeon should stand
on the outer side in amputating the right thigh, as it is awkward to stoop
over the sound limb; which, moreover, is in the way of the surgeon's
hand.




632         AMPUTATION OF THE LEG.
surgeon first grasping the flesh, and transfixing it, and cutting
a flap on one side of the bone, then passing the knife close to
the bone on the other side, (without again piercing the skin,)
and making another flap.
Amputation at the Hip-joint is performed by Mr. Liston
precisely in the same manner in which he amputates the
thigh. The femoral artery being compressed, the knife is
entered about midway between the anterior superior spinous
process of the ilium and the trochanter, and is carried across
the front of the articulation, so as to form the anterior flap.
Then the anterior part of the capsular ligament being cut into,
and the ligamentum teres and posterior part of the capsular
ligament being divided, the blade of the knife is put behind the
neck and trochanters of the femur, and the posterior flap is
formed. The vessels on the posterior flap are tied fast.  But
this method can hardly be preferable to that of making two
lateral flaps; first, passing the knife completely through the
limb, on the inner side of the joint, and carrying it forwards
and inwards, so as to form a flap of the abductor muscles; then
cutting into the joint, and severing the ligamentum teres, and
the muscles attached to the digital fossa, with a short, strong,
curved knife; and, lastly, putting in the knife over the trochanter, and cutting downwards and outwards, so as to make
the external flap. In this manner Mr. Mayo performed this
operation in less than half a minute.  He previously tied the
femoral artery below Poupart's ligament; but most authorities
prefer compressing it during the operation, and tying its cut
orifice afterwards.
AJmputation of the Leg.-The rule generally given is, that
this operation should be performed as near the knee as possible,
unless the patient can afford an artificial foot; because a laboring man would find it very inconvenient to have a long stump
trailing after him, as it would if he rested on the bent knee
with the ordinary wooden leg. But a wooden leg may be procured, which is light and of moderate cost, and which enables
the patient to rest on the stump, and to have the use of the
knee; and therefore it is better not to sacrifice more of the
limb than can be avoided.




AMPUTATION  OF THE LEG.                    633
Circular MJethod.-The artery being under command, as in
amputations of the thigh, and the leg being placed horizontally,
one assistant supporting it at the ankle, and another holding it
at the knee and drawing up the skin, the surgeon (standing on
the inner side for the right leg, and vice versa,) makes a circular incision through the skin, four inches below the tuberosity
of the tibia. The integuments are next to be dissected up for
two inches, and turned back, and the muscles are to be divided
down to the bone by a second circular incision. Then a long,
slender, double-edged knife, called a catling, is passed between
the bones, to divide the interosseous ligament and muscles, and
both bones are sawn through together, the flesh being protected
by a retractor, which should have three tails. The spine of
the tibia if it projects much, may be removed with a fine saw
or bone nippers, and care should be taken not to leave the
fibula longer than the tibia, or it will give much trouble. The
anterior and posterior tibial and peronaeal arteries, and any
others requiring it being tied, the stump is to be treated as
directed after amputation of the thigh. The integuments should
be put together so as to make a perpendicular line of junction.
All surgeons, however, are agreed that the flap operation is
by far the best for this situation, and the easiest way of performing it is as follows: The surgeon passes his knife horizontally behind both bones, at the level of an inch below the
head of the fibula, and cuts downwards and forwards, (Fig.
100,) so as to make a flap of the posterior muscle about four
or five inches long. A semi-lunar incision with the convexity
downwards, is then made across the front of the limb, the skin
is slightly turned back, the parts between the bones are divided,
and the bones are sawn as before. But the manner in which
Mr. Fergusson performs this amputation renders it far more
neat and expeditious. He first places the heel of the knife on
the side of the limb farthest from him, and draws it across the
front of the limb, cutting a semi-lunar flap of skin; when its
point has arrived at the opposite side, it is at once made to
transfix the limb-this stage of the operation is represented in
the following cut-and then the flap is cut as above directed.




634        AMPUTATION OF THE FOOT.
Fig. 100.
When transfixing the right limb, the surgeon must take great
care not to get his knife between the two bones. When the
operation is performed high up, the popliteal artery will be
divided, instead of the two tibials. The tibia, however, should
never be sawn higher than its tuberosity, or the joint will be
laid open. The amputation may be performed near the ankle
in the same manner. If low down, the tendo achillis will require to be shortened after the flap is made. The flap is to be
brought forwards, and confined by a stitch or two, the line of
junction being of course horizontal..Amputations of the Foot.-Amputation of the toes at any of
their joints is performed in precisely the same manner as amputation of the fingers. In removing a single toe from its metatarsal bone, the surgeon should take care first of all to ascertain the exact situation of the joint, which lies rather deeply.
Moreover he should not remove the head of the metatarsal
bone, as he may of the metacarpal, because it is important to
preserve the entire breadth of the foot.
Amputation of all the toes at their metatarsal joints —an operation which may be requisite in case of frost-bite —is performed
by first making a transverse incision along the dorsal aspect of
the metatarsal bones; dividing the tendons and lateral ligaments of each joint in succession; then the phalanges being
dislocated upwards, the knife is placed beneath their metatarsal




AMPUTATION  OF THE FOOT.                   635
extremities, and made to cut out a flap from the skin on the
plantar surface, sufficient to cover the heads of the metatarsal
bones.  The arteries are to be tied, and the foot laid on its
outer side, so that the discharge may escape more readily.
Amputation of the metatarsal bone of the great toe is performed precisely like the operation for the removal of the metacarpal bone of the little finger. It is better, if circumstances
permit, to cut through the bone, than to disarticulate it from
the internal cuneiform bone, and it may be observed that, in
dividing the metatarsal bones of the great or little toes, or the
metacarpal bones of the fore or little finger, the forceps should
be held obliquely, so as not to leave any prominent angle.
Amputation of all the metatarsal bones is performed in the
following manner: The exact situation of the articulation of
the great toe to the inner cuneiform bone (to which the tendon
of the tibialis anticus may serve as a guide) being ascertained,
a semi-lunar incision, with the convexity forwards, is made
down to the bone, across the instep, from a point just in front
of it, to the outside of the tuberosity of the fifth metatarsal
bone. The flap of skin thus formed being turned back, the
bistoury is to be passed round behind the projection of the fifth
metatarsal bone, so as to divide the external ligaments which
connect it with the cuboid. The dorsal ligaments are next to
be cut through, and then the remaining ones, the bone being
depressed.  The fourth and third metatarsal bones are to be
disarticulated in a similar manner, dividing their ligaments with
the point of the knife, and taking care not to let the instrument
become locked between the bones. The first metatarsal is
next to be attacked, and, lastly, the second, the extremity of
which, being locked in between the three cuneiform, will be
more difficult to dislodge. Perhaps it may be convenient to
saw it across. When all the five bones are detached, the surgeon completes the division of their plantar ligaments, and
slightly separates the textures which adhere to their under surface, with the point of the knife, and then, the foot being placed
horizontally, he puts the blade under the five bones, and carries it forwards along their inferior surface, so as to form a flap




636      AMPUTATION  AT ANKLE-JOINT.
from the sole of the foot sufficient to cover the denuded tarsal
bones. The flap should be about two inches wide on the inner
side, and one on the outer.
Amputation may be performed through the tarsus, so as to
remove the navicular and cuboid bones, with all the parts in
front of them. This is commonly called Chopart's operation.
In the first place, the articulation of the cuboid with the os
calcis, (which lies about midway between the external malleolus and the tuberosity of the fifth metatarsal bone,) and that
of the navicular with the astragalus, (which will be found just
behind the prominence of the navicular bone in front of the
inner ankle,) must be sought for, and a semi-lunar incision be
made from one to the other, as in the last described operation.
The flap of skin being turned back, the internal and dorsal
ligaments that connect the navicular to the astragalus are to be
divided with the point of the bistoury-recollecting the convex
shape of the head of the latter bone. The ligaments connecting the os calcis and cuboid are next divided; and, lastly, a
flap is to be procured from the sole of the foot, as in the last
operation..Jmputation at the./lnkle-joint-Symne's Operation.-This
operation is proposed by Mr. Syme to be substituted for amputation above the ankle, in cases where disease or injury of the
tarsal bones implicates the astragalus and os calcis, and for
which, therefore, Chopart's operation is inadmissible.  The
principle of the operation is, that the whole of the bones of the
foot are taken away; and the articular surface of the tibia,
with both malleoli, are cut off smoothly; but the skin of the
heel is preserved, as the best and most natural cushion for the
stump to rest upon. Mr. Syme makes one curved incision
across the instep, from one malleolus to the other, and carries
a second across the sole of the foot. The flaps are dissected
from the subjacent parts, which is easily effected, except just
at the heel; the astragalus and os calcis, with the rest of the
foot, are removed, and the projections of the malleolar processes cut off with forceps. If the ankle-joint itself is diseased,
a thin slice of the lower extremities of the tibia and fibula may




AMPUTATION- OF TnHE ARMa.                  637
be removed with a saw. The thick skin of the heel is then
brought up to cover the ends of the bones, and is retained by
sutures.  It appears useful sometimes to make a puncture
through the integuments of the heel, to let the discharge escape
freely. This operation has been performed very many times in
Edinburgh by Mr. Syme, and once in London by Mr. Fergusson, with very good results.'
Section 2. —Imputation of Upper Extremities..Amputation of the.drm.-In amputating the upper extremity,
the flow of blood may be sufficiently commanded by compressing the artery above the clavicle, or in the arm. If it is
thought proper, however, the tourniquet may be applied so as
to compress the artery against the humerus.
Circular.-The arm being held out, and an assistant drawing
up the skin, one circular incision is made through the skin,
which being forcibly retracted, another is made down to the
bone. ThF se incisions should be made with two slight divergences, so as to cut the skin and muscles rather longer in front
and behind than at the sides. The subsequent steps are precisely similar to those in amputating the thigh.
Flap.-The knife is entered at one side, carried down to the
bone, turned over it, brought out at a point opposite (Fig. 101)
(the vessels being left behind for a second flap), and then made
to cut a neat rounded anterior flap two or three inches long.
It is next carried behind the bone, to make a posterior one of
equal length; and is lastly swept round the bone, to divide any
remaining fibres. The division of the bone, ligature of the
arteries, and treatment of the stump as before.
Admputation at the shoulder may be performed in several
manners. (1.) The patient being seated in a chair and well
- Vide London and Edinburgh Journ. Mled. Science, Feb. and April,
1843; and several papers in the same ably conducted periodical for 1846.




638   AM PUTATION AT SHO ULDER  JOINT.
Fig. 101.
jiN
supported,-or, which is better, being placed on a firm table,
with the shoulder elevated, and projecting beyond its edge,and the subclavian artery being compressed, the surgeon enters
a long straight knife at the anterior margin of the deltoid muscle, an inch below the acromion. From this point, he thrusts
it through the muscle, across the outside of the joint, and
brings out the knife at the posterior margin of the axilla. If
the left side is operated on, the knife must be erniered at the
posterior margin of the axilla, and be brought out at the anterior margin of the deltoid muscle. Then, by cutting downwards and outwards, the external flap is made. The origins
of the biceps and triceps, and insertions of the infra and supra
spinati, are next cut through, and the joint is laid open.
Finally, the blade of the knife, being placed on the inner
side of the head of the bone, must be made to cut the inner
flap.
(2.) The covering for the exposed part of the scapula, in the
preceding operation, was obtained from the deltoid. But it
may also be obtained from the muscles in front or behind, supposing the deltoid to be implicated in the disease or injury
which demands the operation. One elliptical incision may be
carried from beneath the middle of the acromion to the posterior border of the axilla, and another to the anterior border.




AMPUTATION AT THE ELBOW.                     639
These flaps being dissected up, the head of.the bone may be
turned out of the socket, and the remaining soft parts be
divided; or the bone may be sawn through just beneath its
neck. An assistant should be directed to grasp the flap which
contains the axillary artery as soon as it is divided; because the
pressure above the clavicle is generally not sufficient to stop
the circulation..imputation at the elbow is performed by passing the knife
through the muscles in front of the joint, and cutting upwards
and forwards, so as to make a flap of them. Then the operator, (who stands on the inner side of the right arm, or vice
versa) makes a transverse incision behind the joint. He next
cuts through the external lateral ligament, and enters the joint
between the head of the radius and external condyle, then
divides the internal lateral ligament, and, lastly, saws through
the olecranon, the apex of which, with the triceps attached to
it, is of course left in the stump.
J.mputation of the fore-arm should always be performed as
near the wrist as possible.
Circular.-The limb being supported with the thumb uppermost, and an assistant drawing up the skin, a circular incision
is made through it down to the fascia. When the skin has
again been retracted as much as possible, the muscles are
divided by a second circular incision; the interosseous parts
and the remaining fibres are next cut through with a catling;
the flesh is drawn up with a three-tailed retractor, one tail of
which is put between the bones, and the bones are then to be
sawn through together, the saw being worked perpendicularly.
The radial, ulnar, and two interosseous arteries require ligature.
Flap. —The limb being placed in a state of pronation, the
surgeon makes a flap from the extensor side, just as is represented in (Fig. 102;) and he then transfixes the flexor side,
and makes the other flap; taking care not to pass the knife
between the bones, whilst performing either transfixion. The
interosseous parts are next divided, the flesh drawn upwards,
and the bones sawn through. If the tendons project, they
must be shortened.




640        AMPUTATI0 ON OF THE HAND.
Fig. 102..qmputation of the CVrist.
(Circular.) —The  skin being pulled back, a circular
incision is made a little below the level of the line that
\  \~~\~~,~~,!:iQ, X~k  separates the fore-arm from
the palm of the hand.  The
external lateral ligament is
then cut through, and the
~11...\  knife carried across the joint,
/   to divide the remaining at-........     tachments.
Flap.-A  semi-lunar incision is made across the
back of the wrist, its extremities being at the styloid
processes, and its centre reaching down as far as the second
row of carpal bones. This flap being dissected up, the joint is
opened behind, the lateral ligaments are cut through, and the
knife, being placed between the carpus and bones of the forearm, is made to cut out a flap from the anterior surface of the
palm.
This operation is scarcely to be preferred to amputation of
the fore-arm low down, as the flaps with their numerous tendons may not readily unite, and there may be a difficulty in
preserving flesh enough to cover the ends of the bones..Amputation of the Hand.-Amputation of the fingers or
thumb at their last joint mnay be performed thus: The surgeon
holds the phalanx firmly between his finger and thumb, and
bends it, (Fig. 103,) so as to give prominence to the head of
the middle phalanx.  He then makes a straight incision across
the head of the middle phalanx, so as to cut into the joint, and
takes care to carry it deeply enough at the sides to divide the
lateral ligaments. The joint being then thoroughly opened,
the bistoury is carried through it, and made to cut a flap from
the palmer surface of the last phalanx, sufficient to cover the
head of the bone; and it is better to leave too much than too
little.




AMPUTATION OF THE FINGERS.                  641
Fig. 103.
If, however, the joint cannot be bent, this operation may be
performed thus: the surgeon holding the phalanx firmly, with
its palmar surface upwards, first passes his knife horizontally
across the front of the joint, the flat surface towards it, and cuts
out the anterior flap; then divides the lateral ligaments and remaining attachments with one sweep of the knife.
Amputation at the second joint of the fingers or thumb may
be performed in the same manner.
It is always expedient to save as much as possible of the
forefinger and thumb; consequently, in cases admitting of it, a
flap may be made from the soft parts in front; those behind
may be divided by a semi-lunar incision, and then the bone may
be sawn through, or be cut with bone nippers.
Amputation of a finger at the metacarpal joint may be effected
by making a semi-lunar incision on one side of the prominence
of the knuckle, from a quarter of an inch beyond the joint, to
the middle of the digital commissure on the other side of it.
The finger being then drawn to the other side, the extensor
tendon is cut through, and the point of the bistoury is passed
into the joint, and made to divide its ligaments. This will
allow the head of the bone to be turned out, so that the bis41




642      AMPUTATION  OF THE FINGERS.
toury being placed behind it, may cut through the remaining
attachments, and make another flap. This operation may also
be performed by making an incision on one side of the joint,
(as in the method just described), and then bringing it across
the palmar surface, and round the other side, to terminate
where it began. The tendons and ligaments are now to be
divided, and the head of the bone turned out. The digital
arteries must be tied, and, after bleeding has ceased, the wound
may be closed by confining the adjoining fingers together. Tt
must be recollected, that the situation of this joint is full half
an inch above the line that divides the finger from the palm.
Amputation of the metacarpal bone of the thumb is performed
thus: The thumb being separated from the fingers, an incision
must be carried from the centre of the commissure, between it
and the forefinger, down to the articulation with the trapezium.
The incision should be inclined rather towards the metacarpal
bone of the thumb. The thumb being then forcibly abducted,
the blade of the bistoury is to be carried through the joint
(which, it must be recollected, lies obliquely in a line extending to the root of the little finger); the head of the bone is to
be forcibly dislocated towards the palm, the knife is then made
to cut its way out, so as to form a flap of the skin and muscles
which constitute the ball of the thumb.
When the metacarpal bone of the thumb alone is diseased, it
should, as Mr. Fergusson advises, be extirpated alone, and its
phalanges should be preserved. The bone should be exposed
by means of an incision along its radial margin; then its articulation with the phalanges should be divided; and lastly, it may
be turned out and separated from the trapezium-taking care
not to wound the radial artery where it passes between the first
and second metacarpal bones.
Amputation of the metacarpal bone of the little finger, at the
joint between it and the unciform, is performed thus: The flesh
and the integuments being grasped, and drawn away from the
ulnar side of the bone, a bistoury is passed perpendicularly
through them close to the joint, and made to cut its way downwards to a little beyond the articulation with the first phalanx.




AMPUTATION OF THE FINGERS.                   643
The skin of the hand being next strongly drawn towards the
thumb side, the bistoury is placed on the other side of the bone
(without again piercing the skin), and carried along so as to
divide everything down to the digital commissure. Then the
ligaments of the joint are to be divided-first, on the inner,
and next on the dorsal aspect. It is, however, a much better
plan, if it can be effected, to cut through the bone by means of
the saw or bone-nippers, than to remove it at the articulation.
Amputation of the head of a metacarpal bone is effected by
making an incision on each side of it (as in amputation of the
fingers at the joint, but extending higher up), and then cutting
through the bone with the cutting forceps. Mr. Fergusson
recommends the head of the metacarpal bone to be removed, in
almost every instance, where the entire finger is abstracted,
because the deformity is much less. But the part need not be
removed high enough up to divide the transverse ligament.
Care must be taken during the cure to keep the fingers parallel,
and prevent their crossing at their tips.
If a part or the whole of the shaft of one of these bones is to
be removed also, an incision should be made along its dorsum
to the point where the two former ones meet; and then the
flesh being dissected away on either side, the bone may be cut
through or disarticulated, according to circumstances.
Protrusion of the bone after amputation is a very awkward
circumstance. It not only greatly retards the healing of the
stump, but the cicatrix, when formed, is thin, red, constantly
liable to ulcerate, and unable to bear the least pressure or friction. The cause of the conical stump, as it is technically
called, is generally a want of skin and muscle sufficient to
cover the end of the bone. Sometimes, however, it arises
from spasmodic retraction of the muscles-especially if they
have not been properly supported by bandages during the cure.
The remedy is simple, the bone must be shortened. This may
be done in slight cases by making a longitudinal incision over
the bone on the side opposite the vessels, and sawing off a sufficient portion of it-removing at the same time any diseased
portion of the cicatrix; but, if the projection is considerable, a
second amputation is necessary.




644      AMPUTATION  OF THE FINGERS.
Neuralgia of the stump is another very untoward event. It
sometimes arises because the truncated extremities of the nerves
(which, after amputation, always swell and become bulbous)
adhere to the cicatrix, so as to be subject to constant compression and tension. Sometimes, however, it is entirely independent of any morbid state of the extremities of the nerves, but
arises from some irritation in their course, or from some irritation, centric or excentric, of the spinal cord. Sometimes,
again, no local cause whatever can be detected; and the pain is
evidently connected with an hysterical state of the system. In
any case the symptoms are extreme irritability and tenderness,
paroxysms of violent neuralgia, and spasms and. twitchings
of the muscles, which not unfrequently retract, and cause the
bone to protrude and the stump to become conical.
In neuralgia produced by this cause, as well as neuralgia from
other causes, the sensations vary in different individuals, and at
different times in the same individual.  A successful treatment
depends upon an exact correspondence between the symptoms
of the medicine, and the sensations experienced. Such similarity may be found in the Homoeopathic Materia Medica, which
contains ample means wherewith to mitigate or entirely subdue
the sufferings of the patient.
To this storehouse the surgeon must resort, and with patience
and precision select his weapon.
Perhaps among the primary influential impulses which homceopathy received, was the successful treatment, by Hahnemann,
of the distinguished cavalry chief, at the Battle of Waterloo,
the Marquis of Anglesea, who underwent amputation of the leg
in consequence of a wound inflicted by a cannon-shot. Neuralgia of a torturing kind followed, and the fruitless efforts of allopathic physicians induced this renowned nobleman to solicit the
advice of Hahnemann, then practising in Paris. The private
physician of the marquis, Doctor Dunsford, became a convert to
the homeopathic doctrine, after having witnessed the salutary
effects of the medicines which Hahnemann administered.




I ND 1) E X.
A.            Anetirism, fusif, III, 437'      internal, 436
A.BUOigEN. dropsy of, 556'       limited, 437' injuries of, 552';     true, 437
tullors of, 555'      wv ric(se, 438
Abdominal visceral, wounds of, 552                Aneurismi l dil:thesis, 439
A.bernethiys operation fior abscess, 149          Ankle jointl disl..lic  in of, 369
Abscess, 146                                      Ante ri (r1 cpsul:lr c.t:l.ract. 51)1' abdominal pa rietes, 551                   A nterior tiliAil artery, ligature of, l12'    antruin of, 153                         Anth;ronx, 45
o bone in, 3S1                         Antruman abscess of. 153
ear, 522                                Anus, itclhing (,f. 587
consecutive, 343                          "   fissilres of. 586
di;gnosis of, 147                             and rectumr. diseases of, 578
hepatic, 161                            Appea ranee of eve in dise;se, 452
joints. 415                             Application.,f to urnliquet, 123
"    lumbar, 161                             Arcus-senilis, 500
n marmmr ry, 157                        Arnica as a vullerars, 57
pointiing  of, 22, 1.47                    Arteries. lig;tion of, 137
poultice in, 153                       Artliritic ophth: llnia, 473' tonsil of, 533                             Artllropyosis,  415
Absorption of cataract, 507                       Artifici;l I  nlius. 55-1 574
-Acute inflanllnation, 4                              "     pil)il, 482
Acquircd phymosis, 599                            Ascites, 5.56
A (llesiiin, 27                                   Atresia iiidis imper fecta; 481
Admiinistration s of chloroforln.  346'  perfecta, 481;"'; wcther,the, 3-14              Auricle, lhype trophy of, 529
Alo)pecia, 1'24
Atiaurosis, 509                                                          B.
Amputation, 627
at ankle jillt, CGI3                 Balainitis, 205
"'        a: rrl, 637                       Bancl;ges.!nl splints, 279
elib)u. 6Gj                     Bandilge, B. rtll's for jawI, 299
~~        fing'ers  11 Gil'    DessaLlt's for cla:vicle, 308
4          foot, 634                             i'    Feugussom's foi clavicle, 305
foreanrll, 639                      "    fiiur-t; iled, 298
~          tlhand, 610 ()                              Scultetus. 329'          hipi joint, 632                     0    spiral, 256
6 le  632                        Bistoury,'282
lower extremities. 627           Bladder, diseases of, 605
metatzarsal joints, (35'C    stone in, 613'~        slshoulder, 636                  Blepharo ptosis, 520
"t        thigh, 627                        Blood vessels, iiijuries and diseases of, 435
"          upper extremities, 637           Bloody pus, 23
("          wrist, 640                      Bodies, foreign in the eye, 521
Analogy betweeil fever and inflammation, 7'       "     "larynx, 545
An.ilvsis of pus, 20                                          i c   i'; esophagus, 544
Anchlylosis: 4922                                 Boil, 42
i bony, 422                                  Bones, aibscess in. 381'       ligarnentous, 422                       "    curvature of, 410
spurious, 422                                 "    diseises of 379
Aneurism, 436,"    syphilitic -affections of, 223
Anastomosis 1)y, 438                  Bony anclhylosis, 422
cylindroid, 437;'                            Br;chial artery, ligature of, 1.39'      diagnosis froil A  scess, 117        Brain, compression of, 448
diffuse, 437               concussion of 417
dilitation by, 437                   Bronchocele, 546
" dissecting, 437                            Bro)wnish pus: 23
external, 436' Bubo, 219
-       false, 438                            P,,union. 42~
41 *-?




646                                      INDEX.
Burns, 50                                        Classification of ulcers, 175
"    classification of, 51,           venerell dlisease, 207
Bursm, diseases of, 427                               cc            wounds, 56
Clove-hitch, 353
C.   ~C              I u)Cliu)- foo)t, 431
Comnlinuted fraictures, 293
CGchexy, cancerous, 228                          Common  ca erotidl, Itregture of, 141
C lendlula,  mide of preparing, 75               Complicalted h;ore-lip, 536
is a vulnerlr;y, 79                 Compound disloc;till if ankle joint, 369
Cancell:ited exostosis, 398                     Coinpouid fr:ctures,  293, 334
Cancer, 226                                      Compresses, 283'~   cells, 227                                   C; gr.duated, 284
c,   of cheek, 2.34                               "        perfIoratedl, 283
c,   chimney sweeper's, 271;        pyramrnidl I, 284;   fce, 233                            Compression of the br;oin, 448
"         lip, 233                                             spin:ll cord, 451'    ma;rnin', 239                           Concen.led chincres, 209
c    n!se, 234                                Cntctssin of thie lr. in, 447
penis, 6(03                                 "4        i    spin I cord, 451:    ti(gLue. 23.3                           Condl-lomata of iris, 469
(c   uterus, 2417                            Co(l(y-lin:ltoias tuiltors, 224
C.ancerous li thlesis, 228                       Congenital herni., 571
C:ipill lries, action of in inflammation, 1          i,      occlusion of meatus auditorius,
Ci lrbuncle, 45                                                 528
Carcinomla, 226                                  Consecutive abscess, 443
Cardled  iool in gangrene, 38                   Constitutioni.l syph iilis, 221
Caries, 385                                      Contusedl woiUnds, 75;,    varieties of, 387                       Cornea, diseases of, 489
Carotidi artery, ligature of, 141                   "    opacity of, 489
Carpal bones, dislocation of, 353                   4    ulcers on, 492
Cartilage miovwble, 424                          Coxa lgil,, 417
(    ulceration of, 415                     Cracked bines, 340
Castration, 604                                  Crianium, fracture of, 294
Cataract, 497                                    Crepitation in sphacelus, 30
- anterior capsular, 501'~         fractures, 290
ar)borescens, 501                     Croserio's treatment of wounds, 57
m capsular, 501                             Crural, or fernoral hernia, 571
capsulo-lenticular, 501               Curvature of bones. 410
causes of, 499                            "         joints, 414
u     conditions for operating, 503          Cynanche tonsillaris, 538;     couching in, 506
d(liagnosis, 498                                            D.
c~    extraction of, 505'    lentieular, 5()0                       Deafness, 526
M Iorganian, 500                      Definition of fracture, 288
opera ions for, 501                   Deftriiity  of joints, 429
ii    posterior capsular, 501               Delitescence, 1-2
t:    removal by absorption, 507            Deliltrca;timn, line of, 30
i soft, 5()0                                Depression of ci:tarict, 506
spui ious, 497                             Deipression withl fracture, 291
CatarrhAl ip)ithlili.i:, 459                    Dessault's apparatus for fractured clavicle,
Catheter, introductinl of, 611                     3(12
C itrip)tric examlination of eye, 498            Dessault's apparatus for fractured patella,
Ceraltitls, 469                                    330
Ceirvex uteri, excision if, 253                 Dess tult'sapparatus for fractured feniur, 3'28
ClI. ncres, cionccaled, 209                      Dextrine, 4 19
-    ex ein 1, (209                         Di.gnosis bietween boil and carbuncle, 615
"i    Hullteri ii, 210                          i'    of. neulrisiii fromi abscess, 147
illnur;llehl, 210                              C;        lmernil, 559'c   l;Irv;ted, 209                         Di:i lhr:lgrim;tic ielrni:i, 573
i    plh;gedenic, 211                       Diathesis anieu risin;i l, 439
ic    physical cl:haracters, 208                 4    cancer-ous, 228
superficial,( 210                     Dieffenbacil's iOper:;tion for ectropium, 517
treatnent of, 212                     Diffuse aneurism, 437
Charpie, 282                                     Dilatation of pupil by hyos. and bell., 505
Cheek, cancer of, 234                           Director, 281
Chest, injuries and disease of, 550             Diseases of joints, amputation ill, 625
Cliltbl;til, 48                                 Diseases of joints, 414
Chimiiey sweeper's cancer, 271                  Dislocation, 341
Clolurofoirm, adiiniistration of, 346;       of ankle joint, 369
Chlordee, 196                                     i              astragalus, 364
Chronic inflammation, 4                        I                 carpal bones, 353
Cicatrix from burns, 55                      "                   clavicle, 350
Cicatrization, 27                                                elbow joint, 354
Classifieatio,   of biurns. 5 I'.          fe mur. 370




I N O): x.                                     647
Dislocation of fibnla, 367                      Exostosis, ivory-like, 398;, 4    fingers, 352';    medullary, 397
hip j,int, 370                          "      periosteal, 397
linllt.erlus, 339                  "c    questin ( f amputation in, 625
"          jj:w, 319                       External anelrisrm, 436
knee jont, 361                     "    cllhancre, 209
lower exLreriiLties, 363'    otitis. 522'(         Irmet:lc; rpal bones. 353       Extirpation of m:tmma, 245
sternal  extreinities of ribs,  Extraction of cataraet, 505
35l                          Eye, diseases of, 452,'          p ptella, 361                       fioreign bodies in, 5'21
r4          pelvis, 3                        "  fungus h          eer sattodes of, 256,, rdralitus and ulna at wrist,357  Eyelids, tumors of, 513,i          ril)s, 351
tlh rumb, 352                                        F.,'         tibi~a, 365
toes, 361                      Face, cancer of, 233
O;          upper extremities, 352         Facial artery, ligature of, 142
vertebrm, 351                  False aneurism, 437';        vwrist, 357                      False joint, 336
Dissection wounds, 102                          Fauees, inflammation of, 538
Dissecting aneurisin, 4:17                      Fem)nral artery, ligature of, 144
Dissecting forceps, 280                         Feinur, dislocation, 370
Distichioisis, 52t                              Fever, analgy between and inflammation, 7
Double hare-lip, 536                            Fetid pus, 23
])ouble-heided roller, 286                     Fingers, amputation of, 611
Dressing, 279                                   F issures and ulcers of anus, 586
instruments for, 280                 Fistula lachrymnalis, 512
pieces of, 2810                         "    in ano, 582'      rules for, 284'"  in perineo 609
Duodenum, wounds of, 552                        Fluctuation, 22, 147
Dupuytren's apparatus for fracture of the  Foot, amputation of, 634
fibula near the ankle joint, 3241  Forceps artery, 126
classification of burns, 51'    bullet, 109
"   dissecting. 280! "    dressing, 280
E.                        Fore-arm, amputation of, 639
"'    disl:,action,If, 351
E- or, abscess of, 5'22                         Foreign bodies in eye, 521
hemnorrlhage   from, 525                                        la"'    lrynx and trachle:. 5;.
injuries and diseases of, 522   cesophagus, 541
i neuralgi:t of, 525                          Forlnatino  of roller, 285
1 poAlypus of, 529                            Four-tailed b:tndage, 298
"  puriform discharge from, 524               Fractures,'288
Ecchylrmosis in wounds, 75                      Fracture bo,x, 3'23
Eephyi tn cartilageneurn, 424'"    of clavicle, 301
Ecetropiurn, 515                                    "    commrninuted 293
" Dieffenbach's operation for, 517            i"   conpound, 293. 331
i  Jeger's operation for, 517          "    craniuni, 294
perinanent, 516                       "    crepitus in, 290
slrcolm;tosuin, 516                  "    danger of, 29:3
" teinporary, 516                               "    definitimn o(f,'2S8
Egyptian ophthltmrny, 463'~   exciting causes of, 293
Elbow, amputati, m at, 6(39              "              femlur,: 326
"    joint, dislocation   of, 354                "    fibulat, 324
Elnprosthotonos, 114                   "                 fingers, 310
Emphysema, 550                                      "    fot, 321
Ernpyetern, 519'~   fore-arm, 311
ullcysted, or irtfa;ntile hernin, 571                   Ihumllrerus, 315,~ucysted hlytdrocele of the cord, 589              4    impacted., 290
Entropiumn, 517                                     "    inmoltplete, 340
"       Jueger's operation for, 519                  internal inalleous, 325
4'      Tyrell's opter:ttion for, 519           "    leg, 322
Ergot, a cause of galngrene, 3:3                    "    longitudinal, 293
Eruptions, syphilitic, 222                          "    lower jaw, 297
Erysipelas, 38                                      "    lo-wer extremities, 3'2'
butllosutn, 38                               "    mode of union,'291
"      phllegmrnoides, 41                    4"    of the nose, 297
Erysipelatous ophthaltinia, 476                     "    oblique, 29.3
Ether, adtminlistration of,:344                    "    oleerrn,n, 312
Ix:tlnination, catoptric of eye, 498                4C   patella, 333
Excision of cervix ut-eri. 2:33                     CC   pelvis, 3()9
"       tonsils, 540                            "    predtisposing  causes of,'2.3
Exfoi:,stion, 2'28:    radius, 313
F;x-,st,)sis, 30'7                                  "    ribs, SOL




(;648                                   I  KI D  E X.
Fracture of scapula, 299                        Hip joint, dislocation of, 370
simple, 293                           Histry of syplhilis, 190
"    spine. 308                            Hordeolurmr, 519
"    sternum, 306                          Horny excrescences on eyelid, 513
"    tibii, 32i                            Housemrtid's knee, 428
" transverse. 293                          Humerus, dislocation of, 359
"    upper extremities, 310                           fracture of, 315
"c   with depression, 294                  Hu-lterian chancre, 210
Fragilitas ossirn, 41.3                             "      theory of ulcer, 24
Frmenum ling'lu, mtLlformation of, 536          Hyclrocelej 588
Fungus:irticulorum. 420                                    encvsted of the cord, 589
haemrttodes, 25:3                               "       orper tion for, 591
" of eye, 256                    Ilydrops articuli, 415
testicle, 257                          Hydrothorax, 517
"    ulcer, 181               HIyd(rophobia, 85
Furiunculus, 42                                  -ydrophllthalrnit, 486
" poultice in, 44                         Hydlrosa:rcocele, 595
Hypopion, 493
G,
Gangrena senilis, 33                                                  I.
Gangrene,'29:'    acute, 32                             Ichorous pus, 23
i     chronic. 32                          Iliac artery, ligature of, 145,
"    phllvctene in, 29                     I mrn)ovabl app:lral us,:336':    questin of amputation in, 623     Tlnpactcl fr:lctures, 290
"    tralururitic, 33                      Imperfect closure of the pupil, 481
Gib!son's II'er(lorn, 3:30                     Inc.reerate(l hlernia, 562
G1 (udliform  tlmors of eye, 513                Incised wounds, 69
Glaucornt. 507                                  Ineomjlete fralcture, 380
GSitre, 5-16                                    In(lex to treatment of ulcers, 187
GonorrhlEa, 196                                 Indolent ulcer, 18();'  gilu.ldis vel spurious, 205           Indurated chancre, 210
"     tre:ttment of, 198                  Indurations, scirrhoid of the eye, 511
Gonorrhnal ophthalmia, 466                      Inferior maxillary, fracture of, 297
Granulal ion, 27                                Inflammation, 1
Gray pus, 26                                          4;       acute, 4
Greenish pus.'24  chronic, 4
Gutta serena, 509,                      fever and inflammation, 6
"'   treatment of, 13
rH.I                      Injection of perchloride of iron for aueturism, 441
Hematocele, 593                                 Intermediate hemorrhage, 120
Ha erdorn, Gibson's apparatus, 330              Internal aneurism, 436
Hare-lip, 534                                   Internal otitis, 522
comrplicated, 536                         Instruments for dressing, 280
d" ouble, 536                              Inversion of eyelids, 517
"    operation for, 535                    Iris, condylomata of, 469
"    simrple, 534                            "prolapsus of, 484
Head, injuries and diseases of, 445             Tritic ophthalmia, 480
Heat in inflarnm:mation, 5                      Iritis, 480
Hemeralopia, 509                                Irreducible hernia, 561
Hemorrhage, 120                                 Ischuria renalis, 610
"      arresting hy pressure, 121        lsinglas plaster, 72
from ear. 525                     Itching of the anus, 587
intermediate, 120
"      primary, 120;  secon(tarv, 135                                     J.
"      venous, 133
Hemorrhoids, 580                                Jaecer's operation for ectroprium, 517
lIepatic abscess, 161                               ";      entrmopriulm,  511)
Hernia, 558                                    Jameson's probangs, 543;     di inosis of, 559.clly-like pus, 23
congenital 511                        i Joints, abscess of, 415,
crural or femoral, 571                    "   curvature ot, 414
diaphragmatic,  573                            deformlity of, 429
encysted or infantile, 571                     W ounllds,,f. 427
incarcerated, 562                      Jorg's apparatus, 4:30
"    irreducible, 561
"    medical tre:tment of, 563                               K.
obturator, 572
operation for, 573                    tKeratonryxis, 505' reducible, 561                            Kidimeys, womunds of, 553
"    strangulated, 562                     KJing's evil, 273
i' umbilical. 572                             IKnafc jJoint., lisloct iion oft 36




IND EX.                                          649
L.                        Necrosis, 391
"    causes of, 393
tabium  Leporinum, 534                             "    process of, 391
Lacerated wounds, 78                           Needle, exploring,'228
Lapsus palpebrm superioris, 520                    "    for aneurism, 130
Larvated chancres, 209                             "    surgical, 131
Laryngotomy, 545                               Node, 381
Laudable pus,'21                                i" ercurial. 381
Leg, amputation of, 632'-  venereal, 381
Leg, dislocation of, 365                              syphilitic,. 223
Lenticular cataract, 497) 500                   Normal t.erperature of body, 5
Leiucorna, 490                                 Nose, cancer of, 234
Ligamentous anchylosis5 422                           disea:ses of. 531
Ligation of arteries, 1:37                        "   fracture of,'297
a' anterior tibial, 142                    "   polyplts of, 532
"     bracllial, 139                     Nyctalopia, 509.'    common carotid1 141
ftacial, 142                                                  0.
femoral 144
iliac, 1415                        Obliterated pupil, 481
lingual, 141                       Ob1turator hernia, 572'     posterior tibial, 143              Occ(lusion of meatus auditorius, 528
radi:l1, 138                       (Esophagus, sticture of, 542
"  subclavin  140                    "             "        permanent, 512
u" lnar, 138                                 "            "       spasmodic, 541
limited aneurisln, 437                         Olecr.n!n, fracture of, 312
Line of demrtrcation, 30                        Onychia; syphilitica, 2'26
"   separatio(l, 31                        Ophtl-allmia, arthritic, 473
Lint, 282'"                            catarrhal, 459
Lip, cancer of, 233                                  cc      Egypti n, 463
Liquor sangtuinous, in ulceration, 27                "       erysipelatous, 476
J.iquor puris,'20                                   "c       onorrhmal, 466
liston splint for femur, 330                        "       iritic, 4,e0
Lithotrity, 618                                      (       rheumatic, 471
Lithotomy, 615                                       c       scrofulous, 477
Lithotripsy, 619                                     "       syphilitic, 469
Liver, wounds of, 552                                 "      variolous. 476
Lock-jaw, 113                                  Ophthalmitis, 456
Lumbar abscess, 164                            Opisthotonos, 114
Luxation, 341                                  Osteo-cystoina, 401
Osteo-sarcoma, 403
Otalgia, 525
Otitis, 5'22
Malformation of frrenum lingum, 536             Otorrhlea, 524
Matlignaint pus, 24                             Ovarian tumrnors, 553
MalIleolus, internal fracture of, 32             Ozcena, 531.
Mamm:, abscess of, 157
caincer of, 239                                          P
extirpation  if, 245
C     scirrhus of, 239                     Pain in inflammation, 4
Mastodynia apostcmatossa, 157                   Pnnuis, 490
AMeatus au(ltitoriuts, occlusion of, 508        Paracentesis abdominis, 557
Mechanical treatmuent ou' curvature of bonesj                 thoracis, 549
410                   Paraphimrnosis, 601
Medullary sarcoma, 406                          Paronvcllia, 169
Mercurial node, 381                            Pa.tell.l fracture of, 3.33
Mletacarpal bones, dislocation of, 3;3           PearsonS Classifictation of burns 57
Metatarsal joint. amputation of, G35           Pelvis, diislocation of, 363
MIetast~asis, 12                                   "   fracture of, 3(09
Method of evacluating pus, 149                  Penis and testicle, diseases of, 588
lModle of adminlisteringa cllloroform, 346      Periosteum, syphilitic diseases of. 22.9
(("'        ether, 344              Periosteum  an(l bones, diseases of, 379
Mo(de of union of fractures, 291                Periostitis, 380
AMollities oissillu}) 4106                      Perineum, fistula in, 609
MIorlius coxarius, 417                          Perma!nent ectropium, 576
Miorgarniian eat;l -:ct, 500                    Pernio, 48
Mortification, 229                             Phzigedenic ulcer, 27
Mouth, diseases of, 531                              c" Cllncre, 211
AMovable cartilarge, 424                        Plhimosis. 597
Phlel)itis. 4421
Plegrnonoits erysipelas, 41
Physical character of chancres, 208
Nmavi, 438                                      Pleurosthltolnos, 114
Neck, diseases of, 542                          Poisoned wounds, S0
"   topography oft 137                           "'    dissection of, 102




f630                                     J N D E X.
Poisoned wounds, insects, 81                     Scalpel, 282
i"'    serpents, 83                 Sc,ilp, wo)nd(ls of, 445
Polypus of the ear, 529                          S(;!plll:l, frleture of,'299
Potlypus nrsi, 532                               Scirrlrid in(luration of eyelid, 514
Position in inflarnmn tion, 1.8                  Scirrhus, 226
l'osteri;,r (' lpsul ar cataract, 501                 "    of mnamma, 239
Poultice in abtscess, 153                             "    of uterus,!217
i' infl tlnatii)n. 18                     Scissors, dissecting, 131
Pressure in arneurisnm, 444'    strmi-llt, 281
Primary hel, rllage,  120                            "     surgical, 132
" stly)ilis, 210                       Sclerotitis, 471
Piobang, 541                                     Scrofllll, 273'4  J'mineson's 543                         Scrofulous ophtlalrnma, 477
Probes, 281                                                    s pils, 21
Procidentia: iridis, 484                              "      ulcer, 277
Process of necrosis, 391                         Secondary hemorll'rige, 120, 135
Prol;ipsus ani, 579                                   "      syphilis,'221'     iridis 48-1                           Separation, litne of, 31
Properties of pus, 19                            Sequestrumi, 28
Pruritus ani, 5S7                                Slhivering (luring suppuration, 22
Pseudo artlh rosis, 336                          Shoulder, aimputation of( 6:38
Psoroplthalmnia, 484                             Signor(ni's tou rniquet, 125
Pteryiiim, 488                                   Simnple ulcer, 1.6
Ptosis 519                                       Siilns'  uvulsa and tonsil scissors, 510
Punctured wounds, 73                             Single-lheadedt roller, 280
Pupil, artificial, 482                           Sluijing, 28,  imperfect closure of, 481                 SotIutiin,t cataract, 507
"  obliteration of, 481                      Soot wart, 271
Purulent optltlalmlnia, 462                      Sp tul, 21l
Pus, alnnlysis of 20                            lSph acc lus, 30
medicines for different varieties of, 23   Spina  entosai, 401
"  rmetliod (of evacuating, 149               Spinal cord, compression and concussion
Pyogcnic Inernbrane, 146.                                       of, 452
Spine, fracture of, 308
Q.                         Spiral bLndlage, 286
Question of anputation, 619                      Slrlints  n(t Landages,  279
it  "L~    i    in compound frac-   Sprains, 36
tures, 621          Spurious anchylosis, 422
"    cataract, 407
"    " i             in diseases ofj oints;      "    gonarhar, 4 5
"    gonorrhma, 205
in exostosis, 626          "    talipes, 432
c    "c' <    in ga:lngrene and'Staphtyloma, 495
rortification, 623  Sternumrn, fracture of, 306
0       i ~    in necrosis, 626         tolaci, wounds of, 552
Strabismus, 514
R.                         StraL gulated l-ernia, 562
Stricture of cmsophtlgus, 512
Rabies canina, 85                                            rectum, 586
R:ichitis. 406;       urethl rb, G6U
Ratdial artery, ligature of, 138                 Struina, 273
Radius fracture of, 307                          Stye, 519
Radius and ulna, dislocation of, 357             Subluxation, 376
Ranula, 537                                      Sutperficial chancre, 210
Rectum, diseases of, 578                         Suppuration, 19
tumo)rs of, 585                       S"welling in in larrmmation, 5
"    Ftric ture of 586                     Synovitis, 414
Redness in init:l irnrtiuon, 6                   SyphIilis, 205
Reucitble hernia. 56t1                               4    constitutional'221
Resolution, II                                            l history of', 190)
Res;t inl int i:mlmnation. 18 1                           primrnv,' 210
Retention of urine, 61t                         Syphilitic;Iflec( it,n of bones, 2o23
Ribs. disloc:;tin o f.'351                                           of periostculn, 223'  fractture of, 3()7                              "    erluption, 22
Rheumrn;atic opltthalriia) 471                        "    n->las, 23
Roll, 283                                             "    ophthalmia, 469
Roller, 285
Rupture, 558                                                          T
Rupture of muscles and tendlons, 78            I
S.                         Talipes, 431
"   calcaneus, 432
Salt pus, 24                                        "   equinns, 431
Slini)ius  pus, 21                              1      "; spuriis, 432
8 r..oc'rele. 5)91                                  i'  v          4:312s,  1 3
allts nIi lburns, 50)                               " 4   Vt     31




INDEX.                                          6l51
Tampon, 283                                     Uterus, cancer of, 217
Temperature of infliamed part —, 5              Uvula and tonsil scissors, Sims', 540
Temporary ectropium, 516
Tenaculum, 129                                                       V,
Tenotomy, 430
Tent, 283                                       Varicocele, 593
Testicle and penis, diseases of, 588            Varicose aneurism, 4.8
fungus of, 257                              "    ulcer, 185
Tetanus, 113                                    Varieties of caries, 387
Thigh, amputation of, 627                       Variolous ophthalmia, 476
Thomnnpson's classification of burns, 51        Varix, 443
Thumb, dislocation of, 352                      Vascular ulcer on cornea, 492
Thorax, diseases of, 547                        Veins, inflHimmation of, 442
Tongue, calncer of, 4>233;"  injuries and diseases of, 442
Tonsil, abscess of, 538                                wounds of, 442
enlargemlent of, 539                    Venereal disease, 190.?excision of, 510'        "    classification of, 207
h hyperir(,phly of 539 3 9                                     simple, 196
Tonsillitis, 538                                    "    node, 3S1
Top)(g ilraphy if neck, 137              w.irts. 224
Tortie hllis, 429                               Venou s h ernl rrhl. ge. suppression of, I;3:
Tourniquet, 122                                 Vesicull r tumors of eyelids, 514
cc    Signoroni's, 12,3                   Vidal I's forceps, 71
Tracheotomy, 546                                Viscid pus, 23
Traumatic g-lngrene, 33                         Vital turgescence, 3
Trephine, 296, 451
Trichiasis, 521                                                      V.
Trismus, 113                                    Warts, venereal. 221
True aneurismn, 437                             X WVatery pus, 23
cataract, 497                             Whitlow, 1.(9
Tumors, of abdomlen, 555                        Wind contusions, 107
eyelids, 51:3                        W Wool, in treatmnenit of g:lmgrene, 38
joints, 527                          Wounds, 56
"   ovarian, 555                                "    in abdomen. 62
~   of rectum, 585'    in cellular mnemubrane, 58'    in cliest, 61
U.'    classification of, 5(
contused, 75
Ulceration, 24                                      "    Croserio's treatment of, 517'    of cartilage, 415,              dissection. 102
Ulcers, 174                                         "    duodenumrn  552
"   classification of, 175                       "    eye, 61
fulngous, 181'    fibrous parts, 60
index to treatment of, 187                   *    glandular textures 60
ind(olent, 18)0'    gun-shot, 102
indurated syphilitic, 210'    illcised, 61
infiamned, 26                               "    inisects, 81
irritable, 177                             ";   of joints, 427'   on the cornea, 49'2'"                    kidneys, 552'   phagedenic, 27, 211'4   lacerated, 78;  scrofulous 277;;   liver. 552
"   simple. 176                                  "       arnera, 62
~   sloughing, 27'    poisoned, 80;   superficial, 210'    punctured, 73'~  varicose, 185;    scalp, 445
Ilnar artery, ligation of, 138'"   serpents', 83
Union of fracture, 291'4   stomach, 5.52
Urethra and bladder, diseases of, 605               "    veins, 442
extraction of stone from, 614         WVry-neck, 429
stricture of, 605
Urinary calculi, 613                                                 Z
Urine, retention of, 610                       Zymosis, 81.




ERR A T A.
Page 10. Line  7 from bottom, read empiricism for empyricism.
"c  13.  "   1' "       "    read lye. for lye.
"   13.  "   10  "       "    read natr. for nati.
"   13.  c"    3  "      c    read erethi.sn  tor erythism.'"   13.  "   2  "       "    read Trii?,zks for Trenks.
("  16.   "    7  "      "    read haryta-c. for haryta-e.
"   23. Note.-For Chapter VII. read Chapter IX.
"   26. Line 12 from bottom, read its for their.'"  28. Last Note.-For Chapter VfIjl read Chlapter X.
"   45. Line 6 from bottom, read sanious for saneous.
"  206.  "  22  "  top, read ever for never.
"  211.  "   19, and 22 from top, read diphtheritic for diptheritic.
558. For Chapter XXJI. read Chapter XXXIT.




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